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16,053
| 113,453
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53210+59509
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Discharge summary
|
report+addendum
|
Admission Date: [**2119-4-18**] Discharge Date: [**2119-4-24**]
Date of Birth: [**2056-4-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
"My VNA found me at 65%"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 63 yo male with severe COPD on home oxygen, s/p
recent PEA arrest, referred to the ED by his VNA. Per his
report, his visiting nurse found him satting 65% on his
supplemental O2. He states that his sat rose to 81% with "some
exercises." He states that he felt extremely short of breath at
the time but is unable to identify any precipitating event. He
states that he felt sluggish that morning and had returned to
bed, but was up out of bed by the time his VNA arrived. He
denies any fever or chills or rigors. He has had a productive
cough for several months, which he distinguishes from his
baseline "smokers cough." He reports that it is occasionally
productive of deep green sputum. He states that his coughing has
been limited by chest wall pain since he underwent CPR 2 weeks
ago. He was recently seen by the NP[**Company 2316**] on [**4-13**] and was
prescribed a steroid taper for a COPD flare at that visit; he
states that he did not take this taper as prescribed. He
continues to smoke [**4-18**] cigarettes per day.
In the ED, he received combivent nebs x3, azithromycin 500 mg
PO, ceftriaxone 1 g IV, ASA 325 mg, and prednisone 60 mg PO.
Past Medical History:
1. COPD- on home O2 (3L), FEV1 22% predicted, FEV1/FVC
ratio 43% predicted, last intubated 3 years ago. followed by
Pulm
2. Tobacco Abuse
3. DM II
4. Diverticulosis
5. h/o SBO
6. C6-C7 HERNITATION
7. B12 Deficiency- on monthly injections
8. Obesity
Social History:
Pt is married and lives with wife and 2 of his children. He is
currently umemployed- former restaurant manager
Tob: smokes [**6-20**] cigs/day, used to smoke 5PPD for 50 years, cut
down 3 years ago
EtOH: last drink over [**Holiday 944**], used to drink heavily
Drugs: no IV drug use, no other illicits
Family History:
Mother and Father died of lung cancer in their 60s, sister just
recently died at age 50s from lung CA, daughter with cystic
fibrosis
Pertinent Results:
[**2119-4-18**] 11:00AM WBC-9.3 RBC-4.59* HGB-13.4* HCT-42.3 MCV-92
MCH-29.2 MCHC-31.7 RDW-14.1
[**2119-4-18**] 11:00AM NEUTS-75.4* LYMPHS-15.1* MONOS-6.7 EOS-2.5
BASOS-0.3
[**2119-4-18**] 11:00AM CK-MB-NotDone
[**2119-4-18**] 11:00AM cTropnT-0.02*
[**2119-4-18**] 11:00AM CK(CPK)-53
[**2119-4-18**] 11:00AM GLUCOSE-128* UREA N-22* CREAT-0.8 SODIUM-148*
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-37* ANION GAP-10
[**2119-4-18**] 11:00AM PLT COUNT-199
[**2119-4-18**] 11:00AM PT-11.9 PTT-22.1 INR(PT)-1.0
Brief Hospital Course:
A/P: Mr. [**Known lastname **] is a 63 yo male with severe COPD who presents
with hypoxia
.
1) COPD flare: No clear infectious trigger identified with a
clear CXR, normal WBC, negative ROS. Treated with steroids, IV
then to prednisone with slow taper. Plan to see NP[**Company 2316**] in
week and determine whether can taper to off.
2) Diastolic heart failure: Continue lasix 40 mg daily
3) Hypertension: Continue Norvasc, Lisinopril
4) Chest wall pain, s/p chest compressions: Ibuprofen PRN
5) DM2: Glyburide, Glucophage at home. Required insulin while
on higher doses of steroids, but fsbg better controlled as
glucophsge restarted and prednisone tapered down. Pt told to
check fsbg at home and report to his primary nurse practitioner.
6)Pneumonia: CXR c/w pneumonia, sputum with MRSA. Double
coverage with Bactrim and Levofloxacin.
Medications on Admission:
Prednisone 10 mg QOD
Albuterol MDI 2 puffs 4x/day
Aledronate 70 mg PO qMonday
Norvasc 5 mg daily
ASA 325 mg daily
Calcium + Vit D [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Senna 2 tabs qHS
Combivent QID
Flonase 50 mcg 2 sprays daily
Metformin 100 mg [**Hospital1 **]
Glyburide 2.5 mg QOD
Lasix 40 mg daily
Prilosec 20 mg [**Hospital1 **]
Ranitidine 300 mg qHS
Ferrous sulfate 325 mg daily
Advair 250/50 [**Hospital1 **]
Ibuprofen 600 mg TID:PRN
Lisinopril 20 mg daily
Lumigan OU daily
Vitamin B12 1000 mcg qmonth
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID W/ MEALS ().
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
14. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
16. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
18. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO twice a day.
19. Prednisone 10 mg Tablet Sig: 1-3 Tablets PO once a day: Take
30 mg [**4-25**], then Prednisone 20 mg per day until you see
your nurse [**5-2**].
Disp:*30 Tablet(s)* Refills:*0*
20. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
21. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhalation
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
COPD flare
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please continue your steroids (prednisone) until you see your
nurse at [**Hospital6 733**]. She will let you know how much
longer you need to take the prednisone. Please continue the
antibiotics until completed. Call your PCP with increased
shortness of breath.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2119-5-2**] 10:00
Provider: [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Date/Time:[**2119-5-29**] 2:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2119-4-28**] Name: [**Known lastname **],[**Known firstname 77**] Unit No: [**Numeric Identifier 17962**]
Admission Date: [**2119-4-18**] Discharge Date: [**2119-4-24**]
Date of Birth: [**2056-4-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12246**]
Addendum:
MRSA pneumonia: Pt treated for MRSA pneumonia based on clinical
evidence of pneumonia and sputum with MRSA on cx. Treated with
Bactrim.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 12247**]
Completed by:[**2119-5-6**]
|
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"V09.0",
"562.10",
"V46.2",
"491.21"
] |
icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
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340, 347
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1847, 2151
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,054
| 166,017
|
39589
|
Discharge summary
|
report
|
Admission Date: [**2159-9-13**] Discharge Date: [**2159-9-28**]
Date of Birth: [**2111-6-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
unhelmeted MCC
Major Surgical or Invasive Procedure:
[**9-13**]: Emergent placement of tracheostomy
[**9-13**]: Right Craniectomy and evacuation of hemorrhage
[**9-18**]: PEG placement and IVC Filter placement
History of Present Illness:
49yo gentleman involved in MCC this evening, unhelmeted, ETOH=
107. GCS reportedly 8 on scene. [**Location (un) 7622**] to [**Hospital1 18**],vecoronium
given but unable to secure airway. Upon arrival to ED, multiple
airway attempts and more vecoronium given. Short airway placed
and patient rushed to OR for emergent trach. After tracheostomy
patient was taken for a CT scan which revealed a large right
SDH/IPH.
Past Medical History:
previous right craniectomy
Social History:
construction worker, married, 2 children in college. + etoh
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
O: T: BP: 103/59 HR: 63 R 16 O2Sats 100%
Gen: short airway in place
HEENT: Pupils: 1.5mm b/l nonreactive, no corneals
Neck: hard collar
Abd: distended, obese
Extrem: no mvmt
Cranial Nerves:
unable to obtain
PHYSICAL EXAM UPON DISCHARGE:
No eye opening
PERRL 4mm
trach mask (sutures out)
following commands with right upper and lower extremity
spontaneous movement of left and upper and lower extremity
Peg tube site C/D/I
Pertinent Results:
[**9-13**] Head CT: IMPRESSION: Multicompartmental subdural,
subarachnoid, intraparenchymal and intraventricular hemorrhage
as detailed above. Intraventricular hemorrhage extends into the
third ventricle. There is associated 10 mm leftward midline
shift. A component of low attenuation seen immediately adjacent
to the right frontal lobe suggestive of a hyperacute component
to this extensive multicompartmental hemorrhage. Associated
scalp hematoma. There is no ventriculomegaly as of yet.
[**9-13**] Cspine CT: IMPRESSION:
1. No acute fracture or dislocation. Extensive pharyngeal edema
with the
patient noted to be status post tracheostomy with tip
terminating within the mid trachea.
2. Bilateral posteriorly located right greater than left air
space
consolidation, likely massive aspiration.
[**9-13**] Cspine CTA: IMPRESSION:
1. No acute fracture or dislocation. Extensive pharyngeal edema
with the
patient noted to be status post tracheostomy with tip
terminating within the mid trachea.
2. Bilateral posteriorly located right greater than left air
space
consolidation, likely massive aspiration.
[**9-13**] Trauma Panel: IMPRESSION:
1. Collapse of left lower lobe; change of atelectasis/aspiration
within
bilateral lower lobes are dependently as described above. In
addition, small foci of centrilobular opacities seen in the
right upper lobe may also represent the change of aspiration.
2. Status post tracheostomy and associated postsurgical changes.
3. No post-traumatic visceral injury is visualized within the
chest, abdomen, and pelvis, allowing for the contrast injection
technique, which is suboptimal as it was tailored for the next
CT.
4. Distention of stomach, small, and large bowel with gas,
likely related to laryngeal mask, airway ventilation in the
field.
5. Congenital absence of the left kidney and left seminal
vesicles
[**9-13**] Head MRI: IMPRESSION:
1. Punctate areas of restricted diffusion at the [**Doctor Last Name 352**]-white
matter junction in the bilateral frontoparietal lobes with
associated microhemorrhage, consistent with diffuse axonal
injury. No evidence of hypoxic injury.
2. Stable leftward shift of midline structures with right-sided
extensive
subdural hematoma, subarachnoid hemorrhage, and intraparenchymal
hemorrhage as
described above and on the prior head CT.
[**9-13**] Head CT: IMPRESSION:
1. Status post right frontoparietal craniotomy with improved
appearance of
right ventricle and midline shift and expected subcutaneous
emphysema and
pneumocephalus.
2. Relatively unchanged appearance of previously described right
frontoparietal intraparenchymal hemorrhage, subarachnoid
hemorrhage, subdural hemorrhage, and intraventricular
hemorrhage.
3. Paranasal sinus air-fluid levels likely indicate facial
fractures, better evaluated on facial bone CT performed on the
same day.
[**9-13**] CT Max-Face: IMPRESSION:
1. Minimally rightwardly displaced nasal bone fracture.
2. No evidence of orbital or mandibular injury.
[**9-14**] LE duplex: IMPRESSION:
No evidence of acute deep venous thrombosis in the evaluated
bilateral lower extremities, although evaluation is limited in
the right inguinal regionespecially at the level of the common
femoral vein and greater saphenous vein junction.
[**9-14**] R TIB/FIB Xray: IMPRESSION: No evidence of acute fracture
[**9-15**] Head CT: IMPRESSION:
1. Slight interval increase in size of the lateral and third
ventricles,
concerning for developing hydrocephalus. 2. Unchanged amount of
distribution of multicompartmental intracranial hemorrhage.
3. 4 mm rightward shift of midline structures (previously 4 mm
leftward shift of midline structures on [**2159-9-13**]).
[**9-16**] Head CT: IMPRESSION: Overall unchanged appearance of the
brain compared with [**2159-9-15**] with right-sided craniectomy and
intraparenchymal, subdural as well as subarachnoid and
intraventricular blood. No evidence of hydrocephalus.
[**9-21**] LENI's: IMPRESSIONS: No evidence of DVT in either lower
extremity.
[**9-22**] CT Chest: IMPRESSION: 1. No definite evidence of pneumonia.
Mild persistent bibasilar and lingular volume loss are
significantly improved as compared to [**2159-9-13**]. 2.
Multiple sub-4-mm right upper lobe and right middle lobe
pulmonary nodules. As [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] guideline, follow-up in 12
months is recommended in a patient with increased risk for lung
cancer. Otherwise no follow-up is indicated. 3. Persistent
moderate pneumoperitoneum.
[**9-22**] CT head:
Overall stable appearance of the brain as compared to [**9-16**], [**2158**]. No new focal hemorrhage
[**9-25**] CXR: No evidence of pneumonia as can be identified on
single AP chest
view bedside examination.
Brief Hospital Course:
This patient was admitted after emergent tracheostomy. Mannitol
was given in attempt to reduce intracranial pressure. Patients
examination did not show sign of improvement therefore an MRI
was requested to evaluate for hypoxic injury. This was negative
therefore it was decided to take the patient for surgical
decompression. He was taken for a right craniectomy which was
performed without complication.
A routine postoperative head CT was performed which revealed
post operative changes and excellent decompression.
On [**9-14**] his neurological exam was slightly improved. He
continued on mannitol and dilantin. A lower extremity duplex was
performed which was negative for DVT.
On [**9-15**] The patient was off the ventilator and tolerating a
trach mask. dilantin was rebolused and physical exam was
slightly improved. Head CT was done and stable.
On [**9-16**] Repeat head CT was stable and the patient began
following commands. Dilantin was increased for persistant low
level. mannitol wean was started.
On [**9-17**] subdural drain was removed and sutured. Peg and Filter
consultations were requested.
On [**9-18**] transfer orders to the stepdown were written. Social
Work consultation for gaurdianship was requested. mannitol cont
to be weaned. Peg & IVC Filter were placed.
[**9-19**] Pt was febrile to 103. Pan culture sent. Mannitol wean
completed. Seen by PT and OT who recommend discharge to rehab.
[**9-21**] Fevers continued therefore ID was consulted and he was
started on Vancomycin and Zosyn.
[**9-23**] the patient was again febrile and was noted to have streaks
of blood in his stools. HCT checked and followed.
[**9-25**] Pt pan cultured again for low grade fever per ID rec's.
[**9-26**] neurologically stable. cultures all NGTD. has remained
afebrile x 24 hrs. Will check urine cx and vanco trough per ID.
PICC line placed and central line removed.
[**9-27**] Pt again febrile overnight. Subgaleal collection tapped per
ID recommendations.
[**9-28**] Pt afebrile, gram stain for fluid collection negative for
any cells. Infectious Disease cleared the patient for discharge.
He is to continue current antibiotic regimen through [**9-30**]
for VAP. Pt was cleared for discharge to rehab.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg/20.3 mL Solution Sig: [**12-30**] PO Q6H (every
6 hours) as needed for fever.
2. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dryness.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
9. Ibuprofen 100 mg/5 mL Suspension Sig: Twenty (20) ml PO Q6H
(every 6 hours) as needed for fever.
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 8H (Every 8 Hours): Continue through [**9-30**].
13. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours): continue through
[**9-30**].
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Traumatic Brain Injury, right SDH/IPH/IVH
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery.
MEDICATIONS
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, you may
safely resume taking this on XXXXXXXXXXX.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Known firstname **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2159-9-28**]
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25,658
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50626
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Discharge summary
|
report
|
Admission Date: [**2178-10-2**] Discharge Date: [**2178-11-9**]
Date of Birth: [**2110-3-24**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / Amiodarone
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
AICD firing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 68 yo male with a PMH of CAD s/p CABG [**2163**] (LIMA->LAD,
SVG->D->OM2 jump graft, SVG->LPDA) with stents to distal and
proximal LCx, s/p VT ablation and AICD implantation [**2-16**], who
presents after his AICD fired 3 times this AM. The pt was
walking out from his bathroom and tripped and fell (with his
headhitting the mattress), at which time his AICD fired 3 times
over a 6 minute period. He denies associated syncope or
associated CP, SOB, n/v, diaphoresis. He has been feeling more
weak over the last two weeks and has been unable to use his cane
like normal because of right wrist pain. He initially presented
to [**Hospital **] Hospital and was transferred to [**Hospital1 18**] for further
evaluation.
.
Per EP fellow's note, the pt was recently admitted for stable VT
two days after fem-fem bypass R->L. During that hospitalization
([**7-16**]?), the pt was initially loaded on amiodarone, but this was
subsequently discontinued for concern of toxicity. The threshold
on the pts ICD was changed at that time. However, pt had 4
episodes of ICD discharge for continued stable VT. Therefore,
patient was started on sotalol during previous admission.
.
In the ED the pt was found to have a SBP initially in the 80s
and a HCT of 25 (BL 31). He was given 2 units of PRBC and his
SBP rose to 110s. EP interrogated his paecmaker and found the
pt to have had three shocks for what appears to be ATach around
the same rate as his VT (VT lower detection limit is 600ms). He
was given Toprol XL 25 mg po x1 per EP recs as well as [**Month/Year (2) 11573**] 20
mg IVx1 and 1 L NS.
.
Overnight patient received an additional 40 mg of [**Month/Year (2) 11573**] IV with
300 cc of UOP overnight. He was also started on 20 mg of
prednisone for presumed gouty attack. This am he continues to
complain of right wrist pain. He states that this is similar to
prior gouty attacks. It has been going on for ~ 1 week. He has
also had fevers as high as 102 in the last week reported by his
visiting nurse. [**First Name (Titles) **] [**Last Name (Titles) **] dose was also increased approximately
1 month ago from [**Hospital1 **] to TID given increased lower extremity
edema and fluid on the lungs. He does not complain of anything
else but when questioned, he does note that he has been more
weak in the last 2 weeks. He lives alone and can normally walk
with a cane or walker but has had more difficulty walking around
recently. He notes that he has not been able to use his cane as
he normally would because of his painful wrist. Pt denies
nausea, vomiting, abdominal pain, increased leg swelling,
orthopnea, subjective fevers, chills. He also denies BRBPR,
melena, focal weakness/numbness.
Past Medical History:
1)CAD s/p CABG CABG [**2163**] (LIMA->LAD, SVG->D->OM2 jump graft,
SVG->LPDA)
- cath([**2177-1-31**]: patent LIMA->LAD, patent SVG->diagonal and OM2.
Occluded SVG-> L PDA.
- Underwent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2->proximal and distal left circumflex/PVA
2)HTN
3)Hyperlipidemia
4)s/p VT ablation and ICD implantation [**2-16**]
5)COPD
6)Gout
#chronic LLE ulcers
#PVD/claudication
- s/p right external iliac artery stent [**8-/2176**]
- complicated by LUE hematoma, ? nerve injury;
- s/p right to left fem-fem bypass grafting in [**2178-5-11**]
#spinal stenosis
- s/p back surgery
#bilateral renal masses
#s/p L inguinal hernia repair
#s/p cataract surgery
Social History:
Single, lives alone. Has visiting nurse service. Active smoker
of 10 cigarettes per day. Has smoked 1-2 packs per day for [**10-25**]
years. Denies ETOH. Retired construction worker.
Family History:
Non-contributory
Physical Exam:
T 98.1 BP 98/54 P 64 R 20 Sat 98% 2.5L NC
Gen: chronically ill appearing man,resting comfortably. NAD
HEENT: NCAT. No icterus. EOMI, PERRL, OP clear, uvula midline,
MMM
Neck: JVP at the level of the mandible. No HJR. No thyromegaly.
No carotid bruits
CV: distant heart sounds, RRR, nl S1/S2, no m/r/g noted
Lungs: bibasilar crackles. No wheezes or rhonchi
Ab: NABS. soft, NTND, no HSM. no rebound or guarding
Extrem: R wrist erythematous, warm, swollen, and tender. No
palpable effusion. 1+ pitting edema in LLE up to knee, trace
pitting edema in RLE up to the knee. Non-palpable DP/PT pulses.
well-healed incision scar L calf
Neuro: A and O x 3. CN II-XII grossly intact. Some decreased
attention on cranial nerve exam but able to follow commands.
Paratonia in lower extremities and rigidity to assisted range of
motion but patient able to move all extremities in all ranges of
motion except for right wrist. Downgoing plantar reflexes bilat.
LE reflexes could not be performed [**2-12**] rigidity.
Skin: L foot wrapped with clean dressing. Not removed. Per prior
exam: well healing 1cm ulcer on L heel, well healing 1 cm R
medial malleolus ulcer, 2 1 cm ulcerations on the dorsum of the
L foot which appear non-infected and have no drainage
Pertinent Results:
PA AND LATERAL CHEST RADIOGRAPHS: The left-sided pacemaker is
seen with leads terminating in appropriate position. The patient
is status post CABG and median sternotomy wires are noted. There
is moderate cardiomegaly which is unchanged. The lungs are
clear. The osseous structures are unremarkable. IMPRESSION: No
acute cardiopulmonary abnormality.
.
EKG: A paced, LAD, IVCD, TWI V3-V6 I AVL AVF (all old)
Brief Hospital Course:
Patient is a 68 yo male with a PMH of CAD s/p CABG and PCIs, VT
ablation and AICD implantation [**2-16**], PVD s/p fem-fem bypass with
PTFE graft who presents after AICD firing for atrial tachycardia
found to be anemic, thrombocytopenic, hyponatremic, and now
bacteremic with staph aureus.
.
1) Bacteremia: The patient had persistent high-grade MRSA
bacteremia. He grew bacteria in 4 out of 4 bottles in <24 hours
on admission. Cultures were positive in [**4-14**] bottles for several
days. He initially spiked fevers to 102 but was asymptomatic and
quickly defervesced while on IV Vanc 1gm Q24h. ID was consulted
and followed the patient throughout his hospital course. The
patient was noted to have an open LLE foot ulcer draining
tophaceous material. Swab of this wound grew MRSA representing a
possible source for his bacteremia. [**Date Range **] surgery was
consulted and it was decided to not surgically intervene at the
site. Given his persistent high grade bacteremia a source of
sequestered infection was sought. TTE and TEE did not show
vegetations. The patient's ICD and graft site were visualized by
U/S without any fluid collections found. It is still concerning
that the patient relatively recently had his ICD placed.
Cardiology was contact[**Name (NI) **] regarding this issue. The patient
developed a R wrist, R knee and L 3rd finger swelling and
erythema consistent with either gouty flare or septic joints.
The patient's knee was tapped multiple times and was consistent
with gout with an associated low grade infection growing staph
aureus. The patient's R wrist had a surgical washout by hand
plastics and contained gross crystals and on gram stain
contained gram positive cocci in pairs and clusters. The patient
had a transient decline in his blood pressure which improved
after holding diuresis. At that time, the patient's lactate was
2.8. The patient's left foot was debrided by podiatry. He
finally cleared blood cultures on [**2178-10-11**]. The patient
completed a 5-day course of gentamicin (for synergy) and was
continued on Vanc IV alone, dosed renally. Patient continued to
have an elevated WBC with elevated temperatures despite
treatment with Vancomycin. Other sources of infection were
investigated, included her ICD. His ICD was removed and cultures
of the atrial leads grew coag + staph aureus. This was thought
to be his source of infection and may have triggered his
episodes of VT. He was continued on Vancomycin, per ID reccs,
and will continue this for 6 weeks from the last blood culture.
Last blood culture is on [**2178-11-1**].
.
2) Ventricular Tachycardia: Pacemaker was interrogated and he
was found to be in A tach. This may have been secondary to
increased sympathetic tone s/p fall. He has had no further
episodes since that time. The patient was continued on Sotalol
120 mg po bid, Mexiletine 150 mg po Q8hrs, Toprol XL 25 mg daily
per EP recs. He was maintained on tele monitoring without
recurrence. The patient was transferred to the CCU on [**10-30**]
after multiple episodes of sustained ventricular tachycardia.
His blood pressure dropped to SBP in the low 80s. His ICD did
not fire at this time and the patient was asymptomatic. His
device was interrogated by EP at this time and he was given a
bolus of amiodarone, followed by a continuous IV infusion.
While in the CCU he had occasional runs of NSVT for 5-8 beats
each. His SBPs remained in the 90s/100s. The Sotalol was d/c'ed
due to worsening renal function and he was continued on the
Mexiletine. The ICD was removed by EP because it was thought to
be his source of infection, in the context of an elevated WBC
and fevers. He was then transitioned to PO Amiodarone but was
then stopped due to elevated LFTS, per hepatology
recommendations. Plan, per EP, is to have patient undergo VT
ablation in [**2-13**] weeks. He has not had any further episodes of VT
during his stay.
.
3) Coffee ground emesis. The patient had a questionable episode
of bloody emesis. On NG lavage coffee ground emesis were noted
and the patient was sent to the MICU though he was
hemodynamically stable with a stable hematocrit. EGD revealed
diffuse esophagitis and gastritis consistent with Candidal
infection. The patient was started on PO fluconazole. There was
no clear bleeding source. The patient was transfused for a slow
Hct drift downward with good response and maintained a stable
Hct throughout the remainder of his admission. The patient was
H. Pylori serology negative. During the rest of his hospital
stay his hematocrit remained stable and did not require any
further transfusions. Initially both his Aspirin and Plavix were
stopped; but his ASA was then restarted.
.
4) Productive cough. The patient developed a productive cough
growing klebsiella and Enterobacter on culture consistent with a
CXR concerning for a new infiltrate. The patient was started on
Levofloxacin on [**2178-10-14**] and completed a 2 week course. It was
thought that he had a new infiltrate on cxray and was started on
Ceftriaxone but this was d/c'ed since pt was clinically stable.
.
5)CHF: Per the patient's TTE in [**2178**], he has an EF of 25% with
elevated LV filling pressures (systolic and diastolic
dysfunction). On presentation, pt has wet crackles, BNP of
4000, and LE edema. Other evidence for volume overload is
hyponatremia. [**Month (only) 116**] also be contributing to worsening renal
function given known systolic dysfunction. The patient did not
respond to medium dose IV [**Month (only) 11573**] and then was given 100mg IV
[**Month (only) **] with a goal diuresis of 500-1L. The patient was not
significantly negative per I/O recording, however, crackles
appeared improved. His diuresis was held during transient
hypotension. He was placed on a low salt diet, fluid restricted
1.5 L/day. His regimen of Sotalol, Toprol XL was continued but
later held because of elevated creatinine and bradycardia.
Lisinopril was held for renal failure.
.
6)CAD: The patient had no EKG changes on presentation. Troponins
and CKs remained flat. Initial elevation in troponins were
likely due to combination of cardiac stretch, AICD firing, and
renal failure. Excellent cholesterol control. The patient was
initially continued on ASA, Plavix, Pravachol, Sotalol, Toprol
XL. His Sotalol and Lisinopril were held in the setting of ARF.
ASA and Plavix were held due to possibility of GI bleed. ASA was
then restarted towards the end of his hospital stay.
.
7)Anemia. The patient presented with anemia. He had an
appropriate response to transfusion with HCT back to baseline
and stable. B12 and folate studies were normal. Iron studies
were suggestive of anemia of chronic disease. Possible
contribution of marrow suppression secondary to sepsis. The
patient had daily HCT without further decline. Transfusion
threshold was set at HCT<21.
.
8) Thrombocytopenia. The patient presented with
thrombocytopenia. Initial concern was for DIC given sepsis and
declining platelet count and HUS given renal failure on
presentation. Coags were normal and DIC labs were not consistent
with DIC. There was no evidence of hemolysis or schistocytes on
smear to suggest HUS. Marrow suppression secondary to sepsis as
the patient also presented with anemia and a low WBC count in
light of significant bacteremia was thought possible. The
patient was found to be heparin antibody positive. His platelet
count stabilized. After withholding all heparin containing
products including flushes, the patient's platelets began to
climb. Patient was tested for heparin dependent antibodies which
were found to be positive.
.
9) Transaminitis: The patient presented with a mild
transaminitis and elevation in alkaline phosphatase. These were
nonspecific and there were no findings on history or physical
consistent with biliary colic or cholecystitis. It was thought
that this could be a congestive hepatopathy secondary to heart
failure given evidence of R sided heart failure on exam. A RUQ
ultrasound was done to rule out cholecystitis and cholangitis as
the patient was not covered with gram negative antibiotics. RUQ
ultrasound showed some gallbladder wall thickening and no acute
process. Patient's ALT, AST and Alk phos began to rise again
later during his hospital stay. Hepatology was consulted. RUQ
U/S repeated and suggested gallbladder sludge. Hepatitis
serologies negative. Thought to be medication induced hepatitis
secondary to Amiodarone and Fluconazole. Both were d/c'ed. There
was improvement in the ALT/AST but alkaline phosphatase remains
elevated but slowly coming down. Per hepatology, of remains
elevated will consider MRCP. Patient asymptomatic.
.
10)ARF. The patient's Cr improved post blood transfusion and
diuresis on presentation. Possibly this was all secondary to
increased blood volume with transfusion but could also be
contribution of improved cardiac output with diuresis. Although
volume status even now, it is possible that he had been
persistently positive as an outpatient. The patient's CHF was
optimized as above. His Lisinopril was held. Colchicine was
dosed renally. The patient's Cr hovered near his baseline. Over
the course of his hospital stay his creatinine slowly improved
and is currently 1.4.
.
11)Hyponatremia. The patient was hyponatremic on presentation.
This improved with diuresis despite even I/O's. This was felt
most likely [**2-12**] hypervolemic hyponatremia given improvement with
diuresis. It was possibly due to fluid retention [**2-12**] decreased
effective arterial volume during CHF exacerbation. Supported by
FE BUN suggestive of prerenal azotemia. Urine osmolality low
likely secondary to volume overload or diuretics but does not
suggest SIADH. The patient's CHF was managed as described above.
.
12) Swollen/Painful R wrist, R knee and L 3rd digit on the hand.
Initially the patient presented with swelling and erythema of
the R wrist. Ddx included septic joint vs gout. XRay of the
wrist showed no fractures. There were noted changes c/w active
gouty tophi. Rheumatology was unable to obtain fluid by needle.
Hand plastics took the patient to the OR for wash out. Fluid
from this procedure grossly had crystals and on gram stain
revealed gram positive cocci in pairs and clusters consistent
with infectious gouty joint. The patient's R knee was tapped
multiple times and fluid revealed gouty crystals with low level
Staph aureus growth. The patient was diagnosed with
polyarticular gout with overlying septic joints. The R wrist was
washed out as described. The patient was continued on colchicine
(dosed renally) and allopurinol. Steroids were held due to
bacteremia. For pain control the patient was given oxycodone SR
(40, and then 60 [**Hospital1 **]), Percocet PRN for breakthrough, and
Tylenol. The colchicine was d/c'ed due to worsening renal
function. He was continued on Allopurinol 300mg daily and
tolerated well. Patient did not complain of any pain during the
remaining of his stay.
.
13) L foot ulcers: s/p debridement. These appear consistent with
tophaceous gout. White material extruding from ulcers that was
diagnosed as uric acid by rheumatology on past admissions. Was
seen recently by [**Hospital1 1106**] who felt ulcers, which have been
chronic, are improving. [**Hospital1 **] surgery wound care,
rheumatology and podiatry were consulted. XRay did not reveal
any new erosions, though underlying osteo could not be excluded.
Swab culture results revealed MRSA at this site. Podiatry
removed stitches and wound nicely healing. Daily [**Hospital1 **] wet-to-dry
dressings and should remain in MP boots.
.
14) Chronic pain. For chronic and acute gouty pain, the patient
received OxyContin [**Hospital1 **], oxycodone for breakthrough and Tylenol.
Patient found to be drowsy and less responsive with opioids.
Opioids were d/c'ed and patient was maintained on standing
Tylenol.
.
Medications on Admission:
Sotalol 120 mg [**Hospital1 **]
Mexilitine 150 mg tid
Allopurinol 200 mg qd
ASA 325 mg qd
Colchicine 0.6 mg qd
[**Hospital1 11573**] 40 mg tid (increased from [**Hospital1 **] 1 month ago)
Lisinopril 5 mg qd
Oxycontin 40 mg SR [**Hospital1 **]
Plavix 75 mg qd
Pravachol 40 mg qd
Senna qhs
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): Please stop on [**2178-11-17**].
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Please stop on [**2178-11-17**].
6. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain/fever.
9. Papain-Urea [**Telephone/Fax (3) 3335**] unit-mg/g Ointment Sig: One (1) Appl
Topical DAILY (Daily).
10. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical DAILY
(Daily).
11. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**])
units Injection QMOWEFR (Monday -Wednesday-Friday).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours).
18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
19. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
20. Vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
units Intravenous Q48H (every 48 hours): Please check
Vancomycin level in 2 days and then weekly.
21. Procainamide 100 mg/mL Solution Sig: as directed Injection
prn as needed for stable VT: If having stable VT, please
administer drip at 20 mg/min up to 17 mg/kg total dose and may
notify on call EP fellow at [**Hospital1 18**]. [**Month (only) 116**] also try shock for
unstable VT. .
22. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1) injection
Subcutaneous once a day: until patient ambulating three times
daily. Hold day prior to EP study.
Discharge Disposition:
Extended Care
Facility:
Mt. [**Doctor First Name **] Nai
Discharge Diagnosis:
Primary:
MRSA bacteremia with seeding of pacemaker lead, ankle, knee
Recurrent stable ventricular tachycardia
Urinary retention: d/c'd foley [**11-3**] with failed voiding trial
Transaminitis:
Renal failure from ATN
polyarticular gout
intermittent confusion
chronic pain
decub ulcer
Secondary:
Coronary artery disease
Hypertension
Hyperlipidemia
COPD
Chronic LLE ulcers
PVD/claudication: s/p right external iliac artery stent [**8-/2176**],
complicated by LUE hematoma? nerve injury; right to left fem-fem
bypass grafting in [**2178-5-11**]
Spinal stenosis
Bilateral renal masses
Discharge Condition:
Stable.
Discharge Instructions:
1)Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction to <1.5L/day
.
2)Take all medications as prescribed as indicated in discharge
instruactions.
.
3)Attend all follow-up appointments.
.
4)Please fax weekly CBC, Bun/Cr, vancomycin trough to attention
of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3394**] at the [**Hospital **] clinic at [**Telephone/Fax (1) 1419**].
.
5)Please check vancomycin trough level in 2 days ([**2178-11-11**]) and
fax to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3394**] at [**Telephone/Fax (1) 1419**].
.
6)Return to the emergency department or call your doctor for new
fevers, chills or nightsweats, blurry vision, neck stiffness,
worsening redness of the skin or redness, swelling of any
joints.
Followup Instructions:
1)Follow up with EP - they should contact you for potential EP
study procedure in [**2-13**] weeks.
2)Follow-up with Dr. [**Last Name (STitle) **] of orthopaedics 4 weeks from
staple removal - [**2178-11-19**] 10:00a [**Last Name (LF) 1960**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
CLINIC (SB)
[**2178-11-19**] 09:40a X-RAY ORTHO SCC2 X-RAY ORTHO SCC2.
3)Left dorsal foot (debrided on [**2178-10-9**])and left heel ulcer,
follow-up with Dr. [**First Name (STitle) 3209**] in podiatry clinic ([**Telephone/Fax (1) **]) 1 week
after discharge. [**2178-12-11**] 02:30p PODIATRY,[**Hospital **] [**Hospital 1947**]
CLINIC (SB)
4)Follow-up with the renal division ([**Telephone/Fax (1) **]) 4 weeks after
discharge.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7198**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2178-12-2**] 2:30
5)Outpatient follow-up for suppressive therapy at conclusion of
Vanc therapy (6 weeks after [**2178-10-24**]), in [**Hospital **] clinic
([**Telephone/Fax (1) **]) with either Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3394**] - You have an
appointment on [**12-8**] at 11 AM ([**Hospital Ward Name **] basement). Also,
vancomycin results can be faxed to [**Telephone/Fax (1) 1419**] for dosing
adjustments.
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,059
| 139,150
|
54699
|
Discharge summary
|
report
|
Admission Date: [**2139-6-19**] Discharge Date: [**2139-6-22**]
Date of Birth: [**2072-10-19**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 38277**]
Chief Complaint:
hypoxia, need for BIPAP
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 66 yo M with hx CAD s/p BMS x2 to the LAD [**5-19**], CHF
(EF 25-30%) who presented with chest pain.
Patient was recently admitted to [**Hospital1 2025**] [**Date range (1) 111860**]. At that time,
he presented with 10/10 crushing SSCP, found to have anterior
STEMI in ED. Cath showed occluded LAD, and then received BMS x2
to LAD on [**5-19**]. After the cath lab during that admission, he
had persistent chest pain and he was taken back to the cath lab.
Stents were intact, but he had distal LAD disease, so had 2nd
BMS placed. Patient was also found to have HITT and an LV
thrombus during that admission. He was started on Coumadin.
Although he used cocaine in the past, he denies any use since
his recent discharge.
Since his discharge from [**Hospital1 2025**], his activity has been limited by
fatigue and DOE. He sleeps sitting in recliner. Today, he had
a previously scheduled visit with his cardiologist, Dr. [**Last Name (STitle) **], at
[**Location (un) 2274**] [**Location (un) **]. Patient was complaining of chest pain at the
time, and given his LV aneurysm and fixed ST elevations in
V1-V5, patient was transferred directly to the cath lab at
[**Hospital1 18**].
In the cath lab, patient was found to have:
1. Single vessel coronary artery disease (occlusion of the
superior branch of OMB1)
2. Patent stents in the proximal and mid LAD
He did not require any intervention. He continued to have some
chest pain during the procedure. He was maintained on ASA,
plavix and discharged home after the procedure.
After leaving the hospital, the patient had dinner in [**Hospital1 8**].
He had a small amount of broth, but then developed nausea, left
arm discomfort, and chest discomfort similar to other episodes,
and presented to the [**Hospital1 18**] ED.
In the ED, his initial VS were T 36.8 ??????C, P: 105, RR: 34, BP:
123/86, O2Sat: 97, O2Flow: RA. He was diaphoretic, with dynamic
electrocardiogram changes in anterior precordial leads, with Q
waves. CODE STEMI was called. He was seen by cardiology. His
symptoms were thought to be consistent with increasing wall
tension with tachycardia. He already received aspirin 325 mg po.
In the ED, he recieved morphine, SL nitro. Initial plan was for
ED observation. He then developed an episode of shortness of
breath with O2 sat 86% and was found to have bibasilar rales and
CXR c/w pulmonary edema. He was initially started on NRB but
then started on BIPAP as patient's O2 sat remained in 80s on
NRB. He was also given 20 mg iv lasix. VS prior to transfer were
P: 91, RR: 21, BP: 117/92, O2Sat: 100, O2Flow: BiAP, 40% with 10
PEEP.
On arrival to the MICU, he reported improvement of his symtpoms,
and BiPAP was discontinued.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies vomiting, diarrhea, constipation, abdominal
pain, or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
CAD s/p BMS x2 to LAD
CHF EF 32% in [**2139-5-3**]
LV thrombus- Seen during last admission, on coumadin
HTN
s/p L ORIF
Social History:
General married, works in lab stockroom
Tobacco 4 cigarettes/month
Alcohol denies
Illicit drugs past cocaine use, but denies current use
Family History:
brother with cardiomyopathy, died in his 50s
Physical Exam:
Physical Exam on Admission:
Vitals: afebrile 99/60 HR 97 RR 16 98% on 4 liters n/c
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 2-3 cm above clavicle, elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diminished breath sounds bilaterally with rales
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE EXAM:
Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP 2-3 cm above clavicle, elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB w/ scarce crackles bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
Labs on Admission:
[**2139-6-19**] 07:20PM WBC-6.1 RBC-3.98* HGB-11.6* HCT-36.2* MCV-91
MCH-29.2 MCHC-32.1 RDW-14.3
[**2139-6-19**] 07:20PM NEUTS-68.9 LYMPHS-24.9 MONOS-5.1 EOS-0.9
BASOS-0.1
[**2139-6-19**] 12:45PM GLUCOSE-118* UREA N-14 CREAT-1.4* SODIUM-138
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
[**2139-6-19**] 07:20PM PT-21.2* PTT-52.0* INR(PT)-2.0*
[**2139-6-19**] 12:45PM CK(CPK)-96
[**2139-6-19**] 12:45PM cTropnT-0.03*
[**2139-6-19**] 12:45PM PT-21.2* INR(PT)-2.0*
[**2139-6-19**] 07:20PM ALBUMIN-4.1 CALCIUM-9.3 PHOSPHATE-3.0
MAGNESIUM-2.1
[**2139-6-19**] 07:20PM CK-MB-3
[**2139-6-19**] 07:20PM cTropnT-0.03*
[**2139-6-19**] 07:20PM ALT(SGPT)-13 AST(SGOT)-17 CK(CPK)-92 ALK
PHOS-102 TOT BILI-0.4
[**2139-6-19**] 07:39PM LACTATE-1.7
OSH labs:
trop 0.03 at 12:30, [**2072**]
Creat 1.4
INR 2.0
WBC 6, HCT 36, platelets 151
.
Imaging:
.
PERCUTANEOUS CORONARY INTERVENTIONS [**2139-6-5**]:
[**2139-6-5**] Coronary angiography - right-dominant system with a ramus
intermedius branch:
- the left main has no flow-limiting stenosis
- the left anterior descending artery has widely-patent stents
in the
proximal and distal segments with 40-50% residual distal
stenosis and
mildly reduced flow (TIMI-2 to TIMI-3) throughout
- the stent-jailed D1 branch has 50% pinch at its origin,
unchanged
from prior two catheterizations
- the ramus intermedius branch has diffuse moderate stenosis and
has
total occlusion of one of its sub-branches, which is
collateralized
left-to-left (unchanged from prior catheterizations)
- the left circumflex artery has minor luminal irregularities
- the right coronary artery has diffuse 30-40% mid-vessel
stenosis
Cath [**2139-6-19**]
Coronary angiography: right dominant
LMCA: Normal
LAD: Stents are patent in the proximal and mid LAD; 40-50%
mid LAD after stent
LCX: Diffusely disease OMB1 with occlusion of the superior
limb of the OMB1 with left to left collaterals. There was a 40%
distal LCx
RCA: 40-50% mid RCA stenosis
The coronary anatomy is unchanged from the prior cardiac
catheterization report from the [**Hospital1 2025**] in early [**Month (only) 116**]. There was no
evidence of an acute embolus.
TTE:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is moderate to severe regional left ventricular systolic
dysfunction with distal LV/apical dyskinesis and septal/anterior
hypokinesis to akinesis suggestive of CAD (LAD infarct?). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size is
normal. with borderline normal free wall function. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with mild mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
EKG: [**2139-6-19**] 19:11 sinus at 99, P wave abnormality, T wave
inversion in aVL, Q waves in V1-V4, ST elevation in V1-V4
Cardiac Catheterization ([**2139-6-19**]):
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated one vessel disease. The LMCA was normal. The LAD
stents
proximally and distally were patent. The mid LAD had a 40-50%
stenosis
after the stent. The LCX had diffusie disease OMB1 with
occludsion of
the superior limb of the OMB1 with left to left collaterals.
There was a
40% distal LCX. The RCA 40-50% mid RCA stenosis.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures at the central aortic level 87/66 mmHg.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Patent stents in the proximal and mid LAD.
CXR [**2139-6-19**]:
Lungs are low in volume and severely affected by diffuse
infiltrative
abnormality which by virtue of its homogeneous distribution is
more likely
edema than anything else though not necessarily cardiogenic.
Heart shadow is largely obscured, and pulmonary vessels cannot
be assessed. Pleural effusions may be present but not large.
Clinical service is aware of these findings.
CXR [**2139-6-21**]: Pulmonary edema has almost resolved. Heart is
mildly-to-moderately enlarged. The thoracic aorta is generally
large. When feasible, conventional radiographs should be
obtained to see if there is any reason to be concerned about
possibility of aortic dissection.
DISCHARGE LABS:
[**2139-6-22**] WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
5.2 3.68* 10.6* 33.6* 91 28.8 31.5 14.5 131*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2139-6-22**] 06:30 131*
[**2139-6-22**] 06:30 18.4* 30.6 1.7*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2139-6-22**] 06:30 106*1 12 1.3* 137 4.7 105 22 15
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2139-6-21**] 06:10 12 17 86 0.5
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2139-6-22**] 06:30 9.2 3.0 2.1
Brief Hospital Course:
Patient is a 66 yo M with hx CAD s/p BMS x2 to the LAD [**5-19**], CHF
(EF 32%) who presented with chest pain after cardiac
catheterization, with presentation consistent with acute
systolic CHF.
# Acute systolic CHF: Patient developed flash pulmonary edema
in the ED with unknown trigger as patient had no hypertension.
He has underlying CHF with EF 25-30% per records. He received no
IVF. His pulmonary edema may have been related to poor forward
flow in setting of tachycardia. He responded very well to
diuresis with IV Lasix, however, his blood pressures did not
tolerate diuresis and decreased to the 80s. Thus, diuresis was
stopped. Respiratory status was much improved and patient was
on room air. Temporarily held beta blocker in setting of
hypotension. Given soft S3 on exam, patient was started on
digoxin. On discharge, his cardiac regimen includes BB, ACEi,
digoxin and warfarin (given history of LV thrombus). Started
lasix 20mg po daily on discharge.
# CAD/ ST changes: Patient has history of CAD with BMS x 2
placed in LAD in [**Month (only) 547**] during admission at [**Hospital1 2025**]. He has Q waves
and ST elevations in V1-V4, which were thought to be dynamic
changes and not related to acute coronary syndome. His chest
pain may be [**3-5**] mycocardial wall tension in setting of
tachycardia. His cath done on day of admission showed no change
from prior. Did not have troponin leak. On d/c, will continue
ASA, clopidogrel, BB, ACEi, statin.
# LV thrombus- s/p thrombectomy per records. Continued Coumadin,
goal INR [**3-6**]. Will need anticoagulation for 3 months. Placed pt
on warfarin and will get INR check on [**2139-6-23**]. Informed pt to
hold digoxin prior to INR check so as not to skew result.
# Hypertension: Not hypertensive in house. Pressures ran in SBP
80s-90s in unit and patient was comfortable and asymptomatic at
these pressures. Continued BB, ACE-i on d/c due to
cardioprective effects.
# History of HITT- avoided heparin products
# chest pain: considered GERD as a possible etiology, give lack
of ischmemia on EKG and lack of trop elevation during recent CP
episodes. [**Name (NI) **] pt's omeprazole to [**Hospital1 **] in house, but on
discharge, switched to ranitidine 150mg po BID due to the
possible interaction between omeprazole and plavix (it can
decrease plavix levels in blood). also recommended maalox.
TRANSITIONS OF CARE:
- will f/u with cardiology
- check INR and digoxin level on [**2139-6-23**] and adjust doses of
coumadin and digoxin levels accordingly
- consider plain films to evaluate for thoracic/abdominal aortic
dissection as outpatient (could not rule this out on portable
CXR in house, but this was not c/w pt's symptoms so was not
pursued)
- follow up BNP to be used as baseline value (pt thought to be
at dry weight upon dicharge at 75kg)
- uptitrate CHF meds as tolerated
- once medical management optimized, consider AICD placement at
least 40 days post-MI
Medications on Admission:
Pravastatin 20mg daily
Furosemide 20 mg Oral Tablet one po daily
Lisinopril 5 mg Oral Tablet 1 TABLET PO DAILY
Metoprolol Tartrate 50 mg Oral Tablet one po daily
Clopidogrel (PLAVIX) 75 mg Oral Tablet one po daily
Aspirin 81 mg Oral Tablet one po daily
WARFARIN SODIUM (WARFARIN ORAL) None Entered
Hydrocortisone Acetate (ANUCORT-HC) 25 mg Rectal Suppository
Insert rectally twice daily as needed
Clotrimazole-Betamethasone 1-0.05 % Topical Cream apply TWICE
DAILY AS NEEDED to groin rash areas
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Outpatient Lab Work
Digoxin and INR lab draw on [**2139-6-23**]. Please fax results to Dr.
[**Last Name (STitle) **] (cardiologist) at [**Telephone/Fax (1) 79385**].
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for dyspepsia.
Disp:*qs qs* Refills:*0*
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO twice a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*0*
6. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
11. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
acute systolic CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 15352**],
It was a pleasure taking care of you. You were admitted to the
hospital for heart failure. We managed your symptoms and also
managed your heart failure medication regimen. It is very
important for you to follow the diet and lifestyle modifications
that we discussed with you, and also to follow-up very closely
with your outpatient providers (cardiologist, primary care
physician, [**Hospital3 **]).
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Below is your new medication regimen:
clopidogrel 75 mg Tablet Sig: One (1) Tablet by mouth DAILY
(Daily).
aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
by mouth DAILY (Daily).
alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs by mouth up to 4 times a day as needed for dyspepsia.
metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr by mouth twice a day.
digoxin 125 mcg Tablet Sig: One (1) Tablet by mouth DAILY
(Daily). Do not take your digoxin prior to your digoxin level
tomorrow.
lisinopril 5 mg Tablet Sig: One (1) Tablet by mouth at
bedtime.
ranitidine HCl 150 mg Tablet Sig: One (1) Tablet by mouth
twice a day.
warfarin 2 mg Tablet Sig: Two (2) Tablet by mouth once a day.
You will need frequent checks of your INR and the
[**Hospital3 **] will adjust your warfarin as needed.
Lasix 20 mg Tablet Sig: One (1) Tablet by mouth once a day.
pravastatin 80 mg Tablet Sig: One (1) Tablet by mouth once a
day.
Followup Instructions:
It is very important for you to follow-up with your primary care
provider and also your cardiologist.
We are working on appointments with the specialty heart failure
nurse within a week and your cardiologist within two weeks. You
should call Dr.[**Name (NI) 50760**] office on Wednesday if you have not heard
back regarding these appointments.
We have been able to make the following appointment with your
primary care provider, [**Name10 (NameIs) **] bring all of your discharge
paperwork and new prescriptions to this appointent:
Name: [**Name6 (MD) **] [**Name8 (MD) 9501**], Md
Location: [**Location (un) 2274**]--[**Hospital1 **]
When: Thursday [**6-25**] at 10am
Address: [**Hospital1 34796**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 65304**]
|
[
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"V58.61",
"428.23",
"414.8",
"414.01",
"401.9",
"428.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.20",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
14957, 15006
|
10226, 12602
|
301, 307
|
15069, 15069
|
5023, 5028
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|
3720, 3766
|
13723, 14934
|
15027, 15048
|
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9626, 10203
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3781, 3795
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3075, 3407
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238, 263
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335, 3056
|
5042, 8823
|
15084, 15196
|
12623, 13176
|
3429, 3550
|
3566, 3704
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,061
| 187,501
|
54464
|
Discharge summary
|
report
|
Admission Date: [**2126-5-27**] Discharge Date: [**2126-6-5**]
Date of Birth: [**2051-11-7**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Nausea, Confusion
Major Surgical or Invasive Procedure:
[**2126-5-29**]: Right Craniotomy for parietal mass
History of Present Illness:
This is a 74 year old female who presents from her PCP's office
with an abnormal Head MRI. In summary, the patient was
diagnosed with limited stage small cell lung CA [**9-10**], and
received etoposide-platinum based chemo, and radiation therapy.
She refused whole brain radiation at that time. She was seen by
her PCP last week with patient's daughter who noticed the
patient
to be increasingly confused over the past several weeks. An MRI
was ordered today, which revealed a 6cm cystic R frontal lobe
mass with mass effect and midline shift. She presented from MRI
immediately to ED for further evaluation.
At present, the patient complains of persistent nausea for
several months, without vomiting or weight loss. Unrelenting
with Zofran. She also has some baseline blurred vision, but no
new changes in her vision. She also denies headache,
motor/sensory deficits, or ataxia.
Past Medical History:
SCLC history:
H/o resected stage II colon CA, found on routine surveillance
torso CT in [**8-/2123**] to have mediastinal adenopathy. She
underwent a bronchoscopic FNA on [**2123-8-25**] and a cytology was
suspicious and not conclusive for small cell carcinoma. On
[**2123-9-16**], she underwent a cervical mediastinoscopy by Dr.
[**Last Name (STitle) **] with biopsy. Pathology from the resected lymph
nodes was consistent with metastatic small
cell carcinoma. The cells were diffusely positive for keratin
cocktail and focally positive for chromogranin, but negative for
LCA and synaptophysin. Ms. [**Known lastname **] started cycle one day one of
etoposide and cisplatin on [**2123-9-28**]. Her last chemo (cycle 3)
was
[**2123-11-10**] and she has one week left of her radiation therapy
.
PAST MEDICAL HISTORY:
Stage II colon cancer s/p resection [**2121**]
Small bowel obstruction [**9-8**]
Gastroparesis
Emphysema by CXR (pt never been told of diagnosis)
Social History:
An 80-pack-year smoker, currently smoking six cigarettes a day.
Occupation: Retired. Lives alone, drinks occasionally, and
denies exposure history.
Family History:
Mother had what sounds like metastatic cancer involving stomach,
colon, liver, and bone. She has one brother that has question
of liver cancer.
Physical Exam:
PHYSICAL EXAM:
O: T:97.5 BP: 155/87 HR:79 R:18 O2Sats:98%
Gen: WD/WN, comfortable, NAD.
HEENT: NC, AT. Pupils: PERRLA EOMs intact
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: [**3-6**] 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, 5 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 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 [**5-8**] throughout. Left upward
Pronator Drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements
Exam on Discharge:
[**4-8**] lt sided weakness(much improved from pre-operative); AOx3,
full str w/rt side. Wound CDI. PERRL, limited upgaze in
extraoccular movement
Pertinent Results:
ADMISSION LABS:
[**2126-5-27**] 05:30PM BLOOD WBC-5.8 RBC-4.09* Hgb-12.5 Hct-38.0
MCV-93 MCH-30.6 MCHC-32.8 RDW-12.9 Plt Ct-192
[**2126-5-28**] 02:59AM BLOOD PT-11.6 PTT-22.0 INR(PT)-1.0
[**2126-5-27**] 05:30PM BLOOD Glucose-90 UreaN-19 Creat-0.9 Na-141
K-4.1 Cl-105 HCO3-22 AnGap-18
DISCHARGE LABS:
[**2126-6-4**] 05:30AM BLOOD WBC-5.6 RBC-3.41* Hgb-10.6* Hct-31.7*
MCV-93 MCH-31.2 MCHC-33.5 RDW-13.2 Plt Ct-236
[**2126-6-1**] 06:00AM BLOOD PT-11.2 PTT-22.0 INR(PT)-0.9
[**2126-6-4**] 05:30AM BLOOD Glucose-106* UreaN-21* Creat-0.7 Na-139
K-4.1 Cl-100 HCO3-31 AnGap-12
[**2126-6-1**] 06:00AM BLOOD Phenyto-17.8
IMAGING:
MRI Head [**5-27**]: 6cm R-sided Cystic mass in frontal/parietal lobe
with associated vasogenic edema and 9mm of midline shift. No
evidence of uncal herniation.
Head CT [**5-29**](Post-op):
IMPRESSION:
Small amount of hemorrhage surrounding the resection cavity in
the right
frontal lobe with moderate-to-large amount of bifrontal
pneumocephalus,
causing mild-to-moderate sulcal effacement in the bilateral
frontal lobes.
MRI Head [**5-30**](Post-op):
IMPRESSION: The patient is status post right frontal and
parietal temporal
craniotomy. There is residual intraventricular hemorrhage and
pneumocephalus, unchanged since the prior head CT. There is also
persistent midline shifting towards the left with approximately
5.9 mm of deviation. Heterogeneous enhancement is identified in
the surgical cavity with restricted diffusion, raising the
possibility of a residual mass lesion. Small amount of subdural
fluid is noted bilaterally in the frontal regions. Mucosal
thickening is identified in the ethmoidal air cells and left
maxillary sinus as described above.
Brief Hospital Course:
The patient was admitted under Dr. [**Last Name (STitle) **] to the NSurg ICU, for
Q1 hour neuro checks, Dilantin and Dexamethasone loads, and
close observation. She was pre-oped and consented for surgery.
On [**5-29**] she was taken to the operating room for right sided
craniotomy for decompression and resection of right brain mass.
She tolerated this well and was returned to the ICU post-op for
frequent neuromonitoring, and systolic blood pressure control.
She remained intubated until 5/27pm in order to obtain CT of the
head and MRI of the head. Her left sided weakness continued to
improve, and she was stable and appropriate to transfer from the
ICU to the floor. She continued to have mildly garbled speech
with minimal swallowing difficulty, so a speech and swallow
consult was obtained. On [**6-1**] she had a witnessed fall and
complained of hip pain. X-rays were obtained which were
negative. She was evalauted by Pt who deemed that she should be
discharged to rehab. She remained stable over the weekend and on
[**6-4**] was screened for rehab and discharged with follow up plans
in place.
Medications on Admission:
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for anxiety
ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
three times a day as needed for nausea
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Dose adjustment - no new
Rx) - 100 % Powder - 1 packet by mouth once a day Do not use
longer than 2 weeks at a time.
SERTRALINE - 25 mg Tablet - 1 Tablet(s) by mouth once a day
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (OTC) - 600
mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day
MULTIVITAMIN - (OTC) - Capsule - 1 Capsule(s) by mouth once a
day
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Acetaminophen 650 mg Suppository Sig: [**1-5**] Suppositorys
Rectal Q6H (every 6 hours) as needed for pain/fever/ha.
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 99 days.
14. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
16. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-5**]
Tablets PO Q4H (every 4 hours) as needed for pain.
17. Ondansetron 4 mg IV Q8H:PRN NAUSEA
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right Parietal Mass; preliminary path: small cell lung
metastasis
Discharge Condition:
Neurologically Stable
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**10-17**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 2731**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2126-6-17**]
11:30. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. This is a
multi-disciplinary appointment. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your hospitalization.
Completed by:[**2126-6-5**]
|
[
"V10.11",
"V10.05",
"198.3",
"348.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
9109, 9179
|
5793, 6904
|
336, 390
|
9289, 9313
|
4081, 4081
|
14566, 15530
|
2476, 2623
|
7623, 9086
|
9200, 9268
|
6930, 7600
|
9337, 9358
|
4383, 5770
|
2653, 2845
|
12736, 14543
|
279, 298
|
9370, 12709
|
418, 1302
|
3137, 3895
|
3914, 4062
|
4098, 4367
|
2860, 3121
|
2144, 2292
|
2308, 2460
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,496
| 112,676
|
13507
|
Discharge summary
|
report
|
Admission Date: [**2129-12-17**] Discharge Date: [**2129-12-19**]
Date of Birth: [**2083-2-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine / Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
46F with ^DOE and intermittent CP for 2 days.
Major Surgical or Invasive Procedure:
CABGx3(SVG->LAD, Diag, OM) [**2129-12-18**]
History of Present Illness:
46F with a h/o IDDM, HTN, ^chol., CHF, who had progressive DOE
and intermittent CP for 2 days. She presented to [**Hospital1 2519**] and had Q waves in V1-V2 and [**Street Address(2) 5366**]^ in V1-V2 with a
CK of 607 and an MB of 59(10%), troponin was 11.9 and she was
transferred to [**Hospital1 18**] for further treatment.
Past Medical History:
IDDM since age 9
HTN
^chol.
Neuropathy
Retinopathy
s/p C section
Social History:
Lives with husband and 3 children, works in childcare
Cigs: minimal, quit 22 yrs ago
ETOH: none
Family History:
+ DM
Physical Exam:
Gen: WDWN WF in NAD
Temp: 100.3 HR:95 RR: 20 96% on 2 liters NC BP: 93/61
HEENT: NC/AT, PERRLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+=bilat. without bruits.
Lungs: Bibasilar rales
CV: RRR without R/G/M, nl S1, S2
Abd: +BS, soft, nontender, without masses or hepatosplenomegaly
Ext: without C/C/E, pulses 2+=bilat. throughout
Neuro: nonfocal
Pertinent Results:
[**2129-12-19**] 08:20AM BLOOD WBC-11.6* RBC-3.66* Hgb-12.0 Hct-32.6*
MCV-89 MCH-32.8* MCHC-36.8* RDW-15.4 Plt Ct-141*
[**2129-12-19**] 08:20AM BLOOD PT-13.9* PTT-33.7 INR(PT)-1.3
[**2129-12-19**] 03:14AM BLOOD Glucose-193* UreaN-28* Creat-1.4* Na-139
K-4.7 Cl-105 HCO3-24 AnGap-15
[**2129-12-19**] 08:20AM BLOOD ALT-92* AST-413* LD(LDH)-PND AlkPhos-54
Amylase-23 TotBili-3.6*
[**2129-12-19**] 08:20AM BLOOD Lipase-10
[**2129-12-18**] 02:25AM BLOOD CK-MB-34* MB Indx-7.6* cTropnT-1.64*
[**2129-12-19**] 08:20AM BLOOD Albumin-3.1*
[**2129-12-17**] 09:14PM BLOOD Triglyc-54 HDL-58 CHOL/HD-2.3 LDLcalc-65
[**2129-12-19**] 08:27AM BLOOD Type-ART pO2-82* pCO2-39 pH-7.45
calHCO3-28 Base XS-2
[**2129-12-19**] 08:27AM BLOOD Glucose-117* Lactate-3.5* Na-138 K-4.4
Cl-104CHEST (PORTABLE AP) [**2129-12-19**] 5:03 AM
CHEST (PORTABLE AP)
Reason: please eval lungs, patient s/p emergent CABG POD 1,
previous
[**Hospital 93**] MEDICAL CONDITION:
46 year old woman s/p emergency cabg x3 with IABP
REASON FOR THIS EXAMINATION:
please eval lungs, patient s/p emergent CABG POD 1, previously
manifested ARDS pulmonary picture high PIPs and plateau pressure
with PaO2/FiO2<200
AP CHEST COMPARED TO [**12-18**]:
Severe pulmonary edema has changed in distribution but not in
severity. Right lung is now more consolidated than the left.
This raises the possibility of pulmonary hemorrhage or
pneumonia, but could be explained entirely by shift in edema.
Heart is normal size and mediastinal vasculature is not
particularly engorged. Tip of the intra-aortic balloon pump is
approximately a centimeter below the level of the left main
bronchus, approximately 6 cm from the apex of the aortic knob.
Small left pleural effusion is stable. No right pleural effusion
is demonstrated and there is no pneumothorax.
Tip of the Swan-Ganz catheter projects over the right pulmonary
artery, ET tube is in standard placement, midline and right
pleural drains are in place. Nasogastric tube passes to the
distal stomach. Mediastinum midline.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Brief Hospital Course:
The patient was admitted and evaluated by cardiology and had CP
with hypotension during the night of admission. She underwent
emergency cardiac catheterization which revealed: 90%LMCA
stenosis, diffusely diseased tight ostial LAD 60% lesion, 80%
ostial, diffusely diseased, 80% diseased RCA, elevated filling
pressures and 20%EF. An IAPB was placed and she went for
emergency CABGx3(SVG->LAD, Diag, OM)on [**2129-12-18**].
She was transferred to the CSRU on Levophed, Milrinone, Epi,
Vasopressin, Insulin, and Propofol. She had persistent
hypotension and the propofol was d/c'd and she was placed on
Cisatricurium, Fentanyl, and Midaz. She desaturated and
required bronchoscopy and had copius mucous plugging. She
improved following this, but had persistent tachycardia in the
130-150 range and had a good cardiac output and urine output
throughout. Dr. [**Last Name (STitle) 40858**] at [**Hospital1 2025**] was consulted and she was
transferred for the possibility of a Heartmate insertion.
Medications on Admission:
Humalog SS
Lantus 9U SC BID
Lisinopril 2.5 mg PO daily
Allergies: MSO4
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
3. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150) mg
PO BID (2 times a day).
4. Epinephrine 1 mg/mL Solution Sig: .03 mg/kg/min Injection
INFUSION (continuous infusion).
5. Vasopressin 20 unit/mL Solution Sig: 1.5 mg/kg/min Injection
TITRATE TO (titrate to desired clinical effect (please
specify)).
6. Norepinephrine Bitartrate 1 mg/mL Solution Sig: 0.2 mg/kg/min
Intravenous INFUSION (continuous infusion).
7. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: One Hundred
Fifty (150) mg/kg/min Injection INFUSION (continuous infusion).
8. Midazolam 5 mg/mL Solution Sig: 1.5 mg/kg/min Injection
INFUSION (continuous infusion).
9. Furosemide 10 mg/mL Solution Sig: Ten (10) mg/kg/min
Injection INFUSION (continuous infusion).
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) [**Hospital1 **]
Intravenous Q12H (every 12 hours) for 6 doses.
11. Milrinone 1 mg/mL Solution Sig: 0.5 mcg/kg/min Intravenous
infusion.
12. Cisatracurium 10 mg/mL Solution Sig: 0.15 mg/kg/min
Intravenous INFUSION (continuous infusion).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
CAD
IDDM
HTN
MI
^chol.
CHF
Neuropathy
Retinopathy
Discharge Condition:
Critical
Discharge Instructions:
Continue intensive care.
Being transferred to [**Hospital1 2025**]
Followup Instructions:
Tx->Dr. [**Last Name (STitle) **]
Completed by:[**2129-12-19**]
|
[
"518.5",
"428.0",
"414.01",
"424.0",
"250.51",
"357.2",
"410.91",
"V58.67",
"362.01",
"250.61",
"E912",
"934.1",
"785.51",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.06",
"88.72",
"37.61",
"00.17",
"89.64",
"98.15",
"99.05",
"36.13",
"88.56",
"96.04",
"39.61",
"37.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5947, 5962
|
3567, 4566
|
361, 407
|
6056, 6067
|
1417, 2318
|
6182, 6248
|
981, 987
|
4688, 5924
|
2355, 2405
|
5983, 6035
|
4592, 4665
|
6091, 6159
|
1002, 1398
|
276, 323
|
2434, 3544
|
435, 764
|
786, 852
|
868, 965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,367
| 103,759
|
52328
|
Discharge summary
|
report
|
Admission Date: [**2172-1-15**] Discharge Date: [**2172-1-18**]
Date of Birth: [**2133-1-14**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 38 year old
male with past medical history of significant motor vehicle
trauma requiring a craniotomy and eventually a cranioplasty
to the right skull. This accident was remote, however, over
the course of the past several months, the patient has been
complaining of increased frequency of duration of right sided
headaches. He underwent previous CT angiogram which
suggested the presence of an aneurysm versus pseudoaneurysm
in the right internal carotid artery. He underwent a
diagnostic cerebral angiogram on [**2172-1-6**], which showed a
pseudoaneurysm, 3.5 millimeter traumatic dissecting
pseudoaneurysm in the right petrous segment of the internal
carotid artery. He was readmitted on [**2172-1-15**], to have a
stenting of this aneurysm.
PAST MEDICAL HISTORY: Motor vehicle accident thirty years
ago.
MEDICATIONS ON ADMISSION:
1. Vicodin.
2. Protonix.
3. Ambien.
4. Dilantin.
5. Trazodone.
6. Plavix.
HOSPITAL COURSE: The patient was brought to the Endovascular
Neurovascular Suite and underwent a stent graft of his right
internal carotid artery pseudoaneurysm without difficulty.
He was transported to the Surgical Intensive Care Unit where
he was monitored overnight with q1hour neurologic checks and
his blood pressure was kept less than 120. He remained
neurologically intact overnight and was on a Heparin drip at
1000 units per hour. He did require Nipride drip at times to
keep his blood pressure in the 120 range. On his first
postoperative day, he was awake, alert and oriented times
three. He had symmetric smile, no drift, and his motor
strength was full throughout. He had some oozing from his
femoral puncture site. He was transferred to the surgical
floor and was started on Aspirin and Plavix. He was able to
ambulate, walk around, and tolerate a regular diet. On his
second postoperative day, he had been ambulating without
difficulty. He had no further oozing from his angio site.
His speech and comprehension were intact. He was
neurologically stable. On the day of discharge on
[**2172-1-18**], he remained neurologically intact.
DISCHARGE INSTRUCTIONS: He is to continue taking Plavix and
Aspirin daily until further notice. He should follow-up with
Dr. [**Last Name (STitle) 1132**] in one week. He should notify us if he has any
severe headaches not relieved with medication or if he
develops any neurologic difficulties.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg one p.o. daily.
2. Colace 100 mg p.o. twice a day.
3. Plavix 75 mg one tablet p.o. daily.
4. Hydrocodone Acetaminophen 5/500 mg one to two tablets p.o.
q4-6hours as needed.
5. Protonix 40 mg one tablet p.o. daily.
6. Dilantin 100 mg one tablet p.o. three times a day.
7. Nortriptyline 50 mg three tablets p.o. q.h.s.
8. Trazodone 100 mg two tablets at bedtime.
9. Ambien 5 mg tablets, two at bedtime.
CONDITION ON DISCHARGE: The patient was discharged
neurologically intact.
DISCHARGE DIAGNOSES: Traumatic pseudoaneurysm of right
internal carotid artery, status post stenting procedure.
Status post remote head trauma in the past.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 12790**]
MEDQUIST36
D: [**2172-1-18**] 12:11:42
T: [**2172-1-19**] 11:17:58
Job#: [**Job Number 108194**]
|
[
"900.03",
"780.39",
"070.70",
"E819.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"00.61",
"00.63"
] |
icd9pcs
|
[
[
[]
]
] |
3110, 3501
|
2588, 3012
|
1024, 1100
|
1118, 2263
|
2288, 2562
|
165, 933
|
956, 998
|
3037, 3088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,705
| 169,575
|
15970+56717
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-5-11**] Discharge Date: [**2173-5-26**]
Date of Birth: [**2100-12-6**] Sex: F
Service: [**First Name9 (NamePattern2) 45757**] [**Last Name (un) **]
CHIEF COMPLAINT: Pancreatic mass.
HISTORY OF PRESENT ILLNESS: The patient is a 72 year old
female who presented to an outside hospital in [**2173-3-13**],
with three weeks of malaise, anorexia, progressive abdominal
distention and increasing abdominal pain. On workup, she was
revealed to be markedly jaundiced and laboratory work
revealed abnormal liver function tests. The patient was
subsequently transferred to the [**Hospital1 188**] for further workup and was admitted here between
[**2173-3-16**], and [**2173-3-23**]. Please refer to previously dictated
discharge summary for details of her admission. The patient
now presents to [**Hospital1 69**] for
definitive resection of a mass at the head of the pancreas.
PAST MEDICAL HISTORY:
1. Left breast cancer, status post modified radical
mastectomy with radiation therapy and chemotherapy in [**2169**].
2. Left total hip replacement with a revision restatic of
the right leg.
3. Diverticulosis.
4. Colonic polypectomy.
5. Spinal stenosis.
6. Multiple trauma with right arm fracture, injured lower
back, right tibial fracture, ankle fracture, left shoulder
fracture.
7. Congestive heart failure with cardiomyopathy.
MEDICATIONS ON ADMISSION:
1. Neurontin.
2. Tamoxifen.
3. Amitriptyline.
4. Fentanyl Patch.
5. Percocet.
ALLERGIES: Penicillin and Sulfa. The patient also has an
allergy to all antibiotics ending with the term "mycin",
Keflex and Vioxx.
SOCIAL HISTORY: The patient lived alone prior to recent
period of illness.
HOSPITAL COURSE: The patient was admitted to the [**Hospital1 346**] on [**2173-5-11**], and taken to surgery
where she had pylorus sparing Whipple procedure. Surgery was
performed without complications, and the patient was
thereafter transferred to the Post Anesthesia Care Unit in
stable condition. Intraoperatively, she had been noted to
have local invasion by the tumor into the portal vein. She
received one unit of packed red blood cells intraoperatively.
She was on an epidural for pain control. On postoperative day
number one, the patient was doing well with pain relatively
well controlled. She was noted by the nursing staff to be
alert and oriented times three but slightly confused at
times. By late on postoperative day number one, the patient,
however, became increasingly confused, agitated, and started
falling on some of her lines and yelling at family members.
She was evaluated. A one to one sitter was ultimately
requested and Haldol ordered. The patient's pain control on
the epidural was somewhat suboptimal late on postoperative
day number one with a Dilaudid PCA added for better pain
control. The patient's Fentanyl patch was also restarted.
During postoperative day number three, the patient remained
disoriented and agitated requiring Haldol for sedation. She
remained in soft restraints with a bedside sitter. On
postoperative day number three, the patient pulled her own
nasogastric tube out. The decision was made not to reinsert
it. On postoperative day number three, the patient received
a unit of packed red blood cells for a low hematocrit. On the
night of postoperative day number three, the house officer
was called to the patient's bedside when the patient was
noted to have become tachypneic to the 40s, and tachycardic
to the 120s and 130s. A stat chest x-ray was ordered to rule
out pulmonary edema. This was ultimately negative for
pulmonary vascular congestion. An electrocardiogram was also
ordered and was indeterminate. Given an arterial blood gas
was drawn which revealed the patient to be significantly
acidotic, a decision was ultimately made to intubate the
patient and transfer her to the Intensive Care Unit for
further management. In the Intensive Care Unit, series of
cardiac enzymes were drawn and the patient was ultimately
ruled in for myocardial infarction. Cardiology consultation
was requested and the patient's infarction ultimately
localized to the inferior wall. On arrival in the Intensive
Care Unit, the patient's temperature was also noted to be
101. Blood cultures and urine cultures were sent. By the
morning of postoperative day number five, the patient was
stable, remained ventilated and sedated and was improving
arterial blood gas values. During the entire period from the
onset of the patient's tachypnea and tachycardia, the patient
had been unresponsive to stimulation. CT of the patient's
head was ultimately ordered and was negative for stroke.
Part of the patient's workup at the time included duplex
ultrasound to evaluate for portal vein thrombosis. This test
was inconclusive. Flow was noted in the right and main
portal veins but the left portal vein was not confidently
assessed. The patient was also scheduled for CAT scan of the
abdomen and pelvis on the night of postoperative day number
four. The study revealed the patient had no central
pulmonary embolism but was inconclusive about possible
segmental pulmonary embolisms. The patient was also noted to
have heterogeneous enhancement of the right lobe of her liver
relative to the left suggesting hyperemia. Ramifications of
this finding were uncertain. The patient had no evidence of
an intra-abdominal abscess. There was no extravasation of
oral contrast. The lungs were clear.
Blood, urine, sputum and wound cultures were drawn on the
night of the [**Hospital 228**] transfer to the Intensive Care Unit.
The patient's blood cultures ultimately grew out E. coli.
Four out of six of the patient's urine cultures were
ultimately negative. Gram negative rods ultimately
speciated. [**Location (un) 1661**]-[**Location (un) 1662**] drain cultures ultimately also grew
E. coli. The patient's sputum grew out coagulase positive
Staphylococcus aureus, gram negative rods, beta Streptococci.
The patient was started on broad spectrum antibiotics.
Follow-up blood cultures drawn on [**2173-5-18**], were negative.
On [**2173-5-19**], the decision was made to open up a small portion
of the lateral end of the [**Last Name (ambig) 228**] [**Doctor Last Name (ambig) 8314**] incision given
some persisting redness. Wound cultures grew coagulase
positive Staphylococcus aureus. Wound care was initiated
with wet to dry dressings twice a day. On [**2173-5-19**], the
patient was screened for Methicillin resistant Staphylococcus
aureus. The Methicillin resistant Staphylococcus aureus
screen was ultimately negative. By postoperative day number
eight, the patient was clearly improving. She was started on
tube feeds when she began to have bowel movements. Her TPN
was weaned.
By postoperative day number eight, the patient was stable
enough to be extubated In the period immediately following
her extubation, she required frequent pulmonary hygiene. She
was being treated for presumptive aspiration pneumonia.
Later on postoperative day number eleven, the patient was
deemed stable and ready for discharge to the floor. At this
time, the patient was alert and oriented and conversing well
although some times forgetful and a little confused.
Screening for rehabilitation placement was initiated. The
patient was also seen by physical therapy following transfer
to the floor and daily.
The results of the patient's pathology studies ultimately
revealed that the patient had a clear cell cancer of the
pancreas. The findings were discussed briefly with the
patient but it is anticipated that further discussions and
management given this diagnosis will be made following
discharge.
It should also be noted that the patient had a transient
period of thrombocytopenia with her platelet count trending
down into the 50,000 and 60,000 while in the Intensive Care
Unit. Studies were sent for Heparin induced thrombocytopenia
which were ultimately negative. The patient was seen by the
hematology service. The patient's platelet count was well on
the way to recovery by the time of discharge.
Prior to transfer to the floor, the patient had been started
on a regular diet and during the entire time she was on the
surgical floor, she was eating well.
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Oxycodone 10 mg p.o. q4-6hours p.r.n.
2. Metoprolol 12.5 mg p.o. twice a day.
3. Fentanyl Patch 50 mcg per hour q.three days.
4. Gabapentin 400 mg p.o. three times a day.
5. Tylenol 325 to 650 mg p.o. q4-6hours p.r.n.
DISCHARGE DIAGNOSES:
1. Clear cell cancer of the pancreas.
2. Inferior wall myocardial infarction.
3. Pneumonia.
4. Thrombocytopenia.
5. Wound infection.
6. Delirium.
PROCEDURES: Whipple procedure on [**2173-5-11**].
FOLLOW-UP: The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**]
following discharge. The patient is also to follow-up with
her primary care physician within one to two weeks following
discharge.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2173-5-25**] 20:10
T: [**2173-5-25**] 20:37
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern1) 45758**] Name: [**Known lastname 32**], [**Known firstname **] E Unit No: [**Numeric Identifier 8415**]
Admission Date: [**2173-5-11**] Discharge Date: [**2173-5-27**]
Date of Birth: [**2100-12-6**] Sex: F
Service: Gold Surgery
Please refer to previously dictated discharge summary for
[**Hospital 1325**] hospital course.
The patient's discharge was delayed by one day from
[**2173-5-26**] to [**2173-5-27**] for workup of the following issues:
The patient was noted to have persisting edema of the left
upper extremity with complaint of pain on the morning of
[**2173-5-26**]. Given concern for deep venous thrombosis of the
extremity, an ultrasound was requested. The results of the
study were ultimately negative. Review of the patient's
history confirmed that the patient had history of left breast
cancer status post modified radical mastectomy in [**2169**].
Patient was asked to keep her left hand elevated with warm
packs applied and as expected the edema should improve. The
patient complained of continuing pain. This will need to be
monitored. The [**Hospital 1325**] rehabilitation facility has been
asked to provide occupational therapy as needed.
Patient was also noted to have episodes of urinary
incontinence beginning on [**2173-5-23**] and into [**2173-5-26**].
Urinalysis and urine culture were requested. The results of
the urinalysis revealed that patient did not have a urinary
tract infection. The patient's urine culture is pending at
the time of discharge.
As previously noted, the patient remains alert and oriented
times three, but acutely confused.
[**First Name8 (NamePattern2) 116**] [**Name8 (MD) **], M.D. [**MD Number(1) 4989**]
Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36
D: [**2173-5-27**] 10:59
T: [**2173-5-27**] 11:03
JOB#: [**Job Number 8416**]
|
[
"287.5",
"575.12",
"198.89",
"157.1",
"428.0",
"410.41",
"998.59",
"682.2",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"89.64",
"96.72",
"96.04",
"51.22",
"96.6",
"52.7",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
8541, 11136
|
8293, 8520
|
1408, 1626
|
1721, 8233
|
211, 229
|
258, 922
|
944, 1382
|
1643, 1703
|
8258, 8267
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,703
| 197,588
|
793
|
Discharge summary
|
report
|
Admission Date: [**2117-7-7**] Discharge Date: [**2117-7-12**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Lightheadedness, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo M with no prior cardiac hx following p/w 2 day history of
light-headedness, weakness, sweating, dizziness. Symptoms
started while he was out for a walk on Monday, where he had a
sudden onset of lightheadedness and he had to sit down. The
symptoms have been continuous since Monday. His son notes that
the patient is normally very active and independent for ADLs.
Patient took some of his neighbor's dizziness medication' which
is believed to be meclizine, also took some additional Ambien,
possibly 15mg. His denied chest pain, arm pain, diaphoresis on
admission.
In the ED, his initial vitals were 98.9, 125/64, 106, 20, 95% on
RA. EKG showed new atrial flutter with varying conduction and
old LBBB. He received Diltiazem 10mg PO with good HR response
into 80s. Son describes notable improvement s/p treatment in ED.
On arrival to the floor, 96.1, 128/84, 80, 20, 93% on 2L NC. He
has no home O2 requirement.
At 10pm, pt received ambien and 30mg po diltiazem--per nurse he
was in NAD. 30 minutes later, he was found restless and
diaphoretic with sat=75% on 3LNC. HR was in 130s. NRB +6LNC
placed and pt's sat rose to 92%. ABG done at that time
7.30/52/58. He was given albuerol nebs, 20mg IV lasix, and 10mg
IV diltiazem. CXR showed worsened pulmonary vascular congestion
compared to admission film 8hrs prior. HR decreased to 80s and
sats remained in 93-96% range on NRB. He was given another 20mg
IV lasix. Pt transfered to MICU for closer monitoring.
Past Medical History:
- Gastric carcinoma in situ
- BPH
- Anemia
- Anxiety
- Insomnia
- Venous insufficiency
- Osteopenia
- Hx of plantar fascitis
- Hx of right leg pain, now resolved
- Macrocytosis
- Lumbar and cervical spinal stenosis
- Positive for resection of gastric carcinoma [**2114**]
Social History:
The patient lives with his spouse in [**Hospital3 5673**]. Russian speaking only. Son acted as interpreter for
floor team. He ias aware of ICU transfer. Drinks vodka
apparently only on wednesdays.
Family History:
Noncontributory.
Physical Exam:
Vitals: T: 96.7 BP: 110/68 P: 65 R: 18 O2: 96% on NRB
General: Alert, oriented, no acute distress, speaking russian
translated by son
[**Name (NI) 4459**]: Sclera anicteric, [**Name (NI) 5674**], oropharynx clear
Neck: supple, JVP 12-15 cm
Lungs: Rare wheezes with bronchial breath sounds at L base. No
rales, rhonchi
CV: Regular rate and rhythm, distant S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses. Trace edema
Pertinent Results:
Chemistries:
[**2117-7-7**] 11:14PM GLUCOSE-184* UREA N-25* CREAT-1.3* SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
[**2117-7-7**] 11:14PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-2.1
[**2117-7-7**] 02:40PM GLUCOSE-142* UREA N-27* CREAT-1.2 SODIUM-139
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
[**2117-7-7**] 02:40PM estGFR-Using this
[**2117-7-7**] 02:40PM CALCIUM-9.0 PHOSPHATE-2.5* MAGNESIUM-2.1
Hematology:
[**2117-7-7**] 02:40PM WBC-6.6# RBC-3.34* HGB-11.8* HCT-35.8*
MCV-107* MCH-35.2* MCHC-32.8 RDW-15.9*
[**2117-7-7**] 02:40PM NEUTS-83.1* LYMPHS-13.0* MONOS-3.6 EOS-0.2
BASOS-0.1
[**2117-7-7**] 02:40PM PLT COUNT-174
[**2117-7-7**] 02:40PM PT-12.7 PTT-27.6 INR(PT)-1.1
Cardiac Enzymes:
[**2117-7-7**] 02:40PM BLOOD CK-MB-8 proBNP-[**Numeric Identifier 5675**]*
[**2117-7-7**] 02:40PM BLOOD cTropnT-<0.01
[**2117-7-8**] 05:26AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2117-7-7**] 02:40PM BLOOD CK(CPK)-116
[**2117-7-7**] 11:05PM BLOOD CK(CPK)-108
[**2117-7-8**] 05:26AM BLOOD CK(CPK)-77
--------------------
Imaging:
CXR Portable [**2117-7-7**]:
Moderate congestive heart failure. Consolidation cannot be
excluded particularly at the left lung base and repeat
radiographs following
treatment are recommended.
--------------------
CHEST (PORTABLE AP) Study Date of [**2117-7-10**] 9:18 PM
Final Report
HISTORY: Fever and increased oxygen requirement, to evaluate for
volume
overload or pneumonia.
FINDINGS: In comparison with the study of [**7-8**], there has been
some
improvement in the pulmonary vascular congestion. The pleural
effusion on the
right has decreased, as _____ on the left. Persistent
opacification in the
retrocardiac region most likely represents atelectasis.
[**2117-7-8**] ECHO
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is severe global left ventricular hypokinesis
(LVEF = 20%), c/w global process (toxic, metabolic,
tachycardia-related) or multivessel coronary disease.
Transmitral Doppler and tissue velocity imaging are consistent
with Grade III/IV (severe) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Dilated left ventricle with severe global
hypokinesis. Moderate mitral regurgitation. Mild pulmonary
hypertension
Brief Hospital Course:
[**Age over 90 **] yo M with no prior cardiac hx p/w lightheadedness x 2 days
and is found to be in heart failure (as evidenced by pulmonary
edema and elevated JVP) likely secondary to new atrial flutter
with RVR.
.
Hypoxia/Pulmonary Edema: Occurred in the setting of rapid atrial
fibrillation. He has no history of cardiac disease but has
evidence of cardiomegaly on CXR and BNP [**Numeric Identifier 5675**] on transfer to
MICU. He had three sets of negative cardiac enzymes.
Echocardiogram c/w systolic CHF with an EF of 20%. He was
diuresed with IV lasix 20 mg x 2 and started on diltiazem with
good effect. Echocardiogram was pending at time of transfer to
the floor.
.
Atrial Fibrillation: Given his level of dunction and the degree
to which he becomes symptomatic with RVR, could consider EP
consult for flutter ablation. Improved rate control with
diltiazem which was uptitrated to 60mg qid. Echocardiogram with
severe global hypokinesis with EF 20%, nl atria. No evidence of
right heart strain. [**Numeric Identifier **]. TSH nl. Patient would qualify for
long term anticoagulation by CHADs criteria but this will need
to be discussed with his family and PCP. [**Name10 (NameIs) **] to r/o DVT (neg
on prelim read)
.
Systolic CHF: Dilated left ventricle with severe global
hypokinesis, EF 20% as well as [**12-25**]+ MR. Ddx global process
(toxic, metabolic, tachycardia-related) v. multivessel coronary
disease.
- Consider changing dilt to beta blocker
- Diuresis prn
- Discuss starting ASA, ACE-I w/ PCP/family given age
- Will need outpt heart failure f/u
.
Chronic cough/TB rule out: Patient is elderly and from [**Country 532**].
Initially concern for TB given abnormal CXR with chronic cough
occassionally productive of sputum. Placed on respiratory
isolation. However, precautions and work-up discontinued as
thought unlikely.
.
Anxiety: Continue citalopram.
.
Insomnia: Per son, is very anxious about his sleep and
constantly requrests ambien.
- Prn for insomnia.
.
FEN: No IVF, diurese, replete electrolytes, regular diet
Prophylaxis: Subcutaneous heparin
Access: Peripherals x2
Code: Full discussed with patient via son as translator
Communication: Patient + son
Medications on Admission:
- Artificial tears 0.5-0.6% 1 gt ou twice a day
- Calcium-D 600mg one capsule by mouth twice a day
- Chondroitin Sulfate 250mg one capsule by mouth once a day
- Citalopram 20mg oral 1.5 tablets by mouth once a day
- Multivitamin one tablet by mouth once a day
- Vitamin B12 one tablet by mouth twice a week please no
sustained or extended release formulations
- Zolpidem 10mg one tablet by mouth at bedtime, may repeat x1
- RECENTLY TAKING NEIGHBOR'S MECLIZINE
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*0*
3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*0 Tablet(s)* Refills:*0*
4. Chondroitin Sulfate 250 mg Capsule Sig: One (1) Capsule PO
once a day.
Disp:*0 Capsule(s)* Refills:*0*
5. Calcium-D 600 mg(1,500mg) -400 unit Capsule Sig: One (1)
Capsule PO twice a day.
Disp:*0 Capsule(s)* Refills:*0*
6. Artificial Tears 0.5-0.6 % Drops Sig: One (1) Ophthalmic
twice a day.
Disp:*0 * Refills:*0*
7. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Disp:*0 Tablet, Chewable(s)* Refills:*0*
8. Vitamin B-12 Oral
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Primary Diagnoses
- Atrial Flutter
- Congestive Heart Failure
Secondary Diagnoses
- Gastric carcinoma in situ
- BPH
- Anemia
- Anxiety
- Insomnia
- Venous insufficiency
- Osteopenia
- Hx of plantar fascitis
- Hx of right leg pain, now resolved
- Macrocytosis
- Lumbar and cervical spinal stenosis
- Positive for resection of gastric carcinoma [**2114**]
Discharge Condition:
Afebrile, in good condition, tolerating PO intake, no urinary or
abdominal complaints, saturating well on room air.
Discharge Instructions:
You were admitted to the hospital with a fast heart rate called
atrial flutter that we believe caused your heart failure. This
is likely the cause of why you were so tired and weak the two
days prior to being admitted to the hospital. While you were
here you spent a short time in the intensive care unit because
of fluid in your lungs. You stayed in the hospital because we
wanted to control your heart rate - we did not want to make it
too fast or slow it down too slow. We also had cardiology
physicians consulted to make sure that you were on the right
medications and management for your new heart failure. You were
stable by the time of discharge.
Changes to your medicines:
Metoprolol succinate 75mg please take one tablet daily. This is
a new medication to better control your heart rate and is of
benefit with your congestive heart failure.
Aspirin 325mg please take one tablet daily.
Ciprofloxacin 500mg one tablet daily for the next 5 days for
treatment of your urinary tract infection.
If you should experience signs of infection such as fever,
chills, sweats, or redness at the surgical sites, or chest pain,
trouble breathing, palpitations, dizziness, fatigue, or any
other medically concerning symptoms, please call your doctor or
911 or go to the emergency room.
Followup Instructions:
The following appointment has been made for you:
MD: NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 715**]
Specialty: Geriatrics
Date and time: Friday, [**7-16**] 8:30am
Location: [**Last Name (NamePattern1) **]., [**Hospital Unit Name **] [**Hospital Unit Name 5676**]
Phone number: [**Telephone/Fax (1) 719**]
MD: NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 715**]
Specialty: Geriatrics
Date and time: Wednesday, [**7-21**] 8:30am
Location: [**Last Name (NamePattern1) **]., [**Hospital Unit Name **] [**Hospital Unit Name 5676**]
Phone number: [**Telephone/Fax (1) 719**]
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date and time: [**2117-7-27**] 8:40am
Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) **]
Phone number: [**Telephone/Fax (1) 62**]
Completed by:[**2117-7-13**]
|
[
"300.00",
"584.9",
"733.90",
"459.81",
"780.52",
"564.09",
"V10.04",
"427.31",
"786.2",
"427.32",
"599.0",
"428.21",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9369, 9432
|
5636, 7824
|
288, 295
|
9831, 9949
|
2962, 3684
|
11279, 12196
|
2333, 2351
|
8335, 9346
|
9453, 9810
|
7850, 8312
|
9973, 11256
|
2366, 2943
|
3701, 5613
|
222, 250
|
323, 1806
|
1828, 2102
|
2118, 2317
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,476
| 103,771
|
53232
|
Discharge summary
|
report
|
Admission Date: [**2137-6-9**] Discharge Date: [**2137-6-14**]
Date of Birth: [**2057-5-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Bactrim / Nsaids
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
The patient reports that she has increased shortness of breath
both at rest and with activity in the past 24 hours with
associated yellow sputum production. She notes fevers and sweats
at home. She denies any new lower extremity edema, weight gain
or orthopnea. Her son corroborates that she had worsening,
labored breathing in the past 24 hours precipitating her to
admission through the ED.
.
In the ED, 102.2 80 138/61 40 84% 2L improved to 98% on 15L face
mask. She received 1L NS, albuterol, ipratropium, acetaminophen,
levofloxacin 750mg IV and cefepime 2g IV.
Past Medical History:
1. CAD - Cath ([**3-/2134**]) - LMCA and LCx, no disease; LAD: proximal
and mid vessel 30% stenoses; RCA - mild luminal irregularities
- Pacemaker/ICD ([**Company 1543**] Sigma SDR303 B pacemaker), in [**1-/2132**]
2. Atrial fibrillation, status post AVJ ablation and DDD pacer
3. Congestive heart failure (EF 20% in [**2134-2-16**])
4. MVR and TVR ([**4-/2132**])
5. Bronchiectasis with presumed pseudomonal colonization
([**Month (only) 404**]
[**2135**] and treated with ceftazidime and azithromycin): Previously
suffered exacerbations in [**Month (only) **] and [**2135-8-19**] that were
treated with meropenem/cipro and ceftaz as outpatient
6. Depression
Social History:
Lives in [**Location (un) 55**]. She worked as a lecturer on Egyptology
at the MFA in [**Location (un) 86**]. Husband is deceased. She lives with her
son and has an aid most days of the week. Has three sons, [**Name (NI) **],
[**Name (NI) **] and [**Name (NI) **]. Quit smoking 30 years ago, had a 5 pack year
history. Previously, she drank one drink/day but no ETOH now
for many years.
Family History:
Her father and mother are both deceased. Her father had HTN. Her
mother had [**Name (NI) 19917**] disease and died as an elderly woman. There
is a negative family history of colon cancer, breast cancer,
diabetes, and premature coronary artery disease. She has three
natural children who are alive and well and one brother who is
alive and well.
Physical Exam:
Gen: Elderly woman in facemask. Pleasant. In mild respiratory
distress. Speaking in full sentences.
HEENT: PERRL.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Tachypneic, using accessory muscles for breathing. Diffuse
harsh crackles in all lung fields worse on the left.
Abd: Soft, nontender, nondistended. No organomegaly.
Ext: No edema.
Pertinent Results:
[**2137-6-9**] 05:30PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-756*
[**2137-6-9**] 10:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2137-6-10**] 04:48AM BLOOD CK-MB-3 cTropnT-<0.01
*Negative trop x 3
[**2137-6-11**] 04:40AM BLOOD WBC-8.0 RBC-4.18* Hgb-12.0 Hct-36.3
MCV-87 MCH-28.7 MCHC-33.0 RDW-13.5 Plt Ct-220
[**2137-6-11**] 04:40AM BLOOD Glucose-93 UreaN-19 Creat-0.7 Na-135
K-3.7 Cl-100 HCO3-30 AnGap-9
==========
[**2137-6-9**]
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are no
filling defects
present within the pulmonary arterial vasculature. The heart is
top-normal in
size. There is no pericardial effusion. The aorta is normal in
caliber and
contour. Scattered vascular calcifications are noted. A
precarinal lymph
node measures 1.5 cm in short-axis diameter (3:46). A right
hilar lymph node
measures 1.8 cm in short-axis diameter (3:51). No pathologically
enlarged
left hilar or axillary lymph nodes are noted. A spiculated
opacity is
present in the left lung apex that is stable compared to
[**2135-5-3**]. A
spiculated opacity located in the right upper lobe is also
stable compared to
the previous chest CT (3:41). Overall, there has been interval
improvement in
scattered areas of peripheral parenchymal opacity. Diffuse areas
of tree-in-
[**Male First Name (un) 239**] opacities; however, are essentially stable compared to the
previous
examination. There is extensive bronchiectasis within both lungs
and several
areas of mucus plugging, most notable at the left lung base. The
imaged
portion of the upper abdomen is unremarkable.
BONE WINDOWS: Demonstrate no suspicious lytic or blastic
lesions.
IMPRESSION:
1. No pulmonary embolism or thoracic aortic dissection.
2. Stable appearance of bronchiectasis involving both lungs with
mucoid
impaction predominately affecting the left lung base.
3. Enlarged mediastinal and right hilar lymphadenopathy and
persistent tree-
in-[**Male First Name (un) 239**] opacities are relatively stable compared to the previous
examination,
likely representing chronic mycobacterial infection.
Brief Hospital Course:
Patient was admitted to [**Hospital Unit Name 153**] from ED due to worsening shortness
of breath. She was placed on a non-rebreather mask initially
and placed on single [**Doctor Last Name 360**] meropenem based on her history of
Bronchiectasis and fear of pulmonary infection. Numerous prior
bronchiectasis flares associated with pseudomonal and
non-fermenter, non-pseudomonal infections sensitive to
meropenem. Second day, patient was weaned to 5L NC (baseline
2.5L NC at home). CXR showed some increased pulmonary
vasculature thought due to fluid overload, goal to keep her
negative and start on spironolactone due to history of CHF --
however, patient was in good condition and was able to ambulate;
as a result patient was transferred to the floor.
A PICC line was placed, and after consultation with Infectious
Diseases and Pulmonary, the patient was planned to complete a
total of 14 days of therapy with meropenem. On discharge, the
patient was at her baseline oxygen requirement and baseline
exercise tolerance, without fevers or leukocytosis.
Medications on Admission:
Albuterol 90mcg 2 puffs q4-6h as needed
Alendronate 70mg weekly
Ciprofloxacin 250mg twice a day x3 days (06.16-19.08)
Citalopram 20mg Daily
Fluticasone-Salmeterol 500/50mcg 1 puff twice daily
Furosemide 10mg Daily
Lisinopril 2.5mg Daily
Lorazepam PRN
Omeprazole 20mg Daily
Simvastatin 20mg daily
Spironolactone 12.5 Daily
Tiotropium 18mcg inh Daily
Warfarin 1mg Daily
Ca-Citrate-Vit D3 315/200 3 pills Daily
Guaifenesin 1200mg twice daily as needed
MVI
Discharge Medications:
1. Meropenem 1 gram Recon Soln Sig: 1000 (1000) mg Intravenous
Q8H (every 8 hours) for 10 days: End date [**2137-6-24**].
Disp:*QS * Refills:*0*
2. PICC line care
PICC line care per Critical Care Systems routine. Normal saline
[**4-27**] mL flush prn and heparin 10 units/mL [**2-20**] mL prn.
3. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Remain upright for 30 minutes after taking dose.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
13. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q12H (every 12 hours) as needed.
14. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
15. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Three (3)
Tablet PO DAILY (Daily).
16. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
17. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
1. Bronchiectasis flare
2. Acute on chronic systolic congestive heart failure
3. Primary hyperparathyroidism
4. Osteoporosis
5. Atrial fibrillation s/p ablation and pacemaker
6. Depression
Discharge Condition:
Fair
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Please contast your primary care physician or pulmonologist if
you develop fevers, sweats, chills, or worsening shortness of
breath.
Followup Instructions:
Provider: [**Name (NI) **] [**Name (NI) **], PT Phone:[**Telephone/Fax (1) 2484**]
Date/Time:[**2137-6-14**] 3:10
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2137-6-17**] 11:15
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4506**] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2137-6-17**] 11:15
|
[
"V45.01",
"494.1",
"414.01",
"427.31",
"428.0",
"V15.82",
"V46.2",
"252.01",
"311",
"428.23",
"458.9",
"V14.2",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7982, 8034
|
4812, 5872
|
306, 322
|
8267, 8273
|
2747, 4789
|
8557, 8995
|
2027, 2374
|
6376, 7959
|
8055, 8246
|
5898, 6353
|
8297, 8534
|
2389, 2728
|
247, 268
|
350, 919
|
941, 1603
|
1619, 2011
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,750
| 141,392
|
52993
|
Discharge summary
|
report
|
Admission Date: [**2147-2-9**] Discharge Date: [**2147-2-13**]
Date of Birth: [**2063-12-9**] Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / Optiray 300
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83yoF w h/o cerebellar and parafalcine mass, gastric bleed
on steroids, now off steroids with progressive lethargy at rehab
x 4 days. She had a recent admission approx 1 wk ago for similar
symptoms found to have UTI with some improvement on treatment.
Patient improved but not to baseline at rehab until few days
ago,
general lack of energy now arousable but non-verbal. J-tube
feeding at rehab. Also intractable nausea unclear relief with
zofran. Denies pain. Noted on CXR at rehab to have signs of CHF
and consolidation thought to be PNA and started on cefpodoxime.
No cough, fevers. Today sent to NWH, CT with obstructive
hydrocephalus, xfr to [**Hospital1 18**].
Past Medical History:
- extra-axial masses in the right cerebellopontine angle and
also in the anterior parafalcine regions, likely meningioma,
base on MRI [**2146-12-21**]
- recent gastric ulcer and perforation, hemorrhagic shock, ARF
[**3-9**] steroid use, requiring ex-lap Bilroth II gastric resection
and esophago-gastroduodenoscopy
- UGIB s/p EGD [**2147-1-23**] found gastritis and ulcer around the
anastomosis
- h/o uterine CA treated with chemo in [**2137**]
- HTN
- vertigo
- lumbar stenosis
- UTI
Social History:
Prior to prolonged and complicated recent hospital course,
patient was living at home with daughter
- denies ETOH, tobacco or IVDA
Family History:
N/C
Physical Exam:
ON ADMISSION PHYSICAL EXAM:
O: Temp: 96.8 HR: 80 BP: 158/87 Resp: 18 O(2)Sat: 100 2L Nasal
Cannula
Gen: comfortable, NAD.
HEENT: Pupils: equal round reactive 4 to 3 mm b/l, pt
non-compliant with EOM exam
Neck: Supple.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Drowsy but arousable, minimally cooperative with
exam, not verbally responsive
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Grossly moving all 4 extremities in bed for purposeful
motions.
Sensation: responds to noxious stimuli
ON DISCHARGE:
Alert
No commands
Nods head appropriately
MAE spontaneously
Pertinent Results:
[**2147-2-9**] CT Head - stable right cerebellopontine large meningioma
with effacement 4th ventricle and hydrocephalus, stable small
left frontal meningioma
[**2147-2-9**] 01:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
[**2147-2-9**] 01:12PM URINE RBC-2 WBC-123* BACTERIA-NONE YEAST-NONE
EPI-1
Brief Hospital Course:
Ms. [**Known lastname **] presented to the [**Hospital1 18**] ED from rehab with increasing
lethargy. She was evaluated by the Neurosurgery team who noted
increased hydrocephalus on CT Head. General Surgery was
consulted for evaluation of potential VPS in setting of recent
abdominal surgery. The patient was admitted to the ICU with
Neuro-oncology, Palliative Care, and Medicine consults. The
patient remained stable overnight with anti-emesis and serial
neuro exams. After extensive discussions by the patient's
family, social work, and palliative care teams, it was decided
to defer any intervention. The patient was transferred to the
floor on [**2147-2-10**]. On [**2-12**], after much family discussion, patient
was made comfort measures only and was transferred to hospice.
Medications on Admission:
Tylenol 650mg Q6
amlodipine 2.5mg qd
cefpodoxime 400mg qd
lactobacilus TID
Ritalin 2.5mg [**Hospital1 **]
lopressor 25mg TID
omeprazole 40mg [**Hospital1 **]
ondansetron 8mg q8h
simethicone 80mg TID
sucralfate 1gm [**Hospital1 **]
Dulcolax 10 qd
milk of magnesia
senna
Atarax 25 q4
Discharge Medications:
1. morphine 10 mg/5 mL Solution Sig: 2.5-5 ml PO Q2H as needed
for pain.
Disp:*100 ml* Refills:*0*
2. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO Q2H.
Disp:*60 Tablet(s)* Refills:*2*
3. Levsin 0.125 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 13054**] Hospice
Discharge Diagnosis:
Cerebellar and parafalcine brain mass
Obstructive Hydrocephalus
Discharge Condition:
Neurologically stable
Discharge Instructions:
You are being discharged to hospice where your comfort focused
care will be continued.
Followup Instructions:
Follow up as requested by Patient and Family. You may call
([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **] as
needed.
Completed by:[**2147-2-13**]
|
[
"V43.64",
"348.9",
"V10.42",
"293.0",
"401.9",
"V43.65",
"V44.4",
"225.2",
"414.01",
"348.5",
"331.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4147, 4202
|
2722, 3510
|
292, 299
|
4310, 4334
|
2332, 2699
|
4469, 4662
|
1671, 1676
|
3842, 4124
|
4223, 4289
|
3536, 3819
|
4358, 4446
|
1719, 1967
|
2252, 2313
|
244, 254
|
327, 997
|
1982, 2238
|
1019, 1506
|
1522, 1655
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,080
| 189,737
|
2856
|
Discharge summary
|
report
|
Admission Date: [**2141-6-13**] Discharge Date: [**2141-6-23**]
Date of Birth: [**2059-7-30**] Sex: F
Service: MEDICINE
Allergies:
Sotalol
Attending:[**First Name3 (LF) 2891**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Chest Compressions
Defibrillation
Cardiac Catheterization
History of Present Illness:
81F with Hx of HTN, HLD, paroxysmal afib with RVR,
moderate-severe MR, and dCHF who presents with shortness of
breath. Patient states she woke up this morning with shortness
of breath which she has been experiencing for the past 2 weeks.
She describes it as intermittent and nature and that it comes in
waves lasting about 30 mins in total with near complete
resolution of her symptoms in between episodes. Interestingly,
she denies associated palpitations nor does she endorse chest
pain associated with these episodes but states this feels
similar to when she presented to her PCP 1 week ago when she was
found to be in afib with RVR. Of note, she was admitted here
from [**Date range (1) 1163**] after she presented to her PCP's office with
new-onset palpitations with associated dyspnea found to be in
afib with RVR and diastolic heart failure. She had a TEE which
showed 3+ MR and no intracardiac thrombus and underwent
successful cardioversion with return into NSR, was started on
sotalol, underwent IV diuresis with good success, and was
discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor and outpatient
cardiology follow-up which is scheduled for next week.
In the ED, initial vitals were 98.6, 80, 145/90, 16, 99%2LNC
-Labs: CBC and Chem 7 unremarkable, INR 1.7, trop negative x 1,
BNP 4983
-Imaging: CXR called as CHF, negative R LENI
-Patient given: Lasix 20mg IV x 1
Vitals on transfer were 97.7, 78, 139/79, 20, 96%RA
On arrival to the floor, patient feels much better following
diuresis in the ED. States she has probably gained 5lbs over the
past 2 weeks and that her normal weight is about 155lbs.
Describes orthopnea, PND, and occasional night-time awakening
for urination. Denies chest pain and states that her SOB is with
exertion as well as at rest.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: pAfib s/p cardioversion [**5-/2141**], on sotalol,
dCHF EF >55% on TEE [**5-/2141**]
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Uterine prolapse
Hematuria
Migraines
Osteopenia
Social History:
Lives in [**Location 2251**], with her son upstairs. Retired office manager.
Non-smoker. She does not drink or use drugs.
Family History:
Father died at 57 due to cancer. Mother died at 71 due to
cancer. No early CAD or sudden cardiac death. No family history
of early MI, arrhythmia, cardiomyopathies, or sudden cardiac
death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS- 98.3, 141/72, 80, 18, 94RA
GENERAL- WDWN woman in NAD. AOx3. Mood, affect appropriate.
HEENT- PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma. 4mm venous [**Doctor Last Name **] on right
upper lip.
NECK- Supple with JVP of of 5 cm above clavicle at 90 degrees.
Mass-like fullness bilaterally (R>L) at base of anterior
triangle that is very soft and empties on palpation which is
likely just her jugular veins
CARDIAC- PMI located in 5th intercostal space, midclavicular
line. RR with what sounds like premature atrial beats, normal
S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS- Rales 1/3rd the way up her bases, no wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- 1+ pitting up to her mid-shins bilaterally, R>L, no
cyanosis.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Neuro: CNIII-XII grossly intact, [**4-29**] in all 4 extremities, no
sensory deficits
.
DISCHARGE PHYSICAL EXAM:
========================
VS- 97.8, P 64, BP: 100/56, RR: 14, 96% on RA
GENERAL- well appearing, NAD. AOx3.
NECK- Supple, no JVD appreciated, no LD
CARDIAC- RRR with occasional premature atrial/ventricular beats.
No m/r/g.
LUNGS- CTAB, no wheezes or rhonchi.
CHEST - no echymosis noted on R chest/shoulder/shoulder blade.
No tenderness to palpation.
ABDOMEN- +BS, soft, NTND.
EXTREMITIES- trace pitting edema mid-shins bilaterally, wwp.
[**Name (NI) 13885**] PT 2+ bilaterally
Neuro: CNIII-X grossly intact, no neuro deficits
Pertinent Results:
ADMISSION LABS:
===============
[**2141-6-13**] 01:50PM BLOOD WBC-8.1 RBC-4.20 Hgb-12.5 Hct-37.9 MCV-90
MCH-29.8 MCHC-33.0 RDW-14.3 Plt Ct-240
[**2141-6-13**] 01:50PM BLOOD Neuts-65.5 Lymphs-25.4 Monos-6.5 Eos-2.0
Baso-0.5
[**2141-6-13**] 02:27PM BLOOD PT-18.3* PTT-58.9* INR(PT)-1.7*
[**2141-6-13**] 01:50PM BLOOD Glucose-92 UreaN-24* Creat-0.9 Na-139
K-3.8 Cl-105 HCO3-24 AnGap-14
[**2141-6-13**] 01:50PM BLOOD proBNP-4983*
[**2141-6-13**] 01:50PM BLOOD cTropnT-<0.01
[**2141-6-13**] 01:50PM BLOOD Mg-2.1
[**2141-6-13**] 05:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006
[**2141-6-13**] 05:10PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2141-6-13**] 05:10PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
[**2141-6-13**] 05:10PM URINE Mucous-RARE
DISCHARGE LABS:
===============
[**2141-6-18**] 06:25AM BLOOD WBC-8.1 RBC-4.17* Hgb-12.5 Hct-38.2
MCV-92 MCH-30.0 MCHC-32.7 RDW-14.3 Plt Ct-240
[**2141-6-22**] 04:23AM BLOOD UreaN-23* Creat-0.9 Na-139 K-3.9 Cl-106
[**2141-6-23**] 04:32AM BLOOD Glucose-95 UreaN-20 Creat-0.8 Na-139
K-4.0 Cl-106 HCO3-22 AnGap-15
[**2141-6-23**] 04:32AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0
PERTINENT LABS:
===============
[**2141-6-14**] 12:08PM BLOOD ALT-163* AST-76* AlkPhos-101
[**2141-6-18**] 06:25AM BLOOD ALT-58* AST-25
[**2141-6-13**] 01:50PM BLOOD proBNP-4983*
[**2141-6-13**] 01:50PM BLOOD cTropnT-<0.01
[**2141-6-13**] 05:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006
[**2141-6-13**] 05:10PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2141-6-13**] 05:10PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
MICRO/PATH: None
===========
IMAGING/STUDIES:
================
CXR PA/LAT [**6-13**]:
IMPRESSION: Findings most suggestive of congestive failure
which has progressed since [**2141-6-6**].
Right Lower Extemity Non-Invasive:
IMPRESSION: No evidence of deep vein thrombosis in the right
leg.
TTE [**6-15**] LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). TDI E/e' >15,
suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR. Eccentric AR jet directed toward the anterior
mitral leaflet.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
MVP. Mild mitral annular calcification. Eccentric MR jet. Severe
(4+) MR. [Due to acoustic shadowing, the severity of MR may be
significantly UNDERestimated.] Due to the eccentric MR jet, its
severity may be underestimated (Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets. Severe [4+]
TR. Eccentric TR jet. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor suprasternal
views. Left pleural effusion.
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are moderately thickened. There is mild
mitral valve prolapse. An eccentric, posteriorly directed jet of
severe (4+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Due to the eccentric nature of
the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Severe [4+] tricuspid
regurgitation is seen. The tricuspid regurgitation jet is
eccentric and may be underestimated. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Biatrial enlargement. Normal left ventricular cavity
size and wall thickness with preserved global and regional
biventricular systolic function. Increased left ventricular
filling pressure. Mild aortic regurgitation. Mild mitral valve
prolapse with severe mitral regurgitation. Severe tricuspid
regurgitation. At least moderate pulmonary artery systolic
hypertension.
X-ray Rib b/l, AP [**6-17**]
Impression: There are no displaced rib fractures. There is no
pneumothorax. There is moderate cardiomegaly. Bilateral
pleural effusions are small. Left lower lobe retrocardiac
opacity has markedly improved from [**6-14**], consistent with
resolving atelectasis. Vascular congestion has almost resolved.
Right lower lobe atelectasis has improved.
ECG [**2141-6-16**]: NSR @ 77bpm, QTc 490, RBBB, TWI's in V1-V5, III,
aVF, biphasic in V5, no concerning ST segment changes
EKG [**2141-6-17**]: NSR @ 74bpm, QTc 560, RBBB, TWI's in V1-V5 and
inferior leads, no ST changes
EKG [**2141-6-18**]: NSR @ 67bpm, QTc 470, RBBB, TWI's in V1-V5, III,
aVF, no ST changes
EKG [**2141-6-19**]: NSR @ 71bpm, QTc 478, RBBB, PVCs, TWI's in V1-V5,
and inferior leads, no ST changes
EKG [**2141-6-20**]: NSR, QTc 478, unchanged from prior
EKG [**2141-6-21**]: NSR, QTc 488, unchanged from prior
EKG [**2141-6-22**]: NSR, QTc 480, unchanged from prior
EKG [**2141-6-23**]: NSR @65bpm, QTc 470, 1 PVC, RBBB, TWI's in V1-V5,
and inferior leads, no ST changes
Telemetry: [**2141-6-23**] PVCs (~10/min) but no sustained Vtach
Stress ECHO [**2141-6-20**]
The patient exercised for 3 minutes and 75 seconds according to
a Modified [**Doctor First Name **] treadmill protocol (2.9 METS) reaching a peak
heart rate of 117 bpm and a peak blood pressure of 140/82 mmHg.
The test was stopped at the patient's request. This level of
exercise represents a fair exercise tolerance for age (although
limited overall). In response to stress, the ECG showed no
diagnostic ST-T wave changes (see exercise report for details).
There was a normal heart rate response to exercise.
Resting images were acquired at a heart rate of 76 bpm and a
blood pressure of 128/70 mmHg. These demonstrated probably
normal regional and global left ventricular systolic function.
Doppler demonstrated mild aortic regurgitation and moderate to
severe (3+) mitral regurgitation with no aortic stenosis or
significant resting LVOT gradient.There is moderate pulmonary
artery systolic hypertension.
Echo images were acquired within 46 seconds after peak stress at
heart rates of 116 - 108 bpm. These demonstrated new regional
dysfunction with distal septal hypokinesis. The mid anterior
wall may be slightly hypokinetic but views were suboptimal. The
remaining segments augment appropriately.
IMPRESSION: Fair/limited functional exercise capacity. 2D
echocardiographic evidence of inducible ishemia at achieved
workload.
CATH [**2141-6-21**]
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated no angiographically-apparent flow-limiting CAD. The
LMCA
was patent. The LAD had an ostial 25% stenosis with proximal
plaquing to
30%. The LAD gave rise to a large, high D1 with a serpiginous
terminal
branch and rapid drainage into the LV. There was a hinge point
in the
mid LAD (with likely systolic kinking) followed by a U-shaped
bend
leading to a likely intramyocardial segment. TIMI 2 slow flow
was noted
in the LAD consistent with microvascular dysfunction. The LCX
had an
ostial 20% lesion and gave rise to a modest OM1, small OM2,
modest OM3,
large tortuous branching OM4/LPL1, modest long OM5/LPL2, and a
tiny,
short left PDA. There was diffuse plaquing in the mid LCX up to
30% with
slightly slow flow consistent with microvascular dysfunction.
The RCA
had mild luminal irregularities throughout with a proximal 20%
lesion.
There was a solitary right PDA without RPLs. There was slightly
slow
flow in the RCA consistent with microvascular dysfunction.
2. Limited resting hemodynamics revealed a normal LVEDP of 7
mmHg.
There was normal systemic arterial blood pressure with a central
aortic
blood pressure of 125/62 mmHg and a mean central aortic blood
pressure
of 84 mmHg. There was no gradient with careful pullback across
the
aortic valve.
3. A TR band was applied to the right radial artery and
initially
filled with 12 cc of air over a pre-existing hematoma. As the
hematoma
was reduced with pressure slight oozing was noted from the
arteriotomy
site and an additional 2 cc of air was inserted to achieve
adequate
hemostasis.
FINAL DIAGNOSIS:
1. No angiographically-apparant flow-limiting CAD with diffuse
atherosclerosis, diffuse slow flow consistent with microvascular
dysfunction, and mid LAD kinking from a hinge point leading to a
likely
intramyocardial segment.
2. Serpiginous terminal coronary artery branches consistent with
hypertensive heart disease.
3. Normal LV diastolic function.
4. Small right radial hematoma reduced with TR band compression.
Brief Hospital Course:
Ms. [**Known lastname 13883**] is a 81 year old female with Hx of moderate-severe
mitral regurgitation, diastolic heart failure (dCHF), paroxysmal
afib with rapid ventricular rate (RVR) status post recent
cardioversion and initiation of sotalol who was admitted with
shortness of breath consistent with mild acute heart failure
exacerbation. She developed VFib arrest the morning of [**6-14**] with
successful resuscitation following chest compressions and direct
current cardioversion (DCCV) x1.
# VFib Arrest: She was found face down on the bathroom floor on
[**6-14**] by staff when tele alarms went off for Vtach and was
pulseless and unresponsive. Morphology appeared consistent with
torsades de pointes. She was recently started on sotalol which
may be responsible for QTc prolongation (QTc was 530 when
discharged with sotalol) so the etiology was felt to be long QT.
She did not have ST changes post-arrest or chest pain to
suggest ischemia as a cause. She was given one cycle of CPR
with return of spontaneous circulation (ROSC), however, she
again went into Vtach and required DCCV x1 to break with ROSC.
The only medications she recieved during the code were magnesium
6 mg IV. Her neurologic exam was nonfocal and so we did not
perform a head CT despite anticoagulation with dabigatran.
Her sotalol was discontinued immediately and her potassium
and magnesium were aggressively repleted. Her heart rates were
initially in the 50s without any medications so she was started
on an isoproterenol drip which was titrated to 9 mcg/min to
achieve a heart rate of 80s-90s to shorten her QTc. However,
this also irritated her afib and she developed afib with RVR to
180s. The isoproterenol was discontinued. She remained
asymptomatic even after rates to 140s persistently for hours but
her blood pressure started drifting down to 90s/60s so
metoprolol tartrate 50 mg PO was given. She continued to be
tachycardic to 130s so she was given 5 mg IV metoprolol. Her
rates decreased to 50s with QTc of 510. She had a few more
hours of isoproteronol titrated to heart rates of 80-100s.
Then, this was discontinued and she remained in sinus rhythm
with rate controlled at 80s without any medications. Started on
metropolol 12.5mg po BID and transferred from CCU to [**Hospital1 1516**]
service. On floor, HR remained stable at 60s, continued to be on
normal sinus rhythm with QTc 490-->560-->470-->478 --> 488 -->
470s ms. A [**2129**] EKG showed a QTc of 434ms. She probably has a
high baseline QTc. We continued to aggressively replete Mg and K
with a goal of K 4.5 and Mag>2. She was discharged with K and
Mag. AT discharge, K = 4 and Mg = 2. Her HRs were in the 70s and
80s on metoprolol 12.5mg [**Hospital1 **], and we increased the metoprolol to
25mg [**Hospital1 **] for better rate control. Her HR has since been in 56-65
bpm. At discharge, her telemetry and EKGs showed PVCs (up to 10
per minute), but no sustained Vtach. She was discharged with a
Kings of Hearts monitor and will follow up with EP (Dr. [**Last Name (STitle) **].
# CAD: new TWIs in inferior leads. Patient is completely
asymptomatic, but new changes were concerning for ischemia. A
stess ECHO was ordered which showed hypokinesis in the distal
septal and the mid anterior wall. These results were concerning
and a cath was performed. Cath showed normal LV diastolic
function, mid LAD kinking from a hinge point, but no
flow-limiting CAD.
# Acute Diastolic CHF Exacerbation with Moderate-Severe Mitral
Regurgitation: LVEF on most recent TTE was >55% but with
moderate-severe MR. [**Name13 (STitle) **] presented with new shortness of
breath with evidence of fluid overload. She was in NSR. Improved
symptomatically with diuresis overnight, then switched to PO
lasix 20 mg daily. Improved signs of volume overload [**1-26**]
diuresis, but expected to have some overload due to severe MR.
[**Name13 (STitle) **] lasix was switched to every other day for appropriate
diuresis. Unclear if pt had tachyarrhythmia rhythm while at
home, leading to CHF exacerbation. Continued aspirin 81 mg
daily, lisinopril 2.5 mg daily, furosemide 20mg PO every other
day, and spironolactone 25mg PO daily. Metoprolol was increased
from 12.5mg [**Hospital1 **] to 25mg [**Hospital1 **].
# Paroxsymal atrial fibrillation (pAfib): CHADS2 score of 2.
Patient currently in NSR on EKG and tele with occasional
premature atrial beats. She did revert to afib with RVR on
isoproteronol and required PO metoprolol tartrate 12.5 mg [**Hospital1 **] to
control her HR. Her metoprolol (per above) was increased to
25mg [**Hospital1 **] on [**2141-6-22**] to better control her HR (now in the
50s-60s). She was discharged with metoprolol 25mg [**Hospital1 **].
Continued dabigatran 150 mg PO BID.
# MSK pain [**1-26**] fall/chest compressions: after code, patient
complained of reproducible pain on right side of chest in
axillary line, R shoulder, and R shoulder blade. X-ray showed no
rib fractures. Her pain has been improving every day. She was
discharged with tylenol 1000mg PO TID.
# [**Hospital 8304**] medical problems: stable and continued with home
medications
-HTN: controlled with lisinopril
-HLD: Continued home niacin
-Osteoporosis: continued with calcium, vitamin D.
#CODE: Full Code (confirmed with patient)
-discharged to STR
#TRANSITIONAL ISSUES:
-Patient should not be given medications that prolong QTc
-Please check K+ and Magnesium and ensure appropriate repletion
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Dabigatran Etexilate 150 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Niacin SR 500 mg PO TID
4. Sotalol 80 mg PO DAILY
hold for SBP < 100, HR < 60
5. red yeast rice *NF* 600 mg Oral [**Hospital1 **]
6. Vitamin D 800 UNIT PO DAILY
7. Calcium Carbonate 500 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Dabigatran Etexilate 150 mg PO BID
4. Niacin SR 500 mg PO TID
5. Vitamin D 800 UNIT PO DAILY
6. Acetaminophen 1000 mg PO TID pain
Do not exceed 4g in day
7. Furosemide 20 mg PO EVERY OTHER DAY
Hold for SBP < 100
8. Lidocaine 5% Patch 1 PTCH TD DAILY
9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
10. Lisinopril 2.5 mg PO DAILY
Hold for SBP < 100
11. Magnesium Oxide 140 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Hold for sedation, RR < 10
14. Potassium Chloride (Powder) 40 mEq PO DAILY
Hold for K >5
15. Spironolactone 25 mg PO DAILY
16. Senna 1 TAB PO BID:PRN Constipation
17. red yeast rice *NF* 600 mg Oral [**Hospital1 **]
18. Metoprolol Tartrate 25 mg PO BID
Hold for SBP<90 or HR<60
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living
Discharge Diagnosis:
Primary diagnosis
- diastolic CHF exacerbation secondary to mitrial regurgitation
Secondary diagnosis
- cardiac arrest secondary to sotalol and low potassium and
magnesium
- paroxysmal atrial fibrillation
- hypertension
- hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 13883**],
It was a pleasure to take care of you at [**Hospital1 827**]. You came to our hospital for shortness of
breath. We found that you had fluid accumulation in your lungs.
You were treated with lasix which helped improve your symptoms.
You also had a cardiac arrest. This was likely from having low
potassium and from a medication you were taking called sotalol.
You were treated with chest compressions, a shock, and
medications. You improved with potassium, magnesium, and
stopping the sotalol.
You also had some pain/soreness in your right side of chest
after the fall and chest compressions. You had no fractures and
your pain is being treated with tylenol.
You had an exercise stress echocardiogram which was slightly
abnormal. You had a cardiac catheterization which showed no
significant coronary artery disease. We increased your dose of
metoprolol to help better control your heart rate.
Please weigh yourself everyday, notice your PCP if weight goes
up by more than three pounds.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2141-6-27**] at 1 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 6738**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: MONDAY [**2141-7-3**] at 3:50 PM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: THURSDAY [**2141-7-13**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2141-6-25**]
|
[
"424.0",
"786.50",
"402.91",
"E942.0",
"733.00",
"276.8",
"272.4",
"719.41",
"427.5",
"427.31",
"428.33",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"37.21",
"88.56",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
20753, 20894
|
14040, 19352
|
288, 348
|
21180, 21180
|
4558, 4558
|
22387, 23393
|
2684, 2903
|
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|
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|
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|
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|
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|
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|
229, 250
|
376, 2195
|
4574, 5395
|
21195, 21307
|
5781, 13581
|
2480, 2529
|
2217, 2271
|
2545, 2668
|
4011, 4539
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,851
| 100,877
|
51091
|
Discharge summary
|
report
|
Admission Date: [**2149-5-5**] Discharge Date: [**2149-5-12**]
Date of Birth: [**2087-9-28**] Sex: F
Service: MEDICINE
Allergies:
Ms Contin
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Fever, abdominal pain.
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **] with metal stent placement on [**2149-5-6**].
RIJ placement on [**2149-5-6**]
Arterial line placement on [**2149-5-6**]
Arterial line removal on [**2149-5-9**]
RIJ removal on [**2149-5-11**]
Left midline placement on [**2149-5-11**]
History of Present Illness:
Ms. [**Known lastname 2973**] is a 61 yo woman w/hx of recently diagnosed
pancreatic
cancer metastatic to the liver who presents with fever, jaundice
and pain for the last 2 days. Patient states that after being
discharged she was doing great at home. Her pain was controlled,
she was urinating and moving her bowels, very active. She only
noted that her apetite was slighlty decreased. She went to see
her oncologist, who decided to get a liver MRI as outpatient to
stage the cancer and to assess for possible liver infiltration
and biopsy. She was getting herself her antibiotics (unasyn 3 g
q6hrs) for cholangitis. She finished the treatment Saturday
afternoon (2 days ago). 24 hours later, she started noticing
chills, rigors and fever up to 102.7 today in the morning. She
was scheduled for and MRI today and was not eating or drinking
anything. She came to the ER.
.
In the ER was found to have T 99.3, BP 126/99, HR 146, RR 16,
SpO2 97% on RA. Then she spiked to 102.7 F. She had nondistended
abomen, was very dehydrated and received 3 L NS. Her bilirubin
was slighlty elevated from discharge (5.4 from 5.1). Her lactate
was 3.6. Her liver USG showed persistent pneumobilia, with large
gallbladder without any duct dilation. She received Vanc/Zosyn,
Tylenol and IV Dilaudid (1 mg). She was admitted to OMED for
further management of her cholecystitis. Her VS before transfer
per ED report were: 98.3 HR 83 BP 100/60 o2 sats 90's on 2L.
.
While on the OMED service, she continued to spike fevers and her
lab data showed a worsening leukocytosis to 22.1 with 20% bands.
Today she became tachycardic to the 140s which was fluid
responsive but her SBP concurrently dropped from the 140s to the
low 100s. She underwent an abdominal MRI which showed worsening
CBD dilation and numerous cm and sub-cm lesions in the liver,
concerning for new mets vs. abscesses. She went to [**Known lastname **] and
became hypotensive to the systolic 70s prior to the procedure.
She received 2L NS bolus and was started on peripheral
phenylephrine. In [**Known lastname **], pus was draining from her old stent
which was pulled and replaced with a larger metal stent of 10mm
diameter. Upon placement, found to have good drainage of frank
pus.
A-line was placed in the OR. She was on both Levo and Neo prior
to transfer and has received an addition 4L of LR.
.
In the [**Hospital Unit Name 153**], her sedation was weaned and she was extubated
without difficulty. Pressors were weaned. Vancomycin and zosyn
were continued. He was given PO vitamin K.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
Initially presented with abdominal pain to [**Hospital3 **],
had T. Bili of 24. Abdominal CT and ultraound demonstarted a
pancreatic mass obstructing the bile duct. She underwent [**Hospital3 **]
with stent placement [**4-11**] at OSH and then due to rising total
bilirubin had a repeat [**Month/Year (2) **] at [**Hospital1 18**] on [**2149-4-15**] during which her
initial stent was removed and a new stent was placed. She
underwent an EUS guided biopsy of her pancreatic mass on [**2149-4-17**]
showing adenocarcinoma.
.
PAST MEDICAL HISTORY:
==================
GERD
Social History:
Lives at home with her husband and daughter. Smokes 1 pack/day.
Denies IV drug use, EtOH.
Family History:
Mother with COPD. Brother with cirrhosis (due to EtOH). 2
Aunts with breast cancer, 1 of them also had uterine cancer.
Grandmother with DM. Uncle had MI.
Physical Exam:
VITAL SIGNS - Temp 99.3 F, BP 113/82mmHg, HR 102 BPM, O2 100% on
A/C TV 500 RR 14 PEEP 5 FIO2 100%
GENERAL - Intubated and sedated
HEENT - NC/AT, PERRLA, EOMI, sclerae icteric, mildy dry mucous
membranes, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, 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, jaundice
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - Intubated and sedated but moving all four extremities
Pertinent Results:
On Admission:
[**2149-5-5**] 10:40AM WBC-12.6*# RBC-3.68* HGB-11.8* HCT-33.1*
MCV-90 MCH-32.1* MCHC-35.6* RDW-18.1*
[**2149-5-5**] 10:40AM NEUTS-89* BANDS-6* LYMPHS-1* MONOS-0 EOS-1
BASOS-1 ATYPS-2* METAS-0 MYELOS-0
[**2149-5-5**] 10:40AM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-1+ TEARDROP-OCCASIONAL
[**2149-5-5**] 10:40AM PLT SMR-HIGH PLT COUNT-467*
[**2149-5-5**] 10:40AM PT-16.2* PTT-25.4 INR(PT)-1.4*
[**2149-5-5**] 10:40AM GLUCOSE-132* UREA N-8 CREAT-1.0 SODIUM-137
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-18* ANION GAP-21*
[**2149-5-5**] 10:40AM ALT(SGPT)-98* AST(SGOT)-123* ALK PHOS-343*
TOT BILI-5.4*
[**2149-5-5**] 10:40AM LIPASE-18
[**2149-5-5**] 10:40AM ALBUMIN-3.7
[**2149-5-5**] 11:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2149-5-5**] 11:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-NEG
.
Abdominal USG [**2149-5-5**]:
1. Increased size of right and left lobe liver lesions compared
to prior
study, with focal adjacent biliary ductal dilatation.
2. Persistent pneumobilia.
3. Aside from aforementioned ductal dilatation adjacent to focal
liver
lesions, there is no generalized intrahepatic ductal dilatation.
Common bile
duct measures 5 mm.
4. Decompressed gallbladder, with unchanged cholelithiasis and
mild wall
thickening. Findings may be seen with chronic cholecystitis.
5. Redemonstration of a simple left kidney cyst.
.
MRI of the liver [**2149-5-6**]:
1. Significant dilatation of the common bile duct which is
increased from the
previous study. There is also intrahepatic biliary ductal
dilatation. There
is sludge within the gallbladder. Distal biliary stent is seen
in the common
bile duct.
2. Rapidly enlarging liver lesions. The larger ones are not
clearly
enhancing and are of increased signal intensity on T2-weighted
images. The
concern is for multifocal abscesses (vs metastatic disease) and
short-term
followup is recommended.
3. Mass in the pancreatic head without significant change,
compatible with
pancreatic carcinoma.
4. No evidence to suggest acute cholecystitis
.
Unilateral (left) venous USG:
Focused exam without evidence of DVT. If more complete exam for
superficial thrombosis is desired, a dedicated exam can be
obtained in the
future.
Brief Hospital Course:
61 year-old woman with metastatic pancreatic cancer was admitted
with cholangitis culminating in septic shock, now s/p biliary
drainage procedure, improving.
.
# Cholangitis: Patient presented with fever and RUQ that was
concerning for cholangitis. She was immediately started in IVF
and antibiotics (Vanc/Zosyn Day 1 [**2149-5-6**]). Since prior
therapy with Unasyn failed Zosyn was chosen. The following day
her WBC almost doubled (11-->22) and her bilirubin was trending
up (5.4-->5.9). An [**Year (4 digits) **] was planned to be done the same day,
while waiting a repeat MRI was done to further assess her liver
metastasis. The report came as new masses in the liver
concerning for abscesses or cancer in the liver that were new
from prior MRI 2 weeks prior as well as 2.5 cm ductal dilation
(See report for details). Patient became tachycardic and did not
respond to 1.5 L NS. Minutes later patient required central line
placement, arterial line and intubation prior to [**Year (4 digits) **]. In the
[**Year (4 digits) **] pus was drained from the biliary duct. The plastic stent
was removed and new metal stent was placed. She was transfered
to the ICU, due to pressor and ventilator requirements. Both
were stopped (levophed and mechanical ventilation) on day 3 of
ICU stay. Antibiotics were continued and she improved. On
[**2149-5-11**] she was transfered to the oncology floor, where she
tolerated regular diet and her pain was controlled. Vancomycin
was stopped. Upon discharge her bilirubin was 2.8 and trending
down. Follow up with oncology was arranged and warning signs and
symptoms were explained. She was discharged with home VNA and a
left midline to complete a 14-day of IV Zosyn.
.
# Pancreatic cancer: With possible metastatic disease in the
liver. MRI findings equivacal for abscess vs MRI. She will need
follow up MRI.
.
# LUE swelling: concerning for DVT while in the ICU and before
placing midline. DVT was ruled out with USG/doppler. It was
thought it was due to fluid administration.
.
#. GERD: currently asymptomatic. Therapy with
omeprazole/ranitidine was continued.
.
#. FEN: Regular diet.
.
#. Access: RIJ, midline and peripherals (See above).
.
#. PPx -
-DVT ppx with SQ Heparin
-Bowel regimen colace/senna
-Pain management with home regimen Fentanyl Patch plus Dilaudid
.
#. Code - Full code.
.
#. Dispo - Home with VNA.
Medications on Admission:
Colace 100mg PO BID
Ursodiol 300mg PO BID X 10 days
Nicotine Patch 21mg/24H
Ranitidine 150 mg PO BID
Omeprazole 20 mg PO DAily
Hydromorphone 2 mg PO 14hrs PRN pain
Fentanyl 25 mcg/hr TD Every third day
Discharge Medications:
1. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
One (1) Piggyback Intravenous Q8H (every 8 hours) for 7 days:
Last day [**2149-5-16**].
Disp:*21 Piggyback* Refills:*0*
2. Line care
Please do midline care per protocol.
3. Remove Line
Please remove midline after antibiotic course is finsihed.
4. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Polyethylene Glycol 3350 100 % Powder Sig: One (1) Packet PO
DAILY (Daily) as needed.
Disp:*10 Packets* Refills:*0*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*15 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Saline Flush 0.9 % Syringe Sig: One (1) Syringes Injection
once a day as needed for As needed for 7 days.
Disp:*7 Syringes* Refills:*0*
13. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*10 Syringes* Refills:*0*
14. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
16. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis:
Acute cholangitis secodnary to stent obstruction due to
pancreatic cancer.
.
Secondary Diagnosis:
Pancreatic cancer
GERD
Discharge Condition:
Stable, tolerating PO, walking.
Discharge Instructions:
You were seen at the [**Hospital1 18**] for fever. You had an USG done that
did not show any ductal dilation. You were given fluids and
antibiotics. The following morning you had an MRI of your liver
to evaluate your cancer and we found multiple new lesions and
big ductal dilation. You had a fever, you received more
natibiotics, fluids and had an [**Hospital1 **] where they removed a lot of
pus in your biliary ducts, your stent was removed and then a new
metal stent was palced.
.
You required ICU care with central line placement, arterial line
and ventilatory support with aggresive antibiotic therapy as
well as medications to keep your blood pressure adequate. Then
you improved. You been tolerating diet and afebrile. You will
need to follow with your oncologist as below.
.
If you have fever, get yellow, have abdominal pain, chills,
rigors or anything else that concerns you come back to our ER.
Followup Instructions:
Please follow up with your oncologist:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2149-5-23**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23551**], MD Phone:[**Telephone/Fax (1) 447**]
Date/Time:[**2149-5-23**] 9:00
|
[
"276.51",
"038.9",
"576.2",
"197.7",
"788.30",
"530.81",
"276.2",
"157.0",
"995.92",
"785.52",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"97.55",
"51.87",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11648, 11697
|
7135, 9496
|
290, 549
|
11881, 11915
|
4767, 4767
|
12870, 13183
|
3883, 4041
|
9748, 11625
|
11718, 11718
|
9522, 9725
|
11939, 12847
|
4056, 4748
|
228, 252
|
577, 3114
|
11835, 11860
|
11737, 11814
|
4781, 7112
|
3732, 3757
|
3773, 3867
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,559
| 115,570
|
24147
|
Discharge summary
|
report
|
Admission Date: [**2117-4-8**] Discharge Date: [**2117-4-14**]
Date of Birth: [**2058-8-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ampicillin / Typhoid Vaccine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Worsening chest pain.
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x 3
History of Present Illness:
This is a 58 yo male patient with no history coronary artery
disease who reports progressive chest pain. Cardiac
catheterization revelaed EF 50%, RCA 100% occlusion, pLAD 80%
occlusion, mLCx 100% occlusion, D1 60% occlusion, and D2 70%
occlusion.
He was then referred to Dr. [**Last Name (STitle) **] for CABG.
Past Medical History:
Diabetes type 2.
Hypertension.
Silent MI.
Depression.
Anxiety.
Migraines.
Sleep apnea.
Diverticulitis s/p GI bleed in [**2116**].
Hyperlipidemia.
Strabismus, s/p many surgeries.
Elbow surgery.
Tonsillectomy.
Penile implant.
Social History:
Lives with wife and three children in [**Name (NI) 61358**], MA. Works as
credit collection manager.
Tobacco: quit 12 years ago -- [**3-4**] ppd prior to that.
ETOH: Never.
Physical Exam:
On presentation:
Ht: 5'8" Wt: 250 pounds.
VS: HR 66 BP 190/70 right 185/68 left
General: Anxious, well appearing in NAD.
Neuro: CN II -XII intact.
Chest: CTA bilaterally.
CV: RRR II/VI SEM.
Abd: Obese, soft, NT, ND, + BS. No paplable masses.
Extremities: Warm, well perfused. No edema, no varicosities.
No carotid bruits noted.
Pertinent Results:
[**2117-4-13**] 06:15AM BLOOD WBC-4.3 RBC-3.64* Hgb-11.2* Hct-32.7*
MCV-90 MCH-30.9 MCHC-34.4 RDW-13.0 Plt Ct-277#
[**2117-4-13**] 06:15AM BLOOD Plt Ct-277#
[**2117-4-11**] 05:30AM BLOOD Glucose-81 UreaN-27* Creat-1.3* Na-140
K-4.3 Cl-107 HCO3-27 AnGap-10
Brief Hospital Course:
Mr [**Known lastname 61359**] was admitted on [**2117-4-8**]; the morning of his operative
day. He proceeded directly the operating room. He underwent a
coronary artery bypass graft x 3 with LIMA to the LAD, SVG to
the RCA, and SVG to the Diag.
He was transferred to the cardiac surgery recovery unit. He was
weened and extubated on the evening of his operative day.On
post-op day one he was transferred to the inpatinet floor for
ongoing management and recovery.
On the evening of post-op day two he had an acute episode of
anxiety versus psychosis, thourgh metabolis cause could not be
ruled-out. A thorough work-up revealed no obvious cause and by
morning Mr. [**Known lastname 61359**] was alerat and oriented and significantly less
anxious.
On post-op day four, patient's blood pressure continued to be
elevated iwth increase in his lopressor. He had no furtehr
episodes of confusion or agitation.
Post-op day five was significant for ongoing hypertension with
increase in both his lopressor and valsartan. He also
progressed with physical therapy and was cleared (from their
standpoint) to be discharged home.
On post-op day six ([**4-14**]) it was decided that he was safe for
discharge home.
Medications on Admission:
Imdur 60 daily.
Celexa 40 dialy.
Atenolol 50 daily.
Actos 45 daily.
Lipitor 80 daily.
Diovan 320 daily,
Omeprazole 20 daily.
Glyburide/metformin 2.5/500 [**Hospital1 **].
Diclofenac 75 daily.
Nitrostat PRN.
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. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Pioglitazone HCl 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. 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*
6. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO every
4-6 hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 7 days.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
10. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
11. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Coronary artery disease; s/p coronary artery bypass graft x 3.
Discharge Condition:
Stable
Discharge Instructions:
No heavy lifting -- greater tha 10 pounds.
No driving x 6 weeks.
No swimming or tub bathing.
You should shower daily and wash incisions with soap and water;
rinse well; pat dry. Do NOT apply any creams, lotions, powders,
or ointments to incisions.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10984**] [**Telephone/Fax (1) 13254**] Follow-up
appointment should be in 1 week
Completed by:[**2117-4-14**]
|
[
"411.1",
"401.9",
"311",
"414.01",
"250.00",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4778, 4849
|
1778, 2985
|
316, 351
|
4956, 4964
|
1498, 1755
|
5261, 5633
|
3243, 4755
|
4870, 4935
|
3011, 3220
|
4988, 5238
|
1146, 1479
|
255, 278
|
379, 692
|
714, 940
|
956, 1131
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,418
| 177,816
|
28204
|
Discharge summary
|
report
|
Admission Date: [**2114-8-9**] Discharge Date: [**2114-8-20**]
Date of Birth: [**2041-6-6**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
xfer for ICD placement
Major Surgical or Invasive Procedure:
BiV/ICD placement on [**8-14**]
History of Present Illness:
Pt is a 73 year old woman with a history of non-ischemic
cardiomyopathy EF 15%, pulm HTN, AF (not on coumadin) and
schizophrenia who is here for CHF management and BiV ICD
placement. She had originally presented to [**Hospital6 33**]
on [**8-6**].
.
At [**Hospital3 **] BNP was 6300. It was managed with digoxin
0.125, lisinopril 2.5mg, and carvedilol 3.125mg twice daily.
She was diuresed 2L and her Cr rose to 1.6. She was seen by
[**Doctor First Name 28239**] [**Doctor Last Name 13177**] there and the decision was made to have a BiV
ICD placed.
.
Arrived at [**Hospital1 18**], where she was noted to be hypoxic and
orthopneic. Also complaining of abdominal pain. She got 40
lasix, however was only net negative 300 because of significant
fluid intake.
.
She went down for procedure on admission but was unable to lie
flat therefore she was transferred to CCU for diuresis and
further management. Prior to arrival in the CCU, patient
received 60 mg of IV Lasix. Upon arrival to the CCU, she was
able to lie flat with O2 sat of 95%.
Past Medical History:
Non-ischemic cardiomyopathy
CHF Class IV EF 15%
Atrial fibrillation (pt off coumadin for unclear reasons since
[**12/2112**])
mod-severe pulmonary HTN
mod-severe MR
[**Name13 (STitle) **] TR
Schizophrenia
Dementia
UTI
Renal insufficiency
Type II diabetes mellitus
Social History:
Pt has been living in a [**Hospital1 1501**]. She has an involved family, her HCP
is her son.
Family History:
Noncontributory
Physical Exam:
VS: T 97 HR 83 BP 123/64 RR 18 Sat 77% RA 99% 2L
Gen: Pleasant elderly woman in no apparent distress
HEENT: OP clear, MMM, cataracts bilaterally, sclerae anicteric
Neck: JVP to jaw
CV: Normal s1/s2, +s3, RRR
Pul: Decreased BS at bases, crackles 1/3 up
Abd: Soft, distended, +BS, nontender. no rebound or guarding.
Ext: Chr venous stasis, trace edema.
Pertinent Results:
ECG: NSR, LBBB, QRS 170.
.
[**8-10**] Echo: Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe
global left ventricular hypokinesis. Tissue velocity imaging
E/e' is elevated (>15) suggesting increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular cavity is
mildly dilated with mild 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 mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with marked elevation of left atrial pressure.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Moderately dilated LV cavity with severe global
systolic
dysfunction. Moderate mitral regurgitation. Mild pulmonary
hypertension.
.
[**8-10**] CXR IMPRESSION: AP chest reviewed in the absence of prior
chest radiographs: Enlargement of the cardiac silhouette is
severe accompanied by mild pulmonary edema, small bilateral
pleural effusions and mediastinal vascular engorgement. No
pneumothorax. Fibrillator pads project over the heart.
.
Micro: Blood cultures negative, Urine cultures negative.
Stool culure positive for Clostridium difficile
.
[**2114-8-9**] 06:55PM PT-12.3 PTT-27.3 INR(PT)-1.1
[**2114-8-9**] 06:55PM PLT COUNT-118*
[**2114-8-9**] 06:55PM MACROCYT-3+
[**2114-8-9**] 06:55PM NEUTS-64.9 LYMPHS-25.1 MONOS-6.5 EOS-1.4
BASOS-2.1*
[**2114-8-9**] 06:55PM WBC-5.0 RBC-3.94* HGB-13.6 HCT-40.4 MCV-103*
MCH-34.5* MCHC-33.6 RDW-15.6*
[**2114-8-9**] 06:55PM TSH-3.9
[**2114-8-9**] 06:55PM ALBUMIN-4.4 CALCIUM-9.2 PHOSPHATE-4.0
MAGNESIUM-2.5
[**2114-8-9**] 06:55PM proBNP-8030*
[**2114-8-9**] 06:55PM ALT(SGPT)-30 AST(SGOT)-22 LD(LDH)-297* ALK
PHOS-76 TOT BILI-0.6
[**2114-8-9**] 06:55PM GLUCOSE-216* UREA N-43* CREAT-1.5* SODIUM-145
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-31 ANION GAP-15
[**2114-8-9**] 07:25PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-8-9**] 07:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
Brief Hospital Course:
Ms. [**Known lastname 68525**] is a 73 year old with multiple medical problems
including non-ischemic cardiomyopathy who presented from an OSH
with pulmonary edema and plan for BiV ICD placement which was
put on hold given hypoxia prior to procedure.
.
Cardiac:
Pump: Ms. [**Known lastname 68525**] has a history of recurrent NYHA stage IV CHF
and was transferred to [**Hospital1 18**] for BiV pacer/ICD placement in the
hope that it would help to manage her refractory CHF (EF
15-20%). An echo was done on [**8-10**] which showed a moderately
dilated LV cavity with severe global systolic dysfunction,
moderate mitral regurgitation and mild pulmonary hypertension.
Prior to the procedure the patient was unable to lie flat due to
hypoxia/ pulmonary edema and was transferred to the CCU for
diuresis. While in the CCU she received multiple doses of 120mg
IV lasix with resultant good urine output. Spironolactone was
added as well, however her creatinine began to rise and her Na
and K became elevated. Spironolactone was then held and she was
given a small amount of free water to normalize her sodium
levels. As her oxygenation had improved, she underwent
[**Company 1543**] ICD, Concerto C154DWK placement on [**8-14**]. Given her
low EF, the device was not tested post-procedure. She developed
a hematoma over the site of ICD placement. A pressure dressing
was applied to the site to prevent further hematoma. A line was
delineated around the hematoma site to monitor for increasing
size of hematoma, which was not noted. She was intubated
electively for the procedure and returned to the CCU with the
ETT tube in place. She was successfully extubated the following
morning and was started on a low dose of captopril and
eventually switched to lisinopril 2.5mg daily. Carvedilol was
also started and was well tolerated. On [**8-17**] she was
transferred to a regular floor. Her wound remained stable. She
will follow up with EP Dr. [**Last Name (STitle) 68526**] for an ICD check 1wk from
discharge. She was discharged on an aspirin and statin. The
patient denied any lightheadedness, chest pain, site tenderness
or palpitations.
.
Rhythm: The patient presented in atrial fibrillation, however
she was not on coumadin for unclear reasons. After BiV
placement, it was felt that anticoagulation was unnecessary.
.
Renal: The patient presented with renal insufficiency, likely
secondary to her diabetes mellitus. Her creatinine increase was
reported at [**Hospital1 34**] likely due to diuresis. A UA done on admission
was negative for infection. She had minimal hematuria which
resolved after her foley was d/c'd. Her creatinine peaked at
2.1, however on the day of discharge it had normalized to 1.1
which appeared to be her baseline. She had adequate urine
output.
.
Pulm: As above the patient was electively intubated for ICD
placement. She was successfully extubated and was satting well
on RA with no shortness of breath. CXR on [**8-18**] showed no
interval change, mild pulmonary edema consistent with CHF.
.
ID: The patient was placed on vancomycin for 5 days post ICD
placement. In addition, as she developed diarrhea a C. diff
toxin was sent which was positive. She was started on a 14 day
course of flagyl and was placed on contact precautions.
She remained afebrile and her WBC count remained wnl.
.
Hematologic: Ms. [**Known lastname 68525**] had a gradual decrease in platelet
count since admission (admission 118, low 81 on [**8-17**]). Her
platelets had trended up to 171 prior to discharge. Heparin
antibodies were sent which were negative, however heparin was
d/c'd and she was given pneumoboots. It was also noted that she
was anemic. Studies did not show iron deficiency or hemolysis
and she was guaiac negative. It was felt that she likely had
anemia of chronic disease. She did not require transfusions.
.
Endocrine: She was placed on 70/30 insulin 48U in AM, 20U in PM.
Her BG were monitored for hypoglycemia.
.
Psych: Ms. [**Known lastname 68525**] was maintained on her outpatient regimen of
aricept and depakote.
.
F/E/N: She was placed on a heart healthy, diabetic diet.
Electrolytes were checked twice daily while she was being
diuresed and repleted as needed.
Medications on Admission:
Insulin 70/30 24u qAM 15u qPM
RISS
Coreg 3.25 twice daily
SLNTG prn
Protonix 40mg twice daily
ASA 325mg
Lovastatin 40mg daily
Aricept 5mg qs
Depakote 750daily
Levaquin (x3days last [**8-7**] for UTI)
(Digoxin 0.125mg discontinued)
Lasix 20 mg [**Hospital1 **] at home, (held [**8-8**], restarted [**8-9**]) got 40-60
IV x3 doses in past 24 hours
Lisinopril (2.5 mg held [**8-9**])
Lovenox (?)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO QHS (once a day (at
bedtime)).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
10. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Forty Eight (48) units Subcutaneous qAM.
12. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous prior to dinner.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary: CHF class IV s/p BiV/ICD placement
Non-ischemic cardiomyopathy
Atrial fibrillation
Mod-severe pulm HTN
Mitral regurgitation
Tricuspid regurgitation
Secondary: Schizophrenia
Dementia
DM, type 2
Discharge Condition:
Stable. The patient is hemodynamically stable.
Discharge Instructions:
You have a diagnosis of heart failure. You need to weigh
yourself every morning, and [**Name8 (MD) 138**] MD if weight increases by > 3
lbs. Please adhere to 2 gm sodium diet.
Some of your medications have changed. You are now taking
metronidazole, an antibiotic, for an infection in your GI tract.
You need to take 10 more days of this medication. In addition,
you will only be taking Lasix 20mg ONCE per day, instead of
twice daily. You have been restarted on digoxin.
Please keep all outpatient appointments as listed below.
If you begin to experience any chest pain, shortness of breath,
palpitations, or pain or swelling at the site of the ICD please
Followup Instructions:
You have an appointment with the Device clinic on [**2114-8-28**] at
2:30 for evaluation of your BiV/ICD.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 68527**] within the next two
weeks. [**0-0-**]
|
[
"250.40",
"424.0",
"584.9",
"285.29",
"585.9",
"998.12",
"416.8",
"427.31",
"428.23",
"287.5",
"295.90",
"V58.67",
"518.82",
"397.0",
"008.45",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"00.51"
] |
icd9pcs
|
[
[
[]
]
] |
10762, 10833
|
4669, 8898
|
325, 359
|
11080, 11130
|
2250, 4646
|
11843, 12086
|
1847, 1864
|
9341, 10739
|
10854, 11059
|
8924, 9318
|
11154, 11820
|
1879, 2231
|
263, 287
|
387, 1433
|
1455, 1720
|
1736, 1831
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
503
| 117,386
|
29234
|
Discharge summary
|
report
|
Admission Date: [**2126-11-16**] Discharge Date: [**2126-11-28**]
Date of Birth: [**2056-1-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
pancreatitis, fever, change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 yo F w/h/o CVA, Dementia, HTN, hypothyroidism presented to
OSH from NH for fevers, increasing somnolence, abdominal pain,
N/V x1. Pt was admitted to NWH on [**2126-11-13**] w/initial VS 100.3 BP
179/98 HR 91 RR 14 97%RA. Fever w/u included CXR-unremarkable,
labs notable for amylase/lipase 1078/457 respectively. Abdominal
U/S w/multiple gall stones. Abd CT w/moderate inflammatory
changes of RUQ>LUQ areas, minimal peripancreatic inflammation
around head/body of pancrease. Abd CT c/b 25cc Contrast
extravasation into L arm. Conservative management of
pancreatitis, surgery consulted and aggreed to continue
conservative management of pancreatitis w/IVF resuscitation, NPO
and pain control. Contrast extravasation also managed
conservatively with elevation and Ice placement, followed by
plastics-no surgical intervention. On [**2126-11-16**] pt found to be
less responsive, febrile 102 w/tachypnea RR 36 using accessory
muscles ABG on 3.5LNC 7.45/32/88. ICU evaluation at NWH, however
no MICU beds available. Transferred to [**Hospital1 18**] MICU for closer
monitoring.
Past Medical History:
Dementia--baseline A&0 x1 self, does not do own ADLs, had been
ambulating w/walker
-HTN
-CVA
-s/p Fall [**12/2125**]
-s/p ORIF L intertrochanteric fxr
-Osteoporosis
-Depression
-Hypoparathyroidism
Social History:
Lives in Sunshine NH in [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) **]. Brother=HCP. At
baseline does not to own ADLs. Retired nurse.
-No TOB or ETOH use.
Family History:
unknown
Physical Exam:
VS: 103.4 Rectally, 182/89 110 24 100%2LNC
GEN: Arousable, not interactive
HEENT: PERRL, Anicteric sclera, Dry MM, cracked tongue, no
cervical LAD
RESP: CTA b/l antly, no wheezing
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft ND/NT, significantly diminished BS, guarding, no
rebound
EXT: No peripheral edema, warm, 2+DP pulses b/l
NEURO: Arousable, does not follow commands, normal reflexes,
downgoing toes b/l
Pertinent Results:
IMAGING:
OSH:
CXR--No PNA/PTX/CHF
ABD U/S--Limited study due to motion; multiple stones in GB
ABD CT--Moderate inflammatory changes RUQ>LUQ; Minimal
peripancreatic inflammation around head/body of pancreas
.
LABS:
OSH
[**11-14**]: Amylase 1078; lipase 457 Tbili 1.0, Dbili0.3; Tn-I<0.01
WBC 24.5 HCT 43.0 PLT 209
[**11-15**]: Amylase 482; lipase 156
WBC 18.7, HCT 38.6 PLT 168
ABG 7.43/27/85 4LNC
[**11-16**]: WBC 19.5 HCT 39.8 PLT 180; Ca 6.3 Ph 1.2
ABG 7.45/32/88 3.5LNC
MICRO Data [**11-14**] Blood--NGT; Urine--E. Coli pan sensitive
Transfer to [**Hospital1 18**] labs:
[**2126-11-16**] 10:31PM BLOOD WBC-19.7* RBC-4.00* Hgb-13.5 Hct-39.7
MCV-99* MCH-33.8* MCHC-34.0 RDW-13.1 Plt Ct-233
[**2126-11-16**] 10:31PM BLOOD PT-15.2* PTT-26.5 INR(PT)-1.4*
[**2126-11-16**] 10:31PM BLOOD Glucose-173* UreaN-10 Creat-0.8 Na-135
K-3.7 Cl-99 HCO3-24 AnGap-16
[**2126-11-16**] 10:31PM BLOOD ALT-48* AST-57* LD(LDH)-878* AlkPhos-140*
Amylase-219* TotBili-1.2
[**2126-11-16**] 10:31PM BLOOD Lipase-114*
[**2126-11-17**] 05:10AM BLOOD Lipase-109*
[**2126-11-18**] 03:00AM BLOOD Lipase-72*
[**2126-11-16**] 10:31PM BLOOD Albumin-3.1* Calcium-7.8* Phos-2.3*
Mg-1.7
[**2126-11-18**] 06:24AM BLOOD Type-ART Temp-38 O2 Flow-4 pO2-101
pCO2-30* pH-7.48* calTCO2-23 Base XS-0 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2126-11-16**] 10:53PM BLOOD Lactate-2.4*
.
IMAGING: [**11-16**] CXR: There are no old films available for
comparison. The heart is mildly enlarged. There is ill-defined
pulmonary vasculature redistribution. The hemidiaphragms are
poorly visualized suggesting bilateral pleural effusions. There
is bilateral lower lobe volume loss. A focal infiltrate cannot
be totally excluded. Some mildly dilated loops of bowel are
seen in the abdomen. IMPRESSION:
1. Fluid overload with bilateral pleural effusions and vascular
plethora.
.
[**11-16**] RIGHT UPPER QUADRANT ULTRASOUND: Limited views of the
liver demonstrate no focal or textural abnormalities. Small
stones and sludge are seen within a nondistended gallbladder.
There is no gallbladder wall edema or adjacent pericholecystic
fluid to indicate acute cholecystitis. Common bile duct
measures 4 mm and is not dilated. There is no son[**Name (NI) 493**]
[**Name2 (NI) 515**] sign. No ascites is seen in the right upper quadrant.
Limited views of the right kidney demonstrate no hydronephrosis
or calculi. IMPRESSION: Limited study. Cholelithiasis and
sludge without evidence of acute cholecystitis. No biliary
ductal dilatation.
.
[**11-20**] HEAD CT: 1. No evidence of acute intracranial pathology,
including no sign of hemorrhage. Chronic small vessel
infarction as described above. 2. Bilateral prominence of the
lateral ventricles out of proportion to the degree of brain
atrophy. Question is raised of communicating hydrocephalus,
which should be correlated clinically.
.
Chest/Abd/Pelvis CT: 1. Overall limited examination; however,
no definite evidence of pulmonary embolus to the segmental
level.
2. Extensive severe pancreatitis with no definite evidence of
pancreatic necrosis. No comparison exams are available at our
institution limiting assessment for change. Due to extensive
inflammatory changes, the patient is at risk for sequela of
severe pancreatitis including necrosis and vascular
complications.
3. Bilateral pleural effusions and compression atelectasis with
no definite evidence of pneumonia.
.
Echo: The left atrium is mildly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is probably normal (LVEF 50-60%)
(The inferior wall appears hypokinetic on some views, but not
all). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Overall low normal LVEF. Cannot exclude a
regioanl wall motion abnormality due to technical limitations.
Brief Hospital Course:
.
#. Fevers: Fevers to 103.2 on presentation raised concern for
SIRS vs. biliary sepsis in the setting of pancreatitis and
E-coli UTI, elevated lactate, and leukocytosis. She was
initially treated with meropeneum empirically for biliary
infection possibility. Upon improvement of pancreatitis,
meropenem changed to cipro for pansensitive e. coli UTI on
[**2126-11-9**].=, however, she developed another positive UA on this
regimen and began spiking fevers again, therefore this was
changed to ceftazadime on [**2126-11-22**]. Blood cultures from the OSH
and [**Hospital1 18**] were all negative. A CT chest showed b/l pulm
infiltrates, but no PNA. She defervesced around [**11-24**]. All
antibiotics were stopped around [**11-24**].(Pnemovac and Flu vaccine
given [**11-14**] at OSH)
.
#. Pancreatitis: Most likely due to gall stones noted on abd u/s
at OSH. Surgery was consulted and did not feel that the patient
was a surgical candidate given her multiple other active medical
issues. She was treated conservatively with IVF, NPO and pain
control. A post pyloric daubhoff was placed by [**Doctor First Name **] for tube
feeding. A repeat CT showed extensive and severe pancreatitis,
but no sign of necrosis. She was started on sips with modified
diet per speech and swallow on [**11-25**] and was tolerating thin
liquids and ground diet on [**11-27**].
.
#. Delta MS/Dementia: Multifactorial in setting of infectious
process, resolved with improvement of acute issues. Baseline MS
per report by patients brother is [**Name (NI) 70299**] to self only, not
independent in ADL's. A head CT was done to rule out acute
intracranial processes; it revealed atrophy along with
enlargement of the ventricals out of proportion to the degree of
atrophy. After transfer to the floor, her mental status
stabilized and her brother felt that she returned to her
baseline on [**11-24**].
.
#. Tachypnea: The patient required supplemental O2 throughout
her stay. She was noted to have worsening pulmonary edema by
CXR despite diuresis at the OSH. She was diuresised with Lasix
40 IV PRN with good response. The patient's PCP was [**Name (NI) 653**];
the patient has no documented history of CHF (though no recent
echo and on standing lasix as outpatient). Bilateral pleural
effusions were noted on Chest CT (negative for PNA or PE). A
TTE was performed to assess for CHF which showed low normal EF.
She was also treated symptomatically with nebs. She remained
stable on room air since transfer to the floor
.
#. HTN: Pt's HTN managed with metoprolol; this was initially
held due to her tenuous original status w/SIRS. Restarted as
blood pressure increased.
.
#. CODE: Full, confirmed w/Brother=HCP [**Name (NI) **] [**Known lastname 14164**]
[**Telephone/Fax (1) 70300**]
.
#. Contact: Brother as noted above and [**Name (NI) **] [**Telephone/Fax (1) 70301**];
Sunrise NH [**Telephone/Fax (1) 70302**]
Medications on Admission:
AT HOME)
-Tylenol 1000mg TID
-Actonel 35mg
-Namenda 10mg [**Hospital1 **]
-Emabolex 7.5mg daily
-Toprol Xl 50mg daily
-Lasix 40mg daily
.
(On Transfer)
-Lovenox 40mg SC daily
-Synthroid 60mcg IV daiy
-Pantoprazole 40mg IV daily
-Lasix 20mg IV daily (received x1day)
-Lopressor 5mg IV Q6hours x3 days
-Aspirin 81 mg PO daily
-Colace
-Senna
-Zosyn 3.375mg IV q8hrs (day1=[**11-14**] received for 3 days total)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever.
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
pancreatitis
pulmonary edema
hypertension
hypothyroidism
fever
Discharge Condition:
Stable. Patient is tolerating thin liquids and ground foods and
her medications in applesauce.
Discharge Instructions:
please take your medication as directed
please call your physician if you develop fever, chills, nausea,
vomiting, abdominal pain or diarrhea as these may suggest a
serious condition.
Followup Instructions:
Please follow-up with your surgeon [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD on [**2126-12-9**]
8:15. His phone number is [**Telephone/Fax (1) 476**].
.
Please call for follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **] [**1-4**] weeks after your discharge from the extended
care facility.
|
[
"428.0",
"294.8",
"599.0",
"041.4",
"244.9",
"574.20",
"401.9",
"577.0",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10653, 10731
|
6662, 9564
|
362, 369
|
10838, 10935
|
2356, 4881
|
11168, 11514
|
1907, 1916
|
10023, 10630
|
10752, 10817
|
9590, 10000
|
10959, 11145
|
1931, 2337
|
278, 324
|
397, 1475
|
4890, 6639
|
1497, 1696
|
1712, 1891
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,911
| 103,604
|
3895
|
Discharge summary
|
report
|
Admission Date: [**2122-5-4**] Discharge Date: [**2122-5-7**]
Date of Birth: [**2055-10-31**] Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66M with CAD s/p CABG, VF arrest s/p AICD, ischemic CMP (LVEF
20-25%), AF/flutter s/p ablation admitted with symptomatic
hypotension. Of note the pt was admitted from [**4-24**] through [**5-3**]
to [**Hospital1 1516**] for progressively worsening shortness of breath and
weight gain and found to have an acute systolic CHF
exacerbation. During the admission the pt denied chest pain,
Trop 0.14, CK-MB was 3, and EKG revealed non-specific findings.
BNP 2218. CXR with pulmonary edema. No clear preciptant was
identified though it was likely due dietary indiscretion and med
non-compliance. Pt was diuresed with lasix gtt and once daily
dosing of Diuril. Of note wt on admission was 221.7 lbs and was
diuresed to a wt of 178.2lbs (43.6 lbs change, below his dry
weight). On d/c Cr had increased from 1.1 to 2. The pt was
discharged on lasix 80mg [**Hospital1 **]. The pt was discharged yesterday.
Today the pt was seen by his VNA to whom he reported feeling
very lightheaded and tired. His BP was 60/30. He drank water and
repeat pressure with 72/40. She recommended he go to the ED and
he refused.
The VNA rechecked readings 60/30 sitting and 50/30 standing.
Patient got home last night. Also of note the pt had not filled
his bactrim or dabigitran. The pt's PCP then called the pt and
spoke to his granddaughter and instructed her to bring him to
the ED.
In the ED initial vitals 96.0 76 83/41 16 97% received 1.5L in
the 80s, starting to feeling better. 100% on 2L. Lactate. UA
negative. CXR clear. Little lightheadedness. ECG stable. Vitals
prior to transfer Afebrile, 90/48 7616 97%2:.
On arrival to the CCU (MICU 7 border) the pt denies
lightheadedness, chest pain, shortness of breath.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Current cardiac review of systems is notable for absence of
chest pain, -dyspnea on exertion, -paroxysmal nocturnal dyspnea,
+orthopnea, +ankle edema, -palpitations, -syncope or
+presyncope.
Past Medical History:
1. Severe CAD s/p 4vCABG [**2107**]
2. V-Fib arrest 4-days post-CABG s/p pacemaker/ICD [**2107**]
- Generator change and pocket revision in [**2120-1-14**] to right
side of chest secondary to pain
3. Ischemic cardiomypoathy / systolic CHF, EF 25%
4. Peripheral vascular disease s/p bilateral femoral-popliteal
bypass
5. multiple lower extremity catheterizations
6. Diabetes Type II - followed at [**Last Name (un) **]
7. Obstructive sleep apnea
8. Gout
9. Asthma
10. Mild sigmoid colonic thickening on recent CT-Abd/Plv,
colonoscopy showing sessile polyps, biopsy will have to happen
off plavix
11. Esophagitis, gastritis, peptic ulcer disease
12. Afib/flutter s/p TTE cardioversion [**1-/2121**], ablation.
Social History:
Married, lives at home with wife. Former 70 pack years tobacco
use but quit in [**2107**]. Denies alcohol or IVDA. Prior to his
admission to rehab he lived at home with his wife. [**Name (NI) **] walks with
a cane. He does not drink or smoke.
Family History:
Mother with kidney problems. Father died of unknown causes. One
sister died of stomach cancer, another sister also with stomach
cancer. Diabetes is prevalent throughout the family. There is no
family history of premature coronary artery disease or sudden
death.
Physical Exam:
Admission Exam
VS: Afebrile, 94/48 76 16 97%2L
GENERAL: comfortable-appearing, lying back in bed,
HEENT: NCAT, MMM, poor dentition
NECK: Supple with difficult to assess JVP
CARDIAC: Sustained PMI, RRR, normal S1 and S2, no m/r/g
LUNGS: Good airmovement bilaterally. No wheezes or rales.
ABDOMEN: surgical scars present, obese but soft, BS+, NT
EXTREMITIES: Trace pitting edema bilateral lower extremities.
SKIN: + Stasis dermatitis. No ulcers, scars, or xanthomas
Discharge exam
GENERAL: comfortable-appearing, NAD
HEENT: NCAT, MMM, poor dentition
NECK: Supple with difficult to assess JVP
CARDIAC: Sustained PMI, RRR, normal S1 and S2, no m/r/g
LUNGS: Good air movement bilaterally. Slight bibasilar rales
ABDOMEN: surgical scars present, obese but soft, BS+, NT
EXTREMITIES: Trace pitting edema bilateral lower extremities.
Distal pulses palpable and symmetric.
SKIN: + Stasis dermatitis. No ulcers, scars, or xanthomas
Pertinent Results:
CBC
[**2122-5-3**] WBC-9.6 RBC-4.11* Hgb-9.2* Hct-30.3* Plt Ct-348
[**2122-5-4**] WBC-9.7 RBC-3.78* Hgb-8.3* Hct-28.0* Plt Ct-298
[**2122-5-7**] WBC-9.3 RBC-4.00* Hgb-9.3* Hct-29.9* Plt Ct-327
Coags
[**2122-5-4**] PT-18.7* PTT-40.3* INR(PT)-1.7*
Chemistries
[**2122-5-3**] 06:54AM BLOOD Glucose-160* UreaN-38* Creat-2.0* Na-135
K-4.0 Cl-89* HCO3-35* AnGap-15
[**2122-5-7**] 04:20AM BLOOD Glucose-137* UreaN-50* Creat-2.2* Na-131*
K-4.9 Cl-95* HCO3-25 AnGap-16
cardiac enzymes
[**2122-5-5**] 12:08AM BLOOD CK(CPK)-83
[**2122-5-5**] 12:08AM BLOOD CK-MB-3 cTropnT-0.02*
[**2122-5-4**] 05:25PM BLOOD cTropnT-0.03*
[**2122-5-4**] 05:25PM BLOOD proBNP-2516*
[**2122-5-3**] 06:54AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.2
[**2122-5-7**] 04:20AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.4
[**2122-5-4**] 05:33PM BLOOD Lactate-2.7*
[**2122-5-5**] 12:07AM BLOOD Lactate-1.6
microbiology
blood cultures ([**5-4**]) - NGTD
urine culture ([**5-4**]) - NG
CXR [**5-4**]
PORTABLE UPRIGHT AP VIEW OF THE CHEST: A right-sided pacemaker
device is
noted with lead terminating in the right ventricle. Abandoned
left-sided
pacer leads are also noted. The patient is status post median
sternotomy and CABG. Mild cardiomegaly persists. The mediastinal
and hilar contours are stable. Pulmonary vascular congestion is
present without pleural effusions or pneumothorax. No focal
consolidation is present. There are no acute osseous findings.
Brief Hospital Course:
66 year old male with CAD s/p CABG, VF arrest s/p AICD, ischemic
CMP (EF 20-25%), AF/flutter s/p ablation with recent admission
for acute systolic CHF with aggressive diuresis admitted with
hypotension and [**Last Name (un) **].
1. Hypotension due to hypovolemia due to overdiuresis. Patient
was noted to be hypotensive at home by visiting RN. Admitted to
CCU. Hypotension resolved with one unit of PRBC and 500 cc of NS
bolus. Subsequently blood pressure remained stable throughout
hospital course.
2. Chronic Systolic heart failure: Compensated. Lasix 120 mg po
BID held on admission. Continued on metoprolol succinate 50 mg
po qdaily. Lisinopril 5 mg po qdaily held due to [**Last Name (un) **]. Was given
IV lasix 60 mg x 1 early morning of [**2122-5-6**] and = restarted
home lasix 120 mg po BID evening of [**2122-5-6**]. Pt was discharged
on above regimen with plans to follow up wtih cardiology
regarding the initiation of lisinopril.
3. Complicated Urinary Tract Infection: Urine analysis was
normal. Urine culture showed no growth. Bactrim was discontinued
due to [**Last Name (un) **] and did not require any antibiotics as patient was
asymptomatic.
4. CAD s/p 4V CABG: Currently chest pain free. ECG unchanged.
Cardiac enzymes negative. Continued on atorvastatin 40 mg PO
daily. Metoprolol succinate 50 mg po qdaily changed to
metoprolol tartrate 25 mg po BID. Lisinopril 5 mg po qdaily
held due to [**Last Name (un) **]. He was continued on aspirin 81 mg po qdaily.
5. Atrial Fibrillation/Flutter s/p Ablation: Currently with good
HR control on metoprolol 25 mg po BID. Anticoagulated with
dabigatran which was held on admission. Restarted dabigatran at
75 mg po BID on [**2122-5-6**].
6. Hypovolemic Hyponatremia: Resolved with volume repletion.
7. IDDM: A1c 7.6% on [**2122-4-10**]. FSG currently in mid-100s.
Continue home dose Lantus 30 units QAM. Continue Pregabalin 75
mg PO BID for neuropathy
8. Gout: Currently without a flare. Holding Allopurinol 600mg
daily and colchicine 0.6 mg po QOD with [**Last Name (un) **]. Restarted
allopurinol at 300 mg po daily given change in renal function.
9 Anemia: On admission pt had microcytic anemia with HCT of 25
and was transfused 1 unit PRBC responding appropriately and
remained stable.
Medications on Admission:
Bactrim 800-160mg PO BID for 13 more doses.
Dabigatran Etexilate 150mg PO BID
Atorvastatin 40mg PO Daily
Metoprolol Succinate 50 mg Tablet ER
Lisinopril 5mg (Has not started back yet)
Allopurinol 600mg Daily
Vicoden 5-500mg PO Q6H PRN PAIN
Colchicine 0.6 mg PO QOD
Pregabalin 75mg PO BID
Lantus 60 units QAM
Lasix 160mg PO BID
Humalog 100 unit/mL Solution Sig: ASDIR
Discharge Medications:
1. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily). Tablet(s)
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. insulin glargine 100 unit/mL Solution Sig: One (1) 60
Subcutaneous once a day.
6. insulin lispro 100 unit/mL Solution Sig: [**11-16**] As directed
Subcutaneous four times a day.
7. furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
8. pregabalin 75 mg Capsule Sig: One (1) Capsule PO twice a day.
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other
day.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis
- Hypotension secondary to overdiuresis
- Acute on Chronic Kidney Injury
- Chronic Systolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with lightheadedness. You were found
to have low blood pressure that was likely due to medications.
You were given IV fluids and had your medications adjusted.
.
Please note the following changes to your medications:
Please START taking:
1) Aspirin 81mg Daily
PLEASE NOTE THE FOLLOWING CHANGES TO THE DOSES OF YOUR
MEDICATIONS:
1) Dabigitran 75mg Please take twice daily (you were previously
prescribed 150mg twice daily)
2) Allopurinol 300mg Daily (you were previously taking 600mg
Daily)
3) Lasix 120mg twice daily (you were previously taking 300mg
Daily)
.
Please STOP taking:
1) Bactrim
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please set up appointments with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 7960**] and
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**] for Mr. [**Known lastname **] in the next week
.
Department: RHEUMATOLOGY
When: TUESDAY [**2122-6-9**] at 2:30 PM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2122-5-8**]
|
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"794.31",
"414.01",
"327.23",
"272.0",
"585.9",
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"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9860, 9918
|
6223, 8492
|
282, 289
|
10097, 10097
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317, 2558
|
10112, 10224
|
2580, 3289
|
3305, 3550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,251
| 101,410
|
47576
|
Discharge summary
|
report
|
Admission Date: [**2129-9-14**] Discharge Date: [**2129-10-6**]
Date of Birth: [**2072-9-6**] Sex: M
Service: MEDICINE
Allergies:
sertraline
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Agitation, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient was unable to participate in interview with me. This
note is based heavily on the information gathered by the ED
physicians and the Neurologist who consulted in the ED. Mr.
[**Known lastname 62523**] is a 56-year-old man with a history of alcohol abuse
with recent admission for presumed Wernicke encephalopathy,
alcohol withdrawal who presented from his skilled nursing/rehab
center for agitation after being discharged from [**Hospital1 18**] two days
ago. At the rehab facility, the patient spent the last 24 hours
in severe agitation that required 4-point restraints and
multiple chemical restraints in order for him to calm down.
According to the Neurologist in the ED, he was disoriented,
tachycardic, agitated, and diaphoretic in the setting of
presumed 3 days abstinence from benzos. Mr. [**Known lastname 62523**] had some
restriction in eye movements but no gaze deviation and no
lateralizing signs at this point. Neurology believes withdrawal
is the most likely etiology. If fevers develop, he may require a
lumbar puncture. such as infection Metabolic derangements, drug
overdose, hepatic failure, and gastrointestinal bleeding can
also mimic or coexist with withdrawal. In the absence of
complications, symptoms can persist for up to seven days.
Additionally as he does not seem to have full abduction of his
eyes, Neurology recommends continuing on IV thiamine for
presumed Wernicke's. Given that the mammillary bodies are
enriched with dopamine receptors, would avoid Haldol as this may
exacerbate his Wernicke Korsakoff's pathology.
Past Medical History:
-HTN
-ETOH abuse
-HCV
-h/o Agoraphobia previously treated w/ sertraline, but stopped
for concern of serotonin syndrome
- Methadone maintenance for opioid detox
Social History:
Former waste management truck worker and cement mixer for 22
years.
Last HIV test negative 2.5 years ago.
Last drink was 3pm on [**2129-8-23**].
Denies ever smoking. Lives with his brother, [**Name (NI) **].
Family History:
DM2 in both parents, PTSD in his father. Brother is also on
methadone maintenance program.
Physical Exam:
Admission physical exam:
Vitals: T: 97.7, BP:128/81, P: 57, R: 19, O2: 97% RA
General: Diaphoretic, mumbling to self, arouses only to noxious
stimuli, can state name but not following other directions
HEENT: Sclera anicteric, MMM, oropharynx clear and without
erythema and exudate, PERRL, small pupils but responsive to
light
Neck: supple
CV: S1, S2, no murmurs auscultated
Lungs: Clear to auscultation bilaterally
Abdomen: soft, non-tender, non-distended, bowel sounds present,
bruising from heparin injections
GU: condom catheter in place
Ext: warm, well perfused, 2+ pulses, scarring on left knee
Neuro: Patient cannot follow instructions for neurological exam,
moving all four limbs spontaneously
Discharge:
VS: 97.6, 110/75, 83, 16, 100%RA
General: alert, NAD, oriented to self, [**Hospital1 18**], year and month and
date
HEENT: Sclera anicteric, MMM, PERRLA, supple, no LAD
CV: RRR, normal S1, S2, no m/r/g
Lungs: CTAB, no rales wheezes or rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
bruising from heparin injections
Ext: warm, well perfused, 2+ pulses, no edema
Back: mild tenderness of R flank
Neuro: CN II-XII intact,rigid with some mild cogwheeling and
occasional myoclonic spasms of his bil LE.
Pertinent Results:
Labs:
[**2129-9-14**] 05:14PM WBC-7.4 RBC-3.68* HGB-12.5* HCT-36.2* MCV-98
MCH-34.0* MCHC-34.6 RDW-14.2
[**2129-9-14**] 05:14PM NEUTS-68.5 LYMPHS-20.5 MONOS-6.0 EOS-4.3*
BASOS-0.6
[**2129-9-14**] 05:14PM ASA-NEG ETHANOL-NEG ACETMNPHN-5* bnzodzpn-POS
barbitrt-NEG tricyclic-NEG
[**2129-9-14**] 05:14PM TSH-0.59
[**2129-9-14**] 05:14PM TSH-0.59
[**2129-9-14**] 05:14PM ALBUMIN-3.8
[**2129-9-14**] 05:14PM ALT(SGPT)-45* AST(SGOT)-31 ALK PHOS-51 TOT
BILI-0.3
[**2129-9-14**] 05:14PM GLUCOSE-111* UREA N-16 CREAT-1.0 SODIUM-131*
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-23 ANION GAP-15
[**2129-9-14**] 05:19PM LACTATE-1.5
[**2129-9-15**] 05:14AM BLOOD Ammonia-35
[**2129-9-14**] head CT:
IMPRESSION: No acute intracranial process.
[**2129-9-14**] CXR:
FINDINGS: A single portable supine chest radiograph was
obtained. Exam is limited by patient rotation. Lung volumes
are low. Pulmonary vessels are engorged. There is no effusion
or pneumothorax. Cardiac and mediastinal contours are normal.
IMPRESSION: Low lung volumes and engorged pulmonary vessels
[**2129-9-15**] EKG:
Sinus bradycardia. Non-specific slight ST segment elevation in
the precordial leads and lateral leads. Possible early
repolarization. Compared to the previous tracing of [**2129-9-7**]
bradycardia is new, ST segment elevation is slightly more
pronounced and could be rate related.
Brief Hospital Course:
The patient is a 57-year-old man with a history of alcohol
dependence who was recently discharged after detoxifying at [**Hospital1 1535**] but also suffering from
Wernicke-Korsakoff's syndrome, who presented from his nursing
facility with altered mental status.
#. Delirium/altered mental status: Patient had been agitated at
nursing facility. TSH, B12, folate, and lactate all within
normal limits. Ammonia also normal. Patient was been afebrile,
WBC was normal, CXR and UA negative. CT head was negative.
Neurology and Psychiatry consulted. Psychiatry discovered that
patient was receiving oxazepam at facility. Combined with the
significant (12mg IV) lorazepam he received in Emergency
Department and 5mg IV more on initial evening in ICU,
benzodiazepine intoxication felt to be responsible for much of
altered mental status. Benzos stopped and replaced with Zyprexa
to a maximum dose of 35mg daily with monitoring of QTc (407 on
last day of ICU stay). Patient continued on folate,
multivitamin, vitamin D and thiamine. Patient restarted on home
olanzapine 5 mg QAM and 15 mg QPM per psychiatry recs. EKG was
periodically monitored for prolongation of the QTc. He continued
to be agitated particularly at night and was started on
trazadone 100 mg QHS and mirtazepine 30 mg PO QHS. He improved
on this regimen. After originally planning to send the patient
to a dementia unit, eventually his brother made the decision to
take him home with 24 hour supervision at his home. Vitamin
supplementation was discontinued on discharge as patient is no
longer drinking alcohol. He will follow up frequently with his
PCP and will also follow up with cognitive neurology.
#. Hyponatremia: Patient presented with hyponatremia. He may
have been volume down at his nursing facility, esecially if he
has been agitated and unable to take PO. During his last
hospitalization, his sodium was well within normal limits.
Sodium corrected to low normal with maintenance fluids.
# Back pain- Patient has migratory low back pain without any
neurological deficits or signs of infection. This is a chronic
issue for Mr. [**Known lastname 62523**]. He was treated with ibuprofen, tylenol
and lidocaine patch, which helped.
Chronic Issues:
#. Hypertension: Continued home propranolol and lisinopril.
#. Essential tremor: Continued home proprnaolol.
#. Presumed CAD: Continued home aspirin.
#. Presumed BPH: Continued home tamsulosin.
#. Presumed GERD: Continued home omeprazole.
Transitional Issues:
- Olanzapine: maximum dose 30 mg daily in a 24 hour span
- Monitor QTc regularly (goal QTc < 500 ms)Qtc on [**2129-10-4**] 400
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY Start: In am
2. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]
3. FoLIC Acid 1 mg PO DAILY Start: In am
4. Lisinopril 10 mg PO DAILY
Hold for SBP < 100.
5. Multivitamins 1 TAB PO DAILY Start: In am
6. Omeprazole 20 mg PO DAILY Start: In am
7. Propranolol 20 mg PO BID Start: In am
Hold for HR < 60, SBP < 100.
8. Tamsulosin 0.4 mg PO HS
9. Thiamine 100 mg PO DAILY Start: In am
10. Vitamin D 400 UNIT PO DAILY Start: In am
11. Mirtazapine 15 mg PO HS
12. OLANZapine 5 mg PO QAM
13. OLANZapine 15 mg PO QPM
14. OLANZapine 5 mg PO BID:PRN agitation/psychosis
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]
RX *fluticasone 50 mcg 2 sprays intranasal twice a day Disp #*1
Unit Refills:*0
3. Lisinopril 10 mg PO DAILY
Hold for SBP < 100.
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
5. OLANZapine 15 mg PO QPM
RX *olanzapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Propranolol 20 mg PO BID
Hold for HR < 60, SBP < 100.
RX *propranolol 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
8. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
9. Mirtazapine 30 mg PO HS
RX *mirtazapine 30 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
10. OLANZapine 5 mg PO QAM
RX *olanzapine 5 mg 1 tablet(s) by mouth in the morning Disp
#*30 Tablet Refills:*1
11. traZODONE 100 mg PO HS
RX *trazodone 100 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
12. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg [**11-22**] tablet(s) by mouth every six (6)
hours Disp #*120 Tablet Refills:*0
13. Ibuprofen 600 mg PO Q8H:PRN back pain
RX *ibuprofen [Advil] 200 mg 3 tablet(s) by mouth every eight
(8) hours Disp #*120 Tablet Refills:*0
14. Outpatient Occupational Therapy
Patient needs outpatient OT, would recommend Cognitive Neurology
Department at Spauling.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary: Korsakoff's psychosis, back pain, agitation
Secondary: Hypertension, BPH, GERD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 62523**],
You were admitted to the hospital with confusion and agitation
from your rehabilitation hospital. You were seen by neurology
and psychiatry and your medications were changed. There was no
infection or new [**Last Name **] problem found. This may have been due to
a kind of medication called benzodiazepine. Your agitation and
confusion improved over the course of your hospitalization. You
also worked with physical therapy and occupational therapy. You
were treated with tylenol and ibuprofen for your back pain.
We really encourage you to abstain from alcohol. Any further
drinking will cause your mental status to deteriorate.
Medication changes:
Please take trazadone 100 mg at night
Please take mirtazepine 30 mg at night
Please take acetominophen 325-650mg every 6 hours as needed for
back pain (do not exceed 4 grams per day)
Please take Ibuprofen 600mg every 8 hours as needed for back
pain, must take with food to avoid stomach damage
Please stop taking Thiamine.
Please stop taking Vitamin D.
Please stop taking Folic acid.
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: MONDAY [**2129-10-10**] at 10:15 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12175**], MD [**0-0-**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: BIDHC [**Location (un) **]
When: WEDNESDAY [**2129-11-2**] at 2:45 PM
With: [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], MD [**0-0-**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: COGNITIVE NEUROLOGY UNIT
When: FRIDAY [**2129-11-18**] at 2:00 PM
With: DR. [**Last Name (STitle) **] & DR. [**Last Name (STitle) 15661**] [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: BIDHC [**Location (un) **]
When: FRIDAY [**2130-1-6**] at 1 PM
With: [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], MD [**0-0-**]
Building: [**Street Address(2) 1126**] ([**Location (un) **], MA) [**Location (un) 861**]
Campus: OFF CAMPUS Best Parking: On Street Parking
|
[
"571.2",
"584.9",
"724.2",
"530.81",
"333.1",
"600.00",
"276.1",
"414.01",
"401.9",
"303.90",
"291.1",
"E939.4",
"070.54",
"349.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10146, 10221
|
5091, 5375
|
302, 308
|
10352, 10352
|
3692, 4380
|
11633, 12953
|
2328, 2420
|
8415, 10123
|
10242, 10331
|
7739, 8392
|
10534, 11205
|
2460, 3673
|
7585, 7713
|
11225, 11610
|
230, 264
|
336, 1902
|
4389, 5068
|
10367, 10510
|
7320, 7564
|
1924, 2086
|
2102, 2312
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,158
| 138,239
|
18137
|
Discharge summary
|
report
|
Admission Date: [**2139-12-13**] Discharge Date: [**2140-1-21**]
Date of Birth: [**2119-11-6**] Sex: M
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old
gentleman who fell five feet off a porch with loss of
consciousness and unresponsiveness. The patient had been on
a week-long binge of heroin and ethanol.
The patient presented to an outside hospital unresponsive to
pain with stimulation and was intubated and paralyzed. A
head computed tomography showed a basilar skull fracture and
a subarachnoid hemorrhage. The patient was transferred to
[**Hospital1 69**] for further management.
PHYSICAL EXAMINATION ON PRESENTATION: On admission, the
patient's temperature was 99.6 degrees Fahrenheit and his
blood pressure was 145/palp. He was intubated and sedated
but was moving all four extremities spontaneously. He was
opening his eyes. His pupils were 2 mm down to 1 mm. His
lungs were clear to auscultation. He was bradycardic with a
regular rhythm. His abdomen was soft. The pelvis was stable.
Extremities with multiple tattoos. No abrasions. Spine with
no stepoff.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed the patient's white blood cell count
was 33.6, his hematocrit was 41.9, and his platelets were
377. The patient's Chemistry-7 revealed sodium was 142,
potassium was 3.7, chloride was 103, bicarbonate was 21,
blood urea nitrogen was 11, creatinine was 0.1, and his blood
glucose was 136.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no
pneumothorax.
A head computed tomography revealed a subarachnoid hemorrhage
and left frontotemporal contusion, and intraparenchymal
hemorrhage, and multiple basal skull fractures.
A computed tomography of the spine was negative.
A computed tomography angiogram of the head and neck revealed
no evidence of neurovascular injury.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Trauma Surgical Intensive Care Unit for close
neurologic and vital sign observation.
The patient had blossoming of contusions on repeat computed
tomography scan 24 hours after his admission. The patient
continued to move his extremities spontaneously and
purposefully. His pupils were 6 mm down to 3 mm and
symmetric. He was opening his eyes spontaneously.
On [**12-13**], the patient's condition deteriorated. He
became less responsive. A head computed tomography showed
further blossoming of contusions, and a ventricular drain was
placed on [**2139-12-14**].
On [**12-15**], the patient's intracranial pressure continued
to climb and his hydrocephalus was worse despite ventricular
drain placement. The patient was taken to the operating room
for evacuation of the subdural hematoma, the left
frontotemporal hematoma, and craniectomy.
Postoperatively, he lifted his lower extremities off the bed
to sternal rub with the left upper extremity. No movement of
the right upper extremity. Withdrew the lower extremity.
The right upper extremity was flaccid and areflexive. The
pupils were equal and reactive. The brain flap was very
tight.
On [**2139-12-17**], the patient was intubated, off propofol,
slightly sedated, withdrew his left upper extremity and lower
extremities to painful stimulation localized on the left.
There was still no movement of the right upper extremity.
The pupils were equal and reactive to light. He had a
diagnostic angio to rule out vascular malformation which was
ruled out. Postoperatively, the patient's condition was
stable.
On [**12-19**], the patient was still intubated and was moving
the left side spontaneously. His eyes were slightly open.
The pupils were 4 mm down to 3 mm. The gaze was not
conjugant. The brain flap was tense. We continued to be
monitored with a ventricular drain in place leveled at 10 cm
above the tragus. The patient continued to be worked up for
fevers. Currently on oxacillin for ventricular drain
coverage. The patient was on no other antibiotics at this
point. Levofloxacin was added for gram-negative blood
cultures that were positive from [**12-18**] and gram-negative
rods in his sputum. The cerebrospinal fluid remained
negative (culture wise).
On [**2139-12-22**], the patient had tracheotomy and
percutaneous endoscopic gastrostomy tube performed without
complications. Postoperatively, his vital signs were stable.
He continued to spike a temperature to 102.3 degrees
Fahrenheit. He had Enterobacter grow out from his blood
cultures from [**12-18**] and Staphylococcus aureus from his
sputum from [**12-18**]. The cerebrospinal fluid continued to
remain stable and without infection on the tracheostomy mask.
On [**2139-12-24**] off the ventilator, his vital signs
remained stable. He continued to be awake. He was moving
the left side spontaneously. The right side with a right
facial droop and was moving right upper extremity slightly.
He was following commands on the left side, localizing in the
right upper extremity. He continued to improve
neurologically. Santalol was discontinued on [**2139-12-25**].
On [**12-29**], the ventricular drain was raised to 18 cm
above the tragus. The patient tolerated this well. He
remained neurologically awake and alert. He was following
commands in all extremities. The patient was opening his
eyes.
On [**1-1**], the patient spiked a temperature to 102.1
degrees Fahrenheit and was fully cultured. The patient had
2+ gram-positive cocci in his sputum. Urine cultures were
pending. Blood cultures were pending. The patient was
started on vancomycin for gram-positive cocci in his sputum,
and oxacillin was discontinued. The patient was awake and
alert. He was following commands and was moving all
extremities spontaneously and purposefully. The brain flap
was soft but prominent. The patient's ventricular drain was
clamped at this point (on [**2140-1-3**]). On [**1-4**], the patient pulled out his ventricular drain. It was
replaced without complications.
The patient was taken to the operating room on [**2140-1-9**] for cranioplasty and replacement of bone flap. The
patient tolerated the procedure well. Postoperatively, the
patient remained neurologically stable status post
cranioplasty and status post bone flap replacement. He
tolerated that without any changes in his neurologic status,
and his ventricular drain was eventually clamped and
discontinued. The ventricular drain was discontinued on
[**2140-1-13**] along with the [**Location (un) 1661**]-[**Location (un) 1662**] drain that was
in place. The patient was seen by the [**Hospital 878**]
Rehabilitation Service and was followed by the Physical
Therapy Service and Occupational Therapy Service.
He was transferred to the regular floor on [**2140-1-14**].
He has remained neurologically stable to date. He was
alert, awake, and oriented times three. He was moving all
extremities. He was walking with some assistance. His vital
signs have been stable. He has been afebrile. His
gastrojejunostomy tube had been removed. His Foley catheter
was out. He was voiding spontaneously. He was tolerating a
regular diet and walking with some assistance.
DISCHARGE DISPOSITION: The patient was to be discharged to
the [**Hospital **] Hospital with followup with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**] in
one month. The patient's staples should be removed on
postoperative day fourteen from his cranioplasty surgery
incision (which was on [**2140-1-9**]).
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
MEDICATIONS ON DISCHARGE: (His medications at the time of
discharge included)
1. ? one to two tablets by mouth q.4h. as
needed.
2. Colace 100 mg by mouth twice per day.
3. Trazodone 50 mg by mouth at hour of sleep as needed.
4. Levofloxacin 500 mg by mouth q.24h.
5. Lacri-Lube one application both eyes four times per day
as needed.
6. Artificial Tears 1 to 2 drops both eyes as needed.
7. Famotidine 20 mg by mouth twice per day.
8. Metoprolol 50 mg by mouth three times per day (hold for a
heart rate of less than 60 or blood pressure less than 100).
9. Heparin 5000 units subcutaneously q.12h.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2140-1-21**] 09:30
T: [**2140-1-21**] 09:28
JOB#: [**Job Number 50164**]
|
[
"041.04",
"331.4",
"305.60",
"790.7",
"E882",
"801.16",
"305.00",
"305.50",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"96.72",
"02.06",
"99.04",
"43.11",
"31.1",
"96.6",
"97.29",
"99.07",
"02.2",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
7182, 7495
|
7587, 8426
|
1928, 7158
|
7510, 7560
|
174, 1899
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,707
| 123,293
|
16654
|
Discharge summary
|
report
|
Admission Date: [**2172-1-20**] Discharge Date: [**2172-1-20**]
Service: SICU
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old
female with a history of diverticulitis status post sigmoid
colectomy, total abdominal hysterectomy, bilateral
salpingo-oophorectomy, appendectomy, femoropopliteal bypass x
3, transferred from an outside hospital with worsening
abdominal pain and urinary tract infection. The patient was
taken to the operating room from the emergency room for
exploratory laparotomy, gastrostomy and jejunostomy tube
placement, during which she was given 3.5 liters of
intravenous fluids and 3 units of packed red blood cells.
The patient had an arterial cutdown over the left radial arm
that resulted in decreased perfusion to the left hand and the
line was pulled. The patient had dopamine started in the
emergency room. She was admitted to the surgical intensive
care unit for postoperative management.
PAST MEDICAL HISTORY: Peripheral vascular disease,
hypercholesterolemia, and spinal stenosis.
PAST SURGICAL HISTORY: Sigmoid colectomy in [**2168**] with
Hartmann's pouch, total abdominal hysterectomy, appendectomy,
right femoropopliteal bypass x 2, left total hip replacement,
and left femoropopliteal bypass.
MEDICATIONS: Lipitor, Vioxx and Tylenol.
SOCIAL HISTORY: Positive tobacco, positive alcohol use.
ALLERGIES: The patient has no known drug allergies..
PHYSICAL EXAMINATION: Vital signs showed a blood pressure of
115/38, heart rate 87, respiratory rate 22, mechanical
ventilation, SIMV, tidal volume of 550, respiratory rate 9 on
100% FIO2. In general she was elderly and intubated. Head,
eyes, ears, nose and throat examination showed pupils to be 8
mm bilaterally reactive; nasogastric tube in place; positive
gag. Chest examination showed coarse breath sounds. Abdomen
was soft with silent bowel sounds. Dressing was clear, dry
and intact. Extremities showed the right hand to be blue
with negative Doppler pulses in the upper extremities.
Neurologic examination showed her to be following commands,
minimally sedated.
LABORATORY DATA: White count was 3.9, hematocrit 40,
platelet count 160, sodium 147, potassium 3.4, chloride 110,
bicarbonate 21, BUN 39, creatinine 1.5, glucose 75, INR 1.9,
calcium 8.2, phosphorous 4.4, magnesium 1.9, CPK 2720, MB
index 3.3, troponin 1.8, ALT 1,981, AST 4,108, alkaline
phosphatase 82, total bilirubin 1.5.
EKG showed sinus rhythm. Transthoracic echocardiogram
demonstrated an ejection fraction of less than 20% with
global hypokinesis.
HOSPITAL COURSE: The patient is an elderly female with a
history of peripheral vascular disease admitted with acute
abdomen and taken emergently to the operating room. The
patient rapidly developed a worsening lactic acidosis
requiring multiple pressors for blood pressure support as
well as large amounts of fluid resuscitation. The patient
had a Swan-Ganz catheter placed for improved hemodynamic
monitoring. The patient's hand improved with attempts at
papaverine as well as warming and improved blood pressure
control. The patient's lactic acidosis continued to worsen
and blood pressure remained marginal despite aggressive
hydration and pressor support. The patient suffered a PA
arrest and bilateral chest tubes were placed with improved
hemodynamics. Dr. [**Last Name (STitle) 957**] held a family discussion with Ms.
[**Known lastname 16643**] daughter and son and the decision was to make her
DNR/DNI and to withdraw support per the family.
DISCHARGE STATUS: To funeral home.
DISCHARGE CONDITION: Expired.
FINAL DIAGNOSES:
1. Sepsis.
2. Ischemic bowel.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern1) 16516**]
MEDQUIST36
D: [**2172-1-20**] 20:13
T: [**2172-1-24**] 10:08
JOB#: [**Job Number 47161**]
|
[
"427.31",
"038.49",
"599.0",
"443.9",
"276.2",
"272.0",
"560.2",
"557.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.39",
"38.91",
"38.93",
"46.73",
"54.59",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
3603, 3613
|
2603, 3581
|
1096, 1334
|
3630, 3905
|
1470, 2585
|
106, 123
|
152, 976
|
999, 1072
|
1351, 1447
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,464
| 150,428
|
33747
|
Discharge summary
|
report
|
Admission Date: [**2197-9-18**] Discharge Date: [**2197-9-26**]
Date of Birth: [**2170-11-12**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
low back pain
Major Surgical or Invasive Procedure:
First thoracolumbar laminectomy for decompression and
resection with Microscopic resection and Duraplasty.[**2197-9-21**]
History of Present Illness:
This is a 26 year old female with history of schwannomatosis
status post five resections from [**10-3**] - [**5-6**] who recently
completed CyberKnife stereotactic
radiation therapy to the left cerebellopontine angle resection
site on [**2197-8-10**] who presented to the Emergency Department with
acute low back pain. She stated that the pain began the day
prior to admission, but was much worse the day of admission.
The pain was in her lower back and radiated to her bilateral
anterior thighs. It was both stabbing and dull and was [**9-4**] in
intensity. She also reported it had caused weakness as she was
unable to get off of it the toliet earlier. The pain was
exacerbated by sudden movements or having to lay flat.
In the ER, she received Morphine 16mg IV, Valium 10mg,
Gabapentin 300mg, Oxycodone 5mg, Toradol 30mg, and Dilaudid 4mg
IV and was sent for MRI. She was unable to tolerate the scan.
When she returned to the ER, she received an additional 2mg IV
dilaudid, afterwhich she was drowsy, and sent for MRI again, but
again could not tolerate it. On the floor, she had [**4-4**] pain in
her low back pain and was tired but otherwise had no complaints.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies arthralgias or myalgias. Denies
rashes or skin breakdown. No other numbness/tingling in
extremities. All other systems negative.
Past Medical History:
Past Medical History:
anemia, chronic constipation, cesarean section
(1) surgical resection of a left vestibular schwannoma by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2194-10-3**],
(2) surgical resection of a schwannoma from the proxiimal right
median nerve at the arm level by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2195-2-13**],
recurrance at this site will likely require additional
ressection.
(3) surgical resection of an L4 intradural schwannoma by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2195-9-11**],
(4) surgical resection of a sacral schwannoma at [**Hospital6 2121**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 78069**] on [**2197-2-13**],
(5) surgical resection of a recurrent left vestibular schwannoma
by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on [**2197-5-10**], and
(6) received from [**2197-6-26**] to [**2197-8-10**] CyberKnife stereotactic
radiation therapy to the left cerebellopontine angle resection
site to 5400 cGy (180 cGy x 30 fractions).
(7) Right supraclavicular schwannoma scheduled for resection
Past Surgical History: She had a cesarean section in [**2192**].
Social History:
She is disabled. She lives with her husband and [**Name2 (NI) **] in
[**Name (NI) 34697**]. She smokes 1 pack of cigarettes per day for 6
years. She has one alcoholic drink per month. She does not use
illicit drugs.
Family History:
Her mother is 47 years of age and she has
schwannomatosis; her mother is of Italian, Irish, and French
descent. Her father is 46 years of age but she has no
information about his health; her father is [**Name (NI) **] [**Name (NI) 14285**]. She
has 2 brothers, age 29 and 20, and they do not have any
schwannoma. She has a 4-year-old [**Name (NI) **] and she is healthy.
Physical Exam:
VS: T97.6 bp 108/76 hr 76 rr 14 SaO2 100 on RA
GEN: Young woman in NAD, awake, alert, interactive
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ DP/PT bilaterally
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, CN II-XII intact, [**3-30**]
strength throughout, intact sensation to light touch
PSYCH: appropriate, slightly anxious
PHYSICAL EXAM UPON DISCHARGE:
The patient is alert and oriented to person place and time.
Face is symetric. Strength is [**3-30**] in all muscle groups.
Sensation is intact. No Clonus.incision is healing well-
disolvable suture are in place. No drainage No erythema, No
edema. The patient denies pain . She is tolerating a regular
diet. She denies recent bowel movement + Flatus.
Pertinent Results:
[**2197-9-17**] 06:00PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2197-9-17**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2197-9-17**] 03:47PM GLUCOSE-88 UREA N-6 CREAT-0.6 SODIUM-140
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
[**2197-9-17**] 03:47PM WBC-7.3 RBC-3.89* HGB-11.4* HCT-33.3* MCV-86
MCH-29.2 MCHC-34.1 RDW-13.2
[**2197-9-17**] 03:47PM NEUTS-63.6 LYMPHS-31.0 MONOS-3.4 EOS-1.7
BASOS-0.3
[**2197-9-17**] 03:47PM PLT COUNT-250
MR L- Spine /T-SPINE W &W/O CONTRAST Study Date of [**2197-9-24**] 3:58
PM
Radiology Read Postsurgical changes status post T12-L1 resection
of two spinal
schwannomas. There is a persistent 9mm enhancing lesion in the
terminal spinal cord at L1 level representing a residual
schwannoma.
ECG Study Date of [**2197-9-19**] 9:13:02 AM Sinus rhythm. Compared to
the previous tracing of [**2197-5-11**] there is ST-T wave
flattening and slight ST segment depression which is new as well
as T wave inversion and biphasic T waves in leads V3-V4 which
may represent active anteroapical ischemia. Followup and
clinical correlation are suggested.
MRA THORACIC SPINE Study Date of [**2197-9-20**] 9:59 AM Radiology
ReadIMPRESSION:
Several small tortuous vessels are identified in the vicinity of
the enhancing masses in the lower thoracic/upper lumbar region.
Though it is, even on the arterial phase, difficult to
distinguish arteries from veins, there are no dominant or
enlarged feeding vessels identified.
L-SPINE (AP & LAT) IN O.R. Study Date of [**2197-9-21**] 8:57 AM
FINDINGS AND IMPRESSION: Lateral views of the lumbar spine.
Surgical
instruments are seen posterior to the L3 and L2 vertebral
bodies. Status post T12-L2 laminectomy.
[**2197-9-24**] 09:10AM BLOOD WBC-13.9* RBC-3.53* Hgb-10.7* Hct-30.7*
MCV-87 MCH-30.4 MCHC-34.9 RDW-13.1 Plt Ct-294
[**2197-9-19**] 03:00AM BLOOD PT-13.0 PTT-26.7 INR(PT)-1.1
[**2197-9-24**] 09:10AM BLOOD Plt Ct-294
[**2197-9-24**] 09:10AM BLOOD Glucose-155* UreaN-11 Creat-0.4 Na-137
K-4.3 Cl-97 HCO3-34* AnGap-10
[**2197-9-24**] 09:10AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
Brief Hospital Course:
A/P: Pt is a 26 Y F with history of schwannomatosis s/p 5
resections from [**10-3**] - [**5-6**] who recently completed CyberKnife
stereotactic
radiation therapy to the left cerebellopontine angle resection
site on [**2197-8-10**] who presents to the ER with acute low back pain.
#Acute low back pain
- Will need to obtain MRI to eval for cord compression
- Neurosurgery consult when MRI is obtained
- Strict bedrest pending result
- Empiric Decadron pending MRI (10mg IV on AM [**9-18**] then 4mg q6)
- If unable to control pain with IV narcotics safely, may
consider anesthesia support
- NPO in case patient will requite urgent surgery
#Schwannomatosis
- s/p CyberKnife stereotactic radiation therapy to the left
cerebellopontine angle resection site on [**2197-8-10**]
- Planning on having right supraclavicular mass and right median
nerve mass possibly resected surgically in the future
#Neuro - pain control
- Continue Fentanyl patch
- IV Dilaudid for breakthrough
#Endocrine - amenorrhea for 2 months, question of pituitary
abnormality
- Check TSH, prolactin
- PPI while on decadron
- Monitor AM glucose, not initiating insulin at this time
- Calcium and Vit D when no longer NPO
#Prophylaxis - Venodynes, bowel regimen
#FULL CODE
On [**9-19**] she was transferred to the [**Hospital Ward Name **] SICU on the
Neurosurgical service. She underwent an MRI/MRA with anesthesia
for preoperative planning on [**9-20**] and was prepped for surgery.
On [**9-21**] she went to the operating room and underwent a T12-L2
laminectomy resection of intradural tumor. Please review
dictated operative report for details. Patient was extubated
without incident and transferred to SICU in stable condition.
She was maintained on flat bed rest for 48 hours. Pt tolerated
advance in her diet and pain was controlled on Diluadid PCA.
Pt advanced to sit up position on [**9-23**] without problems however
pain control continued to be an issue. She was transitioned
from Dilaudid PCA to an oral PRN regimen. Muscle relaxants were
increased and Valium was added for night time pain relief.
She was seen by PT and OT who felt that she would be safe for
discharge home.
On [**9-25**] her fentayl patch was increased to 100mcg and a Lumbar
Corset was obtained for comfort.
On [**9-26**],the day of discharge. The patient is afebrile:
98.7-87-99/62 RR 20 o2sat 100% and neurologically stable.
Patient's pain is well-controlled and the patient is tolerating
a good oral diet. The incision is closed with disolvable
sutures and is clean, dry and intact without evidence of
infection. The patient denies recent bowel movement , but +
flatus. She is ambulating independently
Medications on Admission:
DIAZEPAM - 2 mg Tablet - 1 Tablet(s) by mouth at night for
severe
muscle spasm
FENTANYL [DURAGESIC] - 75 mcg/hour Patch 72 hr - one patch every
72 hours
GABAPENTIN - 300 mg Capsule - 2 Capsule(s) by mouth three times
daily
OXYCODONE-ACETAMINOPHEN - 10 mg-325 mg Tablet - 1 Tablet(s) by
mouth every six (6) hours as needed for Pain
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*180 Capsule(s)* Refills:*0*
2. methocarbamol 500 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
Disp:*270 Tablet(s)* Refills:*0*
3. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
4. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*100 Tablet(s)* Refills:*0*
5. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*140 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Shwanomatosis
T12-L1 intradural tumors
constipation
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? Dressing may be removed on Day 2 after surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**6-4**] days (date of your surgery
[**2197-9-21**]) for a of your wound check as you have disolvable
sutures and will not need these removed. This appointment can be
made with the Nurse Practitioner. Please make this appointment
by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 6 weeks.
Completed by:[**2197-9-26**]
|
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66,823
| 168,512
|
45531
|
Discharge summary
|
report
|
Admission Date: [**2162-11-22**] Discharge Date: [**2162-11-30**]
Date of Birth: [**2081-12-20**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2042**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 80 year old male with history of
bronchoalveolar carcinoma undergoing chemotherapy with
gemcitabine, CAD s/p stent placement, DMII, OSA on CPAP,
presenting with chief complaint of shortness of breath and
hypoxia for 1 week. The patient reports that he frequently uses
a home O2 monitor along with his CPAP. Over the last few days,
this O2 monitor has been demonstrating readings in the low 80s.
He typically only uses O2 in the evenings (6L), but over the
last few days has been using O2 continuously. The patient also
endorses worsening dyspnea, both on exertion and at rest over
the last week. As of a few weeks ago, he was able to walk on a
treadmill for ~5 minutes without significant SOB. Over the last
few days, he has spent most of his time in bed. Endorses
increase in cough over last week, with mild sputum production.
No fevers or chills. No sick contacts at home.
Of note, the patient began chemotherapy with Gemcitabine on
[**11-9**]. He
received 1000 mg/m2 on days 1,8, and had planned for day 15.
In the ED inital vitals were, HR 78, O2 80% RA. Labs were
significant for WBC 2.4 (baseline [**6-1**]), plts 107 (baseline
200s), lactate 1.6, and Cr 1.3 (baseline). CXR showed worsening
mid to lower lung ground-glass opacities which may reflect
worsening bronchoalveolar carcinoma versus superimposed
pneumonia. EKG was unchanged from prior. The patient was given
cefepime X 1 and vancomycin X 1 for presumed HCAP. He was also
given albuterol and ipratropium nebs X 1. Vitals at the time of
transfer were: 98.0 80 109/49 22 90 6L (Pt baseline at home
90-92 on [**4-30**] L)
On arrival to the ICU, the patient's VS: 97.9 81 111/65 24 94%
NRB 15L O2. He reports ongoing cough with mild sputum
production.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Past Oncologic History:
Dr. [**Known lastname 97128**] is a 78-year-old man with bronchoalveolar carcinoma
diagnosed in [**4-3**]. CT scan done on [**2160-4-1**], while admitted for
treatment for pneumonia, demonstrated widespread ground-glass
opacities, more severe in the right lower lobe with increased
number of mediastinal lymph nodes. A transbronchial biopsy on
[**2160-4-3**] showed a pathology suspicious for bronchioalveolar
carcinoma. A PET scan done on [**2160-4-17**] showed a FDG-avid area of
lobar ground glass opacity with bowing of the intralobar fissure
involving the right lower lobe compatible with history of
pneumonic type bronchoalveolar carcinoma, though given high
avidity may represent superinfection in this region. He also had
interval improvement in the left lower lobe and right middle
lobe ground-glass opacity since the chest CT from [**2160-4-1**]. MRI
brain [**2160-4-17**] did not show any evidence of metastases. He was
followed clinically for several months, but he was hospitalized
frequently for pneumonia and ultimately for altered mental
status
in [**11-3**]. An MR of his head at that time showed new cortical
T2/FLAIR-hyperintensity along the medial aspect of the left
frontal lobe, and extending along the base of the left frontal
lobe and the orbitofrontal gyrus in the anterior cranial fossa.
He started therapy with Alimta [**2160-12-9**] and had a dramatic
clinical improvement but stable imaging findings.
Other Past Medical History:
1. Diabetes mellitus type 2, on glipizide and metformin.
2. Coronary artery disease, s/p MI [**2139**], and s/p stenting in
[**2149**].
3. Bladder cancer, followed by [**Doctor Last Name **].
4. Obstructive sleep apnea on CPAP.
5. Hypertension.
6. Hyperlipidemia.
7. Allergic rhinitis.
8. Status post right total knee replacement.
9. Chronic back pain/spinal stenosis s/p L4/L5 laminectomy in
[**2113**].
10. Status post right ulnar impingement release.
11. Erectile dysfunction.
12. History of erysipelas with chronic right lower extremity
skin changes.
13. GERD.
14. Depression.
15. Bronchoalveolar carcinoma, Dx [**2160-3-26**], on chemotherapy.
Social History:
He lives with his wife. They are independent for all of their
activities of daily living. He was a three-pack-per-day smoker
until his early 20's (15-20 pack-year hx). He does not drink or
use drugs. He is still occasionally working as a psychiatrist,
but is not working presently.
Family History:
Lymphoma in his father, mother with rectal cancer. Both parents
had heart disease. Other relatives had diabetes mellitus.
Physical Exam:
Admission Exam:
Vitals: 97.9 81 111/65 24 94% NRB 15L O2
General: Alert, oriented, speaking in full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Course breath sounds scattered bilaterally. Good air
entry.
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
Pertinent Results:
[**2162-11-22**] 03:00PM BLOOD WBC-2.4* RBC-3.79* Hgb-12.3* Hct-35.8*
MCV-95 MCH-32.4* MCHC-34.2 RDW-13.5 Plt Ct-107*
[**2162-11-22**] 03:00PM BLOOD Neuts-50.1 Lymphs-44.0* Monos-1.4*
Eos-3.6 Baso-0.9
[**2162-11-22**] 03:00PM BLOOD Glucose-129* UreaN-27* Creat-1.3* Na-140
K-3.7 Cl-105 HCO3-26 AnGap-13
[**2162-11-22**] 03:00PM BLOOD LD(LDH)-187
[**2162-11-23**] 03:31AM BLOOD Calcium-9.5 Phos-2.4* Mg-1.5*
[**2162-11-22**] 10:43PM BLOOD Type-ART pO2-55* pCO2-29* pH-7.47*
calTCO2-22 Base XS-0
[**2162-11-22**] 03:09PM BLOOD Lactate-1.6
CXR [**2162-11-22**]:
FINDINGS: PA and lateral views of the chest were obtained. There
is interval increase in ground-glass opacities involving the
bilateral lower lungs which is concerning for interval
progression of bronchoalveolar carcinoma though the possibility
of a superimposed pneumonia is impossible to exclude. No large
effusions or pneumothorax. Cardiomediastinal silhouette is
normal. Bony structures appear grossly intact.
IMPRESSION: Worsening mid to lower lung ground-glass opacities
which may
reflect worsening bronchoalveolar carcinoma versus superimposed
pneumonia. Recommend followup post-treatment films.
CTA [**2162-11-23**]:
MEDIASTINUM: Pulmonary artery proximal to the bifurcation
measures 26 mm and is normal in caliber. No filling defects
within main, lobar, segmental, or subsegmental branches of
pulmonary arteries to suggest pulmonary embolism.
Heart is normal in size without pericardial effusion. There is
no septal
bulge or right heart strain. Atherosclerotic calcification in
the coronary
arteries is moderate to severe. The thyroid gland is normal.
Borderline
sized lymph nodes and multiple other small nodes which do not
meet CT size
criteria for pathological enlargement are unchanged since
[**2162-10-14**].
AIRWAYS AND LUNGS: Airways are patent to subsegment bronchi.
Allowing for
differences in CT technique, since [**2162-10-14**], multifocal
ground-glass opacities predominantly in bilateral lower lobe
have progressed, which is marked in left lower lung. Given that
known multifocal BAC has been slowly progressing, this short
interval increase in opacities is more likely a result of
superimposed aspiration or infection or hemorrhage. Interval
progression of lung malignancy is less likely.
ABDOMEN: ThiS study is not designed for assessment of
subdiaphragmatic
pathologies; however, limited views are unremarkable. Adrenal
glands are
normal in morphology.
BONES: D3 and D7 vertebral bodies demonstrating mild wedging and
endplate
sclerosis is unchanged. Degenerative changes at multiple
vertebral levels are present. No bone lesion suspicious for
malignancy.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Interval progression of bilateral ground-glass opacities,
predominantly in the left lower lobes since [**2162-10-14**] is
likely from aspiration or infection or hemorrhage. Malignancy is
less likely considering short duration and prior imaging history
demonstrating slow disease progression of multifocal BAC.
.
ECG [**2162-11-22**];Normal sinus rhythm. Q waves in leads II, III and
aVF. J point elevation in leads II, III, aVF and V5-V6.
Consider prior inferior wall myocardial infarction. Compared to
the previous tracing of [**2160-12-27**] no diagnostic interval change.
.
Discharge Labs from [**2162-11-30**] (unless otherwise noted):
137 | 107 | 24 |
----------------< 297
4.7 | 25 | 1.1
CA [**60**].1
Mg 1.9
P 2.5
ALT 38
AST 35
AP 78
TB 0.2
4.9 > 37.1 < 401
[**2162-11-29**] vanco trough 16.4
Brief Hospital Course:
The patient is an 80 year old male with history of lung cancer
undergoing chemotherapy with gemcitabine, CAD s/p stent
placement, DMII, OSA on CPAP, presenting with chief complaint
of shortness of breath and hypoxia for 1 week.
.
# Hypoxia/pneumonia:Chest CTA done and was negative for a PE but
did show bilateral infiltrate suggestive of bilateral pneumonia
although progression of disease is also a possibility. Pt was
initially admitted to the [**Hospital Ward Name 332**] Intensive Care Unit and treated
with Vancomycin, Cefepime, Levofloxacin and Oseltamavir.
Continued CPAP overnight per home protocol. Influenza swab
negative and oseltamavir discontinued. Legionella Ag negative.
Blood cultures remained negative. B-glucan was 66 (low
intermediate) and informal infectious disease consult
recommended repeating test which is pending at the time of
discharge.
.
# Bronchoalveolar carcinoma: Recently started on gemcitabine
after progressing on pemetrexed. Continuing to hold therapy at
the time of discharge until his pulmonary status has improved.
.
#ARF: Developed a transient increase in cre to 1.6 and mild
hyperkalemia to K=5.2 on hospital day 7 that appeared to be
pre-renal exacerbatd by polyuria from elevated blood sugars. Cre
resolved to 1.1 with with gentle hydration.
.
#Thrombocytopenia - Secondary to chemotherapy. Nadir = 61k on
[**2162-11-25**]. Resolved by the time of discharge and did not require
transfusion.
# CAD: No EKG changes. No chest pain. Continued home ASA,
metoprolol succinate, and diltiazem.
.
# Diabetes: Covered with insulin sliding scale. Held metformin
and glipizide while in the hospital.
.
# Depression. Continued home Bupropion.
.
# GERD. Continued home ranitidine.
Medications on Admission:
BUPROPION HCL ER - 300 mg by mouth qAM
CLONAZEPAM - 1 mg by mouth at bedtime
DILTIAZEM HCL ER - 180 mg by mouth once a day
FOLIC ACID - 1 mg by mouth daily
GLIPIZIDE - 5 mg Tablet - 2 Tablet by mouth twice a day 10 AM;
5 PM
ISOSORBIDE MONONITRATE - 120 mg - 1 Tablet by mouth once a day
METFORMIN - 850 mg Tablet - 1 Tablet by mouth twice a day
METOPROLOL SUCCINATE - 50 mg by mouth once a day
ONDANSETRON HCL - 8 mg by mouth every eight as needed for nausea
RANITIDINE HCL - 300 mg by mouth daily
ROSUVASTATIN - 20 mg by mouth once a day
ACETAMINOPHEN - 500 mg, 2 Tablet(s) by mouth twice a day
ASPIRIN - 81 mg by mouth once a day
DIPHENHYDRAMINE HCL - 25 mg, 2 Capsule(s) by mouth at bedtime
GUAIFENESIN - Dosage uncertain
LORATADINE - 10 mg by mouth once a day
Discharge Medications:
1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day: Hold for SBP < 100 or
HR < 50.
4. folic acid 1 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 once a day: Hold for
SBP < 100 or HR < 50.
6. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: Hold
for SBP < 100.
7. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 9 days.
11. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours) for 2 days: intravenous
reconstituted solution.
12. cefepime 2 gram Recon Soln Sig: Two (2) grams Injection Q12H
(every 12 hours) for 2 days: intravenous reconstituted solution.
13. insulin regular human 100 unit/mL Solution Sig: sliding
scale see attached Injection QACHS: see attached sliding scale.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for loose stools.
15. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours for 7 days: Begin after completion of Cefepime
and Vancomycin.
16. Outpatient Lab Work
Check chem 10 and vancomycin trough in AM, [**Name8 (MD) 138**] MD to adjust
vancomycin dose
17. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
18. Continue
CPAP at night per home protocol
19. COntinue
oxygen 5L nasal cannula, titrate as possible
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
bilateral pneumonia
lung cancer
acute renal failure
thrombocytopenia-drug induced
diabetes non insulin dependent
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:
Dr [**Last Name (STitle) **], you were admitted because of shortness of breath and
hypoxia. You were initially admitted to the intensive care
unit.A chest CT angio scan showed no evidence of a blood clot
but did show that you had pneumonia.You were treated with broad
spectrum antibiotics for the pneumonia. Your breathing improved
and you were transferred to the oncology service. You will
continue on IV antibiotics for the next 2 days and then complete
a 7 day course of oral antibiotics. At the time of your
discharge to [**Hospital6 459**] for the Aged you are still
requiring 5L oxygen by nasal cannula.
.
The following changes have been made to your medications:
HOLD Loratadine 10 mg daily
HOLD Diphenhydramine 50 mg at bedtime
HOLD Glipizide 10 mg twice daily at 10am and 5pm
HOLD Metformin 850 mg twice daily
CONTINUE Insulin Sliding Scale until your rehabilitation
physician feels it is safe for you to resume your Glipizide and
Metformin
CONTINUE Vancomycin IV for two more days
CONTINUE Cefepime IV for two more days
CONTINUE Levofloxicin by mouth every other day for 9 days total
(~4-5 doses)
START Cefpodoxime twice daily for a full 7 days after you
complete Vancomycin and Cefepime
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2162-12-7**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], 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 [**2162-12-7**] at 10:00 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V43.65",
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"327.23",
"530.81",
"276.7",
"287.49",
"V45.82",
"162.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13742, 13827
|
9237, 10958
|
303, 310
|
13984, 13984
|
5708, 9214
|
15392, 16035
|
5018, 5141
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|
13848, 13963
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10984, 11751
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2095, 2543
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256, 265
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338, 2076
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13999, 14143
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4053, 4703
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4719, 5002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 192,256
|
22420
|
Discharge summary
|
report
|
Admission Date: [**2132-8-4**] Discharge Date: [**2132-8-6**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Prochlorperazine / Tramadol
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
27 year old female PMHx T1DM, gastroperesis, grade1 varices on
recent EGD [**1-/2132**], chronic LBP [**1-2**] MVC in [**2129**], and recent
admission for DKA that was complicated by a right-sided
pneumothorax presenting with an acute non-traumatic worsening of
lower back pain. In addition, the patient complains of nausea
and vomiting x10 today. No clinical features to suggest acute
abd process including aortic dissection or infectious processes
including epidural abscess or acute spinal cord impingement.
Reassuring that this is per the pt identical to prior
exacerbations.
There are no features on exam to suggest respiratory distress or
tension pneumothorax. She also complained low back pain that was
relieved. Based on review of prior EGD report, she does have
known grade 1 varices.
.
ED course: HR132 BP171/116 O2 100%/RA. She vomited 20cc of
coffee ground emesis. She refused NGT lavage. Groin line was
placed and PIV. She was given 2L NS IVF and 3mg IV dilaudid for
pain, reglan for gastroparesis. EKG negative for ischemic
changes or QT prolongation.
In addition to the lower back pain, patient is noted to be
actively retching with approximately 10-20 cc of coffee-ground
emesis.
EKG: no changes or QT prlongation. She was started on a protonix
gtt
octreotide gtt.
.
On the floor, she reports that she felt unwell since this AM
with back pain and began to experience vomiting clear liquid
around noon and presented to the ED. Once she arrived here she
vomited small amount of coffee ground emesis. Denies frank
hematemesis, abd pain, diarrhea. Nausea and vomiting now
resolved. Has had occasional chills, subjective fevers. Denies
EtOH, drugs or recent tobacco use. Passing flatus. Last BM on
[**Year (4 digits) 2974**], stools every 3-4 days at baseline. Of note pt states
that she has been under high levels of emotional stress as she
has been having high anxiety states and panic attacks
surrounding sexual abuse flashbacks from age 11yo. She declines
social work consult currently.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
- Diabetes mellitus type I: diagnosed age 16 in [**2120**] after her
first pregnancy. followed at [**Last Name (un) 387**].
- Severe anxiety/panic attacks
- Previous admissions for nausea/vomiting with h/o esophagitis
and with concern for diabetic gastroparesis on metoclopramide
- Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**]
- Stage I diabetic nephropathy
- Grade I esophageal varices seen on scope in [**2132-1-1**],
negative liver ultrasound, normal LFTs, hep panel negative
- Anxiety/panic attacks
- Depression
- Hyperlipidemia
- S/P MVA [**5-3**] - lower back pain since then.
- S/P MVA [**2130**], ex-lap
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
- Genital Herpes
- H pylori, s/p 2-week triple therapy on [**2132-1-24**]
.
Social History:
Lives with her 9 yo son. On disability.
- Tobacco: quit "years ago"
- Alcohol: [**12-2**] glasses wine or champagne at holidays/special
occasions (none recently)
- Illicits: none, denies IVDU
Family History:
Grandmother with diabetes, no other significant family history
Physical Exam:
Admission Physical
Vitals: T:98.0 BP:138/78 P:109 R: 17 O2:98/RA
General: Alert, oriented, thin AA female, sitting in bed, no
acute distress
[**Month/Day (2) 4459**]: Sclera anicteric, oral mucosa pink/dry, 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, R groin line in place
Pertinent Results:
[**2132-8-3**] 03:30AM [**Month/Day/Year 3143**] WBC-7.6 RBC-2.93* Hgb-8.7* Hct-25.1*
MCV-86 MCH-29.6 MCHC-34.4 RDW-13.4 Plt Ct-185
[**2132-8-6**] 08:05AM [**Month/Day/Year 3143**] WBC-7.5 RBC-3.39* Hgb-9.5* Hct-29.4*
MCV-87 MCH-28.1 MCHC-32.3 RDW-13.9 Plt Ct-292
[**2132-8-4**] 11:12PM [**Month/Day/Year 3143**] PT-12.9 PTT-25.2 INR(PT)-1.1
[**2132-8-3**] 03:30AM [**Month/Day/Year 3143**] Glucose-250* UreaN-11 Creat-1.1 Na-136
K-3.4 Cl-100 HCO3-30 AnGap-9
[**2132-8-6**] 08:05AM [**Month/Day/Year 3143**] Glucose-278* UreaN-10 Creat-1.0 Na-134
K-4.4 Cl-99 HCO3-27 AnGap-12
[**2132-8-5**] 03:22AM [**Month/Day/Year 3143**] ALT-10 AST-14 AlkPhos-54 TotBili-0.4
CHEST (PA & LAT) Study Date of [**2132-8-4**] 9:41 PM
FINDINGS: The lungs are well expanded and clear. The mediastinum
is
unremarkable. The cardiac silhouette is within normal limits for
size. No
effusion or pneumothorax is noted. The osseous structures are
unremarkable.
IMPRESSION: No acute pulmonary process. No recurrent
pneumothorax seen.
.
.
CHEST (PORTABLE AP) Study Date of [**2132-8-3**] 5:10 PM
HISTORY: Chest tube pulled.
FINDINGS: The right-sided chest tube has been removed. There is
no
pneumothorax. The lungs are clear.
.
.
Cardiology Report ECG Study Date of [**2132-8-4**] 6:58:34 PM
.
Sinus tachycardia. Accelerated A-V conduction. Compared to the
previous tracing of [**2132-8-2**] no significant change.
.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
129 118 76 312/432 79 81 60
Brief Hospital Course:
Ms. [**Known lastname **] is a 27y F hx of DM1, recent PTX s/p rIJ placement
with recent admission for DKA presenting with low back pain,
nausea/vomiting and episode of coffee ground emesis concerning
for UGIB, initially monitored overnight in MICU, but found to
have stable hematocrit, [**Known lastname **] resolved after several hours.
# Coffee Ground Emesis
Patient had scant amount of coffee ground emesis in the ED which
resolved on arrival to floor. She continued to have
nausea/vomiting but was non-bloody bilious vomiting wo coffee
grounds or frank [**Known lastname **]. There was low concern for UGIB - thought
to be self resolving [**Doctor First Name 329**] [**Doctor Last Name **] vs PUD given Hpylori
positive, has been treated in past but unclear if re-infected.
She was started on protonix and octreotide gtt in the ED and was
transitioned to protonix IV bid in the MICU without octreotide
given clinical stability. She did have grade 1 varix on EGD in
[**1-/2132**], though unclear etiology and no hx of prior variceal
bleed. Very low suspicion for variceal bleed given HD
stability, HCT stable and cessation of emesis. GI was not
consulted in the ED on presentation and given her clinical
stability in the MICU and low suspicion for ongoing GIB, MICU
team did not consult GI as she did not require EGD. She was
transitioned to PO meds: antiemetics, po dilaudid and
pantoprazole. She was bolused with NS for dehydration and poor
po intake prior to presentation - and tachycardia. Femoral line
(placed in the ED) was discontinued prior to transfer to the
floor. Her diet was advanced to clears and then as tolerated. On
transfer to the floor, patient's [**Year (4 digits) **] of nausea/vomiting had
resolved.
# Gastroparesis
Chronic cause of her nausea/vomiting. Nausea/vomiting flares
are often triggered by stressors such as the low back pain, per
patient, though she reports they are not the same as her
gastroparesis flares. She was continued on home reglan and
lantus. Her pain was controlled with IV dilaudid and
transitioned to PO dilaudid when her vomiting decreased.
Transitioned back to po oxycodone on arrival to the floor which
is what she was given at discharge on prior hospitalization
(given 15 pills with no need for refills at that time).
Patient's [**Year (4 digits) **] had resolved by discharge.
# Low back pain
Related to hx of MVA, now has chronic pain. Psychiatric issues
could be contributing to back pain [**Year (4 digits) **]. Was on dilaudid in
MICU but was transitioned back to oxycodone on arrival to floor
and has pills left from previous hospitalization to take as an
outpatient. Heat packs helped with pain. Continued on home
gabapentin.
# PTSD
Patient has hx of sexual abuse, had psych consult on previous
admission, resulting in setup of outpatient psych eval for day
program. She feels these social stressors weigh down her
significantly, and that the stress may have triggered last DKA
episode. Citalopram was continued at home dose. Outpatient
psych eval rescheduled for this [**Year (4 digits) 2974**].
# DM1
Patient presented with DKA on previous admission, sugars have
been stable on home regimen. She gets lantus at baseline with
humalog sliding scale adjusted by carb counting and fasting
[**Year (4 digits) **] sugars. By time of transfer to floor, she was tolerating
POs and was back on home regimen. She did have one episode of
hypoglycemia with [**Year (4 digits) **] sugar to 39 on the morning of discharge
which resolved with dextrose.
# HTN
Patient was continued on home lisinopril.
# Communication: Patient, mother/[**First Name8 (NamePattern2) 58257**] [**Known lastname **] [**Telephone/Fax (1) 58276**]
mother
# Code: Full Code during this hospitalization
Medications on Admission:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
PRN (as needed) as needed for Itching.
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for lower back pain: 12 hours on, 12 hours off as needed
for lower back pain.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
disp:*30 Tablet(s)* Refills:*2*
6. Lantus 100 unit/mL Solution Sig: 20 U Subcutaneous at
bedtime.
7. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS.
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain. Disp:*15 Tablet(s)* Refills:*0*
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): QACHS.
6. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
7. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) unit Topical
twice a day as needed for itching.
8. Humalog 100 unit/mL Solution Sig: per home sliding scale
Subcutaneous QACHS: per home sliding scale.
9. (patient had also been given oxycodone from previous
hospitalization and has some tablets left, but this is not a
home medication to be continued)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Nausea and Vomiting
Low Back Pain
Secondary:
Diabetes Mellitus Type 1
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital because you were having nausea
and vomiting and your vomit looked like it may have been old
[**Last Name (LF) **], [**First Name3 (LF) **] you were monitored overnight in the intensive care
unit to make sure you did not have any bleeding, then transfered
to the regular floor.
Your [**First Name3 (LF) **] sugars were under good control this hospitalization,
but you did have one episode of low [**First Name3 (LF) **] sugars while you were
sleeping. Please be very careful about this at home.
No changes have been made to your medications.
Please be sure to keep the psychiatric evaluation appointment in
[**Location (un) **] this [**Location (un) 2974**]. As we discussed, it will be very helpful
for you to help gain coping strategies to help you get past the
difficult times you have been through.
Followup Instructions:
Please be sure to keep all of your followup appointments.
Psychiatry Evaluation:
[**Location (un) 2974**], [**8-8**] at 9:15am
[**Street Address(2) **], [**Location (un) **], MA, [**Telephone/Fax (1) 1691**]
Department: SPINE CENTER
When: THURSDAY [**2132-8-7**] at 10:00 AM
With: [**Name6 (MD) 1089**] [**Name8 (MD) 1090**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Primary Care:
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2132-8-12**] at 1:45 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: [**Hospital Ward Name **] [**2132-8-15**] at 10:00 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
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"578.0",
"536.3",
"311",
"272.4",
"250.83",
"300.01",
"338.29",
"054.10",
"250.63",
"583.81",
"285.1",
"309.81",
"456.1",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11573, 11579
|
6119, 9866
|
301, 307
|
11703, 11703
|
4621, 6096
|
12751, 13977
|
3898, 3963
|
10711, 11550
|
11600, 11682
|
9892, 10688
|
11854, 12728
|
3978, 4602
|
2359, 2809
|
257, 263
|
335, 2340
|
11718, 11830
|
2831, 3671
|
3687, 3882
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,134
| 157,636
|
10986
|
Discharge summary
|
report
|
Admission Date: [**2202-8-20**] Discharge Date: [**2202-8-26**]
Date of Birth: [**2163-9-18**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Orencia / Remicade
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
ICU callout after admission for acute renal failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 17385**] is a morbidly obese 38-year-old gentleman with
multiple medical problems including DM2, HTN, hyperlipidemia,
irritable bowel syndrome, psoriatic arthritis, and a recent MSSA
abscess in the left lower extremity that required surgical
intervention and fasciotomy ([**2-/2202**]) who is sent in from [**Hospital **]
clinic with confusion on [**8-20**]. He is now called out of the ICU
after a 24 hour stay. He was admitted after intermittent
decreased urine output over the past 1 week, and then with 1 day
of vomiting and a rapid increase in his creatinine to 8. He
endorsed hallucinations and confusion initially which has been
slowly clearing.
He denies N/V now, taking in about 4 liters of fluid per day.
No weight changes. No SOB, CP. No pedal edema. No LH or
syncope. All other systems are negative.
Past Medical History:
1. Psoriatic arthritis.
2. Left gastrocnemius abscess and bacteremia growing MSSA ([**Month (only) 958**]
[**2201**]).
3. History of MRSA infection status post eradication in [**2195**].
4. Morbid obesity.
5. Obstructive sleep apnea on CPAP.
6. Irritable bowel syndrome.
7. Hypertension.
8. Diabetes mellitus type 2.
9. Hyperlipidemia.
10. Peripheral neuropathy.
11. Nonalcoholic fatty liver disease secondary to previous
methotrexate treatment.
12. Keratoconus status post bilateral corneal transplant ([**2186**],
[**2190**]).
13. Status post four anal fistulotomies.
14. Status post tonsillectomy x2 and adenoidectomy.
15. Degenerative joint disease, status post L4/L5 discectomy.
16. Patellofemoral syndrome, status post arthroscopic surgery
for both knees x3 each.
Social History:
Living on disability. Before, he was a teacher taking care of
autistic children. He is married with four young children ages
[**8-10**]. A lifetime nonsmoker. He drinks alcohol occasionally and
denies illicit drug use.
Family History:
Mother: Ulcerative colitis, hypertension, hypercholesterolemia,
and bipolar disorder.
Father: Non smoking-induced COPD and hypertension.
Brother: Dermatologic psoriasis and ulcerative colitis. Sister:
Hypertension, hypercholesterolemia.
Paternal aunt: Crohn disease and sarcoidosis.
Physical Exam:
BP 131/101 HR 88 RR 12 O2 sat 100% on RA
GEN: NAD, AOX3
HEENT: JVP 9CM
CARD: RRR, NO M/R/G
PULM: CTAB
ABD: SOFT, NT, ND, NO MASSES OR ORGANOMEGALY
EXT: WWP, NO C/C/E
NEURO: AOX3, CN 2-12 INTACT, GROSSLY NORMAL
Pertinent Results:
CT HEAD [**8-20**] NON CONTRAST:
IMPRESSION: No acute intracranial abnormality.
Slight prominence of the right aspect of the adenoid tissues is
partially
imaged, although without significant interval change since the
prior study. Clinical correlation advised.
[**2202-8-20**]: RENAL ULTRASOUND
FINDINGS: The right kidney measures 12.9 cm in length and the
left kidney
measures 13.5 cm in length. There is no evidence of
hydronephrosis, stones, or son[**Name (NI) 5326**] evidence mass in both
kidneys. The urinary bladder is decompressed and not well seen.
IMPRESSION: No evidence of hydronephrosis.
[**2202-8-20**] CXR:
FINDINGS: There is no focal consolidation. There is no pleural
effusion and no pneumothorax. The cardiomediastinal silhouette
and hila are normal.
IMPRESSION: No acute cardiopulmonary process.
[**2202-8-22**] 07:08AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.2* Hct-30.4*
MCV-88 MCH-29.5 MCHC-33.6 RDW-15.1 Plt Ct-198
[**2202-8-20**] 01:25PM BLOOD WBC-13.4*# RBC-4.28* Hgb-12.6* Hct-37.2*
MCV-87 MCH-29.4 MCHC-33.8 RDW-15.3 Plt Ct-257
[**2202-8-21**] 02:31AM BLOOD PT-15.7* PTT-21.4* INR(PT)-1.4*
[**2202-8-20**] 02:17PM BLOOD PT-14.6* PTT-20.9* INR(PT)-1.3*
[**2202-8-22**] 07:08AM BLOOD Glucose-138* UreaN-25* Creat-1.4*# Na-139
K-3.8 Cl-104 HCO3-25 AnGap-14
[**2202-8-20**] 01:25PM BLOOD Glucose-134* UreaN-61* Creat-8.1*# Na-141
K-3.9 Cl-93* HCO3-25 AnGap-27*
[**2202-8-22**] 07:08AM BLOOD CK(CPK)-1338*
[**2202-8-21**] 02:31AM BLOOD CK(CPK)-3406*
[**2202-8-22**] 07:08AM BLOOD Calcium-9.2 Phos-1.9* Mg-1.8
[**2202-8-20**] 01:25PM BLOOD Calcium-9.7 Phos-11.1*# Mg-2.3
[**2202-8-20**] 03:07PM BLOOD Glucose-121* Na-139 K-3.9 Cl-95*
calHCO3-25
Brief Hospital Course:
Acute Renal faillure: Pre-renal, very severe renal failure with
a peak creatinine of 8, improved to baseline with IV fluids.
Renal ultrasound normal. Foley was discontinued on [**8-22**] and
patient had normal urine output following this. I felt this was
likely due to relative adrenal insufficiency causing profound
prerenal state from hctz and volume loss from vomiting following
recent steroid taper. Dose doubled and plan slow outpatient
taper. Communicated to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Recurrent nausea and vomiting: has led to volume depletion and
acute renal failure in the past. I felt this was likely due to
relative adrenal insufficiency (also explaining above and
extreme sensitivity to volume loss from vomiting especially in
the setting of recent start of HCTZ - resolved with doubling of
prednisone
Fever/Leukocytosis: Resolved with rehydration. Pyuria with
negative cultures. Blood cultures were negative. Antibiotics
discontinued on a.m. of [**8-22**]. When he was admitted to the ICU
on [**8-20**] he was on vancomycin / cipro with the thought that he
had severe sepsis, but given lack of objective data of any
infection antibiotics were discontinued and he did well.
Chronic pain: Discharged on his home medication regimen. Home
regimen was renally dosed initially and dosage changed to normal
when his creatinine clerance returned to [**Location 213**].
HTN: HCTZ was held given severe acute pre renal azotemia and
senisitivity to volume loss - plan to resume if BP is 140 or
higher with increase to prednisone.
Psoriatic arthritis: Prednisone and azathioprine with bactrim
PPX were continued.
CK ELEVATION: to 3000, likely not the cause of renal failure but
secondary to severe dehydration. This improved with rehydration.
Atorvastatin was held. Recheck of CK as an outpatient prior to
restarting a statin is advised.
Medications on Admission:
HOME MEDICATIONS:
ASA 81'
Alendronate 35mg qweek
Azathioprine 100''
CalciumVitD
Drisdol 50.000 3x/week, onT/T/S
Ferrous Sulfate 325 mg'
Gabapentin 900'''
HCTZ 25'
Insulin
Atorvastatin 80 mg'
Tizanadine 8mg'''
Morphine 30mg q4hr prn
Metoprolol succinate 200 mg'
Nortryptilin 25 qhs
Prednisone, on taper, currently 20 mg' (down from 80mg' more
recently)
Bactrim SS, 3x/week
Prilosec 20mg' started [**7-28**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QMON (every
Monday).
3. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. Morphine 15 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for pain.
5. Calcium with Vitamin D Oral
6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO [**Month/Day (4) **] (3
times a day).
8. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous
at bedtime.
9. Tizanidine 4 mg Tablet Sig: Two (2) Tablet PO three times a
day.
10. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO once a day. Tablet(s)
11. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
14. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Insulin Glargine 100 unit/mL Solution Sig: Eight (8) units
insulin Subcutaneous at bedtime.
16. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale Units, insulin Subcutaneous TIDACHS: resume your home
sliding scale insulin regimen.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
acute renal failure
nausea with vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with vomiting and found to have renal failure
as a result of dehydration. Please make every effort to stay
well hydrated. If you have recurrent nausea/vomiting or
diarrhea please return to the ER.
This was attributed to relative adrenal insufficiency due to a
rapid taper of prednisone. This improved with doubling of your
prednisone dose. You will need to taper this very slowly as
directed by Dr. [**Last Name (STitle) **]. Please call him to discuss a taper
schedule.
MEDICATION CHANGES:
Please stop taking HCTZ as we discussed - ok to resume if your
BP at home is persistently high (over 140/90)
Please stop taking your ATORVASTATIN until your CK (muscle
enzyme) can be rechecked by your PCP.
weeks of leaving the hospital: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 35614**]
While here you missed an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
Urology. Call to reschedule for next available appointment at:
([**Telephone/Fax (1) 4276**]
Followup Instructions:
Department: RHEUMATOLOGY
When: THURSDAY [**2202-10-14**] at 8:00 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2202-12-27**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV OF GI AND ENDOCRINE
When: MONDAY [**2202-11-1**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"348.39",
"696.0",
"V58.67",
"564.1",
"787.01",
"V85.4",
"272.4",
"276.51",
"721.3",
"401.9",
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"584.9",
"357.2",
"276.2",
"278.01",
"571.8",
"255.41",
"250.60",
"787.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
8281, 8287
|
4479, 6384
|
340, 347
|
8391, 8391
|
2796, 4456
|
9645, 10640
|
2264, 2549
|
6841, 8258
|
8308, 8308
|
6410, 6410
|
8542, 9038
|
2564, 2777
|
6428, 6818
|
9058, 9622
|
249, 302
|
375, 1217
|
8327, 8370
|
8406, 8518
|
1239, 2012
|
2028, 2248
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,065
| 179,802
|
44777
|
Discharge summary
|
report
|
Admission Date: [**2200-10-27**] Discharge Date: [**2200-10-31**]
Date of Birth: [**2121-5-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine / Sulfur / Hydrochlorothiazide / Lipitor
/ simvastatin
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2200-10-27**]: heart catheterization with three bare metal stents
placed in the proximal and distal RCA for 50-60% diffuse disease
in the proximal-mid artery and total occlusion in the distal
artery, and one bare metal stent placed in the PDA for 90%
stenosis
History of Present Illness:
Pt is a 79 yo F w/ PMH CAD s/p MI w/ 2 stents and angioplasty in
[**2190**], DMII (last HbA1C 7.2 in [**1-19**]), dyslipidemia, and CVA [**2197**]
p/w chest pain that began in the middle of last week. The pt
reports that her pain began in the middle of the night last
Wednesday or Thursday. It woke her up at 2am and she felt pain
in her left arm and left chest. This pain lasted all night
though the pt tried to apply hot pads, ice packs and take advil,
it did not take the pain away very long. She denies nausea or
shortness of breath associated with the episode but does denote
chills. She remembers feeling pain like this in the past, when
she had her last MI [**99**] years ago. This pain continued
intermittently through the weekend and actually felt better
today, so much so that she was almost not going to call her
doctor. She was sent from her doctor's office to the ED due to
STE on EKG.
.
In the ED, initial VS were T 99.1, P 70-80, BP 104-148/41-93), R
18, O2 98 RA. By the time she arrived she had no cp/sob, and
stated 0/10 pain, but had L arm pain yesterday. She was given
ASA 325mg and started on a heparin gtt. She was shortly taken to
the cath lab.
.
In the Cath Lab, the LAD showed diffuse ISR with serial 70-80%
lesions including ostium of LAD. Diagonal had 50-60% diffuse
disease. The LCX showed mild luminal irregularities with OM1
upper pole 50% and lower pole 40%. The RCA proximal and mid
diffuse 50-60%, distal total occlusion with collaterals from LCA
filling PL but not PDA. PTCA was performed with a 2.0 mm balloon
in the distal RCA. A 2.25 x 28 mm Minivision BMS was placed in
the distal RCA. A more proximal overlapping 2.25 x 8 mm
Minivision stent was deployed in what appeared to be a filling
defect. A more proximal nonoverlapping 2.5 x 28 mm Minivision
stent repaired the mid vessel lesion. The mid portion was
postdilated with a 3.0 mm balloon in a focal area of
underexpansion. A 90% origin PDA was repaired with a 2.25 x 8
mm Integriti stent placed in a distal overlapping fashion with
the first stent. Final angiography revealed normal flow, no
dissection and 0% residual stenosis in the stents. There was
residual 40% stenosis in the proximal RCA.
.
In the CCU, the pt was resting comfortably in bed, with no
complaints of chest pain, sob, abd pain, or nausea.
Past Medical History:
CAD s/p MI with 2 stents and angioplasty [**2190**] (cardiac cath
showed single vessel disease with stenting to the LAD
percutaneous transluminal coronary angioplasty of diagonal. LAD
had an 80%
proximal lesion, 70% mid lesion, and diagonal branch had 90%
lesion.
1. CARDIAC RISK FACTORS: +Diabetes (last HbA1C 7.2%),
+Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- s/p hysterectomy for fibroids
- CVA, [**2-/2197**] Acute left PCA infarct
Social History:
Lives at home alone. Retired bookkeeper.
- Tobacco history: Denies
- ETOH: Denies
- Illicit drugs: Denies
Family History:
- Mother: had few MIs, died of MI at age 61
- Father: had emphysema
- Mother's brother: died of MI at age 47
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=97.6 BP= 129-170/47-64 HR= 71-96 RR= 19-26 O2 sat= 96-99%
RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. No JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Crescendo/decrescendo murmur heard best
over the RUSB, and soft holosystolic murmur heard at the mitral
space w/ radiation to the axilla.
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
palpable. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+
Left: Carotid 2+ Radial 2+ DP 1+
.
DISCHARGE PHYSICAL EXAMINATION:
Tmax: 37.6 ??????C (99.7 ??????F) Tcurrent: 36.7 ??????C (98 ??????F) HR: 76 (65 -
110) bpm BP: 107/58(66) {97/45(35) - 132/79(97)} mmHg RR: 22 (9
- 27) insp/min SpO2: 97%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple. No JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly irregular, normal S1, S2.
Crescendo/decrescendo murmur heard best over the LUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, ND, slightly tender over sites of the shots, but
also slightly tender in the RUQ. Neg [**Doctor Last Name **]??????s sign.. +BS. No HSM
or tenderness. Abd aorta not palpable. No abdominial bruits.
EXTREMITIES: No c/c/e
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 1+
Left: Carotid 2+ Radial 2+ DP 1+
Pertinent Results:
Admission labs:
[**2200-10-27**] 02:00PM BLOOD WBC-15.7*# RBC-4.93 Hgb-14.2 Hct-40.2
MCV-82 MCH-28.8 MCHC-35.2* RDW-13.0 Plt Ct-211
[**2200-10-27**] 02:00PM BLOOD Neuts-82.5* Lymphs-12.3* Monos-4.9
Eos-0.1 Baso-0.2
[**2200-10-27**] 02:00PM BLOOD PT-13.0 PTT-21.1* INR(PT)-1.1
[**2200-10-27**] 02:00PM BLOOD Glucose-215* UreaN-21* Creat-1.1 Na-133
K-4.0 Cl-98 HCO3-22 AnGap-17
[**2200-10-27**] 02:00PM BLOOD CK(CPK)-584*
[**2200-10-27**] 02:00PM BLOOD CK-MB-22* MB Indx-3.8
[**2200-10-27**] 02:00PM BLOOD cTropnT-1.05*
.
Relevant labs:
[**2200-10-27**] 10:20PM BLOOD CK(CPK)-735*
[**2200-10-27**] 10:20PM BLOOD CK-MB-29* MB Indx-3.9 cTropnT-2.29*
[**2200-10-28**] 12:40AM BLOOD CK(CPK)-715*
[**2200-10-28**] 12:40AM BLOOD CK-MB-25* MB Indx-3.5
[**2200-10-28**] 03:35PM BLOOD CK(CPK)-629*
[**2200-10-28**] 03:35PM BLOOD CK-MB-17* MB Indx-2.7 cTropnT-1.95*
.
Discharge labs:
[**2200-10-31**] 07:35AM BLOOD WBC-8.0 RBC-3.76* Hgb-10.7* Hct-31.2*
MCV-83 MCH-28.4 MCHC-34.2 RDW-13.0 Plt Ct-230
[**2200-10-31**] 07:35AM BLOOD PT-17.4* PTT-28.6 INR(PT)-1.6*
[**2200-10-31**] 07:35AM BLOOD Glucose-148* UreaN-23* Creat-1.0 Na-138
K-4.5 Cl-106 HCO3-24 AnGap-13
[**2200-10-31**] 07:35AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1
[**2200-10-28**] 12:40AM BLOOD %HbA1c-7.5* eAG-169*
[**2200-10-28**] 12:40AM BLOOD Triglyc-210* HDL-56 CHOL/HD-3.9
LDLcalc-119
[**2200-10-28**] 12:40AM BLOOD Cholest-217*
Cardiac catheterization [**2200-10-27**]:
PTCA was performedwith a 2.0 mm balloon in the distal RCA and
proximal PDA withrestoration of flow, but flow degraded over 10
minutes ofobservation. The decision was made to definitively
repair theRCA. A 2.25 x 28 mm Minivision BMS was placed in the
distal RCA.A more proximal overlapping 2.25 x 8 mm Minivision
stent was deployed in what appeared to be a filling defect. A
moreproximal nonoverlapping 2.5 x 28 mm Minivision stent
repaired themid vessel lesion. The mid portion was postdilated
with a 3.0 mmballoon in a focal area of underexpansion. A 90%
origin PDA was repaired with a 2.25 x 8 mm Integriti stent
placed in a distal overlapping fashion with the first stent.
Final angiography revealed normal flow, no dissection and 0%
residual stenosis in the stents. There was residual 40%
stenosis in the proximal RCA.
.
TTE [**2200-10-28**]:
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-12**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild aortic valve stenosis.
Mild-moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2197-2-21**],
the findings are similar (PA systolic pressure could not be
quantified on the current study).
.
Chest x-ray [**2200-10-28**]:
AP single view of the chest has been obtained with patient in
sitting semi-upright position. The heart is moderately enlarged.
The configuration suggests a relative prominence of the left
ventricle, but there is no conclusive evidence for left atrial
enlargement. The thoracic aorta is
generally widened and elongated, but no local contour
abnormality or
significant wall calcification is identified. The pulmonary
vasculature is
not congested. No signs of acute infiltrates are present and the
lateral
pleural sinuses are free. No pneumothorax is seen in the apical
area.
Our records include a previous chest examination dated [**9-13**], [**2190**].
Remarkable is that the findings are very similar in as much the
patient already at that time had cardiomegaly with left
ventricular prominence, but absence of conclusive pulmonary
congestion. The patient underwent a chest CT on [**2199-1-21**]. This study is also reviewed and confirms the
observations made on the plain portable chest x-ray. In
addition, moderate
degree of aortic valve as well as coronary arterial
calcifications were
identified and a mildly widened and elongated thoracic aorta was
noted. The left lower lobe pulmonary condyloma was examined and
was found to be innocent.
IMPRESSION: Mild-to-moderate cardiac enlargement mostly
involving left
ventricle. No signs of acute congestion or infiltrate on
portable chest
examination.
.
[**2200-10-30**] Carotid Series Complete: There is a mild intimal
thickening and heterogeneous bilaterally along the common
carotid and proximal internal carotid arteries. The peak
systolic velocity in the right internal carotid artery ranges
from 45-101 cm/sec and on the left internal carotid artery
ranges from 63-87 cm/sec. The peak systolic velocity in the
right common carotid artery is 74 cm/sec and left common carotid
artery is 56 cm/sec. Bilateral external carotid arteries are
patent. There is antegrade flow in the bilateral vertebral
arteries. The ICA/CCA ratio on the right is 1.4 and 1.6 on the
left.
Brief Hospital Course:
79 yo F w/ PMH CAD s/p MI w/ 2 stents and angioplasty in [**2190**],
DMII (last HbA1C 7.2 in [**1-19**]), dyslipidemia, and CVA [**2197**] p/w
chest pain, found to have an inferior STEMI, treated with three
bare metal stents in the RCA and one in the PDA, with hospital
course complicated by post-intervention atrial
fibrillation/flutter.
.
.
ACTIVE ISSUES:
# CAD: Pt has hx of MI in [**2190**] w/ stent placement, found to have
STE on EKG and taken to the cath lab and is now s/p 4 stent
placement, 3 in RCA, 1 in PDA with possible plans for a CABG in
one month. She was put on ASA 325mg daily, and continued on her
home clopidogrel 75mg daily that she will need to take for at
least one month, but to be stopped 5 days prior to her CABG. She
was continued on her home lopressor and was switched from her
home simvastatin to rosuvastatin due to complaints of muscle
cramps on simvastatin. Her home olmesartan was held due to low
blood pressures, and then re-started at half her home dose as
her blood pressure tolerated it. Cardiac surgery saw the patient
for possible CABG and her pre-op work-up began with carotid
ultrasound, which showed no evidence of significant carotid
artery stenosis bilaterally, but did show mild intimal
thickening and heterogeneous plaque along the common carotid and
proximal internal carotid arteries.
.
# Atrial fibrillation/flutter: One day post-intervention, the
patient was noted to have irregular rhythm, alternating between
coarse atrial fibrillation and atrial flutter. She was
subsequently anticoagulated with warfarin 5mg daily, and was
bridged with lovenox injections. Her rate was controlled with
metoprolol 25mg TID. On the day prior to discharge, she was
successfully cardioverted into normal sinus rhythm with
occasional PACs. She will be discharged on pradaxa.
.
.
CHRONIC ISSUES:
# Hypertension: Documented history of this problem, for which
the patient had been treated with metoprolol 50 mg TID,
amlodipine 10 mg daily and olmesartan 40mg daily prior to
admission. She was hypotensive after her intervention, so her
medications were initially held and she was restarted on her
home metoprolol. Her amlodipine was discontinued due to her
being post-myocardial infarction.
.
# Hyperlipidemia: Documented history of this problem, for which
the patient had self-discontinued treatment with simvastatin
secondary to intolerable leg cramping. Following her
intervention, the patient was started on rosuvastatin, which she
tolerated well. During this admission, her lipid panel
demonstrated uncontrolled lipids with total cholesterol 217,
triglycerides 210, HDL 56, chol/HDL 3.9 and LDL 119.
.
# Diabetes: Last HbA1C prior to this admission was 7.2% in [**2198**].
During this admission, the patient's HbA1c was 7.5%, indicative
of ongoing poorly-controlled diabetes. While an inpatient, the
patient was treated with a sliding scale of insulin. She was
also counseled regarding the importance of diet and exercise
modifications. Her PCP may consider initiation of treatment
with metformin.
.
.
TRANSITIONAL ISSUES:
1.) Recommend initiation of treatment for poorly-controlled
diabetes with metformin, though pt will need further teaching
into importance of medications.
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet PO daily
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet PO daily
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet PO TID
OLMESARTAN [BENICAR] - 40 mg Tablet - 1 Tablet PO daily
SIMVASTATIN - 20 mg Tablet - 1 Tablet PO daily-- REPORTS NOT
TAKING
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain.
4. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Please take one pill under tongue, call 911 if you still have
chest pain after one tablet. .
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Pradaxa 150 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
8. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Outpatient Lab Work
Please check Chem-7 and CBC on Tuesday [**11-4**] with results
to Dr. [**Last Name (STitle) 2204**] at Phone: [**Telephone/Fax (1) 2205**]
Fax: [**Telephone/Fax (1) 7922**]
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction
Diabetes Type 2
Dyslipidemia
History of stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had chest pain and a heart attack. You were brought to the
catheterization lab at [**Hospital1 18**] and blockages were found in your
right coronary artery and posterior descending artery. These
blockages were fixed with 4 bare metal stents. You will need to
take aspirin 325 mg and Plavix 75 mg every day for the next
month without fail to keep these stents open. Do not stop taking
aspirin and plavix for any reason unless Dr. [**Last Name (STitle) **] tells you it
is OK. You also had an irregular heart rhythm called atrial
fibrillation that was converted to a regular rhythm after an
electrical cardioversion. Your heart may revert back to atrial
fibrillation over the next month so we want you to use an event
monitor to check your rhythm. Atrial fibrillation makes a stroke
more likely so you will be started on Pradaxa for the next month
to prevent a stroke. Dr. [**Last Name (STitle) **] will let you know if you need to
continue this medicine after a month. This medicine makes it
more likely for you to have minor bleeding such as a nosebleed
or bleeding gums, this is normal. A major bleeding event would
be dark or bloody stools, fatigue and trouble breathing. Please
call Dr. [**Last Name (STitle) **] right away if you notice this. Your other
medicines have been adjusted as noted below. Your blood sugars
have been high, please follow the high fiber, low carbohydrate
diet that we discussed and talk to Dr. [**Last Name (STitle) 2204**] about starting
medicines to lower your blood sugars.
.
1. STOP taking amlodipine
2. Decrease benicar to 20 mg daily ([**1-12**] of a pill)
3. Continue to take plavix every day for one month at least
along with aspirin 325 mg to prevent the stents from clotting
off
4. START Pradaza (dabigatran) to prevent a blood clot if your
atrial fibrillation returns.
5. START Crestor (rosuvastatin) to lower your cholesterol.
6. Take acetaminophen (tylenol) instead of advil for any pain
7. Take nitroglyerin if you have shest pain that is similar to
the chest pain you had before your heart attack. Call Dr. [**Last Name (STitle) **]
if you have any chest pain.
Followup Instructions:
Department: CARDIAC SURGERY
When: THURSDAY [**2200-11-27**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) 2946**] S.
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 2205**]
*It is recommended that you see Dr. [**Last Name (STitle) 2204**] within one week.
His office will contact you with appointment information.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] [**Last Name (Titles) **]/CARDIOLOGY
Address: [**Street Address(2) **], [**Location (un) **], MA
Phone: [**Telephone/Fax (1) 4105**]
When: Wednesday, [**1-9**], 3PM
|
[
"427.32",
"272.4",
"410.41",
"V45.82",
"250.00",
"412",
"427.31",
"414.01",
"401.9",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.66",
"99.62",
"00.48",
"00.41",
"99.20",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
16026, 16032
|
11376, 11719
|
351, 615
|
16158, 16158
|
5806, 5806
|
18442, 19518
|
3661, 3771
|
14927, 16003
|
16053, 16137
|
14623, 14904
|
16309, 18419
|
6678, 11353
|
3786, 3796
|
3339, 3410
|
4732, 5787
|
14442, 14597
|
301, 313
|
11734, 13189
|
643, 2950
|
5822, 6662
|
16173, 16285
|
3441, 3520
|
13205, 14421
|
2972, 3319
|
3536, 3645
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,532
| 164,052
|
1626
|
Discharge summary
|
report
|
Admission Date: [**2138-3-15**] Discharge Date: [**2138-3-17**]
Date of Birth: [**2060-12-10**] Sex: F
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Cardizem / Calan
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
ruptured AAA
Major Surgical or Invasive Procedure:
ex lap
AAA tube graft
swan ganz catheter
arterial line placement
endotracheal intubation
History of Present Illness:
77F NH resident with known AAA, presented to OSH with sharp
midback pain. Her imaging revealed an enlarged confined rupture
of her AAA (8cm from baseline 5.2cm). She opted for a surgical
intervention.
Past Medical History:
IDDM
HTN
CAD s/p MI s/p CABG
h/o L ACA infarct
CRI (creatinine 1.5)
known AAA
DNR/DNI
Social History:
NH resident
Family History:
daughter [**Name (NI) **] health care proxy
Physical Exam:
Elderly, chronically ill patient
RRR
CTA bilat
Distended tender epigastrium
Cool mottled extremities
Pertinent Results:
see carevue for specifics
Brief Hospital Course:
[**3-15**]: Taken to OR directly from ED. Intraop events included
repair of abdominal aorta c/b brief episode of ventricular
arrhythmia. Admitted to SICU postop.
SICU course: Aggressively resuscitated with IV fluid & blood
products.
NEURO: She did not awake following removal of all sedating
medications. CT head showed chronic & subacute infarcts.
CV: Initial postop hypertension controlled with esmolol, nipride
& milrinone gtts. On POD#2, her blood pressure slowly dropped
despite fluid & pressors. Her heart rate slowed until she
became asystolic. Her family was notified & they refused
resuscitation at this point, given her numerous complications.
She was pronounced dead at 11:07am on [**3-17**]. NEOB & OME refused
case. Family denied autopsy.
RESP: mechanical ventilation
FEN: postop renal failure [**1-30**] ATN
GI: NPO
HEME: multiple transfusions
ID: no issues
ENDO: poorly controlled diabetes
Medications on Admission:
cozaar, effexor, [**Doctor First Name 130**], allopurinol, levoxyl, lipitor,
norvasc, protonix, labetalol, ativna
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
ruptured AAA
myocardial infarction
acute renal failure
ARDS
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2138-3-17**]
|
[
"427.1",
"V45.81",
"518.5",
"584.5",
"401.9",
"441.3",
"250.00",
"410.91",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44",
"99.04",
"89.64",
"99.05",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
2138, 2147
|
1025, 1946
|
318, 408
|
2250, 2260
|
975, 1002
|
2312, 2346
|
794, 839
|
2110, 2115
|
2168, 2229
|
1972, 2087
|
2284, 2289
|
854, 956
|
266, 280
|
436, 640
|
662, 749
|
765, 778
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,760
| 184,259
|
24857
|
Discharge summary
|
report
|
Admission Date: [**2178-10-3**] Discharge Date: [**2178-11-14**]
Date of Birth: [**2109-8-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Transferred from OSH for Epidural/Abscess
Major Surgical or Invasive Procedure:
Evacuation of T5-T6 Epidural Hematoma/Abscess
History of Present Illness:
69yo M with PMH of ESRD on HD, DM, MVR, Afib, cirrhosis, and
prostate cancer, presented to OSH last week with LBP and LE
weakness, found to have a T5-6 epidural abscess with cord
compression on MRI and GPC bacteremia. He was transferred to
[**Hospital1 18**] on [**2178-10-3**] and was taken that night to the OR for T5-6
laminectomy and drainage of abscess. His tunneled HD cath was
removed and had a temporary femoral line placed today for HD.
He was also seen by Thoracic Surgery for anterior paraspinal
abscess, but no surgical intervention is necessary at this time.
ID consulted and the organism is thought to most likely be
coag-neg. Staph. and source is thought to be his HD catheter.
Transferred to Medicine service for further workup of source
including TEE for endocarditis and CT abd/pelv.
Currently states he feels well, only complaint is mild pain in
his back. He denies CP, SOB, abdominal pain, feeling feverish,
chills, headache, feeling confused, N/V, and LE pain.
Past Medical History:
ESRD, on dialysis
Atrial fibrillation, rate-controlled
Social History:
married, lives with wife who is debilitated by stroke, h/o EtOH
abuse- has not used since starting dialysis
Family History:
NC
Physical Exam:
T 98.2 HR 80 BP 116/64 RR 20 O2sat 93%RA
General- lying in bed, NAD, pleasant
HEENT- telangiectasias on face, sclerae anicteric, moist MM
Neck- no JVD
Pulm- CTAB
CV- irregularly irregular, 1/6 SEM heard best at LUSB
Abd- distended but soft, bulging flanks, nontender, no
peritoneal signs, NABS, no hepatomegaly, umbilical hernia easily
reducible and nontender
Back- dressing in place
Ext- no peripheral edema, +2 DP pulses
Neuro- able to move toes R>L, 4+/5 UE strength b/l, decreased
sensation to LT in upper thighs, no sensation to LT throughout
rest of legs
Pertinent Results:
Cultures:
[**2178-11-7**] Blood - pending
[**2178-11-6**] Blood - negative
[**2178-11-5**] Blood - negative
[**2178-10-29**] Blood - negative
[**2178-10-29**] Blood - negative
[**2178-10-29**] Urine - neagtive
[**2178-10-29**] Sputum - contaminated
Imaging:
[**2178-11-10**] CXR - Dense retrocardiac opacity, including a layering
pleural effusion as well, although an under lying consolidation
or atelectasis could be present. When clinically feasible, PA
and lateral could be helpful for further followup. The
appearance is unchanged, however.
[**2178-11-6**] Abdominal U/S - Massive ascites. Left flank marked for
paracentesis.
Brief Hospital Course:
69yo M with ESRD on HD, MVR, Afib, and DM, p/w epidural abscess,
cord compression, and coag-neg Staph bacteremia, with drainage
with paraplegia.
1) Altered mental status: On morning of [**10-8**], had [**Doctor Last Name 29943**] change
in personality and behavior, also with disorientation. His
differential included CVA, subdural,
toxic-metabolic--hyponatremia, elevated ammonia, infection
(bacteremia, SBP). Psych consult saw the patient and deemed him
incompetent to make medical decisions secondary to delirium.
Later in the morning was more oriented, and noted to be
primarily angry and doubtful of his diagnosis. His orientation
and attention was intact. Labs were negative for electrolyte
abnormalities, leukocytosis, elevated ammonia. Neurology
consult recommended EEG, continued toxic-metabolic w/u, MRI head
to look for CVA, MRI C/T/L spine to eval for persistent/new
abscess. His EEG was consistent with encephalopathy. He had a
diagnostic paracentesis that was negative for SBP. He was found
to have a FQ-resistant E. coli UTI, and was put on ceftriaxone
to complete a 14d course. Multiple attempts were made to get
the MRI, but he was unable to tolerate the study. It was
performed on [**10-20**] and showed a recurrent T5-T6 epidural abscess
with destruction of the T5 and T6 vertebrae, and a question of
lumbar discitis. His MRI head showed an old cerebellar and
chronic microvascular infarcts, but no new infarcts. He
continued to have attentional deficit and intermittent
disorientation to place and time. He was taken to the OR for
debridement and fusion of his T5-T6 vertebrae. The patient
continued to be intermittently delirius after surgery.
2) Epidural abscess: He was transferred to Medicine s/p drainage
of his posterior fluid collection. The abscess fluid culture
grew coag-neg Staph and he was maintained on vancomycin to treat
his bacteremia and osteomyelitis, with the intention of treating
for 6 weeks. His most likely source was thought to be his HD
line, and it was removed. He also had cord compression with
paraplegia as a result of the abscess. Thoracic [**Doctor First Name **] was
initially consulted and stated there was no evidence for
discrete anterior paraspinal abscess, so no indication for
surgical intervention. Blood cultures here were negative, as
was the cath tip culture negative. A TTE showed no visible
endocarditis. A TEE was not performed as his antibiotic course
would adequately treat for endocarditis. A recurrent abscess
with osteomyelitis was found on MRI as stated above. He also
had the possibility of lumbar discitis that appeared to be new
when compared to his OSH MRI, and would have developed while he
was on vancomycin. ID recommended no change in his antibiotics
until after surgery. Dr. [**Last Name (STitle) 363**] came and spoke with the patient
and his family and it was decided that no further surgical
intervention was warranted. Further surgery to stabalize his
back was risky and painful. The patient decline and elected to
be fitted for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] brace.
3) ESRD: He started HD several months ago and had a tunneled
line placed at that time. It was pulled this admission as it
was thought to likely be the source of his bacteremia, and
ultimately his epidural abscess. He initially had a temporary
femoral catheter placed, which was later pulled and a new
tunneled line was placed by IR. He was maintained on his MWF
schedule, had temporary femoral catheter pulled on [**10-7**]. He was
followed by Renal throughout his stay.
4) Afib: He is rate-controlled on diltiazem, digoxin, and
metoprolol as an outpatient. He stated he had not been on
anticoagulation for several years per the patient. Further
history was obtained from his wife, who stated he had a severe
upper GI bleed a year and a half ago, and also had multiple
falls over the past several years. He was well rate-controlled
throughout his stay. He was maintained on beta blockade
perioperatively.
5) Respiratory Distress - On [**10-29**] pt was noted to be tachypneic
at 36/m w/ O2 sat 90% 4L/m NC which prompted a trigger. He was
treated w/ O2 by NRB, w/ sat increasing to 98%. Suctioning
returned copious thick secretions, and O2 sat improved to 98% on
4L/m, but pt remained tachypneic w/ increasing confusion. CXR
demonstrated LLL infiltrate, unchanged from recent imaging.
Patient transferred to MICU for closer monitoring and frequent
suctioning. Patient was transferred back to regular medical
floor after improved respiratory and mental status. Patient no
longer having copious secretions and is not requiring frequent
suctioning. Now with O2 sats in high 90's on RA. Mental status
has also improved.
6) Questionable PEA Arrest - On [**2178-11-5**] a code blue was called
on the patient and he was transferred to the ICU for a
questionable PEA arrest. Patient improved rapidly after event,
not likely PEA given recovery without need for intervention.
Possibly a mucus plug or aspiration causing an hypoxic arrest.
Of note, he has had multiple aspiration events in the past. PE
causing PEA possible but less likely given rapid improvement and
lack of hypoxia. Possible that he had a bradycardic event as he
had recently had long pauses and been taken off diltiazem and
BB. However, in stable Afib on telemetry overnight. Cardiac
enzymes stable so not likely MI. The patient was transferred
back to the general medical floor.
6) Cirrhosis/Ascites: Likely secondary to alcohol abuse. His
PT/INR was slightly elevated, and his albumin was low. He was
not on SBP prophylaxis as an outpatient. No SBP on his
diagnostic paracentesis. He was treated empirically with
lactulose after he was found to be delirious. His history of GI
bleed should be confirmed with his PCP as may be an indication
for SBP prophylaxis as an outpatient.
7) MV repair: He is s/p a MV repair in [**2159**] per the patient.
His TTE showed an annuloplasty ring. A TEE to look for
endocarditis was not performed as his osteomyelitis antibiotic
course would adequately treat endocarditis.
8) Anemia: Hct was stable throughout his admission. His stools
were guaiac negative.
Code status: After the patient returned to the medical floor
from the ICU for the 2nd time during his admission, a family
meeting was held to address goals of care as his overall medical
condition remained tenuous. At the first meeting, the patient
and family decided that the patient would be DNR/DNI (consistent
with the patient statements to multiple family members in the
past). Over the next few days, the patient continued to express
wishes to stop dialysis and all other tests. Another family
meeting was held including the presence of the patient, and it
was decided that the patient would be CMO (including stopping
dilaysis). The patient was made CMO on [**2178-11-11**] and passed away
on [**2178-11-14**].
Medications on Admission:
Unknown
Discharge Medications:
Expired on [**2178-11-14**]
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Expired on [**2178-11-14**]
Discharge Condition:
Expired on [**2178-11-14**]
Discharge Instructions:
Expired on [**2178-11-14**]
Followup Instructions:
Expired on [**2178-11-14**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"599.0",
"324.1",
"403.91",
"995.92",
"286.9",
"536.3",
"572.3",
"571.2",
"996.62",
"293.0",
"427.5",
"250.60",
"707.03",
"722.72",
"344.1",
"730.18",
"518.81",
"424.0",
"585.6",
"287.5",
"303.93",
"280.0",
"730.08",
"572.2",
"337.1",
"507.0",
"038.11",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.51",
"84.51",
"81.04",
"39.95",
"81.63",
"03.09",
"86.05",
"96.6",
"38.95",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
9929, 9944
|
2904, 3061
|
358, 406
|
10015, 10045
|
2247, 2881
|
10121, 10243
|
1642, 1646
|
9877, 9906
|
9965, 9994
|
9845, 9854
|
10069, 10098
|
1661, 2228
|
277, 320
|
434, 1422
|
3077, 9819
|
1444, 1501
|
1517, 1626
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,133
| 189,112
|
47077
|
Discharge summary
|
report
|
Admission Date: [**2160-4-24**] Discharge Date: [**2160-4-29**]
Date of Birth: [**2099-12-4**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Ativan
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
left upper extremity AV fistula-gram
History of Present Illness:
60F w/ HCV, HTN, HL, ESRD s/p cadaveric transplant on
cyclosporine/cellcept presentes with dyspnea x 1 day. Patient
noticed increasesing dyspnea over the course of the day.
Althought this is not documented in recent discharge summary,
apparently patient has been using oxygen for the last month
since her most recent discharge, and using 2L while sleeping and
ambulating. Today her dyspnea was not responsive to oxygen. She
reports a mild nonproductive cough, worsening LE edema and
orthopnea without PND. She denies chest pain, fevers, chills,
palpitations and nausea. She has no sick contacts. Denies
[**Name2 (NI) **] noncompliance.
.
In the ED, patient was initially found to have a room air sat of
75% which came up with 5 L of oxygen to 88%. She was also found
to be hypertensive with systolics above 200. BNP was 21,602
from an older value of 11,653 in [**Month (only) **]. CXR was consistent
with mild pulmonary edema. She was started on a nitro drip and
given lasix 40 mg IV x1. Initial cardiac enzymes were elevated
with a troponin of 0.13, with a baseline of 0.04 to 0.76 given
he renal function. EKG demonstrated lateral ST changes and an
old Q wave inferiorly. On transfer, VS were 99, 95, 229/79, 24,
and 95% on 4l.
.
Of note, patient was recently admitted [**3-21**] to [**2159-4-3**] for
seizures, complicated by aspiration pneumonia with parapneumonic
effusion and later acute on chornic renal failure. In regards to
partial seziure, this was felt to be secondary to cipro and/or
cylcosporin. Imaging and LP were negative. Cipro was stopped and
cyclosporine was decreased, and patient was discharged on
antiepeleptics. Patient was note to have right lobar
consolidation with associated effusion which was transudative,
and negative for infection and malignant cells, and was treated
with Piperacillin x 8 days. In regards to renal failure, Cr was
slightly elevated from baseline, but u/s unchanged and biopsy
complicated by perinephric hematomoa, but biopsy did not show
acute rejection, but did show chronic allograft nephropathy.
.
In the ICU, patient reports her dyspnea has improved but she now
has a headache since starting the nitro drip. She still denies
chest pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Past Medical History:
ESRD [**3-12**] hypertension s/p cadaveric transplant on
cyclosporine/cellcept
Hepatitis C s/p Interferon tx, followed at [**Hospital1 2177**]
HTN
Osteoporosis
Hyperlipidemia
Hyperparathyroidism
Herpes Zoster
Past Surgical History:
[**2159-12-4**] Fistulogram, 12-mm balloon angioplasty of intrastent
stenosis brachiocephalic vein.
[**2153-7-4**] Cadaveric renal transplant
[**2153-7-8**] Re-exploration of transplant kidney,
ureteroureterostomy
over double-J stent
[**2129-6-12**] Sebaceous cyst excision left shin
[**2152-3-3**] Brachiocephalic fistula in the left upper arm.
Social History:
Lives with boyfriend, [**Name (NI) **] [**Name (NI) 99807**] ([**Telephone/Fax (1) 99808**]). Distant
history (20y ago) of IVDU with heroin and polydrug use,
self-cutting. No illicit use since. Denies EtOH or Tobacco use
(previous use 15y ago).
Family History:
No CAD, no renal disease
Physical Exam:
ADMISSION EXAM:
Vitals: T: 99.6 BP: 157/82 P: 97 R: 10 O2: 94% 5L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles in the bases bilaterally, no wheezes, rales,
ronchi
CV: Systloic ejection murmur, Regular rate and rhythm, normal S1
+ S2, no , rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: 2+ LUE swelling, palpable thrill over LUE fistula in
anticubital fossa, 1+ bilateral LE edema, warm, well perfused,
2+ pulses, no clubbing, cyanosis
Pertinent Results:
ADMISSION LABS:
[**2160-4-24**] 03:10AM BLOOD WBC-6.7 RBC-3.64* Hgb-9.8* Hct-30.9*
MCV-85 MCH-26.9* MCHC-31.7 RDW-15.6* Plt Ct-213
[**2160-4-24**] 03:10AM BLOOD Neuts-59.7 Lymphs-32.6 Monos-4.2 Eos-2.8
Baso-0.7
[**2160-4-24**] 07:16AM BLOOD PT-13.2 PTT-27.3 INR(PT)-1.1
[**2160-4-24**] 03:10AM BLOOD Glucose-84 UreaN-83* Creat-4.5* Na-144
K-4.3 Cl-109* HCO3-17* AnGap-22*
[**2160-4-24**] 03:10AM BLOOD proBNP-[**Numeric Identifier **]*
[**2160-4-24**] 03:10AM BLOOD cTropnT-0.13*
[**2160-4-24**] 07:16AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.6
[**2160-4-24**] 03:20AM BLOOD Lactate-1.6 K-4.3
[**2160-4-24**] 07:10AM BLOOD Type-ART pO2-60* pCO2-32* pH-7.43
calTCO2-22 Base XS--1
[**2160-4-24**] 04:55AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2160-4-24**] 04:55AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2160-4-24**] 04:55AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
[**2160-4-24**] 04:55AM URINE CastHy-6*
DISCHARGE LABS:
[**2160-4-29**] 06:30AM BLOOD WBC-4.8 RBC-3.64* Hgb-9.8* Hct-30.3*
MCV-83 MCH-26.8* MCHC-32.2 RDW-14.9 Plt Ct-233
[**2160-4-25**] 03:18AM BLOOD Neuts-58.0 Lymphs-34.2 Monos-3.7 Eos-3.0
Baso-1.1
[**2160-4-29**] 06:30AM BLOOD Glucose-105* UreaN-105* Creat-4.4* Na-139
K-4.6 Cl-101 HCO3-25 AnGap-18
[**2160-4-29**] 06:30AM BLOOD Calcium-9.8 Phos-5.2* Mg-2.3
CARDIAC ENZYMES:
[**2160-4-24**] 07:16AM BLOOD CK-MB-4 cTropnT-0.13*
[**2160-4-24**] 04:06PM BLOOD CK-MB-3 cTropnT-0.13*
[**2160-4-24**] 09:43PM BLOOD CK-MB-3 cTropnT-0.12*
[**2160-4-25**] 03:18AM BLOOD CK-MB-3 cTropnT-0.13*
[**2160-4-25**] 04:28PM BLOOD CK-MB-4 cTropnT-0.13*
[**2160-4-24**] 07:16AM BLOOD CK(CPK)-125
[**2160-4-24**] 04:06PM BLOOD CK(CPK)-114
[**2160-4-25**] 03:18AM BLOOD CK(CPK)-83
[**2160-4-25**] 04:28PM BLOOD CK(CPK)-86
MICRO:
[**2160-4-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2160-4-24**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
IMAGING:
[**4-24**] TTE: The left atrium is markedly dilated. The right atrium
is moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect.
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) are mildly thickened
but aortic stenosis is not present. There is no valvular aortic
stenosis. The increased transaortic velocity is likely related
to high cardiac output. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal global and regional biventricular systolic function. Mild
mitral regurgitation. Moderate pulmonary hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2159-12-18**], pulmonary pressures are higher. The
other findings appear similar.
[**4-24**] ECG: Sinus rhythm. Borderline P-R interval prolongation.
Poor R wave progression which is non-diagnostic. Non-specific
inferolateral ST-T wave changes. Compared to the previous
tracing of [**2160-4-24**] there is no significant diagnostic change.
[**4-24**] CXR: Acute pulmonary edema; basal pneumonia not excluded.
[**4-24**] LUE Ultrasound: No evidence of deep vein thrombosis in the
left arm. Patent AV fistula in the left arm is noted.
[**4-25**] CXR: Cardiomegaly is severe, unchanged. Bilateral pleural
effusions and bibasilar atelectasis are unchanged, extensive.
The patient is still in interstitial edema with multifocal
opacities involving both lungs, worrisome for infectious
process.
[**4-28**] AV Fistulogram
AV FISTULAGRAM WITH VENOPLASTY
MEDICAL HISTORY: Swollen left arm, potential angioplasty for
stenosis.
OPERATORS: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] (fellow) and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12166**]
(attending
interventional radiologist) was present and supervising
throughout the
procedure.
PROCEDURES:
1. Fistula access into the veous limb,close to the arterial end.
2. Carbon dioxide fistulogram and central venogram.
3. Conventional Optiray contrast central venograms.
4. Balloon angioplasty of stent stenoses and cephalic arch band
like
stenosis/web.
5. Post-procedure conventional Optiray contrast venograms.
MEDICATIONS: Moderate sedation was provided by administering 100
mcg of
fentanyl and 1 mg of midazolam throughout the total intraservice
time of 78
minutes during which the patient's hemodynamic parameters were
continuously
monitored. 1% lidocaine was used for local pain control.
In order to minimize contrast exposure given renal failure,
carbon dioxide
venograms were also performed. Total 90 cc CO2 was used along
with 50 cc of
contrast.
TECHNIQUE: After discussion of the risks, benefits and
alternatives to the
procedure with the patient, written informed consent was
obtained. The
patient was brought to the angiography suite and placed supine
on the imaging
table. The left upper extremity was prepped and draped in usual
sterile
fashion. A preprocedure huddle and timeout were performed per
the [**Hospital1 18**]
protocol.
Under palpatory guidance, a 21-gauge micro needle was directed
in an antegrade
fashion into the venous limb of the fistula just distal to the
A-V
anastamosis. A 0.018 microwire was advanced under fluoroscopic
guidance. A
4.5 French Angiodynamics micropuncture sheath was exchanged for
the needle.
The wire and inner dilator were removed and a 0.035 angled
Glidewire advanced
centrally. A 4 French straight vascular sheath was exchanged for
the
micropuncture sheath. Venograms were performed over the wire
using carbon
dioxide of the fistula centrally, sequentially. A 4 French
straight flush
catheter was advanced over the wire, and the wire removed.
Through this,
carbon dioxide was injected to perform central venograms. Given
demonstrated
abnormalities, contrast was injected for improved definition.
Based on the
results, the flush catheter was removed and a 6 French [**Last Name (un) 2493**] Tip
sheath
exchanged for the pre-existing sheath. A 10 mm x 4 cm Bard
peripheral balloon
was advanced over the Glidewire and the venous pathway from just
central to
the stent to the cephalic arch was venoplastied. Next, the 6
French sheath
was exchanged for 7 French and a 12 mm x 4 cm Bard peripheral
balloon advanced
and the same segment again venoplastied.
Post-procedural venograms were performed. All wires, catheters
and sheaths
were removed after a 0 silk pursestring suture was placed at the
puncture
site. The patient tolerated the procedure well and there were no
immediate
post-procedure complications.
FINDINGS:
1. Two focal tight stenoses within the long stent which extended
from the
left subclavian to the SVC, one within the left brachiocephalic
vein and the
second at the junction of the left subclavian and left
brachioceohalic vein at
the site of overlapping of the two stents.
2. Band-like stenosis at the cephalic arch. Upon plasty of this
stenosis,
the graft was demonstrated to collapse and the character of flow
change from
pulsatility to thrill.
3. Post-procedural venograms demonstrate resolution of the
band-like stenosis
and improvement of the stenoses within the long stent.
IMPRESSION: Successful venoplasty of two focal tight stenoses
within the long left subclavian to SVC stent and band-like
stenosis at the cephalic arch.
Brief Hospital Course:
60F w/HCV, HTN, HL, ESRD s/p cadaveric transplant that presented
with flash pulmonary edema in setting of malignant hypertension
secondary to renovascular disease. Secondary issues was left
upper extremity swelling s/p AV fistulogram with successful
venoplasty of two focal tight stenoses.
# Flash pulmonary edema
ICU Course: Dyspnea was secondary to pulmonary edema in setting
of hypertensive urgency in setting of renovascular disease and
worsening renal function. No suggestion of dietary or medication
non-adherence. CXR was consistent with volume overload given
interstitial edema and bilateral effusions. Troponin was at
relative baseline given her renal dysfunction and remained
stable, though EKG did show some signs of demand. Pneumonia
seemed less likely given lack of fever and leukocytosis, though
given immunosupression did consider atypical infections, fungal
and PCP. [**Name Initial (NameIs) **] BP was treated aggressively with nitro gtt
and uptitration of antihypertensives as below. Patient was
diuresed aggressively, including with lasix gtt started [**2160-4-24**]
and metolazone. TTE on [**4-24**] demonstrated normal LV systolic
function (LVEF >55%), trace AR and mild MR, as well as moderate
pulmonary artery systolic hypertension.
On the [**Month/Year (2) **] floor, she was converted to furosemide 100 mg PO
BID and metolazone PO BID. She was discharged on furosemide 100
mg PO BID with metolazone PO qAM 30 minutes before home lasix
dosage. On discharge, she was able to ambulate well near her
baseline and did not require oxygen. She had required 2 L of O2
intermittently throughout hospitalization that she had been
using at home after a recent pneumonia.
Admission weight was 76.2 kg with dry weight of 73.9 kg.
Discharge weight was 71.2 kg.
She will follow-up with Dr. [**First Name (STitle) 805**] (renal).
# Malignant hypertension
ICU course: SBP in 200s on initial presentation to ED. Her blood
pressure was treated aggressively with nitro gtt titrated to SBP
180-200. Increased labetalol to 300mg TID, and continued
patient on home regimen norvasc. Cardiac enyzmes trended, and
trop remained stable around 0.12-0.13 in setting of worsening
renal function, with flat MBs. Patient's ASA dose was increased
to 325mg daily while ruling out MI. Started clonidine for
additional BP control, and nitro gtt weaned [**2160-4-25**].
On the [**Month/Day/Year **] floor, she was continued on clonidine 0.1 mg
patch, amlodipine 10 mg PO BID. Her labetolol was uptitrated to
400 mg PO TID. She will follow-up with Dr. [**First Name (STitle) 805**] and her PCP
for further titration of regimen.
# Left upper extremity swelling:
Patient reported several week history of left upper extremity
swelling with no evidence of DVT on US. AV fistulogram performed
on [**2160-4-28**] showing two focal tight stenoses within long stent
which extended from left subclavian to SVC and band-like
stenosis at cephalic arch s/p balloon angioplasty with
post-procedural venograms demonstrating resolution of band-like
stenosis and improvement of stenoses within long stent. A total
of 50 mL of contrast was used.
# ESRD s/p transplant: Patient had recent episode of humoral
rejection and admitted with dyspnea and pulmonary edema as
discussed above. Given outpatient volume management has been
difficult, she is likely approaching need for renal replacement
therapy. She was continued on her home prednisone, cyclosporine,
epoetin alfa and calcium acetate. Her sodium bicarbonate was
decreased from 1300 mg PO BID to 650 mg PO BID.
# Hepatitis C: Failed IFN therapy. No plan for further therapy
per recent hepatology notes.
# Communication: Patient, [**Name (NI) **] [**Last Name (NamePattern1) 99807**] ([**Telephone/Fax (1) 99811**]
# Code: Full (discussed with patient)
TRANSITIONAL CARE ISSUES:
- renal follow-up
- hypertensive regimen may need uptitration depending on blood
pressure measurements.
- assessment of renal function on diuretic regimen and in
setting of recent contrast load (50 mL).
Medications on Admission:
per last d/c summary
# prednisone 5 mg po daily
# furosemide 40 mg po BID
# Omeprazole 20 mg po daily
# Aspirin 81 mg po daily
# Amlodipine 10 mg po BID
# Cyclosporine 50 mg [**Hospital1 **]
# Senna [**2-10**] Tablet po BID prn
# Polyethylene glycol 3350 17 gram daily prn
# Docusate sodium 100 mg po BID prn
# Albuterol sulfate 90 mcg/Actuation HFA Aerosol prn
# labetalol 200 mg po TID
# Calcium acetate 667 mg po TID
# Sodium bicarbonate 1300 mg po BID
# EPO 10,000 units weekly
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
5. cyclosporine modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
7. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
10. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. epoetin alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
13. furosemide 20 mg Tablet Sig: Five (5) Tablet PO twice a day:
take metolazone 30 minutes BEFORE morning dose of lasix.
Disp:*300 Tablet(s)* Refills:*0*
14. metolazone 5 mg Tablet Sig: One (1) Tablet PO qAM: Take 30
minutes BEFORE lasix in the morning. .
Disp:*30 Tablet(s)* Refills:*0*
15. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal once a week.
Disp:*4 patches* Refills:*1*
16. labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: pulmonary edema, malignant hypertension secondary to
renovascular disease, chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for shortness of breath from fluid in your
lungs and high blood pressure. It is important to take your
medications on a regular basis. You also had the fistula in your
left arm dilated so that it will work better.
*** Please call Dr. [**Last Name (STitle) 18991**] office and schedule an appointment
on Friday.
MEDICATION CHANGES:
CHANGE furosemide to 100 mg by mouth TWICE daily
CHANGE labetalol to 400 mg by mouth THREE times daily
CHANGE sodium bicarbonate to 650 mg by mouth TWICE daily
START metolazone in the morning. Take medication 30 minutes
BEFORE lasix dose in morning.
START clonidine patch
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) 805**], [**First Name3 (LF) **] E. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appt: please call and schedule an appointment for Friday, [**5-2**], [**2160**]
Name: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Location: [**Hospital6 **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**Telephone/Fax (1) 53828**]
Appt: [**5-22**] at 1:15pm
|
[
"996.81",
"272.4",
"733.00",
"428.31",
"403.01",
"428.0",
"585.6",
"588.81",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
18570, 18627
|
12325, 16118
|
292, 331
|
18778, 18778
|
4590, 4590
|
19666, 20236
|
3891, 3918
|
16880, 18547
|
18648, 18757
|
16374, 16857
|
18929, 19260
|
5608, 5964
|
3265, 3612
|
3933, 4571
|
2572, 2988
|
5981, 12302
|
19280, 19643
|
245, 254
|
16144, 16348
|
359, 2553
|
4606, 5592
|
18793, 18905
|
3032, 3242
|
3628, 3875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,242
| 134,291
|
34608
|
Discharge summary
|
report
|
Admission Date: [**2112-8-15**] Discharge Date: [**2112-8-20**]
Date of Birth: [**2060-8-12**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
black stools
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 52 yo M with history of EtOH abuse ([**2-10**] pint- 1 pint
2-3 times per week x 20 years), who presented with melena and
loose stools. The patient reported that two days PTA he felt
weak the whole day and in the evening he noted passing formed,
black stools twice. He was nauseated and did not eat, and the
following day he had another black, loose bowel movement. He
then decided to present to the ED in [**Hospital3 4298**], where he
was admitted. He stated he has been fatigued for the past few
months, had lost his appetite and lost approximately 50 pound in
the past year, but denies vomiting, prior hematemesis, jaundice,
swollen abdomen. Takes no medication and only occasionally has
nausea with his drinking.
In [**Hospital3 4298**] an Ultrasound of his liver was obtained
that showed an echogenic pattern consistent with fatty liver.
His initial labs were significant for a hct 31, t.bili 6.9
albumin 3.4, AST 77, ALT 30, plts 111, INR 1.4. At the OSH, a
CXR was also negative for any acute pulmonary process. He was
then transfered to the [**Hospital1 18**] ED for further evaluation and
management.
In the ED, initial vs were: 97.9, hr 72 BP 95/65 RR 18 Sa02
99RA.
A 16g and 18g PIV were placed. He transiently had a bp of 88/69
which improved w/ 3L of IVF w/ modest improvement of sbp to the
mid 90's. An NGL w/ 500cc was negative. He was guaiac positive.
He had a BM which by nurse's report was dark brown. GI and Liver
were contact[**Name (NI) **]. [**Name2 (NI) **] was also given IV protonix and octreotide. A
hematocrit drop from the OSH to the [**Hospital1 18**] ED was noted as
significant (31 to 25). He was then transferred to the MICU.
Past Medical History:
etoh abuse
gout in multiple joints in BLE and BUE.
Social History:
unemployed, previously in maitenance, lives alone, smoke 1.5ppd
x 30year. [**2-10**] to 1 pint of vodka 2-3x/weeks x 20 years.
Family History:
Mother died of an MI in her 70's, father w/ several "valve
replacements." no liver disease or alcoholism in the family.
Physical Exam:
VS: 97.7, 103/61,80, 13, 98 RA
GEN: NAD, laying in bed, flat affect, cachectic
HEENT: icteric sclera, crust surround both eyes, dry MM, flat
JVP.
CV: RRR, no murmurs
PULM: CTAB, no rales or wheezes
ABD: thin abdomen, normal BS, soft when patient able to relax,
+hepatomegaly 4-6 cm below costal margin. No ascites.
EXT: no edema, 2+DP, WWP
NEURO: alert and oriented, no asterixis
skin: no spider nevi
Pertinent Results:
RUS: fatty infiltration of the liver. No stone seen in the gall
bladder. Unremarkable examination of the abdomen otherwise.
CXR ([**2112-8-15**])no acute pulm process.
.
ECG [**2112-8-16**]: low voltage, no STTW changes
.
[**2112-8-15**] 10:00PM WBC-4.6 RBC-2.59* HGB-8.6* HCT-25.0* MCV-97
MCH-33.3* MCHC-34.4 RDW-17.4*
[**2112-8-15**] 10:00PM PLT SMR-LOW PLT COUNT-92*
[**2112-8-15**] 10:00PM ALT(SGPT)-22 AST(SGOT)-62* LD(LDH)-159
CK(CPK)-17* ALK PHOS-125* TOT BILI-5.1*
[**2112-8-15**] 10:00PM LIPASE-30
[**2112-8-15**] 10:00PM GLUCOSE-84 UREA N-5* CREAT-0.4* SODIUM-136
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-25 ANION GAP-19
Brief Hospital Course:
Briefly, this is a 52 yo M with history significant for ETOH
abuse and cacchexia, transferred from OSH with melena, anemia,
abnormal LFTs. The following issues were addressed during this
hospitalization:
1. Melena. Given the patient's significant EtOH abuse history
and his use of NSAIDs for gout, upper GI ulcer was determined to
be the most likely cause of his bleed. Given his significant
drop in hematocrit during transfer to [**Hospital1 18**], he required 2 units
PRBCs in the MICU, after which his hematocrit remained stable.
In the [**Last Name (LF) **], [**First Name3 (LF) **] NGL was negative. He was initially maintained on
IV PPI twice a day, but was later transitioned to an oral PPI.
He received 1 dose of octreotide in the ED, however, this was
stopped as patient had neither hematemesis nor varices. GI was
consulted and performed an EGD, which found "no evidence of
varices or gastropathy. Good view of entire UGI except small
area in body. No cause seen for melena." Outpatient follow-up
with colonoscopy and/or small bowel evaluation was recommended.
Melena resolved during his MICU course and the patient had no
further melena following transfer to the floor.
2. Elevated LFTS: RUS showed fatty liver, and portal
hypertension. His AST/ALT ratio as well as history of heavy
drinking made chronic alcoholic hepatitis by far the most likely
scenario. He denied any other hx. of hepatitis, and hepatitis
serologies were found to be negative.
3. Weight loss: The patient's 50 pound weight loss in the past
year was of particular concern, prompting a work-up for possible
malignancy. Given this patient's extensive smoking history,
painless jaundice, hepatomegaly, and GI bleed, at CT of the
chest, abdomen, and pelvis was performed. The liver was notable
only for hepatic steatosis. Also of note were "Several cystic
lesions in the pancreas and peripancreatic region ... location
in the peripancreatic region with extension to the stomach and
mild inflammatory changes about the pancreas make these most
consistent with pseudocysts." GI was further consulted
regarding the possibility of cyst aspiration to confirm the
diagnosis, or consideration of ERCP, EUS, or colonoscopy given
continued concern for possible malignancy, but they felt
strongly that were benign cysts and recommended outpatient
follow up with repeat imaging. Colonoscopy and/or small bowel
evaluation was also deferred as per above. It was made explicit
to the hepatology team that this patient has significant
limitations (financial and geographical) to follow-up care, as
well as explicit to the patient that medical follow-up is of
high importance.
4. Hyperbilirubinemia: likely [**3-12**] to alcoholic cirrhosis, given
the patient's history. Bilirubin was fractionated and found to
be nearly all conjugated responsible for the increase.
Abdominal exam was significant for hepatomegaly.
RUQ US showed no obstruction of the gall bladder. The bilirubin
trended down during his stay from 5.1 on admission to 2.2 at
discharge.
5. EtOH abuse: The patient has a long history of alcohol use.
During his stay he had no signs of withdrawal. He was maitained
on a multivitamin, folate, and thiamine. A social work consult
was intiated, however, a few questions into the interview, the
patient preferred to not to continue.
6. Tobacco abuse: The patient was given a low dose of a nicotine
patch during his stay in the hospital which proved inadequate
for his 1.5 ppd smoking habit. While on the floor, the patient
was observed by a nurse smoking in the solarium, and upon trying
to avert her, tripped over a bucket. He had no injuries,
bleeding, mental status changes, or point tenderness. He was
placed on fall precautions and dosage of his nicotine patch was
increased.
7. FEN: The patient tolerated a regular diet well throughout his
hospital stay. Although the patient cited early satiety as a
likely contributer to his 50 pound weight loss, he complained of
no difficulty finishing meals in house.
Medications on Admission:
Ibuprofen prn for gout
Colchicine prn for gout
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
4. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*60 Cap(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Gastrointestinal Bleed
Alcoholic hepatitis
Peripancreatic pseudocysts
Discharge Condition:
Stable, with SBP between 85 and 100. Tolerating po well,
ambulating well. No baseline neurological, ROM, or cognitive
deficits.
Discharge Instructions:
You were admitted to the hospital because of bleeding from your
gut that made your stools black. You also had a low blood
pressure and had lost enough blood to require 2 units of a blood
transfusion.
If you have further black stools, dizziness, fainting or
near-fainting episodes, nausea, vomitting, vomitting blood,
diarrhea, yellow skin or eyes, or anything else that worries
you, please seek immediate medical attention.
Take all of your medications as prescribed.
Please, it is very important that you find a primary care
doctor.
Followup Instructions:
It is important that you find a primary care doctor near you and
schedule an appointment to see him or her in the next 1-2 weeks.
* It is very important that you have a follow-up CT scan of your
abdomen in 3 months ([**2112-11-9**]) to monitor the cysts found in
your pancreas.
* It is very important that you have an ultrasound of your
thyroid to further evaluate the left thyroid nodules found on CT
scan.
You should also follow up with a liver specialist in 1 month.
If you would like to be seen here, please call ([**Telephone/Fax (1) 1582**]
and make an appointment to see Dr. [**Last Name (STitle) **]. If you would prefer
to be seen closer to your home, your new primary care doctor can
refer you to somebody.
Completed by:[**2112-8-28**]
|
[
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"327.23",
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"571.2",
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"285.1",
"305.1",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
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] |
7993, 7999
|
3477, 7484
|
308, 316
|
8119, 8251
|
2815, 3454
|
8837, 9590
|
2255, 2377
|
7581, 7970
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8020, 8098
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7510, 7558
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8275, 8814
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2392, 2796
|
256, 270
|
344, 2020
|
2042, 2095
|
2111, 2239
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,614
| 153,831
|
7961
|
Discharge summary
|
report
|
Admission Date: [**2123-12-29**] Discharge Date: [**2124-1-4**]
Date of Birth: [**2082-4-14**] Sex: M
HISTORY OF PRESENT ILLNESS: This is a 41 year old with
history of recently diagnosed hypertension transferred from
[**Hospital3 4527**] for acute coronary syndrome and
hyperglycemia. The patient reports first feeling poorly a
his right hand and arm. Approximately seven days ago or
perhaps more he began having weakness in his hand. Seven
days ago he began having intermittent substernal chest pain,
feeling "like a screwdriver is stabbing me", lasting
approximately 30 minutes, moderately severe, occurring about
two times per day. No associated diaphoresis, nausea,
vomiting or shortness of breath. Over the past three to four
as blurry vision. In the AM of admission he did not eat
breakfast and felt quite poorly. He does not remember much
else. He was found by his jailmates to be seizing. His
glucose in the field was greater than 500. He was sent to
the [**Hospital3 4527**] Emergency Department where they found a
glucose of 845. His toxicology screen was negative and serum
ketones were negative. His sodium was 129, bicarbonate was
22. He seized again twice in the Emergency Room and was treated
with Ativan. A head computerized tomography scan was done which
was negative. Initially there was no complaint of chest pain but
during the Emergency Department course he began to complain of
chest pain. Electrocardiogram done showed ST elevation to 5 mm
in V4 through V6 as well as milder elevation in 2, 3, and AVF. He
was started on Lopressor, Aspirin, Nitroglycerin, Integrilin and
heparin and was sent to [**Hospital6 256**] for
catheterization. In the laboratory he was found to have a right
dominant system. There was no significant left main disease.
The left anterior descending had a large thrombus at its origin.
His circumflex had diffuse disease with TO distal and TO of the
first obtuse marginal branch upper pole with right to left
collaterals. The right coronary artery had mild diffuse disease.
Angio-jet was done with resolution of thrombus in the LAD. This
was complicated by dissection which was treated with PTCA. The
obtuse marginal upper pole lesion was dilated with a balloon.
Final results were TIMI 3 flow in the LAD and Cx. There were no
stents placed and he was admitted to the Coronary Care Unit.
PAST MEDICAL HISTORY: The patient was given a diagnosis of
hypertension approximately three to four weeks ago. He had a
laminectomy in the past, and has chronic back pain after being
hit by a truck.
MEDICATIONS ON ADMISSION: He reported taking Atenolol,
but was unclear on his dose.
ALLERGIES: He denied any drug allergies, though noted that
Motrin causes gastrointestinal upset.
SOCIAL HISTORY: He is an inmate at [**Location (un) 912**] Prison. He formerly
smoked one pack of cigarettes per day. He denied alcohol use.
He initially denied any illicit drugs, however, later a history
of some cocaine use in the past was obtained.
PHYSICAL EXAMINATION: Initial physical examination revealed
a temperature of 100.2, pulse 104, blood pressure 150/80. He
was an obese white male in no acute distress with multiple
tatoos in restraints and ankle cuffs. His pupils were equal,
round and reactive. His extraocular movements were intact.
His neck was supple. He had no lymphadenopathy. He was
tachycardiac with no murmurs, gallops or rubs with a normal
S1 and S2. His lungs were clear to auscultation bilaterally.
He had positive bowel sounds. He was obese. He was
nontender, nondistended. He had 2+ pulses in his extremities
and no edema. The patient was mildly confused but knew the
street, month and year. His neurological examination was
significant for decreased handgrip and wrist flexion and
extension with also a decreased sensation in a similar area.
HOSPITAL COURSE: 1. Cardiac - The patient was treated for
his cardiac disease with a catheterization as above as well
as aspirin, beta blocker and ACE inhibitor. His peak
creatinine kinases were in the 4000. He continued to have
chest pain. It was initially described as sharp and
intermittent, different from his chest pain with his
myocardial infarction. There were no associated
electrocardiogram changes; later he complained of a dull constant
substernal chest pain, also without electrocardiogram changes.
This pain was relieved with Morphine. He denied any exacerbating
or relieving factors though it was noted that he was more
uncomfortable while transferring in between the stretcher and the
bed, and thus pain seemed to be worse with movement. Throughout
this reported chest pain his creatinine kinases continued to
decline. He was noted to have severely reduced left ventricular
ejection function on an echocardiogram with an ejection
fraction of 20 to 30% secondary to severe hypokinesis of all
but the basal segments of the left ventricle. An apical
thrombus could not be excluded. Given these findings and
the thrombus in his coronary arteries as well as his recent
cerebrovascular accident he was treated with hepariin and
coumadin. He initially did not demonstrate signs or symptoms of
CHF, however following aggressive volume repletion in the
setting of his hyperosmolar nonketotic state he eventually
developed mild dyspnea and hypoxia, and was diuresed accordingly
with good response.
2. Endocrine - Without a diagnosis of diabetes, the patient
had symptoms and glucose consistent with hyperosmolar
nonketotic state, the glucose over 800 and mental status
changes as well as seizures. Upon arrival to the Coronary
Care Unit he was started on insulin drip and with the input
of the [**Last Name (un) **] Consult Service his sugars were brought under
control. He was eventually switched over to subcutaneous
insulin, and his regimen was titrated up to achieve better
glucose control; his total insulin requirement at this point is
over 100 units/day.
3. Neurology - Right hand weakness, the patient was seen by
Neurology and it was felt that his symptoms were consistent
with cortical hand, consistent with a cerebrovascular
accident. An magnetic resonance imaging scan confirmed these
findings with the left middle cerebral artery territory likely
embolic stroke. By history this stroke was 2-4 weeks old. He
was treated with anticoagulation as described above. Carotid
ultrasounds were done with no clear evidence of source.
There was consideration for a right to left shunt, however,
bubble study could not be done due to the patient's body
habitus. Due to the symptoms on [**1-1**], of left hand
weakness, he underwent a head computerized tomography scan
which was negative for any sign of bleed. Neurological
examination repeated by the neurology resident and was thought to
be unchanged with no evidence for new or extended cerebrovascular
accident.
His seizures were initially thought secondary to hyperglycemia
but in the setting of his recent cerebrovascular accident, other
etiology could not be ruled out. An electroencephalogram was
done which was negative, however, he was started on Trileptal;
duration to be decided by the neurological team.
4. Hematology - Due to his stroke, myocardial infarction and
thrombus in his coronary arteries particular workup was begun
for hypercoagulable state while he was anticoagulated on
heparin and started on Coumadin. Homocysteine was sent which
was normal. Other studies are pending at this time. His
platelets remained stable and his hematocrit slowly drifted
down due to blood draws and hydration but remained above 30.
During his entire hospitalization he remained under the
supervision of custody of [**Location (un) 86**] police. There was a poor
communication between the patient and his family. His renal
function remained stable. He had good p.o. intake and was
seen by physical therapy and occupational therapy and will be
sent to [**Hospital **] Rehabilitation.
DISCHARGE DIAGNOSIS:
1. Acute anterior myocardial infarction
2. Cerebrovascular accident involving left middle cerebral
artery territory
3. Diabetes with hyperosmolar nonketotic state
4. Seizures
5. Hypertension
DISCHARGE MEDICATIONS:
1. Lisinopril 10 mg p.o. q.d., hold for systolic blood
pressure less than 105.
2. Toprol XL 200 mg p.o. q.d., hold for systolic blood
pressure less than 105.
3. Enteric coated aspirin 325 mg p.o. q.d.
4. Percocet 1 to 2 tablets p.o. q. 6 prn times five days
5. Trileptal 300 mg p.o. b.i.d. times four days and then 450
mg p.o. b.i.d.
6. Lipitor 10 mg p.o. q.d.
7. Lantis 70 units subcutaneously h.s.
8. Humalog sliding scale, q. a.c., fingerstick 80 to 150 10
units, 151 to 200 13 units, 201 to 250 16 units, 251 to 300
19 units, 301 to 350 22 units and 351 to 400 25 units and 401
to 450 28 units, greater than 450 30 units. Q. h.s.
fingerstick 150 to 200 4 units, 201 to 250 6 units, 251 to
300 8 units, 301 to 350 10 units, 351 to 400 12 units, 401 to
450 14 units and greater than 450 16 units Humalog.
9. Coumadin. Anticoagulation planned for at least 6 months, and
probably indefinately.
10. Heparin IV until INR >2, goal INR [**2-14**].
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Activity restriction secondary to large
myocardial infarction with severely reduced ejection fraction
as well as new cerebrovascular accident. The patient will
require rehabilitation stay and needs follow up from primary
care physician, [**Name10 (NameIs) **], as well as Neurology all within
the next four to six weeks. His INR will need to be checked
on Coumadin in the next two days, adjust prn.
Hypercoagulable workup should be followed by calling [**Hospital6 1760**] Laboratory.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Name8 (MD) 13286**]
MEDQUIST36
D: [**2124-1-2**] 13:23
T: [**2124-1-2**] 16:34
JOB#: [**Job Number **]
|
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icd9cm
|
[
[
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[
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icd9pcs
|
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[
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9146, 9924
|
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|
7948, 8145
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,188
| 137,709
|
38529
|
Discharge summary
|
report
|
Admission Date: [**2197-2-2**] Discharge Date: [**2197-2-10**]
Date of Birth: [**2138-10-15**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain, constipation
Major Surgical or Invasive Procedure:
Small-bowel resection plus primary anastomosis.
History of Present Illness:
Mr. [**Known lastname **] is a 58 year old man with a history of metastatic
melanoma with brain mets who presents to the ER with abdominal
pain and constipation. History is obtained with the assistance
of his wife who states that they recently traveled on a cruise
and during this trip he was developing worsening headache which
were treated with Oxycontin (10-20 mg [**Hospital1 **]) and Oxycodone 5 mg
taken 2-4 tablets per day. He has been taking Dexamethasone 4
mg every 6 hours for the past few weeks. He has been
constipated and last moved his bowels 5 days ago. He has had
increasing abdominal discomfort over the past few days and his
narcotics have been held for the past 3 days. For the
constipation he was taking an over the counter senna but this
has not been helping. He was taking this once a day.
In the emergency department, initial vitals: 97.1 120 109/84 16
100%. A KUB was performed which showed moderate fecal loading
in the colon and no free air. CXR was unremarkable. He was
given Miralax in the ER. Rectal exam showed no stool in the
rectal vault and guaiac was negative. His wife states he
received 2L of IVF in the ER (unable to confirm this on
documentation).
On arrival to the floor, he is somnolent which his wife states
occurs when he stops the dexamethasone. He has no headache and
denies abdominal pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies current headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. Denied arthralgias or myalgias.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- [**2194**]: noticed a mole on the right temple
- [**2195-4-17**] mole was resected, pathology revealed melanoma
involving the dermis and subcutis extending to the deep margin,
measuring 9 mm in thickness.
- [**2195-5-8**] CT Torso revealed a 2.5 x 1.2 cm dominant left upper
lobe
ill-defined lung nodule, additional small satellite nodules, a
1.8 x 1.7 cm RUL nodule anteriorly, and multiple liver lesions;
largest measuring 1.6 cm. Head MRI revealed right cerebellar
lesion. He underwent gamma knife radiosurgery on [**2195-5-19**]. He
commenced in temozolomide 200 mg/m2 x 5 days course with largely
stable disease but some areas of disease progression.
- [**2195-8-12**]: CTLA4-ab compassionate access protocol
- [**2195-10-14**] admitted with Hypotension, Acute renal failure,
Pan-hypopituitary syndrome, amd grade 4 rash. He was discharged
on [**2195-10-16**] in good condition. His Rash responded to 2mg/kg/day
dose of prednisone with grade [**1-30**].
- His CT scan and head MRI for week 24 revelaed a new R deep
insular, L parietal CNS lesions, parotid gland involvement as
well as a new
subcutaneous mass in the R temple. He was taken off of protocol
at that time.
- [**12/2195**]: underwent CK to the two new lesion found on the MRI,
R insular and L parietal lesions
- [**2196-4-7**] underwent resection of a melanoma from the right
parotid region by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**].
- [**2195-5-4**]: Cyberknife radiosurgery on [**2196-5-3**] to a left frontal
metastasis to 2200 cGy at 74% isodose line, and status external
beam
irradiation to the parotid gland at [**Hospital 1474**] Hospital by [**Last Name (NamePattern1) 85702**].
- [**9-/2196**]: began WBXRT due to progression in the CNS, completed
[**10/2196**]
OTHER PAST MEDICAL HISTORY:
GERD
Panhypopit [**3-2**] Ipilimumab
Hypothyroidism
Social History:
Married, four children. The patient owns business in sheet
metal parts. He is still working.
Family History:
No malignancy in family.
Physical Exam:
On admission:
VS: T96.1 BP 126/84 HR 104 RR 16 97% RA
GENERAL: Lethargic but arousable and answers questions
appropriately, NAD
HEENT: No scleral icterus. Inability to abdjuct eyes
bilaterally. MMM, OP clear
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: Soft, non-distended. Discomfort with palpation of the
lower quadrants bilaterally. No rebound. + guarding.
EXTREMITIES: No c/c/e. Left first finger with work-related
injury in which the fingertip has been cut off. Does not appear
infected.
NEURO: Inability to abdjuct the eyes. Other cranial nerves
appear intact. 4/5 strength of left upper and lower extremities
bilaterally. Right side is intact. Sensation intact. Gait
assessment deferred.
On discharge:
VS: 96.2 94 126/80 20 90%RA
GEN: alert, NAD
CARD: RRR. No m/r/g
LUNGS: CTA bilaterally, slightly diminished LLL
ABD: Soft, nontender, nondistended. +flatus, incision OTA with
staples, minimal errythema or drainage
EXTR: Pink, warm, well-perfused. No edema.
Pertinent Results:
[**2197-2-2**] 11:45AM BLOOD WBC-15.5*# RBC-4.64 Hgb-13.5* Hct-41.1
MCV-89 MCH-29.2 MCHC-33.0 RDW-13.9 Plt Ct-392#
[**2197-2-2**] 11:45AM BLOOD Neuts-85* Bands-13* Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2197-2-2**] 11:45AM BLOOD Glucose-142* UreaN-82* Creat-3.1*# Na-140
K-5.4* Cl-99 HCO3-23 AnGap-23*
[**2197-2-2**] 02:11PM BLOOD Lactate-1.9
[**2197-2-2**] 03:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2197-2-2**] 03:30PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2197-2-2**] 03:30PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
KUB:
FINDINGS: Bowel gas is seen within non-dilated small bowel and
large bowel including down to the rectum. There is no evidence
of free air. Moderate fecal loading is seen in the colon. Imaged
osseous structures appear unremarkable.
IMPRESSION: Nonobstructive bowel gas pattern. No free air.
CXR: No evidence of acute cardiopulmonary disease. Likely stable
nodule at the right lung apex.
[**2197-2-3**] CT of abd:
1. Jejunal dilatation and wall thickening. Aneurysmally dilated
loop of
jejunum with nodular wall thickening and adjacent contrast and
free air
consistent with perforation. Additional areas of nodular wall
thickening and enlarged mesenteric lymph nodes. Findings most
likely secondary to known melanoma.
2. Sigmoid colon diverticulosis without associated inflammatory
changes.
3. Focal hepatic hypodensities, which likely represent cysts or
hamartomas, stable.
[**2197-2-9**] c-xray
Cardiomediastinal contours are normal. Aside from minimal
atelectasis in the left lower lobe, the lungs are grossly clear.
There is no pneumothorax or pleural effusion.
Brief Hospital Course:
Mr. [**Known lastname **] is a 58 year old man with a history of metastatic
melanoma with brain metastases who presents with constipation
and abdominal pain. His initial KUB and c-xray on admission did
not show evidence of free air in the abdomen, and revealed only
fecal loading in the colon. He was initially admitted to the
medical service for further evaluation of his abdominal pain and
treatment of his presumed constipation. He was given stool
softeners and a bowel regimen and hydrated with IV fluids. His
dexamethasone was continued. Blood and urine cultures were
obtained on admission which have no growth.
On [**2197-2-3**] his abdominal pain did not improve and a CT of
abd/pelvis was contained which demonstrated SB perforation with
contrast extravasation. The Acute Care Surgery Service was
consulted and took Mr. [**Known lastname **] to the operating room on [**2197-2-4**] for
a small bowel resection with primary anastomosis. Findings
intra-operatively included diffuse intra-abdominal metastatic
melanoma including two areas of proximal small bowel perforation
with related purulent peritonitis. Please see note by Dr. [**Last Name (STitle) 853**]
for further details. Pt tolerated the procedure well and was
brought to the SICU intubated for further care under the ACS
service.
Shortly after arrival to the SICU patient was deemed stable for
extubation. Pain was initially controlled with dilaudid PCA
though switched to intermittent dilaudid [**3-2**] poor patient
comprehension of PCA usage. Patient remained A&Ox3 though
confused and perseverative as was apparent preoperative
baseline. Remained hemodynamically stable without pressor
requirement and did require intermittent IV hydralazine for
hypertension. Pulmonary toilet was encourage and patient
complied with this appropriately. Pt kept NPO and hydrated w
IVF. NGT placed intra-operatively was self-d/c'd by pt [**2-3**]
following extubation. Foley catheter was kept in place
throughout ICU stay and patient made adequate urine without need
for IVF bolus. From an endocrine standpoint pt was restarted on
preoperative dose of steroids on POD1. Stress dose steroids
were not given or required. Consideration given to
fludrocortisone though electrolytes remained within appropriate
balance and this was deferred. Insulin sliding scale was
utilized to maintain euglycemia. Cipro and flagyl were
continued postop while in SICU to prophylax against tertiary
peritonitis and pt remained afebrile while in SICU. On [**2-5**] pt
deemed appropriate for floor xfer given stable hemodynamics and
appropriate recovery.
His vitals signs were routinely monitored on the floor and he
remained hemodynamically stable and afebrile. Of note, he
continued to have an oxygen requirement of only 1-2L NC, and
mild crackles were noted on lung exam on [**2-9**]. A cxray was
obtained which showed only mild LLL atelectasis. Incentive
spirometry was encouraged and his oxygen saturations remained
stable in the low 90's on room air at discharge.
On [**2-6**] he reported passing flatus. He was started on sips of
clear liquids and his diet was advanced slowly over the next 48
hours. Prior to discharge he had a bowel movement and was
tolerating a regular diet without nausea or abdominal pain.
However, it was noted that he had a decrease in appetite and
poor PO intake. He was started on an appetite stimulant
(marinol) as well as ensure supplements. His poor intake was
thought to be related to his depressed/flat affect, and he was
also started on a low dose of lexapro for this. Palliative care
was consulted who recommneded changing the marinol to ritalin.
He continued to pass flatus and deny symptoms of nausea or
abdominal pain.
A foley catheter was placed intraoperatively and removed on [**2-6**],
at which time he voided without difficulty. His intake and
output were closely monitored throughout the remainder of his
hospitalization.
Physical therapy was consulted to evaluate the patient's
mobility status who recommended rehab when medically cleared. He
was encouraged to mobilize out of bed as tolerated throughout
his hospitalization. He was also started on SC heparin for DVT
prophylaxis.
Palliative care was also consulted given the patient's prognosis
and diagnosis of metastatic melanoma. The discussion of post
hospital care included options of rehab, home with hospice, or
home with VNA bridging to hospice care. The discussion occurred
with both the patient and his wife, who expressed the desire for
rehab upon leaving the hospital.
Today, he feels well from his abdominal surgery and is preparing
for discharge. His vital signs are stable and he is without
complaints of abdominal pain. He has evidence of bowel function.
He is scheduled for ACS follow as well as follow up with Dr.
[**Last Name (STitle) 724**].
Medications on Admission:
Dexamethasone 4 mg every 6 hours
Levothyroxine 50 mcg PO daily
Oxycodone 5 mg Tablet 1-2 tabs PO q4H PRN
Oxycontin 10-20 mg PO q12H
Compazine 10mg PO TID PRN
Ranitidine 150 mg PO BID
Discharge Medications:
1. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for breakthrough pain.
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 2 days: 2 days starting [**2-8**]. last dose in PM of
[**2-9**].
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days: 2 days starting [**2-8**]. Last dose in
PM of [**2-9**].
5. dexamethasone 4 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily):
titrating steroid dose to patient's headches and diplopia. .
6. levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for pain: not to exceed 4 gm in 24 hours.
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
10. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ritalin 5 mg Tablet Sig: One (1) Tablet PO twice a day:
Please give at 0800 and 1400.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] healthcare center
Discharge Diagnosis:
Primary:
perforated small bowel
Secondary:
metastatic melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a small bowel
perforation. You were taken to the operating room and had part
of your small bowel removed. You are recovering well from the
procedure and have resumed bowel function. You are being
discharged to continue your recovery. You may resume a regular
diet.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Hospital 5059**] at your next visit.
Don't lift more than 15-20 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Month (only) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2197-2-21**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2197-2-28**] at 2:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2197-2-14**]
|
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icd9cm
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icd9pcs
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4029, 4126
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,230
| 166,154
|
28247
|
Discharge summary
|
report
|
Admission Date: [**2153-10-9**] Discharge Date: [**2153-10-18**]
Date of Birth: [**2096-3-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Increasing shortness of breath
Major Surgical or Invasive Procedure:
[**2153-10-11**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary to diagonal artery, vein grafts to left
anterior descending and obtuse marginal) and Mitral Valve Repair
utilizing a 27mm Duran AnCore Band
History of Present Illness:
Ms. [**Known lastname 68603**] is a 57 year old female with congestive heart
failure. She was recently admitted to the [**Hospital1 18**] in [**Month (only) **]
[**2152**] for an NSTEMI. Cardiac catheterization and echocardiogram
at that time revealed severe three vessel disease, severe mitral
regurgitation, an LVEF of [**10-14**]%, and left ventricular thrombus.
She also underwent cardiac MR which showed the LV foward
ejection fraction of 19%. Workup was also notable for a right
upper lobe slightly spiculated 10-mm lung overlying the 6th
intercostal space, worrisome for lung cancer. She was eventually
discharged and placed on Warfarin for the LV thrombus with plans
for cardiac surgical intervention in the near future.
She was admitted on [**10-9**] for Warfarin washout and
heparinization, along with routine preoperative workup and
further evaluation for lung nodule.
Past Medical History:
Congestive Heart Failure, Coronary artery disease, Mitral
regurgitation, History of Left Ventricular thrombus, Recent
NSTEMI, Hypertension, Hypercholesterolemia, History of tobacco
abuse, History of pneumonia, Lung Nodule
Social History:
Tobacco abuse: 2ppd for approximately 40 years. No significant
alcohol use. She is a housewife, and currently lives with her
husband. Three children, three grandchildren. She is not
employed.
Family History:
Noncontributory. No history of premature cardiac disesase.
Physical Exam:
Vitals: BP 109/66, HR 70, RR 14, SAT 99% on room air
General: thin female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, bilateral carotid bruits noted
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2153-10-9**] CT Scan: 1. Spiculated 11-mm right upper lobe lung
nodule concerning for neoplasm. There is also associated
precarinal and bilateral hilar lymphadenopathy. No evidence of
metastases. 2. Mild centrilobular emphysema. 3. Mild tree-in-[**Male First Name (un) 239**]
opacification in the right lower lobe is nonspecific and may be
due to superimposed infection, inflammation, or atelectasis. 4.
Diverticulosis.
[**2153-10-11**] TEE: 1 - PRE-BYPASS: Overall left ventricular systolic
function is severely depressed with an estimated EF of 15-20 %.
No masses or
thrombi are seen in the left ventricle. Resting regional wall
motion
abnormalities include akinesis of inferior and inferoseptal
walls. The remaining left ventricular segments are hypokinetic.
There is an apical left ventricular aneurysm The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral
regurgitation is seen. There is mild MAC. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. 2 - POST-BYPASS:
Well-seated annuloplasty ring in the mitral position. No
paravalvular leak. Trace MR. There is no evidence of [**Male First Name (un) **]. There
is improvement of the overall LV function. LVEF 25-30%. The
aortic contour post decannulation is normal.
[**2153-10-13**] CT HEAD WITHOUT CONTRAST: No hydrocephalus, shift of
normally midline structures, intra- or extra-axial hemorrhage,
or acute major vascular territorial infarct is identified on
these limited views. No fractures are seen. Imaged sinuses are
clear.
[**2153-10-16**] 05:55AM BLOOD WBC-7.3 RBC-4.07* Hgb-12.1 Hct-35.6*
MCV-88 MCH-29.8 MCHC-34.0 RDW-14.8 Plt Ct-247#
[**2153-10-16**] 05:55AM BLOOD Glucose-78 UreaN-5* Creat-0.5 Na-139
K-4.1 Cl-102 HCO3-28 AnGap-13
Brief Hospital Course:
Ms. [**Known lastname 68603**] was admitted and underwent further evaluation which
included dental consultation, CT scan for pulmonary nodule and
carotid ultrasound for bilateral carotid bruits. Dental
consultation found evidence of several tooth fractures and
recommended several tooth extractions. Full body CT scan was
notable for a spiculated 11-mm right upper lobe lung nodule
concerning for neoplasm with associated precarinal and bilateral
hilar lymphadenopathy. There was no evidence of metastases. CT
scan also revealed mild centrilobular emphysema and
diverticulosis. Carotid ultrasound showed a 60-69% stenosis of
the left internal carotid artery. The right internal carotid
artery was normal. The carotid ultrasound also found evidence of
right-sided subclavian steal. Given the above results, tooth
extractions will be arranged postoperatively, and she will
follow up with Dr. [**Last Name (STitle) 952**](Thoracic Surgery) as an outpatient
after she recovers from her upcoming cardiac surgery. Given only
moderate carotid disease, no intervention was indicated. Her
preoperative course was otherwise uneventful and she was cleared
for surgery.
On [**10-11**], she underwent a mitral valve repair and
coronary artery bypass grafting by Dr. [**Last Name (STitle) **]. There were no
complications and she transferred to the CSRU in stable
condition. For further surgical details, please see seperate
dictated operative note. Within 24 hours, she awoke
neurologically intact and was extubated. She weaned from
inotropic support and transferred to the SDU on postoperative
day one. Late on postoperative day two, she experienced altered
mental status, aphasia, nausea and vomiting, along with
decreased left sided movements. She was hypotensive at that time
with a systolic blood pressure in the 70's. She was started on
intravenous Dopamine and emergently underwent head CT scan which
found no obvious evolving large territorial infarction. She
returned to the CSRU for continued pressor support and started
on intravenous Heparin. As her hemodynamics improved with
pressor support and several blood tranfusions, her neurological
status also improved. She was seen by neurology who felt that it
was due to hypetension and that her symptoms were related to
hypoperfusion in the setting of known carotid disease and
subclavian steal. Her aphasia and left sided weakness completely
resolved. She gradually became more alert and oriented over the
next 24 hours. She weaned from pressor support and returned to
the SDU on postoperative day four. She continued on coaumadin
and heparin for LV thrombus, afib and at the recommendation of
neurology.She continued to do well and was ready for discharge
on POD #7.
Medications on Admission:
Lopressor 25 [**Hospital1 **], Lisinopril 5 qd, Warfarin 4 qd, Lipitor 80 qd,
Aspirin 325 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. 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*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 2
days: Have INR checked [**10-20**] and PRN with results to Dr. [**Last Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*0*
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4H as
needed.
Disp:*50 Tablet(s)* Refills:*0*
9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Congestive Heart Failure, Coronary artery disease and mitral
regurgitation - s/p coronary artery bypass grafting and mitral
valve repair, Postoperative Anemia, Postoperative Neurologic
Event, History of Left Ventricular thrombus, Recent NSTEMI,
Hypertension, Lung Nodule, Carotid Disease,
Hypercholesterolemia, History of tobacco abuse, History of
pneumonia
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions. Take Warfarin as directed. Warfarin will
be followed by Dr. **** as an outpatient. PT/INR should be
checked within 48-72 hours of discharge. Warfarin should be
adjusted for goal INR between ********.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in 2 weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 25786**] in [**2-2**] weeks - call for appt.
Local cardiologist, Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**2-2**] weeks - call for appt.
Dr. [**Last Name (STitle) 952**] 3-4 weeks for follow up of pulmonary nodule
Local dentist for tooth extraction after discharge
Completed by:[**2153-10-18**]
|
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,382
| 123,162
|
33843
|
Discharge summary
|
report
|
Admission Date: [**2101-5-25**] Discharge Date: [**2101-6-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Intracranial bleed.
Major Surgical or Invasive Procedure:
CVL placement
Arterial line placement
Intubation
Mechanical Ventilation
Thoracentesis x 2
History of Present Illness:
Ms. [**Known lastname 49695**] is a 87 yo F with h/o afib on coumadin, CHF, and
asthma, who presents following an unwitnessed fall at home from
her chair at 6 a.m. this morning. Per her husband's report, he
heard her calling for help from the kitchen and found her lying
on the floor. He states that she was responsive and
communicative at the time and denied any bladder or bowel
incontinence. He called EMS, and she was transported to [**Hospital **]
Hospital. Stat CT head revealed smal acute subdural hematoma
within the interhemispheric fissure adjacent to an acute corpus
callosum hematoma. She received 1 unit FFP, Vitamin K 10 mg x1,
and 20 meq of KCL at OSH. CT c-spine and pelvic x-ray were
negative. She was found to have a troponin leak of 0.1 with MBI
6.6 at OSH and an EKG with nonspecific ST deviations in the
precordial leads. UA was negative.
On arrival to [**Hospital1 18**], T 98.5, HR 66, BP 108/50, SpO2 95% on 4L
NC. She complained of right hip pain and denied headache or
chest pain. She received 2 additional units of FFP, Vitamin K
5mg SC, Profilnine 4 vials IV, Lasix 40 mg IV, and 20 meq KCl.
ABG was 7.53/50/266. Stat head CT was performed which confirmed
small SDH. Neurosurgery and Neurology were consulted.
Past Medical History:
* PAF
* COPD/asthma
* CHF
* macular degeneration
* s/p TAH
* s/p appendectomy
Social History:
Married to her husband [**Name (NI) **] for 68 years. She smoked briefly
while a teenager. She denies alcohol use.
Family History:
Parents died in their 80's, father of an MI. Her sister died of
breast cancer. Her two daughters are healthy.
Physical Exam:
PHYSICAL EXAMINATION on ADMISSION:
VS: T 100.4, BP 116/53, HR 96, SpO2 96% on 4L NC
GEN: Thin elderly woman, supine in bed with HOB elevated to 30
degrees, in mild distress, pointing to forehead
HEENT: PERRL, sclera anicteric, conjunctivae clear, dried blood
in oral cavity
NECK: Supple, JVP elevated to level of mandible
CV: irregularly, irregular, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. CTAB,
crackles halfway up bilaterally.
ABD: Soft, NT, ND, no HSM
EXT: No c/c/e.
SKIN: multiple ecchymoses in various stages of healing
Neuro: moaning, eyes closed, pupils equal and reactive, no
obvious facial droop but unable to perform cranial nerve exam as
patient does not follow commands, moving all extremities, does
not respond to questions
PHYSICAL EXAMINATION ON TRANSFER:
Vitals - T: 95.2 (but unable to hold po thermometer) BP: 134/69
HR: 84 RR: 20 02 sat: 96% 2 L NC
GENERAL: elderly female, lying in bed with eyes closed,
restrained
HEENT: could not assess ocular movements as pt blind; OP - MM
dry, no erythema, no exudate, but some white spots on tongue, no
LAD, CVL on R in place with c/d/i dressing, carotid pulses
bounding
CARDIAC: RRR, nl S1, S2, no m/r/g
LUNG: CTAB, no w/r/r on anterior exam, but limited
ABDOMEN: NDNT, soft, NABS
EXT: no c/c/e
NEURO: tongue midline, 5/5 strength in bilateral upper
extremiteis, pt not cooperating with assessment of bilateral
lower extremity strength, CN V, VII, XII intact. unable to
assess EOMI as pt blind. A&O x 1 (name, "doctor's office," wrong
year)
SKIN: multiple ecchymoses
Pertinent Results:
ADMISSION LABS:
===============
10.7
7.2 >-------< 228
33.7
MCV 78 Neuts 82.6 Lymphs 10.7 Monos 5.4 Eos 0.8 Basos 0.5
PT 23.5 PTT 44.7 INR 2.3
142 93 40
-----|-----|-----< 168
3.7 39 1.1
Ca 9.5 Mg 2.4 Phos 2.7
CK 313 MB 8 Trop 0.03
PERTINENT LABS DURING HOSPITALIZATION:
=======================================
CK trend: [**Telephone/Fax (3) 78224**]
MB trend:8 - 4 - 3
Troponin trend: 0.03 - 0.04 - 0.07
MICROBIOLOGY:
=============
[**2101-6-3**] 10:46AM PLEURAL WBC-200* RBC-[**Numeric Identifier 78225**]* Polys-24*
Lymphs-34* Monos-34* Myelos-2* Plasma-1* Other-5*
[**2101-6-3**] 10:46AM PLEURAL TotProt-1.8 Glucose-162 LD(LDH)-91
[**5-25**] UCx: negative
[**5-25**] BCx x 2: negative
[**5-31**] UCx: yeast ~1000
[**6-2**] UCx: negative
[**2101-6-3**] 10:46 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2101-6-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2101-6-6**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
[**6-4**] UCx: Yeast. 10,000-100,000 ORGANISMS/ML.
[**6-6**] UCx: STAPHYLOCOCCUS SPECIES. ~[**2092**]/ML.
[**6-6**] UCx: negative
[**6-7**] C. diff: negative
[**6-8**] BCx: negative
[**6-9**] BCx: negative
STUDIES:
=========
CHEST (PORTABLE AP) [**2101-5-25**]
IMPRESSION:
1. Unchanged moderate pulmonary edema with new moderate
bilateral pleural effusions.
2. Right middle and lower lobe opacities appear more confluent
with worsening of retrocardiac consolidation could reflect
worsening atelectasis and/or interval aspiration.
CT HEAD W/O CONTRAST [**2101-5-25**]
IMPRESSION:
1. No interval change in the small-moderate subdural hematoma
with adjacent intraparenchymal hemorrhage in the left frontal
lobe.
2. Hypoattenuation in the right frontal lobe, chronicity of
which is unknown, and may reflect an area of encephalomalacia
from prior infarct. HOWEVER, COMPARISONW ITH PRIOR STUDIES IS
ESSENTIAL FOR BETTER ASSESSMENT AND TO EXCLUDE ACUTE ETIOLOGY.
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) [**2101-5-25**]
IMPRESSION: No evidence of fracture or dislocation.
CT HEAD W/O CONTRAST [**2101-5-25**]
HEAD CT W/O IV CONTRAST: Adjacent to the left falx, there is a
small subdural hematoma superior to the corpus callosum. There
is also an adjacent parenchymal hematoma measuring 3.1 cm (AP) x
2.3 cm (transverse) x 1.8 cm (CC). There is surrounding
vasogenic edema with mild effacement of the sulci. There is no
midline shift. A several centimeter area of hypoattenuation in
the right frontal lobe (2:21) is consistent with
encephalomalacia due to prior infarction, although comparison to
more remote studies is recommended to exclude an underlying
mass. The ventricles and sulci are otherwise normal in size and
configuration. There is no fracture.
IMPRESSION:
1. Left subdural hematoma and adjacent intraparenchymal
hemorrhage related to fall. Resulting vasogenic edema and
effacement of the sulci with no midline shift.
2. Right frontal low density focus consistent with
encephalomalacia, but comparison to older (outside) studies is
recommended to exclude an underlying mass.
[**5-25**] EKG
Atrial fibrillation. Ventricular premature beats. Left axis
deviation which may be left anterior fascicular block and
consider also possible prior inferior myocardial infarction.
Delayed R wave progression with late precordial QRS transition.
ST-T wave abnormalities. The QTc interval appears prolonged but
is difficult to measure. Findings are non-specific but clinical
correlation is suggested. No previous tracing available for
comparison.
TRACING #1
CT HEAD W/O CONTRAST [**2101-5-26**]
IMPRESSION:
1. Small subdural hematoma and left frontal intraparenchymal
hematoma unchanged with mild sulcal effacement. Small focus of
hyperattenuation along the right superior frontal convexity may
represent a small focus of subarachnoid hemorrhage; this is also
unchanged from prior exams.
2. Hypoattenuation in the right frontal lobe which is again of
uncertain chronicity, is likely to reflect an area of
encephalomalacic change from prior infarct. However, comparison
with prior study or MRI is recommended to exclude an acute
process.
[**2101-5-26**] EEG
FINDINGS:
ABNORMALITY #1: Throughout the recording the background rhythm
remained
slow and disorganized, typically reaching a 6 Hz maximum in most
areas.
There were some superimposed faster frequencies.
ABNORMALITY #2: There were additional bursts of generalized
mixed
frequency slowing.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen.
CARDIAC MONITOR: Showed an irregularly irregular rhythm with
frequent
PVCs.
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background rhythm and due to the bursts of generalized slowing.
These
findings indicate a widespread encephalopathy. Medications,
metabolic
disturbances, and infection are among the most common causes. No
prominent focal slowing was evident. There were no epileptiform
features. An abnormal cardiac rhythm was noted.
TTE (Complete) Done [**2101-5-26**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50%). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric,
anteriorly directed jet of mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
supporting structures of the tricuspid valve are
thickened/fibrotic. Moderate to severe [3+] tricuspid
regurgitation is seen. There is at least moderate pulmonary
artery systolic hypertension. The main pulmonary artery is
dilated. The branch pulmonary arteries are dilated. There is no
pericardial effusion.
Impression: at least moderate pulmonary hypertension:
moderate-to-severe tricuspid regurgitation; right heart failure
CHEST (PORTABLE AP) [**2101-5-28**]
FINDINGS: There are bilateral pleural effusions, right greater
than left, with volume loss in both lower lobes. There is
pulmonary vascular re-distribution. Right IJ line tip is in the
right atrium.
IMPRESSION: CHF, cannot exclude underlying infectious
infiltrate.
CT HEAD W/O CONTRAST [**2101-5-31**]
IMPRESSION:
1. No change in appearance of the brain compared to [**2101-5-26**]. Left frontal intraparenchymal hemorrhage unchanged in
size. The findings are not necessarily post-traumatic in
etiology, and the possibility of an underlying mass at this site
cannot be excluded. Further evaluation with MR [**First Name (Titles) 151**] [**Last Name (Titles) **]
gadolinium may be helpful.
2. No change in small parafalcine subdural hematoma.
3. Stable hypodensity of the right frontal lobe, which may
reflect encephalomalacia from prior infarction.
ABD (SINGLE VIEW ONLY) [**2101-6-1**]
IMPRESSION: No evidence of free air or ileus. With this degree
of osteopenia subtle fractures in the spine may not be
identified without cross- sectional imaging.
UNILAT LOWER EXT VEINS RIGHT [**2101-6-2**]
IMPRESSION: No evidence of DVT. Incidental right [**Hospital Ward Name 4675**] cyst
behind the knee.
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2101-6-2**]
IMPRESSION:
1. No evidence of obstruction or abscess.
2. Large gallstone without evidence of cholecystitis.
3. Lobular filling defect in the right atrial appendage which
may represent adherent thrombus, however, echocardiography would
be more specific.
4. Bilateral large effusions with adjacent compressive
atelectasis.
5. Extensive vascular calcifications throughout the
intra-abdominal vessels, without any secondary findings to
suggest bowel ischemia.
PORTABLE ABDOMEN [**2101-6-2**]
IMPRESSION: No radiographic evidence of ileus or obstruction.
CHEST (PORTABLE AP) [**2101-6-2**]
Unchanged radiographic appearance with extensive right-sided
pleural effusion, small left pleural effusion and bilateral
areas of hypoventilation.
UNILAT LOWER EXT VEINS LEFT [**2101-6-3**]
IMPRESSION: No evidence of deep vein thrombosis in the left leg.
CHEST (PA & LAT) [**2101-6-5**]
Since the prior chest x-ray of [**6-3**], the size of the left
pleural effusion is essentially unchanged and there is now a
small right effusion which was not there following stat
thoracentesis.
No other significant change has occurred.
IMPRESSION: Stable left effusion, small right effusion.
CHEST (PORTABLE AP) [**2101-6-6**]
IMPRESSION:
1. No pneumothorax and no focal consolidation.
2. Unchanged moderate bilateral pleural effusion, bibasilar
atelectasis and mild pulmonary edema.
CHEST (PORTABLE AP) [**2101-6-7**]
IMPRESSION: AP chest compared to [**6-5**] and 16:
Moderate bilateral pleural effusion, right greater than left,
has increased since [**6-6**]. Mild pulmonary edema is probably
unchanged. There is no pneumothorax currently.
CT CHEST W/O CONTRAST [**2101-6-7**]
IMPRESSION:
1. Severe right more than left pleural effusion with adjacent
atelectasis.
Without contrast, it is difficult to exclude any superimposed
pneumonia in the atelectatic lung segments.
2. Moderate cardiomegaly.
3. Minuscule left pneumothorax with no mass effect on the
adjacent
ipsilateral structures.
CHEST (PORTABLE AP) [**2101-6-8**]
IMPRESSION:
1. No pneuothorax.
2. Unchanged mild pulmonary edema, bibasilar atelectasis, and
bilateral
pleural effusions.
CHEST (PORTABLE AP) [**2101-6-8**]
IMPRESSION: AP chest compared to [**6-2**] through [**6-8**] at 7:56
a.m.
Moderate bilateral pleural effusion, left greater than right,
unchanged since earlier in the day, worsened on the left since
[**6-7**], obscuring the cardiac silhouette which is moderately
enlarged, but not appreciably changed. Lower lungs obscured by
effusions, and on the left, by atelectasis. Upper lungs show
mild vascular congestion but no edema. No pneumothorax.
Brief Hospital Course:
MICU COURSE:
============
Ms. [**Known lastname 49695**] is an 87 y.o. with afib on coumadin, CHF, and
asthma, admitted after unwitnessed fall at home from her chair
at 6 AM on day of admission, [**2101-5-25**]. Pt was responsive and
communicative at the time and denied bladder or bowel
incontinence. She was transferred by EMS to [**Hospital **] Hospital.
OSH head CT showed small acute subdural hematoma within
interhemispheric fissure adjacent to an acute corpus callosum
hematoma. Received 1 unit FFP, Vitamin K 10 mg x 1, and 20 meq
KCl at OSH. CT C-spine and pelvic XR negative. Had troponin leak
of 0.1 with MBI 6.6 at OSH. OSH EKG with nonspecific ST
deviations in precordial lead.
On admission to [**Hospital1 18**], she received 2 more units of FFP, Vitamin
K 5 mg SQ, Profilnine 4 vials IV, Lasix 40 mg IV and 20 meq KCL.
ABG 7.53/50/266. Stat head CT showed small SDH. Neurosurgery and
Neurology were consulted and no intervention was pursued. She
was intubated on [**2101-5-25**] for respiratory distress for airway
protection and extubated on [**2101-5-27**]. Repeat head CT showed stable
ICH and the hypodensity in the R frontal lobe. Per Neurology,
ddx consists of trauma, coagulopathy, ruptured AVM/aneurysm and
amyloid angiopathy. Per Neuro, will need a repeat MRI in [**5-29**]
weeks to evaluate any underlying lesion as well as
characterization of older hypodensity. Pt's INR actively being
corrected in the MICU with vitamin K for goal INR<1.4.
Hypernatremic in MICU that is also being corrected with D5W. Pt
on seizure ppx per neurology.
On day of transfer to the medical floor, CXR shows ?
CHF/effusion; however, as hypernatremic, holding active
diuresis. Currently, pt being treated with steroids po for
possible COPD and levofloxacin for retrocardiac opacity. Per
family, pt mental status is not at baseline.
MEDICINE FLOOR COURSE:
========================
# Parenchymal bleed & Subdural hematoma: A repeat Head CT
performed during MICU course showed stable lesions. Neurology
and Neurosurgery followed the patient during her
hospitalization. Her aspirin and coumadin were held in the
setting of a bleed. Aspirin was re-started as per Neurology.
Per Neurology, coumadin will not be reinstated until patient is
able to have MRI to clarify underlying issues (amyloid
angiopathy vs AVM) that may have preceded acute bleed.
Additionally, Neurology recommended that INR<1.4, SBP<150. She
was initially loaded with phenytoin and then continued on
phenytoin 100 mg TID for 10 days. This was completed and
titrated off. She remained seizure free. HOB>30 degrees and
neuro checks q2 hours were maintained. She was also on
aspiration precautions.
# Altered Mental Status/Delirium: On the medicine floor, the
patient's altered mental status was waxing and [**Doctor Last Name 688**]. On
several occasions, she was not responsive to sternal rub, but
then would be responsive to pain. She had a CT of the head
during her time on the medicine floor during one of her
unresponsive episodes, which showed stable parenchymal bleed and
subdural hematoma. She will need to have an MRI/MRA once she
can tolerate the study. Most likely, her delirium/altered
mental status is due to her intracranial pathology.
# Respiratory failure: The patient became tachypneic and hypoxic
in the MICU shortly after the 4th unit of FFP with rigors, low
grade temperature, and JVP to mandible. In the MICU, she was
being treated for COPD and aspiration pneumonia. She was
continued on a prednisone taper and then finished this course.
She also completed a course of levofloxacin x 5 days.
Neurogenic pulmonary edema was also considered but she could not
be diuresed due to her hypernatremia.
# Tachypnea: The patient continued to be tachypneic during her
time on the medicine floor. This was most likely due to large
bilateral pleural effusions. She had a R sided thoracentesis
with 1300 cc removed. Pleural fluid supported transudative
fluid, likely [**1-22**] CHF. She was weaned off oxygen and was sating
95% on RA after this procedure, but remained tachypneic. She
then went for a L sided thoracentesis; however, when the small
needle was inserted, air was promptly removed. Most likely, a
bleb had popped overnight prior to this procedure, causing a
pneumothorax. Thoracentesis was abandoned. Her family decided
not to pursue a chest tube. The pneumothorax was monitored with
serial CXRs without progresion. She needed 4 L NC for O2 sat in
mid 90s due to her pulmonary effusions. She continues to remain
tachypnic from high 20s up to 40s. Lasix 10 mg IV daily was
given to help with the bilateraly pleural effusions.
# Hypernatremia: Initially, she was hypernatremic due to being
intravascularly dry. This was corrected with D5W.
# Supratherapeutic INR: On arrival to the floor, the patient's
INR was reversed with Vitamin K for a goal of INR < 1.4. She
remained <1.4 on discharge.
# Atrial Fibrillation: Rate controlled with beta-blockade as
tolerated by BP. As she is NPO, she is getting 2.5 mg
metoprolol IV. When she can tolerate po's, please change to
12.5 mg metoprolol daily. Anticoagulation was held in the
setting of acute bleed. <b> She is not to start anticoagulation
until a repeat MRI is completed in [**3-27**] weeks. </b> She was
monitored on telemetry.
# CHF: Initially, the patient was volume overloaded as per
bilateral pleural effusions, but she was intravascularly dry as
reflected by hypernatremia. She was continued on metoprolol.
Diuresis was originally held as the patient appeared
intravascularly dry. After correction of her hypernatremia,
gentle diuresis was started with IV Lasix 10 mg prn.
# s/p fall: Consider syncope in the setting of hypovolemia/over
diuresis vs. seizure vs. cardiac event vs. mechanical fall vs.
toxic-metabolic process. EEG negative for seizure activity, but
reflects encephalopathy.
# Abdominal pain: The patient moaned and had some guarding with
palpation of her abdomen during her hospitalization. A CT of
the abdomen/pelvis and multiple abdominal XRs were completed
that showed no intraabdominal pathology. She was continued on
aggressive bowel regimen as it appeared that she had copious
amounts of stool in her bowel.
# Bilateral leg pain: The patient complained of bilateral leg
pain. Bilateral LENIs were completed and were negative for
DVTs. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4675**] cyst was found on her right lower extremity.
# Hematuria: The patient continued to have hematuria. This was
most likely [**1-22**] to traumatic foley placement. This was
monitored closely.
# Aspiration: Patient was continued on aspiration precautions.
She was noted to aspirate her thin liquids/soft pureed foods.
For this, she was made NPO and all medications were changed to
IV.
# Right forearm ulcers: Wound care applied.
# FEN: no IVFs, replete lytes prn, pureed diet
# PPX: bowel regimen, pneumoboots, PPI
# CODE: DNR/DNI confirmed with husband and daughter.
# Dispo: Rehabilitation facility.
Medications on Admission:
HOME MEDICATIONS:
Coumadin (5mg x 3d, 2.5x4d)
Fosamax 70mg qweekly
Lasix 80 qday
Lisinopril 10 qday
Toprol 50 qday
ASA 81 qday
KCl 1 tab daily
Caltrate 200 qday
MVI qday
MEDICATIONS ON TRANSFER:
Acetaminophen 650 mg PR q4 hour prn pain
Ipratropium Bromide 1 neb q4 hours prn
Albuterol neb 1 IH q4 hours prn
Cefepime 1 g IV q 24 hours
Insulin SQ SSI
Ipratropium Bromide 1 neb IH q 4 hours prn
Lansoprazole 30 mg po daily
Metoprolol Tartrate 12.5 mg po BID
Phenytoin 100 mg po TID
Prednisone 60 mg po daily
Vancomycin 1 gm IV q24 hours
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
6. Sliding Scale Insulin
Please follow attached sliding scale insulin scale.
7. Furosemide 10 mg/mL Solution Sig: Ten (10) mg Injection DAILY
(Daily): hold for SBP<95.
8. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain/fever.
9. Clindamycin Phosphate 150 mg/mL Solution Sig: Six Hundred
(600) mg Injection Q12H (every 12 hours) for 7 days.
10. Morphine 10 mg/mL Solution Sig: 0.5 mg Intravenous every
four (4) hours as needed for shortness of breath or wheezing.
11. Metoprolol Tartrate 5 mg/5 mL Syringe Sig: 2.5 mg
Intravenous once a day: hold for sbp<95 or HR<60.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary diagnosis
1. Subdural hematoma
2. Intraparenchymal hematoma
3. Aspiration Pneumonitis
Secondary diagnoses
1. Atrial fibrillation
2. COPD
3. CHF
4. Macular degeneration
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for evaluation of a bleed in your head
following a fall from a chair. You were given medicine to
prevent you from having a seizure because of the bleed, and the
bleed was monitored to make sure it was not getting bigger.
Your coumadin (blood thinner) was discontinued to prevent
further bleeding. You were also given supplemental oxygen and
medications to make it easier for you to breath. At one point,
you were intubated to help you breath. You were found to have
elevated sodium levels, and this was corrected with fluid. You
also had a procedure called a thoracentesis to help take the
fluid out of your lungs. The second time this was done, you
were noted to have had a pneumothorax. This was treated with
oxygen.
Please take your medications as prescribed.
Please keep all your medical appointments.
Please go to the emergency room or contact your PCP if you
develop any of the following: shortness of breath, confusion or
decreased alertness or fever> 101.5.
Followup Instructions:
Please see your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 10508**]), on [**6-23**] at 10 AM.
Please see your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 31102**], on [**8-9**]
at 1 PM.
Please following up with Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 2574**])
from Neurology on Tuesday [**7-26**] at 5pm. Please call him to
schedule an MRI of the brain prior to following up with
Neurology.
.
Please consult with your Neurologist to determine whether you
should follow up with the Neurosurgeon who saw you while you
were in the hospital, Dr. [**First Name (STitle) **]
[**Name (STitle) 739**]([**Telephone/Fax (1) 1669**]). Please obtain the MRI prior to
seeing him.
Completed by:[**2101-6-9**]
|
[
"852.21",
"512.1",
"428.0",
"276.0",
"707.8",
"584.9",
"369.4",
"507.0",
"853.01",
"428.23",
"276.3",
"E884.2",
"427.31",
"518.81",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93",
"38.91",
"96.04",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
22997, 23097
|
14208, 21225
|
281, 372
|
23319, 23329
|
3604, 3604
|
24371, 25244
|
1891, 2002
|
21811, 22974
|
23118, 23298
|
21251, 21251
|
23353, 24348
|
2017, 2038
|
21269, 21422
|
222, 243
|
400, 1641
|
3620, 4760
|
2052, 3585
|
4794, 14185
|
21447, 21788
|
1663, 1743
|
1759, 1875
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,303
| 187,793
|
13620
|
Discharge summary
|
report
|
Admission Date: [**2105-3-26**] Discharge Date: [**2105-3-27**]
Date of Birth: [**2042-3-12**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 63 year-old
female with a history of noninsulin dependent diabetes and a
four pack a day smoking history with mild mental retardation
who was transferred from [**Hospital3 **] status post anterior
myocardial infarction on the [**1-22**]. The patient had
awoke in the middle of the night with chest pain, called EMS.
Electrocardiogram on route revealed changes consistent with
anterior myocardial infarction. The patient also had a run
of ventricular tachycardia and was treated with Lidocaine on
route. At [**Hospital1 **] she was treated with aspirin, heparin,
Lopressor and TNK thrombolytics. The plan was to transfer
her here for cardiac catheterization when she had stabilized
at [**Hospital1 **] and echocardiogram at [**Hospital1 **] revealed 35% ejection
fraction and lower septal regional wall motion abnormality as
well as mild to moderate pulmonary hypertension with mild
ventricle valve regurgitation.
PAST MEDICAL HISTORY: Noninsulin dependent diabetes
mellitus, schizophrenia, status post anterior myocardial
infarction with congestive heart failure and ventricular
tachycardia this month. Status post breast cancer. Status
post colon cancer.
MEDICATIONS ON TRANSFER: Tegretol 200 mg po b.i.d., heparin
at 1700 units an hour, Accupril 20 mg po q.d., Lopressor 25
mg po b.i.d., Klonopin 0.5 mg po b.i.d., Zoloft 150 mg po q
day, nicotine patch 21 mg q.d., Prevacid 20 mg po q.d.,
Risperdal 2 mg po b.i.d., morphine 2 to 4 mg intravenous q 2
hours prn for pain.
ALLERGIES: Stomach upset with aspirin.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: Four pack a day tobacco habit. The patient
lives with a roommate and is independent.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.1. Blood
pressure 113/68. Heart rate 96. Respiratory rate 22. O2
sat 92% on 3 liters nasal cannula. In general the patient is
a slightly obese female in no acute distress, alert and
oriented times three and pleasantly conversant. HEENT showed
no JVP. Pupils are equal, round and reactive to light and
accommodation. Extraocular movements intact. Cardiovascular
examination revealed S1 and S2 with regular rate and rhythm.
No murmurs, rubs or gallops. Respiratory examination
revealed fine crackles at bilateral bases. Abdomen was
obese, nontender, nondistended. Extremities showed +2
femoral pulses bilaterally without bruits, +2 dorsalis pedis
pulses bilaterally, mild edema. Neurological examination
showed no focal deficits and she was moving all extremities.
CKs at the outside hospital were 50, 3174, 2164, troponin was
greater then 50.
HOSPITAL COURSE: The patient was admitted with the plan for
catheterization. She was continued on her heparin drip and
her aspirin, Lopressor and Accupril. She was maintained on
telemetry and her electrocardiograms showed residual ST
elevations in the anterior leads. Her electrolytes were
monitored closely.
Endocrine, the patient was maintained on a diabetic diet and
a regular insulin sliding scale. Her Metformin was held.
Gastrointestinal: Prevacid was continued as well as Colace
started.
Neurological: Her home medications were continued.
DISPOSITION: The patient was to have a catheterization at
the time of this dictation. She was refusing cardiac
catheterization and the plan was to send her to a rehab once
she has been evaluated by physical therapy and to follow up
with her cardiologist at [**Hospital1 **]. Please see addendum to
discharge summary regarding this matter.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post myocardial infarction
on [**2105-3-22**].
2. Noninsulin dependent diabetes mellitus.
MEDICATIONS ON DISCHARGE: Aspirin 325 mg po q.d., Lopressor
25 mg po q.d., Accupril 20 mg po q.d., Prevacid 20 mg po
q.d., Zoloft 150 mg po q.d., Klonopin 0.5 mg po b.i.d.,
nicotine patch 21 mg q.d., Tegretol 200 mg po b.i.d.,
Risperdal 2 mg po b.i.d., regular insulin sliding scale for
finger sticks 0 to 60 administer one amp of D50 and [**Name8 (MD) 138**] MD.
For finger sticks 61 to 150 no units of regular insulin.
Finger sticks 151 to 200 2 units of regular insulin. Finger
sticks 201 to 250 regular insulin 4 units. Finger sticks 251
to 300 6 units of regular insulin. Finger sticks 301 to 350
8 7units of regular insulin. Finger sticks 351 to 400 10
units of regular insulin. Finger sticks greater then 400
administer 12 units of regular insulin and please [**Name8 (MD) 138**] MD.
DISCHARGE INSTRUCTIONS: Please follow up immediately with
primary care physician and cardiologist for continuous care
at [**Hospital3 **].
[**First Name11 (Name Pattern1) 177**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 193**]
Dictated By:[**Doctor Last Name 32927**]
MEDQUIST36
D: [**2105-3-27**] 12:56
T: [**2105-3-27**] 13:06
JOB#: [**Job Number 41103**]
|
[
"414.01",
"416.8",
"319",
"410.11",
"427.1",
"428.0",
"250.00",
"E944.4",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"97.44",
"99.20",
"37.61",
"36.01",
"88.56",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
1719, 1729
|
3662, 3789
|
3816, 4587
|
2759, 3641
|
4612, 5031
|
159, 1095
|
1869, 2741
|
1368, 1702
|
1118, 1342
|
1746, 1854
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,158
| 109,407
|
34904
|
Discharge summary
|
report
|
Admission Date: [**2158-3-2**] Discharge Date: [**2158-3-3**]
Date of Birth: [**2099-9-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Hypotension Diziiness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 yo s/p CABGx3/ MV Repair [**2-14**] presents with hypotension,
tachycardia, crea 1.8 - no EKG changes but increased trop
(likely not significant as pt is asymptomatic and post op) Pt
seen by VNA who reported orthostatic hypotension (SBP 90's)and
tachycardia to 120's. Pt reports feeling dizzy with no appetite
over several days. Lopressor and lisinopril recently titrated
down. He states that he was taking Lopressor and Lisinopril
together, with a poor oral and fluid intake secondary to
dizziness. Pt reported feeling less lightheadedness after 1
liter NS. He denies CP, SOB, palpitations, diaphoresis. Due to
bump in troponin and recurrent hypotension, pt was admitted for
observation overnight and echo.
Past Medical History:
Hypertension
Hyperlipidemia
Silent MI
Moderate Mitral Regurgitation
TIA [**2155**]
Glaucoma
Sleep Apnea (does not use CPAP)
Renal insufficiency
[**2158-2-14**] coronary artery bypass x 3 (LIMA-LAD, SVG-OM, SVG-PLV),
Mitral valve repair (28mm ring)
[**2158-2-14**] coronary artery bypass x 3 (LIMA-LAD, SVG-OM, SVG-PLV),
Mitral valve repair (28mm ring)
Social History:
Lives with:alone
Occupation:service tech
Tobacco:1ppd x 25 years
ETOH:denies
Family History:
+CAD in parents and younger brother
Physical Exam:
VS: T 96.8 ST 101 148/71 R 22 99% RA
EKG: ST 114 RBBB old inferior infarct (unchanged from previous
EKG)
PE: Gen: AAOX3 in NAD
CVS: Sinus tachy + S1/S2
Lungs: CTA B/L
Abd: Soft NT ND + BS
Ext: Trace LE edema
Inc: C/D/I. Sternum stable
Labs: Hct 34.4 Crea 1.8 WBC 10 Plts 797 trop 0.17
Pertinent Results:
[**2158-3-3**] 03:09AM BLOOD WBC-8.3 RBC-3.28* Hgb-9.7* Hct-29.1*
MCV-89 MCH-29.7 MCHC-33.4 RDW-14.3 Plt Ct-653*
[**2158-3-2**] 04:20PM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2158-3-3**] 03:09AM BLOOD Glucose-106* UreaN-20 Creat-1.4* Na-140
K-4.4 Cl-111* HCO3-21* AnGap-12
[**2158-3-3**] 03:09AM BLOOD CK-MB-4 cTropnT-0.15*
[**2158-3-2**] 11:07PM BLOOD cTropnT-0.14*
[**2158-3-2**] 04:20PM BLOOD cTropnT-0.17*
[**3-3**] Echo:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with
inferior and very mild inferolateral hypokinesis. The remaining
segments contract normally (LVEF = 45%). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. A mitral valve annuloplasty ring is
present. The gradient across the mitral valve is slightly
higher-than-expected (MG=6 mmHg at 84 bpm). There is no systolic
anterior motion of the mitral valve leaflets. An eccentric jet
of mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Well-seated mitrla annuloplasty ring with slightly
higher-than-expected gradients. Mild residual mitral
regurgitation. No pericardial effusion seen
Brief Hospital Course:
Mr. [**Known lastname **] is a 58 year old male who was admitted with
hypotension and dehyration. He was seen by VNA earlier and was
found to have orthostatic hypotension. He reports feeling dizzy
over the past several days, leading to decreased oral and fluid
intake. He presented to the ED with SBP 90's and ST in 120's.
After IV fluids, SBP 140's and he was asymptomatic. He was
admitted to the CVICU for 24 hour observation and a cardiac
echocardiogram to evaluate for pericardial effusion. Echo
showed EF unchanged, no pericardial effusion.
At the time of discharge, he was sinus rhtyhm in the 80's with
SBP 130's. He was instructed to take his Lopressor 50 mg [**Hospital1 **]
and Lisinopril at a separtate time. Oral and fluid intake were
encouraged, as well as Ensure as a supplement to meals. It was
felt that he was safe for discharge home with visiting nurse
services. Follow up appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]
were scheduled.
Medications on Admission:
Lopressor 100 daily
Lisinopril 20 daily
Zantac
ASA
Zocor 40 daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Hypotension, Dehydration
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Tylenol prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**] [**3-23**] at 1:00 PM
Primary Care Dr. [**Last Name (STitle) **] in [**11-19**] weeks
Cardiologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**11-19**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2158-3-3**]
|
[
"403.90",
"V12.54",
"458.0",
"785.0",
"276.51",
"V45.81",
"327.23",
"424.0",
"585.9",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5219, 5263
|
3616, 4613
|
340, 347
|
5332, 5427
|
1940, 3593
|
5968, 6507
|
1582, 1619
|
4730, 5196
|
5284, 5311
|
4639, 4707
|
5451, 5945
|
1634, 1921
|
279, 302
|
375, 1095
|
1117, 1471
|
1487, 1566
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,179
| 193,131
|
15919
|
Discharge summary
|
report
|
Admission Date: [**2129-9-13**] Discharge Date: [**2129-9-21**]
Date of Birth: [**2064-1-15**] Sex: M
Service: Surgery
CHIEF COMPLAINT:
Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 65 year old
male who was referred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]
from [**Hospital **] Hospital. The patient had presented to his
primary care physician on [**2129-9-12**] with complaints of
chest pain of about two weeks duration as well as
intermittent shortness of breath.
The patient was sent to the [**Hospital **] Hospital Emergency Room
and ruled out for a myocardial infarction. On that
admission, the patient was noted to have some anterolateral
ST-T wave changes that were all new. He was therefore
referred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac
catheterization.
Cardiac catheterization performed on [**2129-9-13**]
revealed the following: Left main 70% occluded, left
anterior descending artery 80% occluded, circumflex 60%
occluded, right coronary artery 80% occluded; left
ventricular ejection fraction 35%; anterolateral hypokinesis.
The cardiothoracic surgery service was consulted at that
point because the patient had severe three vessel disease as
well as left main disease.
PAST MEDICAL HISTORY: 1. Peripheral vascular disease,
status post bilateral femoral-popliteal bypass in [**2118**]. 2.
Hyperlipidemia.
MEDICATIONS ON ADMISSION: Aspirin and Lipitor 10 mg p.o.q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient quit smoking 12 years ago.
FAMILY HISTORY: There is no significant family history of
coronary artery disease.
HOSPITAL COURSE: As noted above, the patient was referred to
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] from an outside hospital
on [**2129-9-13**]. After cardiac catheterization, the
cardiothoracic surgery team was consulted following the
finding of three vessel disease as well as left main disease.
The patient was taken to surgery on [**2129-9-14**], where
he underwent three vessel coronary artery bypass grafting.
The patient was thereafter transferred to the SCRU. He was
extubated without incident.
On postoperative day number one, the patient was transferred
to the cardiothoracic surgery floor. On postoperative day
number four, the patient had periods of rapid atrial
fibrillation, for which his Lopressor dose was increased,
with good rate control achieved. The patient later reverted
to normal sinus rhythm.
During the course of postoperative day number five, the
patient remained stable without complaints. During the night
of postoperative day number five, the patient once again had
periods of rapid atrial fibrillation. His Lopressor dose was
further increased. The decision was made to initiate
anticoagulation with heparin. The patient was also placed on
amiodarone at that point.
The patient reverted back to normal sinus rhythm early on
postoperative day number six. By postoperative day number
seven, the patient remained in normal sinus rhythm. At that
point, he was deemed stable for discharge to home. He is to
be discharged home on amiodarone as well as Lopressor. The
patient's pain was well controlled on Vicodin. His incisions
were all clean, dry and intact. His lung examination was
normal.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
Lopressor 125 mg p.o.b.i.d.
Lasix 20 mg p.o.b.i.d. times 14 days.
Potassium chloride 20 mEq p.o.b.i.d. times 14 days.
Vicodin one to two tablets p.o.q.4-6h.p.r.n.
Isosorbide mononitrate 60 mg p.o.q.d.
Atorvastatin 10 mg p.o.q.d.
Amiodarone 200 mg p.o.q.d.
FOLLOW-UP: The patient was to follow up with Dr. [**Last Name (STitle) 1537**] in
four weeks. The patient was also to follow up with his
primary care physician in two to four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2129-9-21**] 15:13
T: [**2129-9-21**] 15:28
JOB#: [**Job Number 45658**]
|
[
"414.01",
"411.1",
"272.4",
"V15.82",
"715.96",
"443.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"36.15",
"39.61",
"89.68",
"37.23",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
3551, 3560
|
1740, 1808
|
3583, 4292
|
1576, 1666
|
1826, 3529
|
157, 170
|
199, 1410
|
1433, 1549
|
1683, 1723
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,285
| 153,685
|
54974
|
Discharge summary
|
report
|
Admission Date: [**2123-8-1**] Discharge Date: [**2123-8-7**]
Date of Birth: [**2072-5-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Attending Info 8238**]
Chief Complaint:
Pulmonary embolism
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51yoM with Stage IV gliosarcoma diagnosed last year s/p
resection at one site with a second site at brain stem deemed
inoperable s/p chemo and XRT/gamma knife, and hx of PE [**Month (only) 958**]
[**2122**] s/p coumadin finished few months ago, transferred from
[**Hospital3 **] with bilateral PEs in setting of week long
worsening symptoms of shortness of breath after a plane flight
from [**State 2690**] two weeks ago.
Last week, pt started feeling short of breath and it has become
more severe over past few days including shortness of breath
with showering and walking short disatnces. Pt went to LGH where
CTA revealed PE obstructing R main PA and LLL PA. Patient was
started on heparin and transferred here. In [**Name (NI) **], pt reports
having stool guaic which was negative. Trops and BNP were WNL.
Pt subsequently admitted to ICU for tachycardia and RV strain.
Pt endorses 1/10 chest pain which he states is more like
substernal pressure, it has improved throughout the day. He
denies pleurisy or inability to take deep breaths. He denies
palpitations or lightheadedness. He states that his main
symptoms have been dyspnea with small tasks and lots of fatigue.
He states his previous PE last year in left lung had more
symptoms of pleurisy.
Patient denies any hemoptysis, fevers, chills. Does have chronic
headache which he states is unchanged from his normal which he
takes dilaudid for and states that he does have intermittent
periods of weakness. He reports there is a question of the
patient having a [**Doctor Last Name 11332**] mal seizure during his evaluation at the
outside hospital. Patient has a history of seizures and takes
lamictal. Notes that his left visual fields are not as clear as
his right.
Past Medical History:
Stage IV gliosarcoma ([**2122**]) s/p resection, chemo, XRT with
inoperable lesion at brain stem
Left lung Pulmonary embolism ([**2122**])
Herpes
Pneumonia
Depression
GERD
Social History:
Previously worked for Fidelity. Ever since cancer and surgery
has been on disability. Now writes fantasy novels. Lives with
his partner, [**Name (NI) 65250**], in [**Location (un) 112267**], [**State 2690**]. Rest of family in
[**Location (un) 86**]. Denies smoking, Etoh, drugs
Family History:
Mother: Cervical cancer
Father: CAD
Physical Exam:
ADMISSION EXAM
98.2, P 95, 98/80, R 16, O2 96RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, Right
pupil sluggish compared to left, Left homonymous hemianopsia
Neck: supple, JVP not elevated, no LAD
CV: Regular but tachy, normal S1 + S2, no loud S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Other than visual deficit described above, CNs intact,
5/5 strength upper/lower extremities except iliopsoas which is
[**5-20**], grossly normal sensation, reflexes and gait deferred
DISCHARGE EXAM
98.5, P 100-110s, BP 90-100/50-60s, R 18, O2 96RA
Gen- alert, chronically ill appearing, NAD
Psych- does often appear tired/subdued but overall pleasant and
interactive
Head- prior cranial surgical scars noted
CV- tachycardic, regular, no m/g
Lung- CTAB
Abd- soft NT/ND
Gait- ginger and slow, heavy use of assist device (walker)
Pertinent Results:
[**2123-8-1**] 06:35PM BLOOD WBC-7.0 RBC-4.07* Hgb-13.4* Hct-39.0*
MCV-96 MCH-32.9* MCHC-34.3 RDW-15.7* Plt Ct-183
[**2123-8-7**] 07:55AM BLOOD WBC-3.8* RBC-3.46* Hgb-11.3* Hct-33.2*
MCV-96 MCH-32.6* MCHC-34.1 RDW-15.5 Plt Ct-214
[**2123-8-1**] 06:35PM BLOOD PT-10.8 PTT-107.6* INR(PT)-1.0
[**2123-8-5**] 07:45AM BLOOD PT-16.9* PTT-69.3* INR(PT)-1.6*
[**2123-8-6**] 08:05AM BLOOD PT-21.9* PTT-77.0* INR(PT)-2.1*
[**2123-8-7**] 07:55AM BLOOD PT-29.4* PTT-100.5* INR(PT)-2.8*
[**2123-8-6**] 08:15AM BLOOD Glucose-90 UreaN-4* Creat-0.7 Na-140
K-3.6 Cl-105 HCO3-28 AnGap-11
[**2123-8-1**] 06:35PM BLOOD cTropnT-<0.01
[**2123-8-2**] 03:14AM BLOOD cTropnT-<0.01
[**2123-8-1**] 06:35PM BLOOD proBNP-35
TTE [**8-2**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size is normal. with focal basal free wall hypokinesis.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Normal regional and global left ventricular systolic
function. The right ventricle appears mildly dilated with
hypokinesis of the basal to mid RV free wall. No significant
valvular abnormality seen. Resting tachycardia.
Lower extremity dopplers [**8-2**]: no DVT
EKG [**2123-8-6**]- sinus 101 bpm, slightly concave ST segments in II
and V6 < 1mm, low precordial voltages, otherwise no ST-T
abnormalities. Same as admission EKG [**8-1**]
Brief Hospital Course:
51M with gliosarcoma, prior PE, now admitted with new PE.
# Bilateral pulmonary emboli: Likely [**3-18**] to travel in setting of
malignancy and prior hypercoagulable state. No evidence of
lower extremity thrombus on ultrasound study here. Treated with
heparin drip, bridged to warfarin. Initially admitted to ICU for
hemodynamic monitoring. Echo did show RV dysfunction, however
patient was never hemodynamically unstable (aka no hypotension).
It was felt he did not warrant fibrinolytic therapy at any
point.
He was hypoxemic initially, and slowly titrated off; at
discharge, O2 sats 93-96% with ambulation.
He was also persistently tachycardic, see below.
He was bridged with heparin for 6 days total, with therapeutic
INR > 2 on the final 2 days. He was on 5mg daily, with INR
rising to 2.8 on day of discharge. Dose will be decreased to 4mg
on Sunday [**8-8**], and patient will follow up on Monday [**8-9**] with
our [**Hospital1 18**] [**Hospital 191**] [**Hospital3 **] for dosing, until he
returns to [**State 2690**] in a couple weeks. He should remain on lifelong
anticoagulation. The patient preferred to not use LMWH
injections.
I feel he is safe to fly back to [**State 2690**] if on therapeutic doses
of warfarin. I explained the risks of developing DVT with air
travel, and importance of recommendations to reduce risk
including hydration, regular leg stretches, and standing/walking
every hour.
# tachycardia- persistent sinus tachy 100-110s through the
admission, which did not improve despite hydration. Unknown if
he has a baseline elevated HR from his malignancy. More likely
is due to the PE with mild RV dysfunction. Given he did not have
persistent hypoxemia or hypotension, it was felt there is no
indication for repeat CT angiography or further therapy of his
PE aside from standard anticoagulation.
# Brain Ca, Gliosarcoma: Pt has recently undergone gamma knife
and states that he is waiting to hear back from his radiation
oncologist as to what further treatments will be done. He has
Stage IV disease and there is disease in the brain stem which is
inoperable. He had a CT head at OSH with no evidence of bleed.
Neuroncology at [**Hospital1 **] and outpatient rad onc both felt
anti-coagulation was safe. No further inpatient issues.
# Mood- social work consulted in hospital, and there was concern
for patient having low motivation and possibly situational
depression in context of his illness. He may benefit from
further eval of this and possibly a stimulating anti-depressant
medication if appropriate.
# Gait- noted to rely heavily on use of walker, and have slight
difficulty with independent transfers. Unchanged from
pre-admission. Physical therapy not consulted given patient
declines rehab placement and plans to return to [**State 2690**] soon.
STABLE ISSUES
# Hx of seziures: Patient was continued on his home lamictal
# GERD: Patient was continued on his home omeprazole
# Herpes: Acyclovir was exchanged for Valacyclovir due to
formulary issues
.
TRANSITIONAL ISSUES
- INR monitoring
Medications on Admission:
Zolpidem 10mg QHS
Gabapentin 300 mg QHS
Lamictal 300 mg XR QAM
Dilaudid 4 mg Q3-4 hours as needed for pain
Omeprazole 20 mg QHS
Valacyclovir 1 g daily
Discharge Medications:
1. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
4. lamotrigine 300 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
5. Valtrex 1 g Tablet Sig: One (1) Tablet PO once a day.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
7. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
contact [**Hospital3 **] on [**8-9**] for further dosing.
Disp:*10 Tablet(s)* Refills:*0*
8. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for a new blood clot in your lungs. You should
take warfarin 4mg on Sunday [**8-8**], and then get in contact with
the [**Hospital 18**] [**Hospital 2786**] clinic on Monday [**8-9**]. You should
remain on coumadin indefinitely.
Your resting heart rate was elevated. If you develop
lightheadedness or palpitations, you should return to the
hospital.
It is safe to fly home to [**State 2690**] as long as your coumadin dose is
fully therapeutic. If the coumadin levels are below the goal, it
may be unsafe to fly. If you do fly, you should stay very well
hydrated, stretch your legs while seated, and walk up the aisle
every hour to promote blood circulation.
Followup Instructions:
With [**Hospital3 **] [**Hospital3 **] on Monday
[**8-9**]. Their number is ([**Telephone/Fax (1) 10844**].
Your temporary primary care doctor while you stay in [**Location (un) 86**] will
be the physician that cared for you in the hospital, Dr. [**Last Name (STitle) **]
[**Name (STitle) **]. His clinic phone number, where the [**Hospital 2786**]
clinic is located, is [**Telephone/Fax (1) 2010**].
|
[
"530.81",
"785.0",
"415.19",
"054.9",
"191.7",
"345.80"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9794, 9800
|
5749, 8788
|
320, 326
|
9863, 9863
|
3811, 5726
|
10750, 11155
|
2604, 2642
|
8990, 9771
|
9821, 9842
|
8814, 8967
|
10046, 10727
|
2657, 3792
|
261, 282
|
354, 2089
|
9878, 10022
|
2111, 2286
|
2302, 2588
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,300
| 197,198
|
42243
|
Discharge summary
|
report
|
Admission Date: [**2166-8-31**] Discharge Date: [**2166-9-4**]
Date of Birth: [**2085-7-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
STEMI/ Chest Pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
81 yo female with history of DM, afib, CAD s/p CABG with LIMA to
LAD, SVG to RCA and OM who presented to [**Hospital3 6592**] with
chest pain that started at around 2pm while she was watching TV.
Pt reports a pressure like pain across her anterior chest with
radiation down both arms and pain in back. She notes associated
diaphoresis and malaise but denies associated palpitations or
nausea. She took nitroglycerin as well as 81 mg ASA at home
with no relief and then called 911. At [**Hospital1 **] ekg was concerning
for inferior STEMI. She was started on a Heparin gtt, given
300mg Plavix and 325mg ASA and transferred to [**Hospital1 18**] for further
management. Cardiac catheterization showed 3 vessel CAD with
patent SVG to OM and LIMA to LAD as well as occlusion of SVG to
RCA. Pt underwent placement of DES to the in the mid RCA. She
was loaded with plavix 300 mg x 2 and transferred to the CCU. On
arrival to the CCU patient denied any further chest pain or
shortness of breath.
.
The patient notes increasing chest pressure over the past month
that has been responsive to NGT. She has significant shortness
of breath at baseline and states that she cannot walk from one
room to another in her home without becoming short of breath.
She also notes 3 pillow orthopnea as well as peripheral edema at
baseline but denies PND.
.
She reports a 1 month history of cough productive of clear
sputum but denies associated fevers or chills, hemoptysis, blood
in stools, urinary frequency or urgency, history of stroke, or
GI bleed. All of the other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hypertension
2. CARDIAC HISTORY:
- CABG: LIMA to the LAD, SVG to the RCA and OM 7-8 years ago
3. OTHER PAST MEDICAL HISTORY:
- Diabetes Mellitus, non insulin dependent
- PVD s/p R fem-[**Doctor Last Name **] bypass and R toe amputation
- COPD, no home oxygen requirement
- HTN
- Hypothyrodism
- Atrial Fibrillation (on warfarin in the past) now on
amiodarone
Social History:
- Tobacco history: reports 20 pack year history last 7-8 years
ago
- ETOH: none
- Illicit drugs:none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother:
- Father: died of lung cancer
Physical Exam:
ADMISSION EXAM
PHYSICAL EXAMINATION:
VS: T=96.9 / BP= 170/54 / HR= 61 / RR=14 O2 sat= 96% on 3L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate. Lying flat
in no acute distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to the earlobe. Mildy enlarged thyroid
CARDIAC: Median sternotomy well healed PMI located in 5th
intercostal space, midclavicular line. RR, faint S1, S2. [**2-16**]
blowing holosystolic murmur heard best at RLSB. 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 anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES:1+ pitting edema to the level of the mid shin
bilaterally R > L
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP, PT [**Name (NI) **]
[**Name (NI) 2325**]: Carotid 2+ Femoral 2+ DP, PT [**Name (NI) **]
Neuro: CN II-XII intact grossly, moving all extremities well,
sensation in tact throughout
Pertinent Results:
Laboratory Data
From [**Hospital1 **] [**2166-8-31**] at 1800:
WBC 8.7 HCT 23.1 HgB 7.4 Plt 420
PT/INR 13.9/1.10 PTT 31.4
NA 132 K 4.7 Cl 98 CO2 22 BUN 38 Cr 2.3 Glucose 159 Ca 8.8 LDH
182
CK 36
.
Labs on Transfer:
[**2166-9-1**] 03:55AM BLOOD WBC-9.6 RBC-2.99* Hgb-7.0* Hct-22.9*
MCV-77* MCH-23.5* MCHC-30.7* RDW-16.4* Plt Ct-428
[**2166-9-1**] 03:55AM BLOOD Glucose-192* UreaN-37* Creat-2.1* Na-131*
K-5.0 Cl-97 HCO3-25 AnGap-14
[**2166-9-1**] 03:55AM BLOOD ALT-17 AST-34 LD(LDH)-203 CK(CPK)-246*
AlkPhos-99 TotBili-0.3
[**2166-9-1**] 03:55AM BLOOD Albumin-3.5 Calcium-8.4 Phos-4.6* Mg-2.2
Iron-16*
.
Pertinent Labs:
.
Iron studies [**2166-9-1**] 03:55AM: BLOOD calTIBC-416 Ferritn-20
TRF-320
.
A1c [**2166-9-3**] 07:33AM: %HbA1c-6.4* eAG-137*
.
Lipid Panel [**2166-9-2**] 07:20AM: Triglyc-78 HDL-59 CHOL/HD-2.4
LDLcalc-67
Cardiac Enzymes:
[**2166-8-31**] 10:30PM BLOOD CK-MB-18* MB Indx-11.8* cTropnT-0.73*
[**2166-9-1**] 03:55AM BLOOD CK-MB-33* MB Indx-13.4* cTropnT-0.94*
[**2166-9-1**] 04:04PM BLOOD CK-MB-46* MB Indx-13.1* cTropnT-1.24*
[**2166-9-1**] 11:05PM BLOOD CK-MB-32* MB Indx-12.2* cTropnT-1.10*
.
Labs on Discharge:
[**2166-9-4**] 06:20AM BLOOD WBC-9.2 RBC-3.61* Hgb-9.2* Hct-28.7*
MCV-80* MCH-25.5* MCHC-32.1 RDW-16.9* Plt Ct-371
[**2166-9-4**] 06:20AM BLOOD Glucose-120* UreaN-32* Creat-2.0* Na-135
K-4.7 Cl-98 HCO3-28 AnGap-14
.
Pertinent Studies
- ECG ([**8-31**]):
Most prominent are ST elevations in II, III, and AVF. Question
biatrial enlargment post prominent in RA, NSR, normal intervals.
.
- ECHO ([**2166-9-1**]): The left atrium is elongated. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with focal
hypokinesis of the distal inferior wall. The remaining segments
contract normally (LVEF = 55-60 %). The estimated cardiac index
is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). 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) 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. There is mild-moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction c/w CAD. Mild-moderate pulmonary
artery systolic hypertension.
.
- CARDIAC CATH ([**2166-8-31**]):
Findings:
LMCA: Open
LAD: 60% prox / 60-70% mid prior to LIMA
LCX: 90% Prox / OM occlusion
RCA: 90% mid / Diffuse distal
SVG: 1) OM Patent 2) RCA occluded
LIMA: LAD patent
Intervention:
Intervention with DES to mid Native RCA with 0% residual.
Assessment:
3 vessel CAD with patent SVG to OM and LIMA to LAD
Occlusion of SVG to RCA as culprit for STEMI
Successful DES to native RCA
ASA 81mg daily and Plavix 75mg daily
Brief Hospital Course:
Primary Reason for Hospitalization:
81 yo female with history of CAD s/p CABG, DM, HTN p/w STEMI
with thrombosis of SVG to RCA now s/p placement of DES to the
RCA.
.
Active Issues:
# STEMI: Patient was transferred to [**Hospital1 18**] from [**Hospital3 6592**]
where she had presented with chest pain with EKG concerning for
interior STEMI. She was started on a heparin drip, plavix loaded
and underwent cardiac catheterization which showed 3-vessel
disease and thrombosis of her SVG to the RCA. Her LIMA graph and
SVG to OM were patent. She underwent placement of one DES to her
native RCA with restoration of flow. The patient tolerated the
procedure well with impovement in ST elevations on her EKG.
Troponin and CK were noted to peak at 1.24 and 350 (CK-MB 46)
and then trend downward. She initally had [**1-20**] residual chest
pain after the cath which resolved the following morning. She
remained chest pain free for the remainder of the admission.
She should continue taking plavix 75mg PO daily for at least one
year and aspirin 325mg daily indefinitely. She was also started
on atorvastatin 80mg daily.
.
# Acute on Chronic diastolic CHF: Pt reports history of CHF
requiring home lasix. She was clinically volume overloaded on
exam, with elevated JVP and crackles on lung exam and had a
chest xray showing pulmonary edema. She received gentle
hydration post catheterization for renal protection in addition
to 2 units of PRBCs for anemia as described below. She was then
diuresed with bolus [**Month/Year (2) 4319**] of 20 mg IV lasix with good response.
Echo on HD 1 showed normal left ventricular cavity size with
mild regional systolic dysfunction with hypokinesis of the
inferior wall and preserved LVEF of 55-60%. She appeared
clinically euvolemic at the time of discharge.
.
# Sinus Bradycardia- At the time of admission the patient was
noted to be in sinus bradycardia with heart rates in the low to
mid 50s. Given her recent MI there was some concern for
involvement of her conduction system. Her beta blocker was
initially held however she was restarted on a decreased does of
PO metoprolol (25 mg [**Hospital1 **] from 50 mg TID at home) and maintained
heart rates of 55-60.
.
# Hx Atrial Fibrillation: Pt has history of afib previously on
coumadin which was stopped a year ago for unknown reasons. The
patient remained in sinus rhythm throughout her hospitalization
and was continued on her home amiodarone. Electrolytes were
repleted as needed. Her beta blocker was initially held in the
setting of bradycardia but was restarted at a reduced dose on HD
1 as stated above.
.
# Microcytic anemia: Pt was anemic on admission with a Hct of
23.1. Iron studies were consistent with iron deficieny anemia
with a low iron, low normal ferritin and high normal TIBC. The
patinent denied any clear source of bleeding including bright
red blood per rectum, melena or hemoptysis. She was transfused
2 units of PRBCs with appropriate response in her HCT and HCT
remained stable throughout the rest of her hospitalization. She
should start iron supplementation and have an outpatient
colonoscopy in 3 months to evaluate for possible GI source of
bleed.
.
# CKD vs [**Last Name (un) **] : On admission the pts creatinine noted to be
elevated to 2.3. Her baseline Cr is unknown however patient is
not aware of known renal dysfunction. She was given gental IVF
for renal protection in the post-cath setting in addition to the
blood transfusion described above. Her home lisinopril was
initally held in the setting of acute kidney injury. Her
creatinine remained stable over the course of her
hospitalization and was 2.0 at the time of discharge. Her
lisinopril and potassium supplements were discontinued. She
should have repeat labs drawn on [**9-8**] with labs sent to her
primary care provider for continued monitoring of her renal
function and to determine whether she can restart her
lisinopril.
.
Stable Issues:
.
# COPD: Pt with history of COPD not on home oxygen but with new
oxygen requirement on admission, thought likely [**2-12**] pulmonary
edema and not a COPD exacerbation. She was diuresed as above and
weaned off oxygen. At the time of discharge she was maintaining
good oxygen saturation on room air.
.
# DMII- The patients home glipizide was held in the setting of
elevated creatinine. Glucose control was maintained with sliding
scale insulin throughout her admission.
.
# Hypothyroidism: She was continued on her home levothyroxine
dose of 100mcg PO daily.
.
# HTN- Her home lisinopril and metoprolol were initially held,
and she was restarted on a lower dose of metoprolol on HD as
above.
.
#Transitional issues-
- She maintained full code status throughout admission.
- She should continue plavix 75mg daily for at least one year
and ASA 325mg indefinitely.
- She was started on high dose atorvastatin (80mg PO daily).
- Her metoprolol dose was decreased from 50mg TID to 25mg [**Hospital1 **]
due to sinus bradycardia (HR 50s).
- She will need repeat labs next week to monitor renal function
with results sent to her PCP.
[**Name Initial (NameIs) **] Lisinopril and potassium supplements were discontinued due to
her renal failure. She should follow up with her PCP regarding
whether to resume these medications.
- Patient will need to continue iron supplements for her iron
deficiency anemia and schedule outpatient colonoscopy in 3
months.
Medications on Admission:
- Lasix 20mg PO Qd
- Glipizide 10mg PO Qd
- Lisinopril 5mg PO Qd
- Pantoprazole 40mg Po qd
- KCL 20mEq
- Amiodarone 200mg PO BID
- Metoprolol 50mg PO TID
- Levothyroxine 100mcg Qd
- Asa 81mg PO Qd
- Nitro SL PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
10. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
11. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. neomycin-polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops,
Suspension Sig: Four (4) Drop Otic TID (3 times a day) for 6
days.
Disp:*1 bottle* Refills:*0*
13. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended
Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
14. Outpatient Lab Work
Please check Chem-7 and CBC on Monday [**2166-9-4**] and call results
to Dr. [**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 49260**]
Fax: [**Telephone/Fax (1) 91573**]
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Hypertension
Acute Kidney injury
Acute on Chronic Diastolic Congestive heart failure
Atrial fibrillation
Acute blood loss anemia
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 had a heart attack and needed a cardiac catheterization.
this showed a blockage in your right coronary artery that was
opened and stented with a drug eluting stent. You will need to
take a whole adult dose of aspirin (325 mg) and clopidogrel
(Palvix) every day for at least one year. Do not stop taking
this medicine or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] tells you it
is OK. You risk another heart attack from a blocked stent if you
stop taking these medicines. WE also started you on new
medicines to help your heart recover from the heart attack.
You blood count was low when you were admitted and you needed to
get 2 units of blood. We think the bleeding is coming from your
abdomen and you will need to get a colonoscopy in a few months
to check for signs of bleeding. Please discuss this with Dr.
[**Last Name (STitle) **]. You will need to take iron supplements until then.
These can make you constipated so take a stool softener, colace,
at the same time.
You had extra fluid in your body that was making it hard for you
to breathe. You were given extra lasix and your home dose of
lasix was restarted. You need to watch for fluid to accumulate
again. Weigh yourself every morning before breakfast, call Dr.
[**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds
in 3 days.
Your kidney function worsened from the heart attack and the
lasix, you will need to have blood work checked on Monday to
make sure the kidneys are recovering.
.
We made the following changes to your medicines:
1. Start taking clopidogrel (Plavix) to keep the stent open and
prevent another heart attack
2. Increase the aspirin dose to 325 mg daily
3. Discontinue the lisinopril for now until your kidney function
normalizes
4. Stop potassium pills until your kidneys recover
5. Decrease metoprolol to twice daily from three times a day
6. STart atorvastatin (Lipitor) to lower your cholesterol
7. STart antibiotic ear drops to treat the pain in your ear,
stop using these after 6 days.
8. Start iron supplements daily to replete your iron stores.
Followup Instructions:
Dr [**Last Name (STitle) **] (PCP)
Phone: [**Telephone/Fax (1) 49260**] fax: [**Telephone/Fax (1) 91573**]
Date/Time: Thursday [**9-11**] at 1:45pm
.
Cardiology:
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD
Location: [**Location (un) **] PHYSICIANS
Address: 100 [**Last Name (un) **] WAY, [**Location (un) 10068**],[**Numeric Identifier 10069**]
Phone: [**Telephone/Fax (1) 49260**]
Appt: [**10-16**] at 1:30pm
|
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"285.1"
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icd9cm
|
[
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,644
| 163,650
|
43801
|
Discharge summary
|
report
|
Admission Date: [**2112-1-18**] Discharge Date: [**2112-2-2**]
Date of Birth: [**2056-9-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Shortness of breath, abd pain
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
55 y/o female with HCV cirrhosis c/b recurrent hepatic
hydrothorax s/p TIPS [**6-13**] who presented with nausea, vomiting,
cough and SOB x 3days from recurrent L hydrothorax.
In the ED, initial VS: 97.8 100 130/70 28 98% 4L. Chest X-Ray
showed a large left pleural effusion. A thoracentesis was
performed a 1700cc of fluid was drained. She als had a RUQ U/S
which showed a patent TIPS shunt with wall-wall flow. Expected
forward main portal and reversed left portal flow. However
elevated velocities are seen in the mid and distal portions of
the TIPS (190-200), and normal velocity in the proximal TIPS (68
cm/s), concerning for early stenosis. Patent hepatic veins and
arteries. Small perihepatic [**Last Name (un) 2997**], with secondary gallbladder
wall edema. She was given morphine 5mg x3 and zofran 4mg x2. She
subsequently had worsening SOB and confusion. She received
narcan x1 with improvement in symptoms.
This morning she reports feeling confused and somewhat short of
breath but improved from prior to the pleurocentesis. She denies
ABD pain, n/v. The patient is not currently able to provide
significant history because of her confusion.
She has continued to have very low urine output and was bolused
1 L NS. Her labs were notable for an increase in her creatinine
from 0.9 to 1.2, and a wbc increase from 10 to 15. Lactate on
admission was 3.4 and repeat lactate this morning was 6.6. She
has remained tachycardic since admission.
Past Medical History:
- HCV cirrhosis c/b hydrothorax s/p TIPS [**2111-6-16**]
- hepatic encephalopathy
- Hypothyroidism
- Depression/ anxiety
- MSSA spinal osteomyelitis/ discitis/ epidural
abscess/paravertebral abscess and cord compression s/p C2-C3
laminectomy in [**2107**] with resultant disability and "paralysis"
per OMR
- Prior IV cocaine use of short duration
- Negative PPD several years ago
Social History:
On disability since her epidural abscess and laminectomy in
[**2107**]. Prior to that was a nurses aid, teacher, crossing guard
per OMR. Ambulates minimally with a walker and PT at rehab. At
baseline lives with her children but now at [**Hospital3 2558**] since
recurrent admissions. Former smoker, denies alcohol or current
drug use. Past h/o cocaine use per OMR.
Family History:
Mother with HTN and DM. Father unknown. Sister passed away from
pancreatic cancer. Grandmother with lung cancer.
Physical Exam:
ADMSSION EXAM:
VS - Temp F 97.5, BP 116/59, HR 114, RR: 16, 96 O2-sat % RA
GENERAL - patient was somnolent but in NAD A&Ox2 +asterixis
HEENT - Still with small pupils, EOMI, MMM
LUNGS - Lungs with diminshed BS on L and crackles on R. Wheezing
throughout.
HEART - 2/6 SEM heard throughout, nl S1-S2, S3 present
ABDOMEN - NABS, soft/NT, very distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ peripheral edema
NEURO - awake but lethargic, slow to respond to questions, A&Ox2
does not know month, CNs II-XII grossly intact, muscle strength
[**5-7**] throughout, sensation grossly intact throughout
DISCHARGE EXAM:
Vital signs not checked for several days
Exam unchanged:
Icteric
Abdomen is soft, nontender, nondistended
Somnolent but arousable
Pertinent Results:
ADMSSION LABS:
[**2112-1-17**] 09:00PM NEUTS-86.2* LYMPHS-8.1* MONOS-4.0 EOS-1.0
BASOS-0.6
[**2112-1-17**] 09:00PM PLT COUNT-58*
[**2112-1-17**] 09:00PM PT-21.4* PTT-38.5* INR(PT)-2.0*
[**2112-1-17**] 09:00PM GLUCOSE-85 UREA N-13 CREAT-0.9 SODIUM-142
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14
[**2112-1-17**] 09:00PM estGFR-Using this
[**2112-1-17**] 09:00PM ALT(SGPT)-65* AST(SGOT)-139* LD(LDH)-344* ALK
PHOS-266* TOT BILI-8.8*
[**2112-1-17**] 09:00PM LIPASE-57
[**2112-1-17**] 09:00PM TOT PROT-5.3* ALBUMIN-2.9* GLOBULIN-2.4
[**2112-1-17**] 09:13PM LACTATE-3.4*
.
Thoracentesis:
[**2112-1-17**] 10:00PM PLEURAL WBC-120* RBC-1395* POLYS-2* LYMPHS-32*
MONOS-14* MESOTHELI-1* MACROPHAG-51*
[**2112-1-17**] 10:00PM PLEURAL TOT PROT-0.3 GLUCOSE-103 LD(LDH)-42
.
DIC LABS:
[**2112-1-27**] 02:31AM BLOOD WBC-4.2 RBC-2.56* Hgb-8.1* Hct-25.0*
MCV-97 MCH-31.4 MCHC-32.3 RDW-19.9* Plt Ct-25*
[**2112-1-24**] 05:00AM BLOOD PT-52.7* INR(PT)-6.5*
[**2112-1-24**] 12:44PM BLOOD PT-41.5* PTT-62.4* INR(PT)-4.8*
[**2112-1-25**] 01:23AM BLOOD PT-44.8* PTT-66.0* INR(PT)-4.4*
[**2112-1-25**] 05:30PM BLOOD Fibrino-51*
[**2112-1-25**] 11:41PM BLOOD Fibrino-48*
[**2112-1-26**] 04:10AM BLOOD Fibrino-49*
[**2112-1-22**] 05:20AM BLOOD Glucose-95 UreaN-43* Creat-2.5* Na-144
K-4.1 Cl-106 HCO3-23 AnGap-19
[**2112-1-23**] 05:40AM BLOOD Glucose-97 UreaN-43* Creat-2.4* Na-145
K-3.8 Cl-108 HCO3-25 AnGap-16
[**2112-1-24**] 05:00AM BLOOD Glucose-82 UreaN-42* Creat-2.0* Na-146*
K-3.7 Cl-108 HCO3-25 AnGap-17
[**2112-1-24**] 12:44PM BLOOD TotBili-10.4*
[**2112-1-25**] 05:30PM BLOOD ALT-22 AST-44* AlkPhos-53 TotBili-12.5*
[**2112-1-27**] 02:31AM BLOOD ALT-33 AST-77* AlkPhos-52 TotBili-15.2*
[**2112-1-27**] 02:31AM BLOOD Calcium-10.5* Phos-1.9* Mg-2.2
[**2112-1-24**] 04:45PM BLOOD Type-ART pO2-94 pCO2-48* pH-7.37
calTCO2-29 Base XS-1
[**2112-1-18**] 10:03AM BLOOD Lactate-6.6*
.
CXR [**1-17**] pre-thoracentesis
AP CHEST RADIOGRAPH: There is complete opacification of the left
hemithorax, with mild rightward shift of the mediastinum and
trachea. The right lung is well expanded and appears
unremarkable. Mild pulmonary vascular congestion is seen in the
right lung. There are no pleural effusions on the right.
IMPRESSION: Complete opacification of the left hemithorax,
likely secondary to large pleural effusion and/or consolidation.
.
CXR [**1-17**] Post-thoracentesis
IMPRESSION: Interval improvement in the left lung aeration.
Persistent left lower hemithorax opacity, likely represents
residual atelectasis/pleural effusion.
.
ABD US [**1-17**]
IMPRESSION:
1. Patent TIPS with wall-to-wall flow. However, elevated
velocities in the
mid and distal portion of the TIPS shunt, raises concern for
mild stenosis. However persistent reversal of flow within the
left and anterior right portal vein are reassuring.
2. Cirrhotic liver with a small amount of perihepatic ascites
.
KUB [**1-19**]
FINDINGS: Two supine views of the abdomen demonstrate air-filled
non-distended loops of small and large bowel. No free air or
air-fluid levels are seen on these supine views. No radiopaque
foreign bodies visualized on this exam. No suspicious osseous
lesions.
.
IMPRESSION: Nonspecific bowel gas pattern without evidence of
ileus or
obstruction.
.
ABD US [**1-20**]
IMPRESSION:
1. No hydronephrosis.
2. Prominent extrahepatic common bile duct of uncertain clinical
significance. The CBD measures up to 7 mm in diameter. No
intrahepatic
biliary dilatation is seen.
3. Small left pleural effusion.
4. Splenomegaly.
.
ABD US [**1-25**]
Comparison is made to previous study dated [**2112-1-17**].
FINDINGS: The liver demonstrates a coarsened echotexture
consistent with
known cirrhosis along with a nodular liver contour. No focal
liver lesions
are identified. There is no intra- or extra-hepatic bile duct
dilation. The
common duct measures 6 mm. Persistent gallbladder wall edema
which is
decreased from previous. Small amount of perihepatic ascites
which has
increased slightly in size from previous. Persistent
splenomegaly measuring
15.6 cm, previously 14.2 cm.
Sludge present within the gallbladder. No pericholecystic edema
or
gallbladder wall edema. There is a small right pleural effusion
and larger
left pleural effusion.
DOPPLER EXAMINATION: The main portal vein has normal hepatopetal
flow with
flow velocity of 40.3 cm/sec. The anterior right and left portal
veins have
restless flow which is appropriate. The TIPS shunt has normal
wall-to-wall
flow throughout the entirety of the shunt. Persistent elevated
velocities
within the mid and distal portion of the TIPS shunt is decreased
from
previous. Flow velocities within the proximal, mid, and distal
TIPS are 84,
152, 155 cm/sec, previously 77, 192, and 190 cm/sec. The hepatic
arteries
have normal arterial flow and waveforms. The right, middle, and
left hepatic
veins are patent. The IVC has normal flow.
IMPRESSION:
1. Patent TIPS with wall-to-wall flow. Persistently elevated
velocities
within the mid and distal portion of the TIPS shunt. The
velocities within the
mid and distal tips are decreased from previous US. Persistent
reversal flow
within the left and anterior right portal vein.
2. Cirrhotic liver with a small amount of perihepatic ascites.
3. Bilateral pleural effusions.
4. Persistent moderate splenomegaly, slightly increased from
previous.
5. Minimal increase in ascites with a small amount of
perihepatic ascites.
Findings were posted on the nonurgent critical findings database
on [**2112-1-25**]
at 20:05.
.
CXR [**1-27**] COMPARISON: [**2112-1-26**].
FINDINGS: As compared to the previous radiograph, the
pre-existing bilateral
parenchymal opacities, accompanied by pleural effusions, are of
stable
severity. Signs of fluid overload are still clearly present.
Moderate
cardiomegaly with extensive retrocardiac atelectasis. No newly
appeared focal
parenchymal opacities.
.
MICRO:
[**2112-1-18**] URINE CULTURE
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
1/15,[**1-19**], [**1-24**], [**1-25**] BLOOD CULTURE NO GROWTH
[**2112-1-25**] C.DIFF NEGATIVE
[**2112-1-18**] HCV VIRAL LOAD (Final [**2112-1-20**]): 982,897 IU/mL.
Brief Hospital Course:
Ms. [**Known lastname 1692**] is a 55 year old female with HCV cirrhosis complicated
by ascites, hepatic encephalopathy and recurrent hydrothorax
status post TIPS [**6-/2111**] who presented with shortness of breath
now s/p thoracentesis. She was transferred to the MICU when she
developed DIC in the setting of urinary infection and worsening
encephalopathy. Due to her multiple medical problems and poor
prognosis, not liver transplant candidate, her family decided
that she would want to be transitioned to comfort measures only
(CMO).
.
ACTIVE ISSUES:
.
#. Disseminated intravascular coagulation (DIC): Her INR was 2
on admission and rose steadily throughout admssion. When her INR
reached 6, a fibrinogen was sent which was very low. She also
had decreasing hematocrit without obvious source other than
brown guaiac positive stool. The cause of her DIC may be UTI
growing E. coli which has been treated with cefepime and then
transitioned to ceftriaxone. She did not undergo paracentesis on
admission because US did not show significant ascites. After
treatment with antibiotics she has not had fevers and her
hemodynamics were improved. Patient transferred to the MICU on
[**2112-1-24**] and DIC labs checked q6 hours. She received two units of
cryoprecipitate resulting in a modest increase in fibrinogen
levels from 30 to about 60. Due to her deteriorating condition
and acute DIC, broad spectrum antibiotics were initiated in the
MICU with vancomycin, cefepime and flagyl. When her cultures
were negative, these were narrowed to ceftriaxone, and then
Bactrim to treat UTI only for a 7 day course.
.
#. Cirrhosis: MELD 39 during admission however the liver team
felt that she was not a transplant candidate. Her cirrhosis is
due to HCV genotype 1, viral load during this admission
~1,000,000. Was encephalopathic during this admission however
this improved with lactulose and rifaximin. Also had a
decompensation with recurrent hydrothorax even after TIPS.
After discussion with the family about the poor prognosis of her
cirrhosis, they decided to make her CMO and transition to
inpatient hospice. She remained in the hospital on CMO pending
hospice disposition, but expired on [**2-2**]/12pm.
.
#. Altered mental status: Likely hepatic encephalopathy though
she has had hyperactive delirium characterized by frequent loud
moaning. The precipitating factor was believed to be the UTI.
She received ativan twice with subsequent somnolence impairing
lactulose administration. She was transferred to the MICU on
[**2112-1-24**] for continued altered mental status. Lactulose enema was
administered and her mental status improved. She was continued
on lactulose and rifaximin even after she was made CMO so that
she would be able to interact with her family.
.
# Complicated UTI: Urine culture grew E. coli sensitive to
ceftriaxone. Other cultures no growth to date. Was treated
with cefepime from [**Date range (1) 94109**] then changed to ceftriaxone, then
Bactrim to complete a 7 day course until [**1-30**].
.
# Acute kidney injury ([**Last Name (un) **]): The renal team did see the patient
due to concern for hepatorenal syndrome (HRS). They felt that
HRS was possible but the cause of her [**Last Name (un) **] was more likely ATN
from hypotension in the setting of DIC and pre-renal azotemia.
She was treated initially with midodrine and octreotide however
the midodrine was D/Ced because of hypertension and then the
octreotide was also D/Ced when she was made CMO. Renal US
showed no hydronephrosis. Her creatinine did show a trend
toward improvement before labs were stopped due to CMO status.
.
# Anemia: EGD from [**2110**] showed 3 cords of grade I varices in
the gastroesophageal junction. Hemodynamically stable and only
with guiac positive stools but no frank melena or hematemesis.
Her worsening anemia is more likely from DIC. The primary GI
team did not feel a need to undergo repeat EGD and her
hematocrit stablized.
.
# Pleural Effusion: Originally presented with shortness of
breath, 1.7 L removed, fluid consistent with a transudative
effusion, not infected. She has a history of hepatic
hydrothorax, however this is now recurrent after her TIPS
procedure suggesting further deterioration of liver function.
.
# Goals of care: She was transitioned to comfort measures only
given her acute illness and her poor overall prognosis. She
remained and oriented until 1-2 days prior to discharge when she
began to get more somnolent. Her family has been updated with
her status, and would like to be updated with any change.
.
TRANSITIONAL ISSUES:
- Patient was transitioned to CMO care after a family meeting.
Her health care proxy is her sister [**Name (NI) 78820**] [**Name (NI) **] ([**Telephone/Fax (1) 94107**])
who was updated with the patient's status.
Medications on Admission:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
9. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
once a day as needed for constipation.
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q 8H
(Every 8 Hours).
3. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for Abd pain/bloating.
4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
5. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. tramadol 50 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed for pain.
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q6H (every 6 hours) as needed for sore throat.
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Cirrhosis due to hepatitis c
Disseminated intravascular coagulation
Sepsis secondary to urinary tract infection
Acute kidney injury
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2112-2-3**]
|
[
"286.6",
"V66.7",
"511.89",
"599.0",
"V49.86",
"038.9",
"070.70",
"276.2",
"300.00",
"572.4",
"311",
"276.0",
"285.9",
"995.91",
"244.9",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
16800, 16809
|
10109, 10652
|
302, 317
|
17003, 17012
|
3506, 10086
|
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|
2600, 2714
|
15723, 16777
|
16830, 16982
|
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|
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|
2729, 3340
|
3356, 3487
|
14697, 14911
|
233, 264
|
10667, 12332
|
345, 1797
|
12347, 14676
|
1819, 2200
|
2216, 2584
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,622
| 193,688
|
7140
|
Discharge summary
|
report
|
Admission Date: [**2113-1-8**] Discharge Date: [**2113-2-3**]
Date of Birth: [**2032-10-5**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Nortriptyline / Ultram / Diltiazem / Ace
Inhibitors / Norvasc / Percocet / Lipitor / Zetia / Cymbalta
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Abdominal pain
Hypertensive emergency
Major Surgical or Invasive Procedure:
Femoral arterial line
History of Present Illness:
The patient is an 80 yo F with HTN, diastolic CHF, COPD, CRI,
h/o Mobitz II block s/p pacemaker placed [**10-10**], AAA s/p
endovascular repair and ruptured AAA repair w/ graft placement,
SMA/Celiac stents
for mesenteric ischemia, L renal artery stenosis s/p stent c/b
MRSA bacteremia, and a recent admission from [**Date range (1) 26561**] for acute
diastolic CHF, HTN, ARF, who was sent in by her VNA for concerns
of SOB/nausea/diarrhea/weakness. Per the patient, she has had
nausea since prior to her SMA/celiac stent placement and ever
since, including her admission to the hospital a couple of days
ago, and this in no different. She denies nausea or abdominal
pain, fevers, chills. Does have a 30 pound weight loss since
[**Month (only) 958**], mainly in the setting of her abdominal angina prior to
the procedure. In regards to the diarrhea, she was consipated 2
days ago and took colace 2 nights ago, followed by one loose
stool yesterday and took colace again last night, followed by
one loose stool today. No melena or hematochezia, sick contacts,
abnormal foods, or abd pain with this. In regards to the SOB,
she is much improved since her admission on [**1-2**], has not
worsened since discharge, and denies SOB currently. No cough or
URI sxs. In regards to her weakness, this has been longstanding,
in addition to anorexia.
.
ED COURSE: Vitals 97.9, 79, 124/75, 18, 100% RA. After BP
elevated to 192/92, regular home meds of metoprolol and
clinidine were given, as well as one dose of zofran, which
improved her nausea. She was given 1L NS. Guaiac positive.
Touched base with [**Month/Year (2) 1106**] who felt that recent stent, lack of
abd pain, nml lactate made ischemic gut unlikely and did not
recommend imaging (deferred by ED in setting of elevated Cr).
Past Medical History:
1) Vasculopathy--has history of AAA, s/p endovascular AAA repair
(AAA was 4.7 cm)
in [**2109-1-3**]. In [**2112-7-12**] under aortogram, celiac balloon
angioplasty and stent, superior mesenteric artery stent. She
was noted to have endovascular leak in [**10-10**] and underwent open
AAA repair and RAS stent placed.
-# s/p Rt. SFA-TPT vein graft [**10-5**]
-Carotid disease. Asymptomatic. Rt. 60-69% Lt. 40-59%
2) Cardiac conduction disease
--s/p post operative AF [**8-6**]
--s/p SVT s/p ablation [**4-7**]
-- h/o Mobitz II block s/p pacemaker
-- diastolic CHF
3) COPD, [**8-/2112**] PFTs with FEV 1.16 FVC 1.86 0.53 FEV/FVC ratio
63 (92% predicted)
4) Hypertension on multiple agents
5) hypercholestremia
6) Hiatal hernia with reflux/Gastritis/GERD
7) CRI baseline creatinine 1.3-1.5
8) anemia
9) MRSA urine/blood [**11-8**] subsequent to RAS - was on vanc, but
recently changed to doxycycline chronically
.
Other Surgical history:
10) s/p ovarian cyst ecxision with appendectomy [**4-/2059**]
11) s/p CCY [**2-/2080**]
12) s/p spinal surgery [**6-/2085**]
13) s/p spinal fusion [**8-6**]
Social History:
The patient lives at home with a daughter in [**Name (NI) 4628**],
previously a homemaker. Tobacco: 60 years x 2PPD: 120 pk-yr,
quit [**2096**]. ETOH: None. Illicits: None
Family History:
Noncontributory
Physical Exam:
Physical Exam on arrival to MICU
T: 97.9 BP: 210/110 P: 109 with frequent atrial ectopy on
telemetry RR: 24 O2 sats:94% on 4L-- intubated after seizrue
Gen: Intubated, sedated
Eyes: Pinpoint pupils, reactive b/l, unable to assess fundus
Neck. Supple
CV: Tachycardic, no murmur
Chest: Decreased breath sounds
Abd: Soft, mildly distended
Rectal: Guaiac positive in ED
Ext: cool, thready distal pulses
Neuro: Responds to painful stimuli
Pertinent Results:
[**1-9**] CTA abdomen:
1. No CT evidence of mesenteric ischemia.
2. Stable appearance of the aortobiiliac stent graft as well as
celiac,
superior mesenteric, and left renal artery stents.
3. Prior cholecystectomy.
4. Stable appearance of the thrombosed right iliac artery
aneurysm.
[**1-11**] CTA abdomen pelvis
No retroperitoneal hematoma. No significant change from CT of
[**2113-1-9**].
[**1-14**] CTA C/A/P
1. No aortic dissection or pulmonary embolism. Extensive
atherosclerotic
disease is present in the aorta, coronary arteries, and the
branches of the abdominal aorta.
2. Patent stents are seen in the celiac axis, superior
mesenteric artery, and left renal artery. There is focal
stenosis at the origin of the right renal artery.
3. Aortoiliac graft with stents is patent.
[**1-9**] CT head
Diffuse predominantly parietal, occipital, and frontal cortical
hyperdensity. This may represent diffuse cortical hemorrhage
versus enhancement of areas of ischemia/infarct. Recommend MRI
for better characterization of this lesion.
[**1-10**] CT head
Less conspicuous hyperdensity/enhancement of the parietal and
occipital lobes bilaterally with effacement of sulci. The
previously seen
hyperdensity/enhancement of the frontal [**Doctor Last Name 352**] matter bilaterally
has
essentially resolved. Given the relative rapid change in
appearance, these findings less likely represent cortical
hemorrhage and more likely represent persistent enhancement in
areas of ischemia/infarct. The distribution of findings is
suggestive of PRES. This can be better evaluated by an MRI.
[**1-13**] CT head - No acute abnormality seen
CXR [**2113-1-8**]: Two views are compared with recent study dated
[**2113-1-1**]. There has been interval complete resolution of the
findings of CHF, and the lungs are clear with no pleural
effusion. There is baseline hyperinflation with diaphragm
flattening, suggestive of underlying obstructive lung disease,
and residual prominence of the central pulmonary arteries may
reflect underlying
pulmonary hypertension. A left-sided dual-chamber cardiac
pacemaker device has intact leads in the RA and RV apex, as
before. There is diffuse osteopenia.
.
[**2113-1-5**] renal artery U/S:
1. Limited study, with parvus and tardus waveforms of the
bilateral
interlobar arteries, right main renal artery, and upper pole
branch of the right renal artery, suggesting more proximal
stenosis. However, the renal artery ostia could not be
son[**Name (NI) 5326**] interrogated. MRA correlation may be of benefit,
if clinically indicated.
2. Mildly elevated resistive indices of the left renal cortex.
.
[**2113-1-4**] ECHO: Mild LVH, EF >55%, no vegetations
.
[**2112-11-7**]: CT abd/pelvis:
1. No acute intra-abdominal or pelvic pathology.
2. Small filling defect in the SMA distal to the stent
concerning for nonocclusive thrombus. Findings appear new from
recent CTA exam dated [**2112-10-20**].
3. Relatively stable appearance of aorto- bifemoral graft. New
left renal artery stent.
4. Stable, post-operative changes of the spine with grade I
anterolisthesis at the L4-5 level.
Brief Hospital Course:
80 F with MMP admitted of SOB/nausea/diarrhea/weakness.
.
PT was admitted for chief concern of nausea without complaints
of abdominal pain. The morning after admission pt had
increasing abdominal pain and nausea. In the mid morning of HD
2, pt triggered for severe abdominal pain and hypertension (SBP
208/110). PT continued to complain of severe abdominal pain and
was still unable to take PO medication. She was treated with IV
morphine, IV metoprolol, and TD clonidine, and BP improved to
180's. She was sent for a stat CT abdomen, and upon return the
pt lost IV access. She had continued abdominal pain, worsening
hypertension (SBP 200's) and mental status changes. IV access
was not able to be obtained and she received an inch of nitro
paste and 1 SL nitro. Her BP improved to the 180's, and pt was
transferred to the MICU.
.
On arrival to the MICU, PIV in L antecubital obtained. SBP
>200. The patient was witness to seize, 2 mg IV ativan and 10
IV lopressor were given. Pt was noted to foam at mouth and she
was intubated for airway protection.
.
# Hypertensive emergency: PT with hypertensive emergency on HD 2
likely [**2-4**] missing BP medications because of (1) inability to
take PO medication and (2) loss of IV access. Pt initially on
BB drips then transsitioned to PO meds. Regimen including
clonidine, hctz, metoprolol, isosorbide, and losartan was
titrated to SBP between 130-160. Pt had a few additional
episodes of hypertention which responded to IV metoprolol.
Hypertensive episodes appeared to correspond with nausea and
abdominal pain. Finalized regimen was simplified to clonidine
and metoprolol
.
# Nausea: Concern for intermittent diffuse mesenteric ischemia
(NOT infarction) given vasculopathic history. Lactate continued
wnl throughout stay, and CTA showed no blockages of blood flow
to intestines. Nausea controled with zofran, and pt was started
on lansoprazole SL. Nausea and abdominal pain improved greatly
with the addition of sucralfate. Pt did have mildly elevated
lipase (100-110) corresponding with complaints of epigastric
pain - questioned mild pancratitis. However, throughout stay,
epigastric pain improved and lipase returned to [**Location 213**]
.
# AMS: [**2-4**] IV contrast extravasation and seizure. Pt with some
sundowning and visual hallucinations, as well as signs of
depression and limited affect. c/s psychiatry who felt pt likely
with hypoactive delerium, and would improve with time. Advised
to check B12, folate, and TSH which are all wnl. Neuro exam
remains non-focal and mental status improved throughout stay.
By end of hospitalization pt had become much more interactive
and responsive, without any signs of delerium or hallucinations.
Psychiatry recommended outpatient follow up for possible long
standing depression, but there were no acute issues.
.
# Anorexia - Pt did not take PO's during first 2 weeks of
hospitalized stay. Likley due to acute illness, abdominal pain,
hypoactive delerium, and loss of desire to eat. As overall
health and pain improved, pt began to increase PO intake
begining with nutrition shakes, and advancing to solid foods.
megace was started as appetite stimulent and pt recieved MVI
supplements.
.
UTI: UA showed increased wbc and yeast on [**1-22**]. Catheter was
removed and pt was placed on 10 days of cipro with resolution of
suprapubic pain and symptoms.
.
# H/o MRSA with inpatient fevers: DDx intracranial process v.
MRSA bacteremia. Vancomycin started given fevers, and concern
for h/o MRSA bactermia in setting of extensive endografts.
However, MRSA rectal and nasal swabs negative. Continued on
vancomycin and blood cx continued to be negative. PT was
returned to home medication of doxycycline on [**1-16**]
.
# Acute anemia: PT had 10 pt crit drop overnight on [**1-10**].
Stools were guiac negative afterwards (though were previously
positive). No obvious source of bleeing and CT of ab/pelvis
showed no retroperitoneal bleed. PT was transfused 2 U with
appropriate hct bump. Hct recovered to baseline of 34, and
remained stable throughout remainder of stay.
.
# Seizure: Likely [**2-4**] IV contrast extravasation into brain
parenchyma. Neuro consulted and pt placed on seizure prophylaxis
of dilantin 100 mg PO q8. After 10 days dilantin was tapered.
Repeat head CT on [**1-12**] showed mild small vessel ischemic
sequelae only.
.
# PVD: Pt with severe PVD s/p R SFA-TPT artery bypass (SVG),
with SMA/Celiac angioplasty and stenting for mesenteric ischemia
[**7-10**] (90% stenosis of celiac artery s/p stent; 60-70% stenosis
of SMA s/p stent). CTA showed patent arteries. Pt continued on
asprin and plavix.
.
# Renal artery stenosis: PT with previous RA stenosis s/p L
renal artery stent [**10-10**]. R and L renal artery patent per u/s.
CT abd/pelvis demonstrate L renal artery stent in place and R
renal artery stenosis. Pt will f/u with [**Year (2 digits) **] Surgery about
R renal artery stent as outpatient.
.
# Diastolic CHF: Pt titrated back on home meds of losartan and
nitrates. Lasix was not re-instated, and subsequent CXR showed
clear lungs.
# Rhythm: Pt with known high grade AV block in [**10-10**], s/p
[**Company 1543**] Sigma STR DDD placement, Vpaced.
.
# Hyperlipidemia: Continue home Atorvastatin 80mg daily.
.
# COPD: PFTs [**8-10**]: FVC 1.86 (71% pred), FEV1 1.16 (65% pred),
mild obstructive ventilatory defect. Continue home albuterol
.
# Carotid stenosis: Pt is asymptomatic. Repeat carotid US
showed 60-69% right ICA stenosis. 40-59% left ICA stenosis.
.
# AAA: Stable, no new bleed per CT abd/pelvis [**1-11**] and [**1-14**].
.
# GERD: EGD [**5-10**] showed granularity, erythema, and congestion in
the antrum compatible with gastritis, otherwise normal EGD to
second part of the duodenum. Pt continued on lansoprazole and
malox prn
.
# Angina. Pt complained of chest pain [**1-14**] - [**8-13**] substernal,
nonradiating CP at 8 am, accompanied by nausea and SOB, SBPs in
170s, relieved by 2 SLNTG, later recurring and requiring nitro
gtt to control pain. Pt had never experienced CP like this
before in her life. TWI noted at precordial leads, and pt was
therefore cycled but troponin T remained flat. Pt later c/o
radiation to back. Concern for ACS, but troponins remained
flat. Aortic dissection was rulled out by CT torso showing no
tair. Possible pancreatitis, but LFT's and pancreatic enzymes
WNL (pt s/p cholecystectomy). Likely due to unstable angina
given vasculopathic history. Continued NTG 0.3 mL SL PRN for
chest pain, as well as daily ASA and atorvostatin. CP did not
present as problem again during stay.
.
# FEN: PT with decreased appetite and difficutly taking PO.
Megace was started to help improve appetite, and PO was
encouraged.
.
# PPX: Pneumoboots, bowel regimen, PPI
.
# Full code
Medications on Admission:
Medications at home:
Albuterol
Aspirin 81
Bisacodyl
Senna
Clonidine 0.3 TID
Plavix 75 daily
Doxycycline 100 [**Hospital1 **]
HCTZ 25 daily
Vicodin prn 1 tab Q8H prn
Isosorbide Dinitrite 20 TID
Losartan 100 daily
Megestrol 40 QID
Metoprolol 100 TID
MVI
Pantoprazole 40 [**Hospital1 **]
Simvastatin 40 daily
Tizanidine 2mg TID
.
Allergies: Sulfonamides - nausea and vomiting / Nortriptyline -
rash / Ultram - rash / Diltiazem / Ace Inhibitors - elevated Cr
/ Norvasc / Percocet / Lipitor / Zetia / Cymbalta
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
2. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: 6-10 Puffs
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
4. Polyvinyl Alcohol 1.4 % Drops [**Hospital1 **]: 1-2 Drops Ophthalmic PRN
(as needed).
5. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day).
6. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
PRN (as needed) as needed for itching.
7. Clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
10. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
11. Isosorbide Dinitrate 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day): Hold for SBP < 140.
12. Doxycycline Hyclate 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO
Q12H (every 12 hours).
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Megestrol 40 mg/mL Suspension [**Last Name (STitle) **]: Ten (10) mL PO DAILY
(Daily).
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [**Last Name (STitle) **]:
15-30 MLs PO QID (4 times a day) as needed.
16. Hexavitamin Tablet [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for if
constipated.
18. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
19. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
20. Sucralfate 1 gram Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
21. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO
TID (3 times a day): Hold HR<50, SBP<120 .
22. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times
a day): Hold for SBP < 140 .
23. Lorazepam 2 mg IV Q4H:PRN Seizure activity
Do not use for sedation or agitation, if considering giving call
HO
24. Ondansetron 4 mg IV Q8H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
Hypertensive urgency
UTI
mild pancreatitis
Discharge Condition:
Improved
Discharge Instructions:
You were admitted with nausea and abdominal pain. These symptoms
improved over time with a few new medications. Some of your
blood pressure medications have changed. Please take your new
medications as listed on this discharge sheet. Follow up with
the physicians listed below.
Warning Signs:
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please follow up with your primary care physician within the
next few weeks. Please call [**Telephone/Fax (1) 1144**] to make an appointment
Please follow up with Dr. [**Last Name (STitle) 1911**] in cardiology
Call ([**Telephone/Fax (1) 12468**] to make an appointment.
Please Follow up with Dr. [**Last Name (STitle) **] in Neurololgy
Call ([**Telephone/Fax (1) 7394**] to make an appointment.
Please follow up with Dr. [**Last Name (STitle) **] in [**Last Name (STitle) 1106**] surgery
Call ([**Telephone/Fax (1) 18181**] to make an appointment
|
[
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"437.2",
"285.9",
"428.0",
"530.81",
"441.4",
"518.81",
"V45.01",
"577.0",
"496",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
17190, 17255
|
7184, 13980
|
412, 435
|
17342, 17353
|
4050, 7161
|
18549, 19104
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17377, 18526
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14027, 14512
|
3594, 4031
|
335, 374
|
463, 2238
|
2260, 3356
|
3372, 3546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,759
| 121,212
|
28484
|
Discharge summary
|
report
|
Admission Date: [**2110-7-24**] Discharge Date: [**2110-8-12**]
Date of Birth: [**2037-3-6**] Sex: F
Service: MEDICINE
Allergies:
Biaxin / Ciprofloxacin / Procainamide / Ceftin / Lipitor / Latex
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation, pleurodesis
History of Present Illness:
73 year old F with h/o CHF, critical AS, s/p MVR on
anticoagulation, severe COPD, and cryptogenic cirrhosis who
presented from OSH with hyponatremia and change in mental status
transferred to CCU for SOB.
.
On review of discharge summary from OSH, she presented on
[**2110-7-16**] with increasing dyspnea, orthopnea, and chest tightness.
CXR showed small left pleural effusion, bibasilar scarring,
and atelectasis (per patient, pleural effusion is old and [**State 2690**]
MDs did not pursue thoracentesis given anticoagulation). Labs
showed BNP 710, mildly elevated alk phos, LDH, and AST. It was
felt she was volume overloaded and she was diuresed. EKG showed
AFib with LBBB (also old). She reportedly improved with initial
management and was ruled out for MI. Echocardiogram was done
that reportedly showed borderline LVH, dyskinesis of mid to
distal intraventricular septum and adjacent anterior wall with
preserved contractile function of other segments. Peak gradient
of aortic valve was 55-60. Mild to moderate aortic
insufficiency, RV hypertrophy, severe TR, PA pressure 45mm.
Aortic valve area 0.6. She was also seen by pulmonary, who felt
that her pleural effusions were chronic and the her dyspnea was
secondary to her aortic stenosis.
.
An acute change in mental status was noted on the morning of
[**7-24**]. Labs revealed a sodium of 110, urine osmolarity 521,
serum osms 247, amonium 55. Normal saline was given. There are
no records of her Na level between from [**7-20**] to [**7-24**]. Patient
was transfered to [**Hospital1 18**] for further management.
.
On arrival she was noted to be dyspneic on 3L NC, ABG
7.32/68/76. Her mental status declined and repeat ABG 2 hours
later was 7.36/65/70. Her BNP was 4237 and CXR looked congested
so she was diuresed with lasix. Her Na returned at 111, repeat
was 109, and renal was consulted. They recommended 3% NaCl
solution, but due to poor IV access she only received 2 hours
this. This am she again looked distressed and ABG was
7.36/58/187; after lasix IV and MSO4 2 mg IV ABG was
7.25/82/318. She was transferred to the CCU for elective
intubation.
.
After intubation the patient's ABG was 7.40/49/103. During
attempt at A-line placement she received 12.5 mcg fentanyl and
became hypotensive with SBP in the 60s and HR 60s. She received
atropine 1mg and dopamine gtt was started. Her pressure
responded well and this was quickly weaned off.
.
Of note, after speaking with her PCP in [**State 2690**], she was
hospitalized in [**Month (only) **] for b/t LE cellulitis. She was
hyponatremic to 114 at that time and was advised to stop taking
chlorthalidone on discharge (with Na of 127). She was also
noted to have delirium during her hospital stay. Upon traveling
to [**Location (un) 86**], she was worked up in primary care clinic at [**Hospital1 2025**] for
mental status changes. She had a normal brain MRI and work-up
revealed only elev NH4, alk phos, and GGT, and positive [**Last Name (un) 15412**]
1:20.
Past Medical History:
-CHF: preserved EF
-critical aortic stenosis - valve area 0.6
-s/p Mitral valve replacement, INR 2.5-3.5 [**2100**]. on coumadin.
-cryptogenic cirrhosis - followed in TX. no liver bx done.
with hepatomegaly. neg HBV Ag, neg HCVAb. ? of
amiodarone-induced
-idiopathic hyponatremia - baseline 120s
-Atrial fibrillation
-Severe obstructive lung disease: PFTs in [**2106**] with FEV1 0.61
(28% predicted). non-smoker
-Radiation pneumonitis
-Breast cancer @ age 24. s/p left mastectomy, Cobalt radiation.
-Reactive Airway Disease
-Diverticulitis - [**2108**]; last Cscope 6 yrs prior
-Neuropathy
-chronic left pleural effusion
-pulmonary HTN
Social History:
Lives in [**State 2690**] with her husband. She spends every summer here
visiting her daughter. [**Name (NI) **] smoking or alcohol. second-hand
exposure with husband.
Family History:
non-contributory
Physical Exam:
Vitals: T: 97.4 P: 88 BP: 154/37 AC: 450/14/0.40/5
General: intubated, occ agitated.
HEENT: EOMI/PERRL, sclera anicteric. dry oral mucosa
Neck: JVD to level of jaw. 2+ carotid pulses
Pulm: Decrease breath sounds to left base, coarse otherwise.
Cardiac: irregularly irregular, nl S1/S2, systolic ejection
murmur at RUSB with radiation to neck
Thorax: status post mastectomy
Abdomen: soft, non tender, + liver edge 2 cm below costal margen
Extremities: No edema
Neurologic: intubated, sedated. MAE.
Pertinent Results:
CXR: [**7-22**] apical pleural capping, bilateral pleural effusion,
interstitial prominence probably due to vascular congestion.
.
OSH MRI brain: small lacunar infarcts, microangiopathic disease
.
OSH Echo [**2-/2110**]:
Aortic valve area 1.2. nl LVEF. mild AI, mod AS. LAE and
severe [**Last Name (un) **]. RVE. mod/severe TR with mod pulm HTN.
.
CXR [**7-24**]: Mild pulmonary edema. Moderate bilateral pleural
effusions. Question abnormal right hilum.
.
CXR 9/1a: Moderate pulmonary edema has worsened, accompanied by
increasing moderate left and stable small right pleural
effusion. Lobulation of the right hilus and infrahilar
consolidation need to be evaluated to exclude mass.
.
CXR 9/1b: ET tube tip is 45 mm above the carina. NG tube tip is
not included in the film, below the diaphragm. There is no
pneumothorax. The lungs are more expanded. Unchanged biapical
pleural parenchymal scarring. Moderate pulmonary edema is less
conspicuous. Unchanged prominence of the right hilus. Cardiac
contour is obscured by the stable bilateral moderate pleural
effusions.
.
TTE [**7-25**]: LA is mildly dilated. No ASD is seen by 2D or color
Doppler. The IVC is dilated (>2.5 cm). LV wall thicknesses are
normal. The LV cavity size is normal. Overall LV systolic
function is mildly-to-moderately depressed (EF 40%); the apex
appears dyskinetic; left BBB with abnormal septal activation is
also contributing to reduced EF. The RV cavity is dilated. RV
systolic function is borderline normal. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (0.4). Mild (1+) aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen (TR
gradient 51). There is moderate pulmonary artery systolic
hypertension. The main pulmonary artery is dilated. The branch
pulmonary arteries are dilated. There is no pericardial
effusion.
Brief Hospital Course:
73 yo F with h/o CHF, critical AS, s/p MVR on anticoagulation,
severe COPD, and cryptogenic cirrhosis who presented from OSH
with hyponatremia and change in mental status transferred to CCU
for SOB and intubated. S/P extubation, patient went into
cardiogenic shock and was found to have an occlusion of the left
main coronary which was stented. IABP was placed for a few days,
then successfully removed. During her hospitalization, the
following issues were addressed:
.
Cardiovascular: Ischemia: Pt was found to have L main disease by
cath, with ostial 80% lesion with heavy calcification. First
cath, LCA unable to be stented [**12-26**] anatomical variation (too
short) that would not accommodate a stent. 2nd cath, L Cx/LAD
stented. Her CAD was treated medically, she was anticoagulated
on heparin. .
*Valves: Severe AS (area 0.8 confirmed on cath). MVR in '[**00**], on
anticoagulation.
* Pump: Echo with EF 40%. Pt was thought to be intravascularly
depleted given persistent pleural drainage and low BP, likely
due to intravascular depletion; she was given several PRBC
transfusions, IVF, and albumin x2. .
*Rhythm: A. fib, continued on digoxin for rate control and
anticoagulaiton as above.
.
# Respiratory Failure: Patient was intubated at start of
hospitalization for hypercapnic respiratory failure. She was
successfully extubated, but continued to have respiratory
difficulty given her pulmonary hypertension, obstructive
disease, pleural effusions, CHF, R hilar consolidation and
fullness. CT surgery placed bilateral chest tubes which drained
large amounts of transudative fluid daily. Pleurodesis was
performed on the R lung on [**8-10**] and on hte L lung on [**8-11**].
.
#ARF: The patient developed ARF on [**8-10**], and became oliguric on
[**8-11**]. Renal U/S was normal. Likely due to prerenal etiology
due to intravascular hypovolemia as well as hypotension causing
decreased renal artery perfusion, despite NS boluses,
maintenance IVF, albumin, PRBC as above to maintain
intravascular volume and pressors to attempt to maintain BP.
.
#ID: the patient was treated with empiric zosyn and vancomycin
for leukocytosis and abnormal chest xray. Cultures were
persistantly negative.
.
# Hyponatremia: Acute on chronic history of hyponatremia, likely
due to intravascular volume depletion. Na of 109 on admission
improved to baseline of 130's with hydration.
.
# H/O Cryptogenic Cirrhosis: Elevated LFTs and +[**Last Name (un) 15412**], biopsy was
never done due to anticoagulation.
.
On [**2110-8-11**] the patient went into bradycardic/asystolic arrest.
ACLS was performed, and the patient was resuscitated after [**4-2**]
minutes of CPR. She was intubated and started on 2 pressors.
Despite this, she remained hypotensive. A family meeting was
held and the family (husband and daughter) decided to make the
patient [**Name (NI) 3225**] given her obvious discomfort and poor prognosis. A
morphine drip was started and other modalities of care,
including pressors and the ventilator were withdrawn. The
patient died at 12:50AM on [**8-12**] with her husband and daughter at
her side. An autopsy was refused.
Medications on Admission:
Digoxin 0.125 (0.25 in OSH records)
Lasix 40 Qday
Clarinex 5 mg day
potasium chloride 10 meq day
Spiriva one inhalation daily
Advair 250/50
valsartan 80 [**Hospital1 **]
Vitamin b6 50 mg/day
Neurontin 200 mg am, 100 at noon 300 bed time
Coumadin, 2.5, 5- 5- 5, 2.5,
MVI
Calcium 600 mg each evening
Albuterol
Clonidine 0.1 mg PRN
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
|
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19,308
| 120,012
|
23039
|
Discharge summary
|
report
|
Admission Date: [**2143-3-28**] Discharge Date: [**2143-4-2**]
Date of Birth: [**2114-5-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Iodine / Nsaids / Opioid Analgesics
Attending:[**First Name3 (LF) 5806**]
Chief Complaint:
Flushing and tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 2696**] is a 28 year old woman with a 9 yr history of
systemic mastocytosis, with 2 recent admissions for flares,
presenting with an acute flare which began last night.
.
She woke from sleep with symptoms of skin flushing and
palpitations and wanted to seek medical care before things got
worse. She denies n/v, abdominal pain and diarrhea which normall
accompany her flares. She cannot identify a particular trigger.
Since her last admission 2 weeks ago, she has been having some
flushing nightly, and several episodes of "[**Known lastname 500**] pain" in her
wrists, elbows, shoulders and back which is new for her. She is
still on a prednisone taper from her last flare earlier this
month at which time she was admitted from [**Date range (1) 59412**]. That flare
occured while still on a prednisone taper from a flare in late
[**Month (only) 404**] attibuted to a viral illness. The patient is used to
having flares only 2-3 times per year, and never while still on
a prednisone dose.
.
Her first episode began at age 19 with flushing associated with
hypotension and heart racing. She was diagnosed 3yrs later in
[**2136**] when tryptase levels were noted to be elevated. She has not
had a successful [**Year (4 digits) 500**] marrow biopsy in the past despite 2
attempts at UCSF. Triggers include stress, NSAIDS, ASA, opiates,
and iodine including contrast dyes.
.
In the ED Vitals: T 97.6 HR 97 150/87 RR 20 O2 Sat 100% RA.
Patient given 125mg solumedrol, 50mg IV Benadryl x 2, Famotidine
and Tylenol 650 mg PO x1 and NS IV fluids. The patient's
symptoms improved and she was admitted to the floor.
.
This morning, the patient feels well and symptoms are mostly
resolved. She remains very anxious about her conditions and
making sure the flare does not return, and is concerned with the
apparent recent progression of her illness. She also admits to
increase stress secondary to her condition, and is becoming more
convinced that some therapy may be useful to her. She was
recently started on as standing lorazepam dose of 0.5mg [**Hospital1 **] by
her allergist to help her stay more calm.
Past Medical History:
-Systemic mastocytosis, followed by Dr.[**Last Name (STitle) 2603**], Allergy
specialist and Dr. [**Last Name (STitle) **] of [**Hospital1 112**]
-History of coffee ground emesis in the setting of Mastocytosis
flare and nausea/vomitting in [**7-/2142**]
-Anemia, low normal MCV, iron panel in [**3-/2141**] iron 79, TIBC 364,
Ferritin 55, Transferin 280, in [**10/2142**] normal B12 and folate
-Thumb surgery
-Tonsillectomy
-Hemorrhoids
Social History:
Patient employed as a librarian. Honorably discharged from air
force in [**2139**] due to her recurrent mastocytosis flares and
hospitalizations.
Married, no children. Does not smoke or use drugs, social
drinker.
Family History:
Father alive and in good health, mother has MS. [**Name13 (STitle) **] family h/o
allergic, rheumatologic, or autoimmune diseases. Grandfather
with CAD, colon CA and grandmother with skin CA.
Physical Exam:
PHYSICAL EXAMINATION:
VS: 98.3 129/91 108 18 100% RA
GEN: NAD, awake, alert
HEENT: EOMI, PERRL 9->5, sclera anicteric, conjunctivae clear,
pale, OP moist and without lesion
NECK: Supple, no JVD, no LAD
CV: Slightly tachycardic, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Protuberent, Soft, NT, ND, no HSM
EXT: No c/c/e, 2+ radian and PT pulses
SKIN: erythematous macular region on left face. No decoloration
on legs or arms.
Neuro: no focal findings, A Ox3
Psych: appears somewhat anxious, near tearful when discussing
her disease. Overall appropriate.
Pertinent Results:
CHEST (PA & LAT) [**2143-3-28**]:
IMPRESSION: No acute cardiopulmonary process.
HEMATOLOGY:
[**2143-3-27**] 11:55PM BLOOD WBC-12.6* RBC-3.84* Hgb-11.4* Hct-32.2*
MCV-84 MCH-29.6 MCHC-35.3* RDW-15.0 Plt Ct-292
[**2143-3-30**] 09:00AM BLOOD WBC-14.7* RBC-3.31* Hgb-9.9* Hct-29.7*
MCV-90 MCH-30.0 MCHC-33.5 RDW-15.0 Plt Ct-207
[**2143-4-2**] 06:00AM BLOOD WBC-17.9* RBC-4.54 Hgb-13.3 Hct-38.4
MCV-85 MCH-29.2 MCHC-34.6 RDW-14.9 Plt Ct-335
COAGS:
[**2143-3-28**] 06:00AM BLOOD PT-13.0 PTT-26.0 INR(PT)-1.1
[**2143-3-31**] 08:45AM BLOOD PT-16.1* PTT-24.3 INR(PT)-1.4*
[**2143-4-1**] 06:15AM BLOOD PT-14.8* PTT-25.2 INR(PT)-1.3*
CHEMISTRY:
[**2143-3-28**] 06:00AM BLOOD Glucose-126* UreaN-8 Creat-0.9 Na-141
K-4.1 Cl-106 HCO3-23 AnGap-16
[**2143-3-28**] 06:00AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.2
[**2143-3-28**] 06:00AM BLOOD LD(LDH)-235 AlkPhos-54
[**2143-3-31**] 08:45AM BLOOD Glucose-125* UreaN-16 Creat-0.7 Na-141
K-4.1 Cl-109* HCO3-21* AnGap-15
[**2143-3-31**] 08:45AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
[**2143-4-1**] 06:15AM BLOOD Glucose-114* UreaN-17 Creat-0.8 Na-143
K-4.0 Cl-106 HCO3-26 AnGap-15
[**2143-4-1**] 06:15AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.4
URINE:
[**2143-3-28**] 12:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
MISCELLANEOUS:
Test Result Reference
Range/Units
TRYPTASE 98 H [**3-12**] NG/ML
Brief Hospital Course:
## Mastocytosis:
Pt has a 9 yr history of the systemic mastocytosis, with flares
normally 3/year. This is patient's 3rd flare in 2 months, while
still on steroid taper and [**Month/Year (2) 500**] pain which is new for her. She
responded well to 125 mg IV steroids q 8 hrs and IV
diphenydramine in addition to her continuing home regimen. CBC
was at her baseline, w/normal differential. [**Month/Year (2) **] pain was
investigated with LDH and AlkPhos which were both WNL. Her new
[**Hospital1 112**] allergist, Dr. [**Last Name (STitle) **] was contact[**Name (NI) **]. She recommended
repeating her serum tryptase, ordering a 24 hr urine histamine,
and if possible performing an aspirin challenge in house. Serum
tryptase revealed a high value at 84. The patient has a
particularly high level of urine prostaglandins, making aspirin
therapy an ideal treatment. Unfortunately, she had a possible
flare [**3-4**] aspirin in [**2136**]. The challenge was performed the day
of admission and an adverse reaction at the maximum aspirin dose
resulted in an ICU course. She was stabilized on IV steroids and
IV benadryl and transferred back to the medical floor. She
continued on her home histamine receptor blockers and was
transitioned from IV to PO steroids and benadryl and observed
overnight prior to discharge on a steroid taper as recommended
by Dr. [**Last Name (STitle) 2603**], [**Hospital1 18**] allergist. She had no further symptoms of
flushing or tachycardia following transfer from the ICU to the
medical floor and was discharged on her home meds, prednisone
taper, GI prophylaxis with PPI, Calcium and vitamin D, and SS
bactrim for PCP [**Name Initial (PRE) 1102**].
## Anxiety/depression:
Pt admitted to a problem with worsening anxiety, and that she
appreciates the sedative affect of her IV diphenhydramine. She
had been feeling down since her severe flare in [**2142-10-1**], and
that she does not go out with her husband because she fears a
flare. She denied hopelessness or intent to harm self or
others. She has agreed to outpatient therapy and has been
referred. Per PCP [**Name Initial (PRE) **]'s she is discharged on 0.5 ativan TID PRN
up from [**Hospital1 **].
Medications on Admission:
1. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Cromolyn 100 mg/5 mL Solution Sig: Two Hundred (200) mg PO
four times a day.
3. Doxepin 50 mg Capsule Sig: One (1) Capsule PO twice a day.
4. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular once as needed for as directed.- confirmed not
expired
5. Hydroxyzine HCl 50 mg Tablet Sig: One (1) Tablet PO twice a
day.
6. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID
9. Prednisone taper (currently on 30 mg daily but took a total
of 60 mg today at home due to flare)
10. NuvaRing
11. Cromolyn Cream (not currently using)
12. Ketotifen 2mg [**Hospital1 **] (canadian medication)
Discharge Medications:
1. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. ketotifen Sig: Two (2) mg PO twice a day.
5. NuvaRing 0.12-0.015 mg/24 hr Ring Sig: One (1) Vaginal once
a month.
6. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO once a day:
Please take once daily as long as you are taking prednisone.
Disp:*30 Tablet(s)* Refills:*2*
7. Caltrate-600 Plus Vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day: Please take once daily as long as you
are taking prednisone.
Disp:*60 Tablet(s)* Refills:*2*
8. Cromolyn 100 mg/5 mL Solution Sig: Ten (10) mL PO QID (4
times a day) as needed for mastocytosis.
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day): Please
take twice daily as long as you are taking prednisone.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
12. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
13. Prednisone 10 mg Tablet Sig: Five (5) Tablet PO twice a day
for 5 days: At end of 5 days, on [**2143-4-7**], start once daily
prednisone taper as instructed.
14. Prednisone 10 mg Tablet Sig: As per taper. Tablet PO once a
day for 9 weeks: After 5 days of 50 mg twice daily, starting on
[**2143-4-7**] take 6 pills for 5 days, 5 pills for 7 days, 4 pills
for 7 days, 3 pills for 7 days, 2 pills for 7 days, 1.5 pills
for 7 days, 1 pill for 7 days, 0.5 pill for 7 days.
Disp:*210 Tablet(s)* Refills:*0*
15. Diphenhydramine HCl 25 mg Capsule Sig: [**2-1**] Capsules PO Q6H
(every 6 hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Mastocytosis
Secondary Diagnosis:
Anxiety
Discharge Condition:
Hemodynamically Stable
Discharge Instructions:
You were admitted to the hospital with flushing and a fast heart
rate, consistent with a flare of your mastocystosis. You were
treated with IV steroids, IV benadryl, and your home
medications. You have been discharged on a gradual steroid
taper, since you have been on steroids for over 6 weeks now.
Please continue to take you medicines as directed, the changes
you should make are as follows:
Prednisone Taper:
50 mg twice daily for 5 days,
60 mg once daily for 5 days,
50 mg once daily for 7 days,
40 mg once daily for 7 days,
30 mg once daily for 7 days,
20 mg once daily for 7 days,
15 mg once daily for 7 days,
10 mg once daily for 7 days,
5 mg once daily for 7 days.
Caltrate 600 + D: One tablet twice daily while on prednisone to
prevent [**Month/Day (2) 500**] loss.
Omeprazole: One tablet twice daily while on prednisone to
prevent ulcer.
Bactrim: One tablet every day while on prednisone to prevent
infections.
Please attend the follow up appointments listed below.
Please seek medical help if you experience more signs of a
worsening flare, chest pain or pressure, severe fever, or any
other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2143-4-9**] 8:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2143-4-9**]
8:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5808**] Date/Time:[**2143-4-11**]
4:00
Completed by:[**2143-4-7**]
|
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|
2970, 3185
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,777
| 141,636
|
44429
|
Discharge summary
|
report
|
Admission Date: [**2119-12-13**] Discharge Date: [**2119-12-20**]
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
cardiac cath
IABP placement
CABGx3(LIMA->LAD, SVG->OM, RCA)/MVR(25mm pericardial) [**2119-12-13**]
History of Present Illness:
89 y/o active male, presented to ED w/acute onset SOB/cough.
Admitted to medicine service, had respiratory arrest, code
called. Echo showed wide open MR.
Past Medical History:
remote angina
HTN
arthritis
depression
gout
Social History:
non-smoker
social ETOH
married, lives w/wife ([**Doctor Last Name 6165**] in [**Name (NI) 108**])
Family History:
Unremarkable
Physical Exam:
Elderly [**Male First Name (un) 4746**] in respiratory distress
T: 98.2 BP: 150/90 HR: 80 RR: 24 93% sat on 5 liters
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy, or thyromegaly, carotids
2+=bilat.
Lungs: Bilat. rales
CV: RRR, +HSM
Abd: soft, nontender, +BS, no masses or hepatosplenomegaly
Ext: no C/C/E, pulses 2+ throughout
Neuro: nonfocal
Pertinent Results:
[**2119-12-18**] 07:10AM BLOOD WBC-9.9 RBC-3.09* Hgb-10.4* Hct-29.3*
MCV-95 MCH-33.7* MCHC-35.5* RDW-14.0 Plt Ct-160#
[**2119-12-18**] 07:10AM BLOOD Plt Ct-160#
[**2119-12-18**] 07:10AM BLOOD PT-13.1 PTT-28.1 INR(PT)-1.1
[**2119-12-17**] 07:00AM BLOOD PT-13.6* PTT-31.1 INR(PT)-1.2*
[**2119-12-18**] 07:10AM BLOOD Glucose-118* UreaN-33* Creat-1.4* Na-137
K-3.8 Cl-101 HCO3-29 AnGap-11
[**2119-12-17**] 07:00AM BLOOD Glucose-113* UreaN-31* Creat-1.5* Na-136
K-3.6 Cl-100 HCO3-27 AnGap-13
PATIENT/TEST INFORMATION:
Indication: Abnormal ECG. Aortic valve disease. Congestive heart
failure. Left ventricular function. Mitral valve disease. Mitral
valve prolapse. Myocardial infarction. Right ventricular
function. Valvular heart disease.
Status: Inpatient
Date/Time: [**2119-12-13**] at 20:42
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW02-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.0 cm (nl <= 4.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm)
Aorta - Valve Level: 1.9 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.2 cm (nl <= 3.4 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast in the body
of the LA. No spontaneous echo contrast or thrombus in the body
of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
LAA. All four pulmonary veins identified and enter the left
atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Normal LV wall thicknesses and cavity size.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV
systolic
function.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve
leaflets. No AS. No AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
thickening of
mitral valve chordae. Torn mitral chordae. Severe (4+) MR.
Eccentric MR jet.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure.
Conclusions:
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo
contrast is seen in the body of the left atrium. No spontaneous
echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall
thicknesses and cavity size are normal. The right ventricular
cavity is mildly
dilated. Right ventricular systolic function is borderline
normal. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve
leaflets. The aortic valve leaflets are mildly thickened. There
is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are
moderately thickened. Torn mitral chordae are present. Severe
(4+) mitral
regurgitation is seen. The mitral regurgitation jet is
eccentric. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid
regurgitation is seen. There is no pericardial effusion.
Reason: Evaluate right pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
89 year old man with MR s/p CABG/MVR s/p chest tube pull. with
small right pneumothorax
REASON FOR THIS EXAMINATION:
Evaluate right pneumothorax
PA AND LATERAL CHEST [**2119-12-17**] AT 08:42 HOURS.
HISTORY: Pneumothorax.
COMPARISON: Multiple priors, the most recent dated [**2119-12-16**].
FINDINGS: There is baseline emphysema. Evidence of prior CABG is
again noted. There are bilateral pleural effusions.
Near-complete left lower lobe collapse is also again evident.
Otherwise, there is no focal consolidation. The previously noted
right internal jugular vascular sheath has been removed. No
pneumothorax is evident.
IMPRESSION: Interval removal of right internal jugular approach
vascular sheath. Near-complete left lower lobe collapse.
Bilateral effusions.
Brief Hospital Course:
Admitted to medicine service on [**2119-12-13**]. He had respiratory
arrest shortly upon arrival to the floor, and a code was called.
Echo showed wide open MR. Intubated, taken emergently to the
cath lab. IABP was placed. He was found to have 2vCAD, and was
taken emergently to the OR for CABG X 3 (LIMA>LAD, SVG>OM,
SVG>RCA) and MVR (25mm pericardial). Post-op he was taken to
the CSRU on phenylephrine gtt, which was weaned off by the
following morning. He was extubated early am on [**12-15**], and had
his IABP removed. He was transferred to the telemetry floor on
[**12-16**]. He went in to AFib later that day with a controlled
ventricular rate, and stable BP. He was started on coumadin for
this. He progressed slowly from a mobility standpoint, and has
remained hemodynamically stable throughout. He is ready to be
discharged to a rehab facility to progress with ambulation and
independence on POD#6.
Medications on Admission:
Atenolol 25'
ASA 81'
Celexa 10'
Hytrin 1'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
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. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-23**]
Puffs Inhalation Q6H (every 6 hours) as needed.
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablet PO TID (3
times a day).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO BID (2 times a day) for 7
days.
10. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for
1 days: Adjust dose for INR goal of [**2-23**].5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
CAD, MR
[**Name13 (STitle) **] AF
Discharge Condition:
good
Discharge Instructions:
Shower daily, no creams, lotions or powders to any incisions.
No lifting > 10# for 10 weeks
no driving for 1 month
Followup Instructions:
with Dr. [**First Name (STitle) **] in [**4-26**] weeks
Dr. [**Last Name (STitle) **] in [**2-24**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2119-12-19**]
|
[
"593.9",
"311",
"492.8",
"401.9",
"997.1",
"518.81",
"428.0",
"427.31",
"414.01",
"600.00",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"36.15",
"36.12",
"96.71",
"99.07",
"39.61",
"96.04",
"99.04",
"37.23",
"35.23",
"97.44",
"88.56",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
8419, 8504
|
6268, 7186
|
230, 331
|
8582, 8589
|
1147, 1634
|
8752, 8981
|
713, 727
|
7278, 8396
|
5469, 5557
|
8525, 8561
|
7212, 7255
|
8613, 8729
|
1660, 5432
|
742, 1128
|
187, 192
|
5586, 6245
|
359, 515
|
537, 582
|
598, 697
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,547
| 195,915
|
5834
|
Discharge summary
|
report
|
Admission Date: [**2134-9-22**] Discharge Date: [**2134-9-28**]
Date of Birth: [**2058-7-9**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Clinoril / Percocet / Oxycontin / Prednisone
Attending:[**Location (un) 1279**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
left and right heart catheterization, no intervention
History of Present Illness:
76 y/o ESRD on PD who developed resting chest and arm pain in
setting of rapid afib VR 130 during her evening dialysis.
Brought to [**Hospital1 **] by EMS who noted to be borderline hypotensive
with MAP 60s. Asymptomatic without cp , dizziness or
lightheadedness on arrival. Rate not controlled with lopressor
IV, but converted spontaneously.
No previous pmh of afib, but had SVT in [**7-14**] read as a-flutter
vs. MAT. not anticoagulated. In [**7-14**] had echo which showed
diastlolic relaxation dysfunction, hyperdynamic LV, and LVOT
gradient induced to 50 mmHg.
50 pack year smoking history - quit. FH no CAD.
Past Medical History:
1. ESRD: on PD since [**1-13**], PD at home. ESRD [**1-11**] longstanding
HTN, high grade RAS.
2. h/o CHF: [**1-13**] Echo--hyperdynamic LV, EF 70-80%, mild LVH
3. HTN
4. PVD: chronic R heel ulcer
5. COPD: FEV1 0.91, decr DLCO, FEV/FVC 90%, 2L home O2
6. Depression
7. Osteoarthritis
8. ETOH abuce
9. s/p TAH and Lysis of adhesions.
10. h/o hematochezia, grade 2 hemorrhoids, colonoscopy
[**5-14**]--diverticulosis, angioectasia
Social History:
Divorced, 2 children
Prior tobacco 50 pk-yrs - quit 5 yrs ago
Ambulates with walker
h/o ETOH abuse--> last drink 2 d PTA
Family History:
+HTN
No colon ca
Mother and father + CHF
Physical Exam:
VSS, rate 60-80
comfortable
lungs mild crackles 1/3 up
regular S1/S2 [**1-15**] holosystolic murmur tricuspid region, no
gallop/rub
abd soft, nttp, peritoneal catheter no signs of infection
ext: no edema, lower ext very tender to palpation, DP 1+ bilat
Pertinent Results:
CXR ([**2134-9-22**]) - no dissection
LABORATORY on discharge:
CK 33, 32, 46
TnT 0.26 (baseline 0.20)
Cr 8.7
K 3.7
WBC 13.4 --> 8.4 (no bandemia)
Hct 31.9, plt 160
INR 1.2
Cr 6, BUN 26
K 3.1, Ca 8.6, phos 3.6, mg 1.7
TSH 0.67
Imaging:
CXR - mild failure, LLL infiltrate worse than prior 1 week ago
CARDIAC:
EKG: atrial fib with VR 130, st depression in lateral leads
TELE: sinus rhythm, rate 60-80, with intermittent episodes of
afib rate controlled.
Right and Left Heart CAth:
RA 21/21/18, RV 47/23; PCW 27/27/23; LVEDP 24; Ao grad
resting 0 mmHg; CO 3.8, CI 2.4
intra-chamber gradient pressures difficult to assess since
frequent PVC, gradi post PVC 80mmHg
Angiogram:
RCA nml
prox LAD 30%
20% prox Cx
TTE:
LA 5.2x5cm; RA 4.6cm; LV septum 1.3 cm; LVEF 70-80%
E/A 2.75
prolonged E wave decel 345sec
LVOT peak resting 20mmHg
Brief Hospital Course:
76 y/o female with demand ischemia in setting of PAF with RVR
with relief when rate controlled. She was admitted for ROMI and
rate controlled after receiving lopressor IV and dilt IV. Of
note she had not been taking PO for up to 2wks prior to admit
[**1-11**] chronic nausea. Her hospital course was complicated by
hypotension with inappropriate bradycardia symptomatic for
decreased mental status. Vital signs were otherwise stable.
She was transferred to the CCU for observation, hydration with
up to 6 liters (in the ED and CCU), calcium gluconate, and
dopamine gtt. She was quickly weaned from vasopressors and her
BP rose to 100's after 24 hours. It was felt that her symptoms
were secondary to beta and calcium channel blockade in the
setting of volume depletion. She spontaneously converted to
normal sinus rhythm and has remained in it since. She was rate
controlled with increased beta blockade. She she has relative
AS with LVOT obstruction with age>65 (CHADS2 score 3) and has
PAF and she is highly functional (able to perform PD on self,
very alert and educated) it was suggested that she be
anticoagulated with coumadin.
She underwent cardiac catheterization which demonstrated minimal
CAD, however LVEDP and PCW were in mid twenties. Her volume was
controlled with alternating higher dextrose concentration
solutions for her peritoneal dialysis and was net negative
approx 2.5 liters. Post cath, she became extremely paranoid and
angry stating "you didn't really cath me, i'm in a mental
institution" and was attributed to the percocet she received
while in the CCU. She has a known psychotic reaction to
oxycontin and percocet. She developed a small stable hematoma,
however Hct remained stable. Her anginal symptoms were
attributed to elevated LVEDP in the setting of LVOT obstruction.
Echo showed evidence of diastolic relaxation dysfuction with
prolonged E wave decel time and LVOT resting peak gradient of
20mmHg. Her toprol was increased and she was started on low
dose verapamil for treatment of her PAF and LVOT obstruction.
Verapamil was chosen because of its greater effect on blocking
the AV node preferentially to the SA node. When not in Afib she
had a resting heart rate of 40-60's. Digoxin and amiodarone
were considered for additional AV blockade, however given her
LVOT, we did not want to give her a positive inotrope and her
severe underlying COPD would make pulmonary amiodarone toxicity
difficult to monitor. Her blood pressures prevented the
addition of a CCB.
She was noted to have a higher O2 requirement than usual. She
intermittently uses home O2, however had [**Known firstname **] episode of
desaturation to 66% with tachypnia resolving with O2. CXR
showed a worsening LLL infiltrate, but no evidence of worsened
CHF or PTX. EKG and C.E did not suggest and MI. Given that she
has had no worsening cough, has remained afebrile, wihtout a
white count, and recently completed treatment for a pneumonia
with levaquin, she was not treated with additional antibiotics.
Instead, it was felt that she had mild overload in the setting
of chronic lung disease.
She was discharged home with services for PD, PT, and O2 in
stable condition. She will need to have INR checks. She may
benefit from a reminder to not cut her Toprol tablets in half as
she has been doing.
Medications on Admission:
ASA 81 qd
paroxetine 30 qd
lipitor
fluticasone
ipratropium
lopressor 25 [**Hospital1 **]
sulindac
percocet
oxycontin
prednisone
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*1 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).
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO three
times a day.
Disp:*90 Capsule(s)* Refills:*2*
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO at
bedtime.
8. Lipitor 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
10. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 6-8 hours.
11. Peritoneal Dialysis
alternate 1.5% and 2.5% over 5 cycles. See renal
reccomendations.
12. home O2
titrate O2 to keep sats 90-94%. check O2 with head monitor and
not finger or ear monitor as patient has severe peripheral
vascular disease
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Verapamil HCl 100 mg Cap, 24HR Sust Release Pellets Sig: One
(1) Cap, 24HR Sust Release Pellets PO once a day: start in AM of
[**2134-9-29**] for heart.
Disp:*30 Cap, 24HR Sust Release Pellets(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
atrial fibrillation
Hypotension
CAD
DM
PVD
Hallucinations
groin hematoma
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1500 cc
Continue to do your nightly dialysis
take your medications
Followup Instructions:
Provider: [**Name Initial (NameIs) 9484**]CC2 PULMONARY LAB-CC2 Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2134-10-11**]
9:00
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 5091**] Date/Time:[**2134-10-11**] 9:30
Contact your doctor , Dr. [**Last Name (STitle) 8499**] to schedule [**Known firstname **] appointment
within 7 days of admission.
|
[
"414.01",
"E941.3",
"428.30",
"403.91",
"348.31",
"786.51",
"416.8",
"425.8",
"250.00",
"427.31",
"458.9",
"V15.82",
"496",
"276.5",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98",
"99.04",
"38.93",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
7885, 7943
|
2834, 6162
|
332, 388
|
8060, 8066
|
1971, 2021
|
8299, 8846
|
1640, 1682
|
6340, 7862
|
7964, 8039
|
6188, 6317
|
8090, 8276
|
1697, 1952
|
2035, 2811
|
282, 294
|
416, 1033
|
1055, 1486
|
1502, 1624
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,754
| 114,662
|
3263
|
Discharge summary
|
report
|
Admission Date: [**2119-6-18**] Discharge Date: [**2119-6-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 82 yo male with hx of CHF (EF 55% 3+MR), afib,
DMII, and recent MRSA PNA who presents with dyspnea. Pt has
multiple recent hospitalizations the most significant of which
was [**Date range (3) 15221**] during which he suffered an SDH which was
surgically evacuated, liver failure from dilantin toxicity, ARF
due to CHF and pneumonia treated with a course of levofloxacin.
He was readmitted [**Date range (1) 15222**] for mental status changes and
hypoxia requiring intubation for airway protection. BNP was in
the 30,000's and he was found to have a RML infiltrate on CT and
MRSA in his sputum and treated with a 10 day course of
vancomycin which he completed on [**2119-5-27**]. He was also breifly
hospitalized [**Date range (1) 15223**] for apneic episodes at rehab with confusion
thought to be due to [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations secondary to CHF
exacerbation. He represented to the ED yesterday with confusion
and found to have hypokalemia, ARF, and FS of 60 with mental
status improved with correction of these disturbances. CXR was
read as clear by ED staff but final read showed new left sided
effusion and bilateral infiltrates concerning for CHF but head
CT was unchanged.
He now presents from rehab after being started on levofloxacin
since [**6-16**] for fever and suspected UTI and PNA . In the ED he
was found to be hypoxic suspectedly due to CHF with concomitant
PNA. He was given a dose of lasix 40mg IV with vancomycin and
started on BIPAP since the patient was DNR/DNI and appeared to
have difficult work of breathing with hypercarbia on ABG despite
normal O2 sats on 4L NC.
Past Medical History:
1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2. 3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine. No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia
12. ?progressive dementia
Social History:
Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).
Family History:
no Alzhemer's or Parkinson's
Physical Exam:
Admission:
T 99.8 HR 85 BP 135/55 RR 30 O2 sat 95% 4L NC
HEENT-PERRL, MM dry, elevated JVP to ear but pt breathing
forcefully, no ant or post cerv LAD
Hrt-RRR nS1 soft S2 [**2-27**] SM at apex, [**2-27**] diastolic murmur at LUSB
Lungs-bronchial BS at left lung base and dullness to percussion
at bases bilat, no crackles, mild diffuse end expiratory wheeze
Abdomen-soft NT, ND, no organomeg, NABS
Extrem-2+ rad and dp pulses, 2+ pitting edema
Neuro-noncompliant with exam, moving all extrem well, arousable
but agitated and appropriate
Skin-left forearm abrasion 1/2cm
Pertinent Results:
Admission labs:
[**2119-6-17**] 05:45PM BLOOD WBC-4.9 RBC-3.55* Hgb-10.2* Hct-30.8*
MCV-87 MCH-28.8 MCHC-33.2 RDW-17.9* Plt Ct-150
[**2119-6-17**] 05:45PM BLOOD Neuts-50.8 Lymphs-40.1 Monos-7.6 Eos-1.3
Baso-0.3
[**2119-6-17**] 05:45PM BLOOD Hypochr-1+ Anisocy-1+ Microcy-1+
[**2119-6-17**] 05:45PM BLOOD PT-14.3* PTT-26.2 INR(PT)-1.3*
[**2119-6-17**] 05:45PM BLOOD Glucose-79 UreaN-27* Creat-1.5* Na-145
K-3.1* Cl-102 HCO3-33* AnGap-13
[**2119-6-17**] 05:45PM BLOOD ALT-14 AST-21 CK(CPK)-37* AlkPhos-70
Amylase-47 TotBili-0.8
[**2119-6-17**] 05:53PM BLOOD Lactate-1.8
Other labs:
[**2119-6-17**] 06:11PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2119-6-17**] 06:11PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2119-6-17**] 06:11PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-<1
[**2119-6-17**] 05:45PM BLOOD cTropnT-0.04*
[**2119-6-18**] 03:10PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2119-6-17**] 05:45PM BLOOD Lipase-22
[**2119-6-19**] 05:30AM BLOOD %HbA1c-5.1 [Hgb]-DONE [A1c]-DONE
[**2119-6-19**] 05:30AM BLOOD TSH-1.9
[**2119-6-18**] 04:41PM BLOOD Type-ART Rates-/30 pO2-81* pCO2-50*
pH-7.45 calHCO3-36* Base XS-8 Intubat-NOT INTUBA
[**2119-6-19**] 08:06AM BLOOD Type-ART Temp-37.3 pO2-106* pCO2-53*
pH-7.43 calHCO3-36* Base XS-8 Intubat-NOT INTUBA
[**2119-6-18**] 03:34PM BLOOD Lactate-2.1*
[**2119-6-19**] 08:06AM BLOOD Lactate-1.2
[**2119-6-19**] 02:39PM PLEURAL WBC-60* RBC-1295* Polys-3* Lymphs-62*
Monos-28* Eos-2* Meso-1* Macro-4*
[**2119-6-19**] 02:39PM PLEURAL TotProt-2.2 LD(LDH)-105
[**2119-6-19**] Pleural fluid show no maligant cells
Discharge Labs:
[**2119-6-23**] 06:15AM BLOOD WBC-6.3 RBC-3.49* Hgb-10.3* Hct-29.8*
MCV-86 MCH-29.6 MCHC-34.6 RDW-17.0* Plt Ct-147*
[**2119-6-23**] 06:15AM BLOOD Glucose-94 UreaN-23* Creat-1.2 Na-139
K-3.6 Cl-98 HCO3-31 AnGap-14
[**2119-6-23**] 06:15AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9
Echocardiogram ([**2119-6-19**]) The left atrium is moderately dilated.
The right atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild to moderate ([**12-26**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. At least
moderate(2+) mitral regurgitation is seen (view suboptimal). The
mitral regurgitation jet is eccentric. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2119-4-3**], there is no
significant change.
Radiology
CXR ([**2119-6-19**]) -bilat effusion worse on left, patchy opacity in
RLL but no clear focal infiltrate
Brief Hospital Course:
The patient is 82 yo male with hx of CHF (EF 55% 3+MR), afib,
DMII, and recent MRSA PNA who presents with dyspnea. His
hospital course on this admission is as follows:
1. Confusion-Appears to be a delirium with waxing and [**Doctor Last Name 688**]
mental status due to acute illness. We treated his agitation
with zyprexa prn and it completely cleared with diuresis,
improvement in potassium levels and better glucose control.
2. Fever-He had a positive UA at rehab but repeat UA and culture
were negative. There was no clear infiltrate on CXR although he
was presumed to be at risk for aspiration PNA with altered
mental status along with hypoxia. He had been recently treated
with vancomycin for PNA and levofloxacin for UTI along with
watery diarrhea raised concern for Cdiff colitis since he has a
known history of colitis on sulfasalazine in past. He was
initially broadly covered with Vancomycin for recent MRSA PNA,
levofloxacin to cover aspiration PNA with flagyl for C.
difficile. He was never febrile while in hospital with no
elevated WBC or for left shift so antibiotics except for flagyl
was stopped on HD2. Flagyl was then stopped on HD3 after Cdiff
toxin assay was negative x3.
3. Hypoxia-Pt was thought to be at risk for aspiration PNA as
above. Bilateral effusions with LE edema and elevated JVP raised
concern for CHF. Wheeze on exam was likely cardiac wheeze. ECG
showed no acute changes suggestive ischemia or infarct with CE
stable for >24 since his ED visit on the day prior to admission.
Pt had known chronic hypercarbia which were thought to be
related to effusions causing hypoventilation. He required bipap
intermittently over the first night of admission and was
diuresed approximately 2-3 liters over the first 48 hours of
hospitalization. Repeat TTE showed now change in ventricular
function. Left sided thoracentesis was performed due to risk of
parapneumonic effusion and 2L were removed and found to be
transudative and no evidence of malignant cells. We initially
held on his ACE-I due to ARF and afterload reduced with Imdur
and hyralazine. Once patient's condition was stabilized, and
transferred from the MICU to the medicine floor, we d/c his
hydralazine, and started him on lisinopril 5mg PO, which is his
home dose. In additon, we weaned him gradually off supplemental
O2 to up 90% on 2L at the time of the discharge, which is his
baseline.
4. Hypokalemia-Due to poor PO intake and diuresis. Mental status
had been poor in past in the setting of hypokalemia. Initially,
we replete him aggressively and required >120mEq of KCL per day
to maintain serum potassium levels >3.6, then daily potassium
check and supplement as needed. As he was total body potassium
depleted he will likely need standing KCl supplementation with
close monitoring at rehab.
5. Subdural hematoma-Remained stable on head CT from ED visit on
the day prior to admission. His MS continued to improve with
correction of metabolic derangements so no repeat head CT was
performed. We continued Keppra for seizure prophylaxis.
6. AAA-ascending; measured >5cm in [**11-27**] & pt refused surgical
intervention at that time although no hypotension or back pain
to suggest dissection at this time.
7. Acute on CRI-Likely due to CHF and poor perfusion. Creatinine
returned to baseline after he was adequately diuresed.
8. Paroxysmal Afib- We continue metoprolol for rate control
despite acute CHF exacerbation as he needs longer ventricular
filling times due to valvular dysfunction. We did not initiate
anticoagulation with warfarin given recent subdural hematoma and
h/o frequent falls.
9. DM2-Given his recent weight loss we suspected that his
hyupoglycemia was due to loss of insulin resistence and
continued glyburide use. He remained hypoglycemic during the
first 48 hours of hospitaliztion with FS in the 60's requiring
multiple amps of D50. His hemaglobin A1c was 5.1 suggesting no
insulin resistance so glybride should be held indefinitely.
10. Anemia-iron studies were most c/w chronic dz (ferritin 86).
Hct remained stable. We continued ferrous sulfate.
11. Hypothyroidism-He was clinically euthyroid. We continued
synthroid and rechecked TSH which was found to be WNL.
12. Depression-remained stable. Continue celexa.
13. Communication-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (5) 15224**]
14. Nutrition and Diet-on low salt, cardiac, diabetic and renal
diet.
15. Activity-Assist out of bed, PT consults
16. Code- Full code which was reversed by the patient from
DNI/DNR during this admission, but needs to be addressed
further.
Medications on Admission:
Protonix 40 mg daily
ferrous sulfate 325 mg daily
furosemide 40 mg daily
Keppra 250 mg twice daily
Celexa 10 mg daily
vitamin C 250 mg daily
levothyroxine 25 mcg daily
lisinopril 5 mg daily
glyburide 2.5 mg daily
potassium chloride 20 mg once Monday, Wednesday, Friday
metoprolol 50 mg twice daily
RISS
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
CHF excerbation
pneumonia
Secondary Diagnosis:
2 + mitral regurgitation and significant AR [**3-30**]
Atrial fibrillation-off coumadin due to liver coagulopathy and
falls
Ascending aortic aneurysm (not interested in surgery)
Type 2 diabetes
Gout
Hypertension
GERD
chronic renal insufficiency
h/o Asbestosis
Recent B12 and Fe def. anemia
Subdural hematoma s/p evacuation in [**2119-4-12**]
recent MRSA peumonia ([**4-29**])
Discharge Condition:
Patient is discharged in good condition, experiencing no
symptoms of shortness of breath, chest pain, dizziness, O2 sat
up 90% on 2L, which is his baseline.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
If you experience any chest pain, shortness of breath,
dizziness, or other concerning symptoms, please seek medical
attention immediately
Followup Instructions:
Please follow up with your primary care doctor: Dr [**Last Name (STitle) 3649**]
([**Telephone/Fax (1) 3070**]) within one week of discharge, in addition to the
following appointments.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2119-7-3**] 4:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2119-6-23**]
|
[
"427.31",
"276.8",
"584.9",
"511.9",
"285.29",
"530.81",
"501",
"507.0",
"244.9",
"441.4",
"398.91",
"396.3",
"274.9",
"250.00",
"401.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
12182, 12297
|
6207, 10823
|
281, 288
|
12784, 12943
|
3254, 3254
|
13252, 13714
|
2616, 2646
|
11177, 12159
|
12318, 12318
|
10849, 11154
|
12967, 13229
|
4916, 6184
|
2661, 3235
|
222, 243
|
316, 1961
|
12385, 12763
|
3271, 3824
|
12337, 12364
|
1983, 2444
|
2460, 2600
|
3837, 4899
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,519
| 168,881
|
14073
|
Discharge summary
|
report
|
Admission Date: [**2135-11-28**] Discharge Date: [**2135-12-20**]
Date of Birth: [**2062-1-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
1. tracheostomy tube placement
History of Present Illness:
Pt is a 73 yo male resident of [**Hospital 100**] Rehab recent MRSA PNA, and
osteomyelitis, with h/o CAD s/p CABG, hypertension,
osteomyelitis with recent MRSA bacteremia who presented with
shortness of breath at rehab on the AM of admission.
.
He was found to be in septic shock, acute renal failure (which
quickly resolved with fluid administration) was intubated, and
was weaned off pressors, and was empirically treated with
vancomycin and zosyn for presumed nosocomial infection, though
there was no clear source of infection. Despite antibiotic
therapy he continued to spike high temperatures and TEE, abd CT,
RUQ u/s, and MRI C/L/S spine were performed in addition to
routine cultures to look for evidence of endocarditis, occult
abdominal infection, or reoccurence of MRSA epidural infection.
All of these were negative.
.
Blood cultures grew VRE and pt is s/p 14 day course of
linezolid. In terms of his respiratory status initial hypoxic
respiratory failure on admission was felt to be [**1-19**] to high
demand in setting of sepsis. He was extubated on however became
increasing tachypneic and fatigued. Pt was reintubated and felt
to be a high risk of extubation and underwent tracheostomy on
[**12-8**] requiring pressure support and now only trach mask.
.
Course was also complicated by UTI treated with 3 days of cipro,
however, spiked temperature related to cipro and this was d/cd.
His urine culture from [**2135-12-17**] is growing GNR and pt was
started on bactrim this am. Additionally, pt with anemia
(chronic disease) supported by blood transfusions prn.
.
Today, pt feels well. He says that his breathing is stable, no
CP. He has been wearing his Passy-Muir valve for one hour and
still feels well. His right finger has been painful for the
past 2 days wsith decreased ROM.
.
Past Medical History:
1. Hyperlipidemia
2. CAD s/p MI s/p CABG in [**2110**] and [**2125**]. last stress was an
adenosine stress in [**8-21**] showing fixed mid-lateral wall defect
3. CHF with normal EF (last echo [**2135-8-30**])
4. Mild aortic stenosis
5. Mild mitral regurgitation
6. Hypertension
7. Chronic Atrial fibrillation/flutter since [**2128**] on Coumadin
8. Right foot cellulitis [**2133-9-24**]
9. Osteoarthritis
10. Does not have DMII (as all previous notes have said). This
was confirmed with the daughter
Past Surgical History:
1. CABG x2 in [**2110**] and [**2125**]
2. multiple toes right foot amputated from dry gangrene
following aneurysm rupture in right leg (unclear what caused
anyersum)
3. Right leg aneurysm repair
4. Tonsillectomy
5. Appy
Social History:
Social History: lives w/ wife. active @ [**Name2 (NI) 4222**]. Transitioning
to Rehab
Family History:
NC
Physical Exam:
VS: 101.0 110 102/58 28 100% on AC 600x14/40%/5 - ABG
7.31/36/136
Gen: intubated, appears comfortable
HEENT: pupils equal, R > L, reactive; MM dry
Neck: L IJ in place, no cervical LAD
CV: tachycardic, regular, nl S1/S2, 2/6 systolic murmur heard
over LLSB
Pulm: clear anteriorly
Abd: soft, NT/ND, +BS, hypoactive bowel sounds
Ext: well healed scar on RLE; 1st, 3rd, 4th toes amputated on R
foot, no erythema or tenderness to palpation; warm, no edema,
pulses weakly palpated
Neuro: follows commands, shakes head in response to questions,
squeezes both hands but does not move legs on command
Pertinent Results:
[**2135-11-28**] 03:17AM LACTATE-5.0*
[**2135-11-28**] 03:25AM PT-15.0* PTT-24.1 INR(PT)-1.5
[**2135-11-28**] 05:05AM CALCIUM-7.5* PHOSPHATE-3.4 MAGNESIUM-1.3*
[**2135-11-28**] 03:00AM WBC-17.0* RBC-3.84* HGB-11.7* HCT-34.2*
MCV-89 MCH-30.4 MCHC-34.1 RDW-17.3*
[**2135-11-28**] 03:00AM NEUTS-75* BANDS-4 LYMPHS-16* MONOS-3 EOS-1
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2135-11-28**] 07:14AM GLUCOSE-128* SODIUM-140 POTASSIUM-4.2
CHLORIDE-112* TOTAL CO2-18* ANION GAP-14
[**2135-11-28**] 07:14AM DIGOXIN-0.4*
[**2135-11-28**] 07:14AM SED RATE-121*
[**2135-11-28**] 05:05AM ALT(SGPT)-36 AST(SGOT)-28 CK(CPK)-26* ALK
PHOS-80 AMYLASE-166* TOT BILI-0.5
.
.
Brief Hospital Course:
Hospital Course from [**11-27**] to [**12-13**] is briefly summarized by
problems:
1. Septic shock - patient was initially admitted for sepsis
requiring levophed for maintainece of blood pressure and
ultimately weaned off by [**11-28**] after aggressive IVF repletion.
Infectious diseases was consulted and he was empirically treated
with Vancomycin and Zosyn for presumed nosocomial pneumonia
although no clear source of infection was identified. Despite
antibiotic therapy he continued to spike high temperatures and
TEE, abd CT, RUQ u/s, and MRI C/L/S spine were performed in
addition to routine cultures to look for evidence of
endocarditis, occult abdominal infection, or recrudescence of
his MRSA epidural infection. However, all imaging studies were
negative and central venous lines were resited for persistent
fevers. Blood cultures drawn from CVL on [**12-1**] grew GPC
ultimately speciated to be VRE and he was initiated on 14 day
course of Linezolid (started [**12-4**]) with improvement of symptoms
and fevers. He currently finished 14 day course of Linezolid and
has not been spiking fever and leukocytosis is trending down
2. Respiratory failure - initial hypoxic respiratory failure
felt to be [**1-19**] to high demand in setting of sepsis. Pt required
minimal ventilator support and exhibited good lung mechanics.
He was extubated on [**11-28**] but became increasing tachypneic and
fatigued. He was re-intubated on [**11-29**] for increased secretions
and fatigue. Remained intubated despite rapid shallow breathing
indices <90 but copious secretions. Ultimately he was felt to
be high risk of extubation and underwent tracheostomy on [**12-8**]
without complications. Since that time, he has been
intermittently placed on trach mask and requiring PS ventilation
for fatigue. He continues to be actively diuresed for his
secretions. On [**12-12**] he was noted to have some upper airway
bleeding near trach site in setting of systemic heparinization.
It quickly resolved with discontinuation of heparin and felt to
be nose bleed draining around tracheostomy cuff. He was
evaluated and fitted with a Passy-Muir valve. He has been doing
well on regular medical floor on trach mask.
.
3. Fevers - pt had defervesced several days after Linezolid had
been intiated. However he has low grade temperatures that have
not yielded an etiology. He has undergone search for
non-infectious w/u including infection with negative results.
However, his WBC count has trended downwards. He was found to
have UTI in setting of foley catheter and intiated on 3 day
course of ciprofloxacin. On [**12-13**] AM pt had temperature of 102F
without localizing symptoms and hemodynamically stable. His WBC
continues to be low and temporally related to ciprofloxacin
dosing. He has completed his course of ciprofloxacin on [**12-13**].
On [**12-16**], pt spiked another fever and a urine cx from that day
grew Actinobacter which was sensitive to zosyn which was started
on [**2135-12-19**] and has to complete a 5 day course
.
4. Acute Renal Failure - His creatinine at admission was 2.6 and
felt to be pre-renal in setting of septic shock. It quickly
normalized to after IVF resuscitation and currently around 1.0.
.
5. atrial flutter - throught his ICU course he remained in
atrial flutter. He was well rate controlled on digoxin and
b-blockers. His anti-coagulation was held peri-operatively. He
had two episodes of bradycardia into 40's that was felt to be
[**1-19**] digoxin effects from electrolyte derrangements during
diuresis. They quickly resolved after electrolyte repletion.
Please montior pt on telemetry during rehab. Following the
placement of the tracheostomy, pt noted to have large amounts of
bloody secretions from trach. His coumadin and heparin were
held and no further bleeding was noted. Coumadin will need to
be restarted in rehab.
.
6. Anemia - has had gradual decline in hct since admission felt
to be [**1-19**] daily phlebotomy and chronic disease. He has recieved
3 units RBC since [**12-13**] and additional 2 units of RBC in setting
of nose bleed on [**12-13**].
.
7. Nutrition - pt has tolerated tube feedings via his PEG tube.
His latest albumin is 2.5.
.
8. Finger swelling: Likely gout vs pseudogout given history.
Will treat pain with Motrin. Once acute flare is over, will
need initiation of Allopurinol
.
9. Parkinson's- continue sinemet
.
10. Code status - after family meeting he has been declared DNR
but intubatable.
.
11. FOLLOW-UP: please see that the following issues are followed
up after transfer from [**Hospital1 18**].
[ ] evaluation for passy-muir valve
[ ] follow up culture data after temperature spike on [**12-13**]
[ ] pt noted to have small solitary nodule at right lower base;
he needs follow-up chest x-ray in few months.
[ ] re-initiation of anti-coagulation for atrial flutter and
tele monitoring
[ ] completion of 5 day course of unasyn
Medications on Admission:
aspirin 325mg daily
zocor 80mg daily
combivent nebs 4x daily
coumadin 3mg qHS
metoprolol 100mg tid
captopril 25mg tid
digoxin 0.125mg daily
nexium daily
miconazole cream to groin
multivitamin
levofloxacin 250mg daily [**Date range (1) 29038**] for tracheobronchitis
tylenol prn, fleets prn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) puff
Inhalation Q2H (every 2 hours).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours).
9. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
14. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Carbidopa-Levodopa 25-100 mg Tablet Sig: 0.5 Tablet PO QID
(4 times a day).
16. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
17. Ampicillin-Sulbactam [**1-18**] g Recon Soln Sig: Three (3) gm
Injection Q8H (every 8 hours) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. line-associated VRE bacteremia
2. UTI
3. respiratory failure
4. acute renal failure
5. atrial flutter
6. septic shock
Discharge Condition:
good
Discharge Instructions:
1. call 911 or go to nearest ER if you have bleeding,
difficulty breathing, fevers, or feel unwell.
Followup Instructions:
follow-up with PCP [**Last Name (NamePattern4) **] [**2-18**] weeks time once off ventilator
Completed by:[**2135-12-20**]
|
[
"785.52",
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"038.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"31.1",
"96.72",
"88.72",
"99.04",
"00.17",
"96.6",
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icd9pcs
|
[
[
[]
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] |
11217, 11287
|
4408, 9331
|
324, 357
|
11452, 11459
|
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277, 286
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385, 2190
|
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2991, 3063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,883
| 155,525
|
52616
|
Discharge summary
|
report
|
Admission Date: [**2171-8-2**] Discharge Date: [**2171-8-17**]
Date of Birth: [**2086-10-27**] Sex: M
Service: MEDICINE
Allergies:
Coumadin / Heparin Agents
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
L. hand hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname 9780**] is an 84 yo M with a history of cryptogenic cirrhosis
(c/b variceal bleed requiring [**Last Name (un) 10045**]/TIPS [**2171-7-9**]) and
afib/SSS (s/p dual chamber PPM) who was recently admitted from
[**Date range (1) 108604**] with UGI bleed and who was admitted this time on
[**2171-8-2**] with bilateral upper extremity ecchymosses that occurred
in the setting of therapeutic enoxaparin. He had some falls at
rehab but according to his wife these occurred after he already
had the bruises. A trauma workup in the ED was notable mainly
for a hematocrit drop of 30.3 at last dishcarge -> 23.7. He had
OB+ brown stool, negative NG lavage. It was felt that drop in
HCT was most likely related to arm.
He was admitted to the medical floor. Yesterday ([**8-3**]) his HCT
had further dropped to 20.0 and he was transfused 2 units of
pRBCs with appropriate increase to 26.0. He had loose stools
(but is on lactulose) which were reportedly not melanotic but
guiac positive. Early this morning ([**8-4**]) the patient was noted
to be in afib with RVR to the 150s which was asyptomatic. His
blood pressure dropped to 80s/doppler from systolic 110s at
baseline. He has not had any fevers but has had a leukocytosis
since admission. He denies cough or urinary symptoms. He was
therefore transferred to the MICU for management of his afib
with hypotension.
Of note, the patient was recently admitted [**Date range (1) 108604**] with
variceal bleeding, hypotension, and leukocytosis. He required
[**Last Name (un) 10045**] and TIPS. He also had 5 AVMs ablated. During his
hospital stay he was noted to have LUE swelling but LENI
negative for clot, however he was found to have thrombus in RIJ
and thrombus in R. cephalic vein. His dabigatran was stopped and
he was discharged on lovenox. His admission was also complicated
by ICU delirium.
On arrival to the MICU, the patient reports pain in arms left >
right from the injuries but otherwise does not have any other
new complaints.
Past Medical History:
1. Hypertension.
2. Sick sinus syndrome with atrial fibrillation s/p Dual Chamber
Pacemaker ([**Company 1543**] Revo MRI RVDR01).
3. Complications of pacemaker insertion in the past.
4. Fatty liver disease.
5. Cryptogenic cirrhosis with portal hypertension and varices
s/p TIPS on [**2171-7-9**].
6. Upper gastrointestinal bleed from AV malformations in the
duodenum in [**2169**].
7. Chronic anemia, bone marrow suppression, baseline hematocrit
is low. Previously Darbepoetin dependent.
8. Prostate cancer [**2166**] status post radiation therapy.
9. Colon cancer [**2167**] status post colectomy incompletely, this is
now treated.
10. Neuroendocrine tumor of the liver diagnosed in [**2166**] per Dr.
Kahi and Dr. [**First Name (STitle) 1726**] at [**Hospital3 2358**].
11. Orthostatic hypotension.
12. Benign prostatic hypertrophy.
13. Hypothyroidism.
14. Cataracts.
15. Rotator cuff repair.
16. Status post inguinal hernia.
17. Diverticulosis.
18. Asthma.
19. Portal Vein Thrombosis s/p thrombectomy [**2171-7-9**]
20. Upper Extremity DVT (catheter associated) [**7-/2171**]
Social History:
Was living with his wife in an assisted-living facility although
he recently has been in and out of rehab. He is a retired [**University/College **]
professor of chemical process engineering. He stopped smoking 40
years
ago. Has a 30 pack year history of smoking. Takes 2 ounces of
alcohol a week. He uses a cane to ambulate.
Family History:
[**Name (NI) **] father had a stroke at age 63, mother died of unknown
causes at 83.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 140/67 96 18 98% RA
GEN comfortable in no acute distress
HEENT NCAT dry MM, sclera anicteric, OP clear
NECK supple, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, 2/6 systolic murmur at LLSB
ABD soft NT ND normoactive bowel sounds, no r/g
EXT: LUE with bruising and swelling from mid humerous distally.
ROM at shoulder, elbow and wrist limited by pain and swelling.
distal pulse palpable. sensation grossly intact. RUE noted to
have hematoma over wrist with bandage in place and otherwise
NVI. trace LE edema.
NEURO: confused and slow to respond. no asterixis
Pertinent Results:
[**2171-8-2**] 06:15PM BLOOD WBC-17.1*# RBC-2.31* Hgb-7.4* Hct-23.7*
MCV-103* MCH-32.0 MCHC-31.1 RDW-20.4* Plt Ct-98*
[**2171-8-3**] 06:45AM BLOOD WBC-20.4* RBC-1.94* Hgb-6.3* Hct-20.0*
MCV-103* MCH-32.4* MCHC-31.5 RDW-20.7* Plt Ct-73*
[**2171-8-2**] 06:15PM BLOOD Neuts-70 Bands-4 Lymphs-10* Monos-15*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2171-8-2**] 06:15PM BLOOD Hypochr-NORMAL Anisocy-2+
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-2+
Schisto-OCCASIONAL
[**2171-8-2**] 06:15PM BLOOD PT-11.6 PTT-40.6* INR(PT)-1.1
[**2171-8-4**] 03:58AM BLOOD Fibrino-235
[**2171-8-2**] 06:15PM BLOOD Glucose-99 UreaN-24* Creat-1.0 Na-133
K-4.3 Cl-99 HCO3-25 AnGap-13
[**2171-8-3**] 06:45AM BLOOD ALT-44* AST-59* LD(LDH)-240 AlkPhos-130
TotBili-1.0
[**2171-8-4**] 04:00AM BLOOD CK-MB-5 cTropnT-0.01
[**2171-8-3**] 06:45AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.2
[**2171-8-3**] 06:45AM BLOOD Hapto-15*
[**2171-8-2**] 06:24PM BLOOD Lactate-2.1*
Micro:
[**2171-8-17**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2171-8-16**] URINE URINE CULTURE-NEG
[**2171-8-13**] URINE URINE CULTURE-NEG
[**2171-8-12**] STOOL C. difficile DNA amplification
assay-NEG
[**2171-8-12**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2171-8-12**] URINE URINE CULTURE- NEG
[**2171-8-12**] BLOOD CULTURE Blood Culture, Routine- NEG
[**2171-8-9**] URINE URINE CULTURE- NEG
[**2171-8-8**] STOOL C. difficile DNA amplification
assay-Neg
[**2171-8-7**] STOOL C. difficile DNA amplification
assay-Neg
[**2171-8-7**] BLOOD CULTURE Blood Culture, Routine- NEG
[**2171-8-6**] URINE Legionella Urinary Antigen - NEG
[**2171-8-6**] URINE URINE CULTURE- VRE sensitive Linezolid
[**2171-8-6**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2171-8-6**] MRSA SCREEN MRSA SCREEN-NEG
[**2171-8-4**] MRSA SCREEN MRSA SCREEN-NEG
[**2171-8-4**] BLOOD CULTURE Blood Culture, Routine- NEG
[**2171-8-4**] BLOOD CULTURE Blood Culture, Routine- NEG
[**2171-8-3**] BLOOD CULTURE Blood Culture, Routine- NEG
[**2171-8-3**] BLOOD CULTURE Blood Culture, Routine- NEG
STUDIES:
[**2171-8-2**] Chest Xray
IMPRESSION: No definite acute cardiopulmonary process. Hazy
right basilar opacity could be due to layering pleural
effusion. PA and lateral views would offer additional detail.
[**2171-8-2**] CT Head
IMPRESSION: No acute intracranial abnormality.
[**2171-8-10**] CT HEad
No evidence of an acute intracranial process.
[**2171-8-12**] Renal ultrasound
IMPRESSION: Normal renal ultrasound. Small ascites.
[**2171-8-7**] 03:21AM BLOOD WBC-47.5* RBC-2.80* Hgb-9.0* Hct-28.5*
MCV-102* MCH-32.1* MCHC-31.5 RDW-21.1* Plt Ct-55*
[**2171-8-17**] 02:26AM BLOOD WBC-36.1* RBC-2.20* Hgb-7.1* Hct-24.8*
MCV-113* MCH-32.1* MCHC-28.5* RDW-21.4* Plt Ct-121*
[**2171-8-17**] 02:26AM BLOOD Neuts-66 Bands-1 Lymphs-1* Monos-30*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 NRBC-2*
[**2171-8-17**] 02:26AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Burr-2+
[**2171-8-17**] 02:26AM BLOOD PT-14.8* PTT-53.1* INR(PT)-1.4*
[**2171-8-14**] 12:16PM BLOOD CD33-DONE CD45-DONE CD13-DONE CD14-DONE
[**2171-8-14**] 12:16PM BLOOD CD34-DONE
[**2171-8-14**] 12:16PM BLOOD Ret Man-2.9*
[**2171-8-14**] 12:16PM BLOOD IPT-DONE
[**2171-8-4**] 03:58AM BLOOD Fibrino-235
[**2171-8-17**] 02:26AM BLOOD Glucose-163* UreaN-41* Creat-4.5* Na-138
K-4.7 Cl-111* HCO3-14* AnGap-18
[**2171-8-16**] 02:13PM BLOOD Glucose-122* UreaN-39* Creat-3.8* Na-138
K-3.8 Cl-112* HCO3-11* AnGap-19
[**2171-8-17**] 02:26AM BLOOD ALT-44* AST-46* LD(LDH)-289* CK(CPK)-31*
AlkPhos-145* TotBili-0.9
[**2171-8-17**] 02:26AM BLOOD CK-MB-6 cTropnT-0.11*
[**2171-8-16**] 10:57PM BLOOD CK-MB-6 cTropnT-0.10*
[**2171-8-16**] 02:13PM BLOOD CK-MB-7 cTropnT-0.09*
[**2171-8-4**] 04:00AM BLOOD CK-MB-5 cTropnT-0.01
[**2171-8-17**] 02:26AM BLOOD Albumin-4.5 Calcium-9.5 Phos-5.8* Mg-2.3
[**2171-8-14**] 12:16PM BLOOD calTIBC-129* VitB12-GREATER TH
Folate-14.8 Hapto-<5* Ferritn-377 TRF-99*
[**2171-8-3**] 06:45AM BLOOD Hapto-15*
[**2171-8-13**] 03:15PM BLOOD PEP-QUESTIONAB IgG-683* IgA-302 IgM-161
IFE-TRACE MONO
[**2171-8-16**] 02:36PM BLOOD Type-[**Last Name (un) **] pO2-59* pCO2-43 pH-7.13*
calTCO2-15* Base XS--14
[**2171-8-10**] 07:06PM BLOOD Lactate-1.7
[**2171-8-6**] 01:03PM BLOOD Lactate-4.1*
[**2171-8-2**] 06:24PM BLOOD Lactate-2.1*
Brief Hospital Course:
Mr [**Known lastname 9780**] is an 84 yo M with a history of cryptogenic cirrhosis
(c/b variceal bleed requiring [**Last Name (un) 10045**]/TIPS [**2171-7-9**]) and
afib/SSS (s/p dual chamber PPM) who was admitted with bilateral
upper extremity ecchymosses. He was transferred to the MICU on
[**8-4**] for management of hypotension, hypoxia, and altered mental
status
#) Septic Shock: Patient was found to be in septic shock with
pulmonary source- CXR showed new left parenchymal opacity
mid/lower lung zone. A right subclavian was placed and fluid
resuscitated by Rivers protocol. Broad spectrum coverage with
vanc, cefepime, and IV flagyl. The patient's CVP and SVO2 were
stabilized with 5 L NS. Lactate trended down from 2.9 to below
2.0. Further hemodynamic instabiltiy was addressed regarding
Afib with RVR (see below). C diff assay was negative and Flagyl
was DC'd. The patient remained altered throughout his ICU stay.
On [**8-12**] the patient was noted to have increased WBC 34->45,
rising Cr 1.1->1.9, and worsening mental status. Oral meds were
convereted to IV, dilauded was DC'd, and C diff was found to be
negative. Patient started on Linezolid in context of increased
WBC's on UA and urine Cx [**8-9**] growing VRE. White count
eventually trended down, but patient remained altered and NG
tube placed. The patient became hypothermic and required heating
blanket. Patient again became hypotensive with copious
secretions aspirated from nasotracheal suction. CXR showed
bilateral infiltrates consistent with aspiration PNA as well as
pleural effusions. The patient was restarted on vanc and
cefepime after having completed an 8 day course. O2 requirement
remained between 2-5LNC. Pressures improved with combination
albumin and 500cc NS.
#) Afib with RVR: Unclear trigger. No fevers or localizing signs
for infection. Patient does have an apical opacity of unclear
significance on CXR but no pulmonary symptoms. Blood cultures
without growth so far. Patient does have leukocytosis of unclear
significance. This also could have been triggered by bleeding as
discussed below. Finally he may have increased adrenergic state
from pain in his arm. He was successfully rate controlled with a
diltiazem drip and shortly after converted back to sinus rhythm.
His dilt gtt was stopped the morning after transfer to the ICU,
but he continued to have Afib with RVR requiring digoxin and
phenylephrine to support hypotension. He was ultimately
stabilized in the ICU with uptitrating PO diltiazem.
#) Acute Renal Failure: Pt Cr increased sharply on [**8-12**] and urine
output declined dramatically. Nephrology determined this was ATN
secondary to hypotension and given muddy brown casts, and the
patient was given albumin. Cr continued to rise.
#) Acute Blood Loss Anemia - Pt dropped 10 points between [**7-24**]
and [**8-3**]. He has been stable since receiving 2 units yesterday.
Most likely lost some blood into his arm but unlikely to have
lost 3 units into arm. Given his history GI bleed is always a
concern but he has not had any features except occult positive
stool and BUN mildly elevated from baseline (17->24). He was
transfused a 3 units pRBCs from [**Date range (1) 49941**] with an appropriate
increase in his hematocrit. All anticoagulation was held.
Ischemic EKG changes consistent with demand ischemia resolved.
Gastroenterology felt that given that he was having brown stool
it was unlikely that a GIB was the cause of his current blood
loss. In the ICU there was concern for intracranial hemorrhage
due to potential neurological deficits that were difficult to
assess given mental status and left arm hematoma. CT head was
negative. HCT's remained stable thereafter.
#) Upper extremity ecchymoses: occurred in the setting of
therapeutic enoxaparin. He had some falls at rehab but according
to his wife these occurred after he already had the bruises. He
has been evaluated by orthopedics who did not feel that the
patient had compartment syndrome. His pain was difficult to
control and the pain service was consulted... In the ICU there
was concern for compartment syndrome and ortho was consulted who
cleared him for surgical concern. A "[**Doctor Last Name **]" was heard during
movement with nursing and a LUE X-ray was negative. His swelling
stabilized and the patient was not complaining of arm pain.
#) Coagulopathy: The patient had a history of ecchymoses and
hematoma in the settin of liver failure. INR trended up above
2.0, and responded to vit K, coming back down to 1.5. The
patient was noted to have a heparin sensitivity, and SQ heparin
was stopped. The patient was switched to pneumoboots for
prophylaxis.
#) Thrombocytopenia: His platelets are newly low this
hospitalization, of unclear etiology. He has known cirrhosis but
his platelets had been in the 110-200s during his last
hospitalization. Likely he has a consumptive thrombocytopenia in
the setting of his LUE hematoma. His platelets were trended and
remained stable in the ICU.
#) Leukocytosis - patient with elevated white count, however he
has no fevers or localizing signs of infection. Patient does
have an apical opacity of unclear significance on CXR but no
pulmonary symptoms. Blood cultures without growth so far. Of
note, he had an elevated white count on recent admission between
20-40. He was treated during that admission for PNA, SBP ppx x 7
days. Heme/onc was consulted and felt it was most likely [**1-10**] to
leukemoid reaction and WBC had improved to 9 upon discharge.
This may be stress response or inflammation related to arm
injuries. Blood cultures remained negative. WBC jumped to mid
40's in the ICU, trended down after resolution of shock.
Differential was left sided without bands, but with increasing
monocytosis. HemeOnc was consulted, and flow cytometry was sent
to assess for possible lymphoproliferative disease.
#) Cryptogenic cirrhosis (s/p TIPS). Continued on lactulose
which was titrated to [**2-10**] BMs daily. Continued rifaxamin.
Trended LFTs and INR. Received vit K to decrease INR towards a
goal of 1.2. LFT's were elevated but stable in the ICU.
#) Chronic diastolic CHF: Did not appear significantly volume
overloaded on admission so furosemide was held. In the ICU, the
patient was edematous but showed signs of intravascular
depletion. Gentle fluid boluses with albumin were used to
maintain pressures.
#) GI Bleed: In the past required [**Last Name (un) **]. Maintained on PPI
this admission.
#) Hypothyroid: He was continued on his home dose of
levothyroxine.
#) The patient's wife, as health care proxy, made the patient
DNR/DNI [**2171-8-15**]. The patient became increasingly hypoxic [**2171-8-16**],
requiring increased O2 support. He eventually expired on [**2171-8-16**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Enoxaparin Sodium 90 mg SC BID
2. Diltiazem 60 mg PO QID
hold for SBP<100, HR<60
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 20 mg PO BID
hold for SBP<100
5. Lactulose 30 mL PO TID
titrate to [**2-10**] BMs per day
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Rifaximin 550 mg PO BID
9. Pantoprazole 40 mg PO Q12H
10. Atorvastatin 5 mg PO DAILY
11. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH DAILY
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
Acute renal failure
Discharge Condition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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16263, 16272
|
8872, 15607
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304, 310
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16356, 16495
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4554, 8849
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3806, 3892
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338, 2340
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2362, 3446
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,541
| 184,226
|
34511
|
Discharge summary
|
report
|
Admission Date: [**2177-2-10**] Discharge Date: [**2177-2-15**]
Date of Birth: [**2097-1-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfasalazine / Nsaids
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms [**Known lastname 30258**] is an 80yo woman with pmh significant for chronic
systolic congestive heart failure, LVEF 20%, presenting to ED
from nursing home after becoming acutely short of breath in the
morning of admission. The on-call physician at the nursing home
gave the patient lasix 80mg IV, albuterol, and morphine prior to
transfer. No foley was placed, however, upon arrival to ED the
patient's sheets were soaked with urine. In ED, patient was
tachypneic with RR in 40's and had oxygen saturation of 88% on
NRB. BNP was 26,000, CXR showed bilateral infiltrates. She was
also hypertensive with BP 160/100 and tachycardic to 120's. EKG
showed LBBB with lateral depressions. She was given
nitroglycerin and placed on Bipap. She responded with O2
saturation of 98%, respiratory rate of 16, and her blood
pressure and heart rate decreased to 110/60 and 60-70's
respectively. Her ekg changes returned to baseline. Attempts
were made to wean her form Bipap to NRB and venti mask, and were
unsuccessful secondary to O2 desaturation and tachypnea.
.
The patient has had multiple CHF exacerbations recently, which
have all been handled at [**Hospital **] rehab. Per the patient's PCP,
[**Name10 (NameIs) **] has been decompensating somewhat with diminished PO intake.
The patient had an [**Name10 (NameIs) 10718**] of shortness of breath at [**Hospital 100**]
Rehab on [**2-7**] which reoslved with lasix 90mg IV and morphine. She
was "Do Not hospitalize" status 1 week ago, however, given the
difficulty of treating her CHF exacerbations overnight without
doctors on [**Name5 (PTitle) **], it was decided to revoke the "DNH" status for
the purposes of transferring the patient to the hospital in the
event that an exacerbation would occur overnight and no MD's
were avaliable to push IV lasix.
.
Review of symptoms is answered by her son. [**Name (NI) **] has
expressive aphasia.
Also notable for absence of fever, chest pain, dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
HTN
DM type 2 insulin-dependent
PVD (s/p bypass)
CAD (s/p MI in [**9-/2175**])
h/o stroke (in [**9-/2175**] w/ residual complete R sided hemiparesis,
dysphagia, expressive aphasia)
CHF (LVEF 20-25%)
Depression
Intraductal papillary mucinous tumor found on CT [**8-6**]
Parkinson's disease
Social History:
Nursing home resident ([**Hospital 100**] Rehab). Functionally able to feed
self, is in a wheelchair and needs much assistance in moving her
wheelchair from place to place. Puree/nectar liquid diet. On/off
O2 by NC.
Contact: [**Name (NI) **] [**Name (NI) 79286**] - [**Telephone/Fax (1) 79287**].
Family History:
No family history of early MI, otherwise non-contributory.
Physical Exam:
VS: Afebrile, BP=120/60, HR=60, RR=20, O2sat=100% FiO2 50% BIPAP
GENERAL: On Bi-pap, breathing comfortably.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: crackles at bases b/l.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Neuro: aphasic, spastic
Pertinent Results:
LABS:
.
HEMATOLOGY:
[**2177-2-10**] 08:30AM BLOOD WBC-7.8 RBC-3.99* Hgb-12.0 Hct-35.3*
MCV-89 MCH-29.9 MCHC-33.8 RDW-14.8 Plt Ct-287
[**2177-2-10**] 08:30AM BLOOD Neuts-85.6* Lymphs-10.7* Monos-1.8*
Eos-1.6 Baso-0.3
[**2177-2-10**] 08:30AM BLOOD PT-13.8* PTT-38.9* INR(PT)-1.2*
[**2177-2-13**] 05:00AM BLOOD WBC-13.1*# RBC-3.75* Hgb-11.1* Hct-33.0*
MCV-88 MCH-29.6 MCHC-33.7 RDW-15.3 Plt Ct-287
[**2177-2-14**] 11:20AM BLOOD WBC-10.8 RBC-3.50* Hgb-10.4* Hct-31.1*
MCV-89 MCH-29.7 MCHC-33.4 RDW-14.8 Plt Ct-285
[**2177-2-14**] 11:20AM BLOOD Neuts-91.3* Lymphs-6.2* Monos-1.5*
Eos-0.8 Baso-0.2
.
CHEMISTRY:
[**2177-2-10**] 08:25AM BLOOD Glucose-398* UreaN-29* Creat-1.3* Na-140
K-4.8 Cl-101 HCO3-17* AnGap-27*
[**2177-2-10**] 08:30AM BLOOD Calcium-9.0 Phos-6.3*# Mg-2.1
[**2177-2-14**] 11:20AM BLOOD Glucose-345* UreaN-42* Creat-1.4* Na-141
K-3.5 Cl-96 HCO3-32 AnGap-17
.
CARDIAC:
[**2177-2-10**] 08:30AM BLOOD proBNP-[**Numeric Identifier 26477**]*
.
[**2177-2-10**] 08:25AM BLOOD cTropnT-0.03* CK(CPK)-61
[**2177-2-10**] 08:30AM BLOOD cTropnT-0.02* CK(CPK)-25*
[**2177-2-10**] 06:03PM BLOOD cTropnT-0.09* CK(CPK)-34
[**2177-2-11**] 04:02AM BLOOD cTropnT-0.08* CK(CPK)-35
.
Urine-
[**2177-2-13**] 01:31PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2177-2-13**] 01:31PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
.
CARDIOLOGY:
EKG ([**2-10**])
Sinus rhythm
Left bundle branch block
Since previous tracing of [**2177-1-18**], heart rate faster
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 124 118 392/451 42 9 -175
.
TTE ([**2177-2-11**]):
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is severely depressed (LVEF= 20-25
%) with inferior, anteroseptal and apical akinesis/severe
hypokinesis and hypokinesis elsewhere. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. The mitral valve leaflets are mildly thickened. Mild
to moderate ([**1-31**]+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2176-8-5**],
findings are similar.
.
RADIOLOGY:
.
CXR ([**2177-2-11**])
IMPRESSION: Regression of pulmonary vascular congestion during
the last one day interval. Sizable left-sided pleural effusion
persists. No evidence of pneumothorax or new localized
infiltrates. As shown earlier, there is a moderately compressed
vertebral body at level T12.
.
CXR ([**2177-2-13**])
IMPRESSION: Interval development of mild-to-moderate right
pleural effusion, and slight interval decrease in
moderate-to-severe left pleural effusion.
Urine Cx [**2177-2-13**]
- no growth
Brief Hospital Course:
In summary, Ms [**Known lastname 30258**] is an 80 year-old woman with chronic
systolic congestive heart failure, presenting with shortness of
breath.
.
# Acute on chronic systolic congestive heart failure: History
and presentation consistent with CHF exacerbation - LVEF 20%,
BNP 26,000 on admission, lung exam with crackles, CXR w left
pleural effusion/congestion. Unclear etiology of CHF
exacerbation, possibly from upper respiratory infection vs
uncontrolled hypertension (a few SBPs in 140s-150s). Dietary
indiscretion and medication non-compliance are likely not causes
given patient is presenting from [**Hospital 100**] Rehab. Cardiac ischemia
ruled out with negative biomarkers. Pt was diuresed w furosemide
80mg IV at first for a goal of -1L/24hrs, then with furosemide
with HCTZ 30 minutes prior, as pt stopped responding to
furosemide only. Total net -2L in 2 days. Pt improved
clinically. PICC line placement was deferred to [**Hospital 100**] Rehab.
Was transferred back to [**Hospital 100**] Rehab on losartan, metoprolol,
furosemide, HCTZ. She will need electrolytes checked every
other day in the future to monitor.
.
# Shortness of breath: Pt required BiPAP on admission,
transitioned to Venti mask within hours. Successfully weaned to
O2 by NC with diuresis. Distress treated with morphine PRN. Now
on 2L NC.
.
# Pneumonia: After diuresis, patient developed worsening
productive cough and fevers. CXR notable for likely right lower
lobe infiltrate. After discussion with family, decision was
made to treat with oral levofloxacin but not to aggressively
pursue blood cultures or intravenous access for antibiotics,
which had been difficult. Pt is to continue to take levofloxacin
through [**2-19**].
.
# Atrial fibrillation: Patient had a brief [**Month/Year (2) 10718**] of atrial
fibrillation with rapid ventricular rate that was controlled
with beta blocker and returned to sinus after 4 hours. The
decision was made not to anticoagulate with warfarin given that
this was likely precipitated by her acute illness and she was
already on Plavix and full-dose aspirin.
.
# CAD: History of MI in [**2175**]. Will continued aspirin, Lopressor,
and losartan.
.
# Peripheral Vascular Disease: S/p bypass. Continued aspirin.
Restarted Plavix per discussion with PCP.
.
# CVA: Patient with right-sided hemiparesis, right facial droop,
expressive aphasia. Continued aspirations and fall precautions,
as well as supportive measures.
.
# Hypertension: Lopressor and losartan were continued.
.
# Diabetes: Type 2 on insulin. Continued standing insulin in
addition to sliding scale.
.
# Parkinson's disease: Continued carbidopa levodopa TID. As per
family, pt's condition is progressively worse. She is often more
lethargic. Has been refusing meds in hospital, but eventually
took them with family.
.
# Depression: continued sertraline and bupropion.
.
# Goals of care: On admission, patient was DNR/DNI. After
discussion with her family, the decision was made to not
aggressively pursue infectious work-up for fever, but rather
empiric tx for now with levo.
Pt is to be discharge to the [**Hospital6 **].
Medications on Admission:
Aspirin 325 mg PO daily
Metoprolol Tartrate 50 mg PO BID
Furosemide 80 mg Tablet PO Daily
Losartan 50 mg PO Daily
Carbidopa-Levodopa 25-100 mg Tablet. One tablet PO daily
Sertraline 50 mg PO daily
Bupropion 100 mg Tablet Sustained Release PO QAM
Omeprazole 20 mg Capsule, Delayed Release(E.C.) PO BID
Cholecalciferol (Vitamin D3) 1000 units PO daily
Calcium Carbonate 500 mg (1,250 mg) PO daily
Bisacodyl 10 mg Tablet, Delayed Release PO BID
Senna 8.6 mg PO BID
Milk of magnesia
Insulin NPH & Regular Human 100 unit/mL (50-50) Suspension
Sig: Sixteen (16) units Subcutaneous qAM: Please continue
sliding scale coverage as directed.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
7. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
8. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: hold for loose stool.
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
12. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-31**] Sprays Nasal
TID (3 times a day) as needed for nasal congestion.
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation. ML(s)
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for fever or pain: max dose 4000mg per day.
18. Levofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q48H (every
48 hours) for 5 days: last day [**2177-2-19**].
19. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Sixteen (16) units Subcutaneous QAM: check blood sugars
before meals.
20. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous
three times a day: sliding scale,
starting at BG of 150-200, give 2 units, at 201-250 give 4
units, at 251-300 give 6 units, at 301-350 give 8 units, >400
notify MD; half the dose if NPO.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acute on chronic systolic congestive heart failure exacerbation
Pneumonia
Acute renal failure
.
coronary artery disease
hypertension
Parkinson's disease
Discharge Condition:
hemodynamically stable, satting in mid-90s on 2L O2 by NC,
chronic aphasia with right-sided hemiparesis
Discharge Instructions:
You were admitted to the hospital with shortness of breath. It
was caused by exacerbation of your chronic congestive heart
failure in the setting of a respiratory infection. You were
treated with diuretics and antibiotics and your respiration
improved.
.
We changed your medications as follows:
1. started HCTZ 12.5mg daily for diuresis 30 minutes before your
lasix
2. changed losartan 50mg to twice daily
3. changed furosemide 80mg by mouth to twice daily (the rehab
may reduce this dose if you have too much urine output)
4. continue levofloxacin 750mg every other day through [**2-19**] for
your pneumonia
.
If you have chest pain, shortness of breath, fevers, or other
concerning symptoms please seek medical attention.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
Followup Instructions:
rehabilitiation
Completed by:[**2177-2-15**]
|
[
"443.9",
"584.9",
"250.00",
"427.31",
"412",
"414.01",
"332.0",
"401.9",
"486",
"272.4",
"428.23",
"428.0",
"276.0",
"438.20",
"438.11"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13031, 13097
|
7111, 10235
|
316, 323
|
13294, 13400
|
4023, 7088
|
14296, 14343
|
3226, 3286
|
10917, 13008
|
13118, 13273
|
10261, 10894
|
13424, 14273
|
3301, 4004
|
2503, 2573
|
257, 278
|
351, 2396
|
2604, 2895
|
2418, 2483
|
2911, 3210
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,529
| 122,111
|
7625
|
Discharge summary
|
report
|
Admission Date: [**2134-4-29**] Discharge Date: [**2134-5-7**]
Date of Birth: [**2055-11-16**] Sex: F
Service: SURGERY
Allergies:
Ambien
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
right femur fracture
Major Surgical or Invasive Procedure:
right femur intramedullary nail with a cephalomedullary device
[**2134-4-29**]; MERCI clot retrieval [**4-30**]; Right femoral thrombectomy,
right femoral bovine patch profundaplasty, right external iliac
stenting, and pelvic arteriogram and right lower extremity
angiogram [**2134-4-30**]
History of Present Illness:
The patient is a 78 year old female who presented to [**Hospital1 18**] after
a mechanical fall at home while trying to open the
refridgerator. She was transferred from an outside hospital.
Denies LOC.Complains of neck pain and right hip pain
Past Medical History:
COPD
CAD s/p MI w/ PTCA to LAD and stents X 3 to mid/prox RCA
diastolic CHF
s/p dual-chamber pacemaker for tachy/brady syndrome
left carotid stenting
HTN
hyperlipidemia
GI bleed from AVM in [**2102**]
bilateral CEA [**2126**]
cholecystectomy
osteoporosis
Iron-deficiency anemia
Peptic ulcer disease
Afib
bilateral vein stripping
Social History:
[**12-23**] ppd x 20 yrs. Still smoking. Recovered alcoholic for 15 yrs.
No IVDU. Lives with husband in [**Name (NI) 27807**]. No baseline SOB,
DOE. Fully independent on all ADLS although does have a VNA 2X
per week.
Family History:
father and twin sister - died of sudden death in 40's with MI
Physical Exam:
VS- T 98.1, P 60, BP 132/72, RR 18, O2 100% RA
Gen- NAD
HEENT- PERRL, EOMI
Heart- RRR
Lungs- CTA b/l
Abdomen- soft, NT/ND
Neuro- AxOx3
Pertinent Results:
[**2134-5-6**] 03:15AM BLOOD WBC-11.4* RBC-2.75* Hgb-8.1* Hct-24.9*
MCV-90 MCH-29.4 MCHC-32.6 RDW-18.3* Plt Ct-285
[**2134-4-30**] 01:55AM BLOOD WBC-12.8* RBC-3.51* Hgb-10.3* Hct-30.7*
MCV-88 MCH-29.5 MCHC-33.7 RDW-16.1* Plt Ct-216
[**2134-5-6**] 03:15AM BLOOD PT-12.4 PTT-69.6* INR(PT)-1.0
[**2134-5-6**] 09:20AM BLOOD PTT-68.2*
[**2134-5-6**] 03:15AM BLOOD Glucose-142* UreaN-21* Creat-0.4 Na-141
K-3.5 Cl-104 HCO3-29 AnGap-12
Brief Hospital Course:
The patient was admitted on 5/708 s/p mechanical fall at home.
A CT of the C-spine and head were negative. Right lower
extremity X-rays revealed a markedly comminuted and impacted
right subtrochanteric femur fracture, with extension into right
lesser trochanter, large butterfly fragments, and varus
angulation. She was admitted to the trauma service. A medicine
consult was called for pre-operative evaluation since she has
multiple medical issues. Conservative medica therapy was
recommended. On HD 2, she was taken to the OR with orthopedics
for her RLE. Please see operative note for details.
Post-operatively, she was found to be dysarthric, confused, and
unable to move the left side of her body. An emergent stroke
consult was called. A CT of the head showed contrast
enhancement of right basal ganglia and posterior frontal infarct
versus hemorrhagic conversion. She was unable to have an MRI
because she has a pacemaker. She was taken emergently to
neuroradiology for emergent stenting of her right internal
carotid artery and mechanical and chemical thrombolysis of her
distal ICA and right middle cerebral artery. Please see
operative note for full details. The right common carotid
artery was found to be occluded. She was dianosed with a right
MCA stroke. The mechanism was thought to be cardioembolic or
carotid thromboembolism. The sheath was left in her right
groin. Later that night, her RLE became pulseless and ischemic.
She was taken emergently to the OR for a right femoral
thrombectomy, right femoral bovine
patch profundaplasty, right external iliac stenting, and pelvic
arteriogram and right lower extremity angiogram. Please see
operative note for full details. She was then transferred back
to the ICU. Her RLE regained a pulse and looked good. She did
not recover neurologically. She had minimal movement of her
extremities and was minimally responsive. Her SBP was kept <
180, she was started on aspirin and plavix. Repeat head CT
scans showed an evolving right MCA infarct. Tube feeds were
started via an NG tube. She was on peri-operative ancef. She
was started on a heparin drip. An echo did not reveal any
intracardiac thrombus. On [**5-3**], she was extubated. She did
require suctioning as she was unable to control her secretions.
On [**5-5**] she was transferred to step down. A family meeting was
held on [**5-6**] with her son, the health care proxy. At that time,
we were made aware of her living will, which clearly stated that
she would want to be made [**Month/Year (2) 3225**] in this difficult situation.
Therefore, she was made [**Month/Year (2) 3225**]. Palliative care was consulted.
Ethics was consulted because the patient does have a daughter
who may not want her to be [**Name (NI) 3225**]. She was screened for a skilled
nursing facility witrh end of life care.
Medications on Admission:
cardizem 120', plavix 75', lasix 40', lisinopril 5', zocor 20',
toprol 100', synthroid 25', albuterol, spiriva, tums, prilosec,
nitropaste, prozac 10', MSO4 prn
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: [**12-23**] PO Q2H
(every 2 hours) as needed.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for distress.
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed for fever.
4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
5. Hyoscyamine 0.15 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
Lifecare of [**Hospital3 **]
Discharge Diagnosis:
right femur fracture, right MCA stroke, ischemic right leg
Discharge Condition:
[**Hospital3 3225**]
Discharge Instructions:
This patient is comfort measures only.
Followup Instructions:
none
Completed by:[**2134-5-7**]
|
[
"428.0",
"733.00",
"401.9",
"V66.7",
"E885.9",
"820.20",
"427.31",
"496",
"272.4",
"V45.82",
"428.30",
"997.2",
"414.01",
"444.22",
"433.11",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.63",
"38.93",
"96.71",
"39.79",
"88.49",
"88.41",
"00.61",
"99.10",
"00.45",
"96.6",
"00.40",
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
5699, 5754
|
2143, 4991
|
287, 579
|
5857, 5880
|
1690, 2120
|
5967, 6002
|
1456, 1520
|
5202, 5676
|
5775, 5836
|
5017, 5179
|
5904, 5944
|
1535, 1671
|
227, 249
|
607, 852
|
874, 1204
|
1220, 1440
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,855
| 175,199
|
27475
|
Discharge summary
|
report
|
Admission Date: [**2194-8-5**] Discharge Date: [**2194-8-14**]
Date of Birth: [**2128-8-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Tracheobronchomalacia with severe COPD admit for increasing
shortness of breath, possible Y-stent placement.
Major Surgical or Invasive Procedure:
[**2194-8-9**] Bronchoscopy, with therapeutic aspiration.
[**2194-8-7**] Rigid bronchoscopy, Y stent placement.
[**2194-7-30**] Flexible bronchoscopy
History of Present Illness:
The patient is a 65-year-old woman with multiple medical
problems including COPD on home O2 and tracheobronchomalacia who
presents today for progressive dyspnea over the last year. The
patient was evaluated in [**2193-5-24**] by
Dr. [**Last Name (STitle) **] and had bronchoscopy, which demonstrated significant
tracheobronchomalacia. She underwent Y-stent placement in [**Month (only) **]
[**2192**]. The stent was in place for approximately two weeks before
it was removed due to increased coughing and mucous production.
The patient could not tolerate the stent. The patient followed
up on [**2194-8-5**] for reevaluation given that her shortness of
breath has increased from baseline, her mobility is fairly
significantly limited now.
Her previous use of home O2 has now increased to 24 hours a day,
3 liters nasal cannula. She uses CPAP at night. She is referred
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for evaluation for possible re-stenting versus
other surgical procedures.
Past Medical History:
CAD, s/p CABG, with LAD and LCx stenting
CHF, diastolic dysfunction
Chronic reactive airway disease, no prior h/o emergent
intubation
Chronic renal insufficiency (baseline Cr low-1s): erythropoietin
deficiency
AFib
GERD
Gout
Obstructive sleep apnea
HTN
Hyperlipidemia
Hypothyroidism
Depression
Obesity
Discoid lupus (inactive)
s/p MVR with St. Jude valve ([**2188**]), on coumadin
s/p L parietal CVA ([**2186**]), no residual neurologic deficits
h/o bladder CA
h/o colonic polyps
h/o diverticulosis
s/p cholecystectomy, t&a, tubal ligation, C-section, vocal cord
polyp excision
Social History:
15 yr hx tobacco, 1pk every 3d, quit [**2186**]
Occasional EtOH
Disability
Lives alone, just moved to new home without stairs
Divorced, one daughter
[**Name (NI) **] IVDU
Family History:
Cardiomyopathy
AFib
Valvular heart disease
Older sister - RA
[**Name (NI) **] sister - COPD ([**Name2 (NI) 1818**]), GERD
Physical Exam:
general: Obese white female in NAD wearing 4 liters of oxygen
continuously
HEENT: unremarkable
Cor: RRR S1, S2 w/ mech mitral valve
Chest: Course breath sounds that clear w/ coughing. occas
wheezes.
Abd: large, round, soft, NT, +BS
Extrem: no edema
Neuro: intact
Pertinent Results:
Video swallow [**2194-8-12**]:
Pt appears safe from oropharyngeal standpoint for return to a PO
diet of regular solids and thin liquids. She does not require
chin tuck maneuver at this time. She tolerates whole pills with
thin liquids. Pt may wish to have assistance with set up for
meals/cutting meats, etc, but does not require 1:1 supervision
with meals for swallow safety. Maintain standard aspiration
precautions. Please reconsult if there are further concerns for
aspiration or other oropharyngeal dysphagia.
This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 6, WFL.
RECOMMENDATIONS:
1. PO diet: regular solids, thin liquids
2. PO meds whole with thin liquids
3. Assist with meal set up as needed. Pt may require assistance
with cutting foods, etc. Does not require 1:1 supervision with
meals.
4. Maintain standard aspiration precautions.
5. Consider further w/u of coughing during meals not associated
with aspiration and/or c/o GERD to level of pharynx during
today's evaluation. In addition, pt has c/o food getting
"stuck"
at the level of the sternum, even prior to admit.
6. Reconsult if there are further concerns for aspiration or
other oropharyngeal dysphagia.
CXR [**2194-8-11**]:
REASON FOR EXAMINATION: Followup of a patient with known
tracheobronchomalacia and right lower lung pneumonia.
Portable AP chest radiograph was compared to [**2194-8-10**].
The cardiomegaly with bulging of the pulmonary trunk is stable.
There is no
change in the position of the mitral valve. There is no
appreciable change in
the right lower lobe and left perihilar opacities as well. There
is no
increase in pleural effusion. There is no pneumothorax.
ECHO: [**2194-8-12**]
Conclusions
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. A bileaflet mitral valve prosthesis is present. The
mitral prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. The transmitral gradient is
normal for this prosthesis. Mild (1+) 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 no
pericardial effusion.
IMPRESSION: Symmetric LVH with normal global systolic function.
A focal wall motion abnormality cannot be excluded. Mitral valve
prosthesis with at least mild mitral regurgitation and normal
gradients.
Compared with the prior study (images reviewed) of [**2192-3-28**], the
findings are similar. The pulmonary artery systolic pressures
were not estimated on the prior study.
Brief Hospital Course:
The patient was admitted on [**8-5**] to the Interventional
Pulmonology service for treatment of her increasing shortness of
breath due to COPD and evaluation for possible placement of a
Y-stent for tracheobroncialmalacia. On [**8-7**], she had a Y-stent
placed by Dr. [**Last Name (STitle) **] and therapeutic aspiration.
She experienced acute exacerbation of her COPD after placement
of her Y-stent and was admitted to the ICU.
Steroids started, on a 14 day taper down to baseline of 5mg PO
daily.
Admitted to floor from ICU for ongoing pulmonary care.
Pt w/ repeated episode of diarrhea- C-diff toxin neg. Bowel
regimen tapered.
BAL grew out MRSA that was sensitive to Bactrim. Vancomycin
d/c'd.
Will complete a 2 week course of Bacrtim on [**2194-8-23**].
Pt's coumadin was resumed at lower dose than home regimen as she
is on bactrim which will elevate her INR.
[**8-9**] therapeutic bronchoscopy; mid-trachea proximal end of
silicone Y-stent minimal granulation tissue, extensive amount of
mucus secretions in Y-stent successfully
suctioned through the bronchoscope, distal end of the stent
bilaterally with minimal amount of granulation tissue.
[**8-12**] passed video swallow: [**Last Name (un) 1815**] reg diet w/ thin liquids and
meds whole w/o difficulty.
Pt had loose stool x 3days and C-diff toxin A+B were negative
x3. Pt was placed on lactose free diet and imodium.
The patient is on maximal medical therapy for COPD with
inhalers as well as prednisone. Recommendation would be to
continue her medications as prescribed at this time. She remians
on CPAP at night for sleep apnea
Medications on Admission:
aspirin 81', Bumex 4qam, 3qpm, L-thyroxine 0.05', Prilosec
20'', KCl 40'', Lexapro 20', Effexor 150', allopurinol 100'',
Lipitor 80', clonidine 0.1'', Singulair 10', Spiriva, verapamil
SR 240', Coumadin 5 mg/5 mg/7.5 mg alternating, Colace''',
prednisone 5 mg daily)albuterol nebulizer b.i.d., iron 325',
Advair 500/50'', colchicine 0.6'', Klonopin 0.5'', fiber
laxative, Flexeril prn
- bipap, she believes the settings are 17/10.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. Benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
5. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO 8PM ().
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO QAM (once a day (in the
morning)).
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 2.5/3 mg/ml Inhalation Q4H (every 4 hours) as
needed for wheezes.
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
17. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
20. Bumetanide 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
21. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
22. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten
(10) ML PO BID (2 times a day).
23. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Five (5) ML
Miscellaneous TID (3 times a day).
24. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: Ten (10) ML PO
QHS (once a day (at bedtime)).
25. Ipratropium Bromide 0.02 % Solution Sig: Three (3) ML
Inhalation Q6H (every 6 hours) as needed.
26. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-25**]
Puffs Inhalation Q6H (every 6 hours) as needed.
27. coumadin
coumadin dose daily based on INR- Last INR 3.4 on [**2194-8-14**]
Given 1 mg today [**2194-8-14**]
Goal 2.5-3.5
Home coumadin dose 5mg alter w/ 7.5mg
28. prednisone
prednisone 50mg starting [**2194-8-14**] then decrease by 10mg every 2
days until at maintenance dose of 5mg.
29. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO qid prn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital [**Hospital1 189**]
Discharge Diagnosis:
Tracheobronchomalacia with severe chronic obstructive pulmonary
disease.
Atrial fibrillation,
CAD s/p CABG and stent
CHF (diastolic dysfunction), reactive airway disease
CRI (~1.2), pulm nodules, L parietal CVA '[**86**], h/o bladder ca,
diverticulosis, GERD, gout, OSA, HTN, hypercholesterol,
hypothyroid, depression, obesity, ? discoid lupus
PSH: MVR (mechanical valve [**2188**]), CABG, appendectomy,
cholecystecomy, BL tubal ligation, c-sxn, vocal cord polyp
excision
Discharge Condition:
Decondition
Discharge Instructions:
Call Dr.[**Name (NI) 14680**] office [**Telephone/Fax (1) 10084**] if experience:
-Fever, increased shortness of breath, cough, increased sputum
production, difficulty swallowing, or nausea/vomiting.
Prednisone taper 50 mg x 3 days (day one [**2194-8-14**]), 40 mg x 3
days, 30 mg x 3 days, 20 mg x 3 days, 10 mg x 3 days then 5 mg
daily.
Check INR daily until stable therapeutic.
Follow INR daily until INR stabilized between 2.5-3.5
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] as directed
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 42167**] [**Telephone/Fax (1) 54195**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2194-8-18**]
|
[
"V10.51",
"V43.3",
"311",
"428.0",
"274.9",
"585.9",
"V58.61",
"244.9",
"427.31",
"482.41",
"428.30",
"999.9",
"519.19",
"403.90",
"787.91",
"327.23",
"E879.8",
"518.83",
"491.21",
"V09.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"93.90",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
10744, 10816
|
5897, 7505
|
379, 531
|
11332, 11346
|
2808, 5874
|
11829, 12126
|
2387, 2510
|
7988, 10721
|
10837, 11311
|
7532, 7965
|
11370, 11806
|
2525, 2789
|
231, 341
|
559, 1581
|
1603, 2182
|
2198, 2371
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,894
| 152,530
|
43316
|
Discharge summary
|
report
|
Admission Date: [**2103-1-4**] Discharge Date: [**2103-1-23**]
Date of Birth: [**2046-6-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization.
Cornary artery bypass graft x 3.
History of Present Illness:
56 yo M with history of CAD s/p cath [**2096**] showing 3VD undergoing
medical managment, CHF with EF 20%, DM, and severe PVD presents
with intermittent chest pressure/tightness. The patient was in
USOH until the morning of admission when he suffered chest
tightness, progressive in freuqency over the day. The episode
that morning lasted five minutes, then resolved with nitro. The
next several episodes were also releived with nitro. He pain was
localized to the left size of his chest. He denies associated
SOB, LHD/dizziness, N/V, diaphoresis, palpitations.
Pt presented to the ER and was pain-free. In the ED, he was
afebrile, BP 163/86 HR 82, 99% RA. He was started on heparin gtt
and nitro gtt and given Lopressor 5mg IV and 25mg po as well as
aspirin.
Cardiac cath [**1-5**] showing 3VD and referred for coronary artery
bypass grafting.
Past Medical History:
1. CAD s/p cardiac catheterization [**2096**] which demonstrated
severe 3V CAD, apical akinesis and 3+ MR -- treated medically.
2. CHF: Echo ([**8-21**]) EF 20%, mild LAD, severely dilated LV,
severe global LV hypokinesis, left ventricular systolic function
is severely depressed, 1+ MR
3. Diabetes Mellitus type I, has had for over 40 years, on
insulin pump.
4. Status post kidney transplant in [**2082**]
5. Severe PVD, s/p left BKA in [**2083**] and right BKA in [**2091**]
6. Status post left cataract removal in [**2093**], and now has a
significant right cataract
Social History:
Lives with wife. Denies tobacco. Occ alcohol. On disability.
Prior banker. Lives at [**Hospital3 28354**] in [**Location (un) **] with wife, no
children. Has LE prosthesis.
Family History:
M- DM2, alive age 84
F- died 72 from lung cancer
3 brother alive and healthy
Physical Exam:
Temp 98; BP 157/79; Pulse 65; Resp 18; O2 sat 100% RA
Gen - Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes
moist
Neck - JVP 9cm, no cervical lymphadenopathy, no bruits
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, distant HS
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds, LLQ kidney palapble with scar C/D/I
Back - No costovertebral angle tendernes
Extr - bilateral stums, right side dressed with ACE banadage, no
edema
Neuro - non focal
Skin - No rash
Pertinent Results:
[**2103-1-22**] 05:18AM BLOOD WBC-10.9 RBC-2.54* Hgb-8.1* Hct-25.1*
MCV-99* MCH-31.7 MCHC-32.1 RDW-15.3 Plt Ct-505*
[**2103-1-5**] 05:44PM BLOOD Neuts-83.3* Lymphs-12.8* Monos-3.1
Eos-0.4 Baso-0.4
[**2103-1-22**] 05:18AM BLOOD Plt Ct-505*
[**2103-1-22**] 05:18AM BLOOD Glucose-91 UreaN-21* Creat-1.1 Na-139
K-4.2 Cl-103 HCO3-30* AnGap-10
[**2103-1-12**] 02:58AM BLOOD ALT-13 AST-19 AlkPhos-28* Amylase-12
TotBili-0.3
[**2103-1-22**] 05:18AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.8
[**2103-1-5**] 05:44PM BLOOD %HbA1c-6.3*
Brief Hospital Course:
Mr. [**Known lastname 57100**] is a 56 yo M with history of CAD s/p cath [**2096**] showing
3VD undergoing medical managment, CHF with EF 20%, DM, and
severe PVD. He presented this admission with intermittent chest
pressure/tightness. The patient was in USOH until the morning of
admission when he suffered chest tightness, progressive in
freuqency over the day. The episode that morning lasted five
minutes, then resolved with nitro. The next several episodes
were also releived with nitro. He pain was localized to the left
size of his chest. He denies associated SOB, LHD/dizziness, N/V,
diaphoresis, palpitations.
Cardiac cath [**1-5**] showing 60% pLAD, 90% mLAD, subtotal occlusion
of D1 and D2, 60% D3, 70% OM4, 60% OM2, small OM1 and OM2, 80%
RCA.
He was referred for coronary artey bypass grafting at this time.
Pre-op workup included carotid us (no evidence of stenosis in
eother carotid artery), LE vein studies, repeat echo (EF
20-25%), renal consult and ID consult.It was decide that patient
was safe to preceed to the OR.
He underwent a coronary artey bypass graft x 3 with LIMA to the
LAD, SVG to the RPL, and SVG to the PDA on [**2103-1-9**] with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]. Please see OR report for full details.
He was initially slow to [**Doctor Last Name **] from ventilator but was
successfully weened and extubated on the morning of post-op day
one. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**] consult was also obtained on that day for optimal
glucose management.
One POD 2, he remained hemodynamically stable. And underwent
initial evaluation by physical therpay.
POD 3 was significant for sternal drainage and strict sternal
precations were initiated as well as IV vancomycin.
On POD day 4 he was transferred to the floor for ongoing
recovery and rehabilitation.
The next several days were uneventful with ongoing physical
therapy and monitoring of sternal wound with administration of
intravenous vancomycin. He also continued to be closely
followed by the [**Last Name (un) **] team and was restarted on his insulin
pump on POD 7.
Mr. [**Known lastname 57100**] had an open wound on his right BKA stump for which
vascular was following him and on POD 11 ([**2103-1-19**]) it was decided
that he resume use of prosthesis on that side, allowing for
significantly increased ability to ambulate and participate in
physical therapy.
His last documented sternal drainage was [**2103-1-19**]. He was
continued in vancomycin for the full 14 day course and it was
discontined on [**1-23**]. It was felt that Mr. [**Known lastname 57100**] would be safe
for discharge to rehabilitation at this time but there was some
difficulty finding a rehabilitation facility that would
accomodate him.
On POD 14, following discontinuation of vancomycin and increase
in activity with bilateral prostheses in place, Mr. [**Known lastname 57100**] is
awaiting a rehabilitation bed.
Medications on Admission:
Lipitor 10 mg daily, Digoxin 0.125 mg daily, Lopressor 25mg [**Hospital1 **],
Lasix 20 mg daily, Fosamax 70 mg qweek, Prednisone 5 mg daily,
Azothioprine 50mg daily, Aspirin 325 mg daily, Lisinopril 20 mg
a day, and Insulin via pump
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 2
weeks.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 3 months.
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
10. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2716**] [**Last Name (un) **] - [**Location (un) 55**]
Discharge Diagnosis:
1. CAD, s/p Coronary artery bypass graft x 3.
2. CHF EF 20%/post-op EF 40%.
3. Diabetes Mellitus type I
4. Status post kidney transplant in [**2082**]
5. Severe PVD, s/p left BKA in [**2083**] and right BKA in [**2091**]
Discharge Condition:
Good
Discharge Instructions:
Shower daily and wash incisionw with soap and water -- rinse
well. Do NOT apply any creams, lotions, powders, or ointments.
No swimming or bathing in a tub.
No driving for 6 weeks.
No lifting greater than 5 pounds.
Strict sternal precautions -- limited use of upper extremities.
Followup Instructions:
Schedule appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] ([**Telephone/Fax (1) 285**])
following discharge from rehab.
Schedule appointment with Dr. [**Last Name (STitle) 70**] in 4 weeks.
Schedule appointment with Dr. [**Last Name (STitle) 16004**] in [**12-22**] weeks.
Completed by:[**2103-1-23**]
|
[
"V49.75",
"428.0",
"414.01",
"411.1",
"V42.0",
"250.01",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"88.56",
"38.93",
"99.04",
"39.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7663, 7761
|
3219, 6180
|
289, 349
|
8026, 8032
|
2679, 3196
|
8360, 8705
|
2023, 2101
|
6463, 7640
|
7782, 8005
|
6206, 6440
|
8056, 8337
|
2116, 2660
|
239, 251
|
377, 1224
|
1246, 1817
|
1833, 2007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,949
| 157,615
|
43916
|
Discharge summary
|
report
|
Admission Date: [**2162-11-7**] Discharge Date: [**2162-11-10**]
Date of Birth: [**2115-5-2**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Diabetic ketoacidosis
Major Surgical or Invasive Procedure:
Central venous catheterization
History of Present Illness:
Ms. [**Known lastname **] is a 47F with history of DM2 on lantus and metformin
who p/w one day history of nausea, vomiting, abdominal pain,
fevers, and hyperventilation. Patient was in her usual state of
health until yesterday, when she developed significant nausea
and non-bloody, non-bilious emesis. Felt her symptoms may be
secondary to food poisoning, though denies any new/unusual foods
and has not had any sick contacts. Initially went to [**Hospital 7302**], but eloped from the ED before a full
work-up was complete. Per [**Hospital3 5097**] ED attending Dr. [**First Name (STitle) **],
patient had FSBS in 400s prior to arrival, was started on IVF,
had PIV placed, and labs were drawn. Patient became upset about
the time it was taking to be seen, and she left before her labs
had come back. Per report, CBC notable for leukocytosis with
left shift, but lab did not process chem7. Patient states she
went home but became febrile to 102, with increasing shortness
of breath. Was urged by her father to seek further medical
attention, and presented to [**Hospital1 18**] ED for evaluation of
hyperventilation.
.
In the ED, initial VS were 96.9 116 134/88 40 100%. Labs
notable for critically high FSBS, with blood glucose level 542,
K 7.3, Na 130 (corrected 138), bicarb <5, and WBC 29.5 with
92.1% neutrophils. UA showed mod blood, glucose 1000, ketones
150, protein 30, but was not suggestive of UTI. CXR did not
suggest PNA. ECG not concerning for ischemia. Patient had
blood cultures drawn, and was started on empiric antibiotics
with vanc/zosyn. She received sodium bicarb, 4L NS, and was
started on insulin gtt at 8 units/hr that has since been
increased to 10 units/hr. Repeat electrolytes showed glucose
603, K 6.9, bicarb <5. Vitals prior to transfer 104 41 118/57
100% RA.
.
On arrival to the MICU, patient still tachypneic to 30s, though
states that overall she feels better and feels her breathing has
improved. N/V and abdominal pain have resolved. Denies CP or
cough.
.
Of note, patient reports she had a recent episode of
hypoglycemia in which she fell and fractured her left arm. Her
lantus dose was then decreased from 60 units daily to 30 units
daily (15 units [**Hospital1 **]) about one week ago, and her metformin dose
was decreased from 1000mg [**Hospital1 **] to 500mg [**Hospital1 **]. Patient states she
has been compliant with these medications. Also of note, she
had a prior admission to [**Hospital1 18**] in [**2154**] at which time she
presented with general malaise, polyuria, polydipsia, and blood
glucose 540. Was diagnosed with new onset DM and DKA, and
discharged on metformin and glyburide.
Past Medical History:
Diabetes mellitus type 2
Fibromyalgia
h/o left arm crush injury s/p MVC one year ago
s/p recent L arm fracture s/p fall [**3-17**] hypoglycemia
Hypothyroidism (per history, pt not on levothyroxine currently)
Asthma
Social History:
Lives alone. Denies tobacco, EtOH, illicits.
Family History:
Father has DM, heart disease.
Physical Exam:
Vitals: T: 96, BP: 118/78 P: 111 R: 20s-30s 18 O2: 100% 2L NC
General: awake, alert, oriented to person and place, thought it
was [**2161-11-13**] but knew correct day of week, in moderate
respiratory distress
HEENT: sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, L IJ and R EJ in place
CV: tachycardic but regular, no r/m/g
Lungs: tachypneic to 30s, clear to auscultation bilaterally with
no wheezing/crackles/rhonchi
Abdomen: bowel sounds present, soft, NT, ND, no organomegaly, no
guarding or rebound tenderness, no CVA tenderness
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
Skin: slight mottling of left arm and patchy areas of the legs,
no rashes, no areas of skin breakdown or e/o cellulitis in the
feet.
Pertinent Results:
Admission labs:
[**2162-11-7**] 05:35AM BLOOD WBC-29.5*# RBC-4.61 Hgb-13.2 Hct-42.0
MCV-91 MCH-28.6 MCHC-31.4 RDW-12.4 Plt Ct-464*
[**2162-11-7**] 05:35AM BLOOD PT-12.9 PTT-26.6 INR(PT)-1.1
[**2162-11-7**] 03:00AM BLOOD Glucose-542* UreaN-26* Creat-0.6 Na-130*
K-7.3* Cl-101 HCO3-LESS THAN
[**2162-11-7**] 08:50AM BLOOD Lipase-101*
[**2162-11-7**] 08:50AM BLOOD ALT-14 AST-13 AlkPhos-64 Amylase-76
TotBili-0.2
[**2162-11-7**] 08:50AM BLOOD Calcium-6.8* Phos-3.3 Mg-1.9
[**2162-11-7**] 05:42AM BLOOD Type-MIX pO2-90 pCO2-12* pH-6.96*
calTCO2-3* Base XS--29 Intubat-NOT INTUBA Comment-GREEN TOP
[**2162-11-7**] 05:42AM BLOOD Glucose-GREATER TH Lactate-1.9 K-6.4*
Discharge labs:
[**2162-11-10**] 07:20AM BLOOD WBC-7.1 RBC-3.59* Hgb-10.2* Hct-29.9*
MCV-83 MCH-28.4 MCHC-34.1 RDW-13.6 Plt Ct-209
[**2162-11-8**] 03:51AM BLOOD Neuts-81.7* Lymphs-14.4* Monos-3.1
Eos-0.7 Baso-0.2
[**2162-11-10**] 07:20AM BLOOD Plt Ct-209
[**2162-11-10**] 07:20AM BLOOD Glucose-354* UreaN-7 Creat-0.7 Na-136
K-3.7 Cl-101 HCO3-26 AnGap-13
[**2162-11-10**] 07:20AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9
[**2162-11-9**] 06:28AM BLOOD calTIBC-209* Ferritn-54 TRF-161*
Urine Culture - no growth
Blood Culture - pending at time of discharge (no growth to date)
Imaging:
CXR - The lungs are clear. There is no focal consolidation or
pneumothorax. There is no vascular congestion, overt pulmonary
edema, or pleural effusions. The cardiomediastinal and hilar
contours are within normal limits.
IMPRESSION:
No acute cardiopulmonary procss.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
47yo female with DM2 who presents now with DKA in the setting of
recently decreased lantus and metformin doses.
.
# DKA: Pt has type 1 DM [**First Name8 (NamePattern2) **] [**Last Name (un) **] consulting service, not DM2.
She meet criteria for DKA given serum glucose >250 mg/dl,
acidemia, serum bicarbonate <18 mEq/l, and moderate ketonuria.
Trigger for DKA may be medication related, as patient reports
that while she has been compliant with her diabetes medications,
her insulin regimen and metformin doses were recently halfed.
Some concern as well for an infectious trigger, given patient's
history of fever and leukocytosis, though leukocytosis may be
elevated in setting of acute stress. N/V and abdominal pain
prior to admission may have been secondary to viral
gastroenteritis or other acute abdominal process, though may
also have been secondary to underlying DKA. No symptoms or
lab/imaging evidence to suggest UTI, PNA, hepatitis,
cholecytitis, or myocardial ischemia as etiology of DKA.
Patient with anion gap of ~24 on admission, with repeat labs
demonstrating increase in gap to ~30. She also developed a
non-gap acidosis, possibly secondary to ongoing sodium chloride
administration in ED. VBG was concerning for profound acidemia,
with pH of only 6.96. Patient's tachypnea was likely related to
respiratory compensation for profound acidemia.
.
The patient was started on intravenous insulin drip, with serial
monitoring of her blood glucose level and her electrolytes.
Throughout the day the patient's anion gap closed, eventually
becoming none. Once the patient's blood sugar was less than 200,
the patient was switched to D5 half-normal saline with
potassium. In consultation with the [**Hospital6 30927**], the
patient remained on insulin drip, with the D5 half-normal
saline, to insure resolution of the ketosis. The patient's a
eletrolytes were were repeated intermittently, and by nighttime
of her admission the patient was able to tolerate food.
.
For workup of the inciting incident of DKA, repeat physical exam
was performed after her anion gap closed. On reevaluation, the
patient had no fever, no cough, no runny nose, no abdominal
pain, no dysuria, notable for frequency. No vaginal discharge,
no pain in the joints. The patient denied any recent chest pain
or shortness of breath. Laboratory workup for source of
infection were generally not conclusive. The patient was noted
to have a leukocytosis, but this subsequently resolved, over
time. Regardless, the patient was cultured to try to identify a
source of infection. None was found during her medical intensive
care unit stay. We entertained the ideas of pneumonia,
cholecystitis, hepatitis, gastroenteritis, appendicitis, pelvic
inflammatory disease, diverticulitis, abdominal abscess, cardiac
ischemia, and pregnancy.
.
Upon transfer to the floor, the patient was without complaints,
afebrile and with stable vital signs. Her exam was grossly
benign. Her electrolytes were monitored regularly until her gap
was fully closed and she did not require electrolyte repletion.
Her leukocytosis resolved. Her urine culture was negative and
her blood cultures were pending at the time of dischrage. She
had one hypoglycemic episode on the day of transfer with a BS of
41 that responded to cranberry juice. This was thought to be due
to a small dinner. [**Last Name (un) **] Diabetes Center continued to follow
and changed her lantus dose to 28 units at noon with a humalog
sliding scale. Her metformin has been permanently discontinued.
She had no hypoglycemic episodes on her final two days and has
follow-up arranged with [**Last Name (un) **] Diabetes Center in early
Novemeber.
.
# [**Last Name (un) **]: Likely secondary to volume depletion in setting of DKA,
and improving with IVF. Throughout her medical intensive care
unit stay, her creatinine level improved. Ultimately decided
this was likely acute kidney injury, related to prerenal
etiology, from dehydration secondary to diabetic ketoacidosis.
Her values normalized with IV fluid rehydration.
.
# Anemia: Her hematocrit dropped from 42.0 to 28.3 in the first
12 hours of her stay. This is likely dilutional and due to the
large volume of fluids she received as her platelets also
decreased in this time period. Her iron studies revealed a
slightly low TIBC (209) and transferrin (161) but normal Fe and
ferritin which is not suggestive of iron-defficiency anemia and
may be consistent with anemia of chronic disease. Her
reticulocyte was 1.6.
.
#. Fibromyalgia: Continue amitriptyline; no active issues on
this admission.
.
# HL: Continue simvastatin; no active issues on this admission.
Patient was discharged home (will stay with parents) with
follow-up as specified below.
Medications on Admission:
Lantus 15 units [**Hospital1 **] (recently decreased from 60 units daily)
Metformin 500mg [**Hospital1 **] (recently decreased from 1000mg [**Hospital1 **])
Simvastatin 20 mg daily
Amitriptyline 25 mg daily
ASA 81mg daily
Discharge Medications:
1. Blood Glucose Test Strip Sig: One (1) strip Miscellaneous
Qhs/ac (at bed and with meals).
Disp:*250 strips* Refills:*2*
2. Lancets, Super Thin Misc Sig: One (1) lancet
Miscellaneous Qhs/ac (at bed and with meals).
Disp:*250 lancets* Refills:*2*
3. Humalog 100 unit/mL Solution Sig: 2-17 units Subcutaneous As
Directed: According to your sliding scale.
Disp:*QS QS* Refills:*2*
4. Lantus
Please administer 28 units at lunch time
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
7. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for anxiety.
9. Glucagon Emergency 1 mg Kit Sig: One (1) kit Injection ONCE
as needed for hypoglycemia: Please have this available and alert
others to where it is if you are found to be profoundly
hypoglycemic.
Disp:*1 Kit* Refills:*0*
10. Ocuvite Tablet Sig: One (1) Tablet PO twice a day.
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
12. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis, Type I diabetes (previously thought to be
type II)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **]
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted after having nausea, vomitting, fever, and abdominal
pain. You were diagnosed with diabetic ketoacidosis (DKA) and
treated for your high blood glucose and other electrolyte
abnormalities. In the emergency department, you were noted to
have an elevated WBC to 29, a potassium of 7.2, an undetectable
bicarb, and blood sugars in the 500s. You were started on an
insulin drip to better control your sugars and you were given
antibiotics in case you had an infection. You were subsequently
transferred to the ICU where the insulin drip was continued and
your electrolytes were agressively monitored. You were not
thought to have an infection and your antibiotics were
discontinued. While in the ICU your blood sugars returned to
[**Location 213**] levels, your electrolytes began to normalize, and your
WBC started to trend towards normal levels. Your fever resolved.
The [**Last Name (un) **] diabetes center was consulted to assist with you
care. Based on previous lab results and your clinical course, it
was thought that your diabetes is actually type I and not type
II. Your metformin was permanently discontinued.
You were transferred to the medical floor where we continued to
monitor your blood sugars, electrolytes, and WBC. Your
condition continued to improve, you remained without fever and
your electrolytes normalized. Your insulin regimen has been
adjusted as below.
We have made the following changes to your medications:
STOP- Metformin
START- Humalog according to the sliding scale
INCREASE - Lantus to 28 units at lunch time
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] on Friday, [**11-12**] at 10:00 am at South [**Location (un) 538**].
Please follow up with [**Last Name (un) **] Diabetes Center on [**Month (only) **] 3d at 12:00
for registration and an eye appointment and with Dr.[**Name (NI) **] at
1:00p.
Completed by:[**2162-11-11**]
|
[
"V15.51",
"300.00",
"285.9",
"250.13",
"729.1",
"V15.88",
"493.90",
"584.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11994, 12000
|
5790, 10524
|
326, 358
|
12118, 12118
|
4190, 4190
|
13958, 14325
|
3362, 3394
|
10796, 11971
|
12021, 12097
|
10550, 10773
|
12269, 13798
|
4870, 5767
|
3409, 4171
|
13827, 13935
|
265, 288
|
386, 3044
|
4207, 4853
|
12133, 12245
|
3066, 3283
|
3299, 3346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,070
| 131,159
|
1655
|
Discharge summary
|
report
|
Admission Date: [**2105-2-12**] Discharge Date: [**2105-3-2**]
Date of Birth: [**2043-7-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
productive cough, fever
Major Surgical or Invasive Procedure:
intubation
bronchoscopy
History of Present Illness:
Mr. [**Known lastname 7931**] is a 61-year-old male w/ recently diagnosed multiple
myeloma during an admission to an OSH for pneumonia who
currently presents with productive cough (yellow/brown and
bloody), subjective fever, chillls x 3 days. Admits to increased
fatigue and increased shortness of breath (which has never been
this bad before) but denies myalgias, nausea, vomiting,
abdominal pain, diarrhea, chest pain, palpitations. Says he
feels exactly like he felt in [**Month (only) 404**] when he had PNA. Recently
discharged from [**Hospital1 18**] [**2105-2-7**] for treatment of hypercalcemia [**1-23**]
to multiple myeloma. Had been feeling well when discharged but
returned to work Monday [**2-9**] which is when he began to fell ill.
.
In ED, had CXR suspicious for LUL and RLL PNA. Given 1 dose of
Levaquin 500 mg IV, 1 dose of Vancomycin 1 g IV, 80 mEq KCL, and
motrin 400 mg po. Admitted to medicine for treatment of PNA.
Past Medical History:
-Multiple Myeloma with hypercalcemia diagnosed [**12-28**]
-Muscle invasive bladder CA status post radical prostatectomy
and cystectomy in [**2091**] with creation of neobladder
-Hypertension
-AAA with slight interval increased size, last measured [**7-27**]
-h/o MI and CAD s/p RCA stenting in [**2099**]
-EF of 60-65% [**12-28**]
-DVT in his upper extremity in [**2101**]
-COPD
-Tobacco use 51 pack/year history
-Pneumonia in [**7-/2104**], [**12/2104**] (LUL)
-Recently diagnosed AFib on [**2105-1-7**] for which he is on Coumadin.
-Basal cell carcinoma on his right cheek [**2098**]
-Spinal stenosis
-B12 deficiency
Social History:
He lives in [**Hospital1 **] and works as a bartender. He has been
married for 21 years. He has a daughter who is 19 years old and
lives with him. He has two other daughters that are estranged
from him. He smoked a pack per day since [**2053**] but claims to only
smoke [**3-26**] cigarettes a day currently. He drinks two to three rum
drinks a day, he uses marijuana daily.
Family History:
Significant for a mother who is deceased with breast cancer and
[**Month/Day (1) 1902**] after MI at age 60. His father died at age 71 and had
Alzheimer's disease. He has one brother with diabetes,
hypertension and coronary artery disease.
Physical Exam:
VS: T 96.7 (100.0 in ED) P 72 BP 140/64 RR 20 Pox 98% RA
GEN: slightly uncomfortable with SOB, irritable, bloody mucus in
tissue in trash can at bedside.
HEENT: PERRL, anicteric sclerae. Oropharynx moist without
erythema, lesion, or thrush.
NECK: Supple.
CV: RRR no MGRC.
LUNGS: poor air movement diffusely, LUL + rhonci, LML/LLL +
rhonchi/wheezes.
ABD: + BS, S/NT/ND
EXT: No edema, cyanosis, or clubbing.
SKIN: Generalized rosy complexion. Warm, dry, and intact. No
rashes noted.
NEURO: CN 2-12 grossly intact
Pertinent Results:
CXR PA/lat ([**2105-2-12**]): The heart size is normal. The mediastinal
and hilar
contours are normal. There is increased opacity within the left
upper lobe and a smaller degree within the right lower lobe,
which suggest pneumonia. There is no pleural effusion or
pneumothorax. Osseous structures are unremarkable.
.
CT Abd ([**2105-2-16**]): Consolidation in bilateral lung bases, query
aspiration pneumonia. Stable appearance of infrarenal abdominal
aortic aneurysm. Nonobstructive stone within the left kidney.
No evidence of hydronephrosis or hydroureter in either kidney.
Stable appearance of neobladder without evidence of perforation,
however, evaluation of the lower pelvis is limited by streak
artifact from surgical clips. Diverticulosis without evidence of
diverticulitis.
.
Viral screen ([**2105-2-15**]): positive for influenza A by DFA
Brief Hospital Course:
Upon his initial arrival to the floor, he became tachypnic to
the 30's and 40's with increasing dyspnea, spiked a fever to
103.0 and had an increasing oxygen requirement. He was given
several courses of albuterol nebs which resulted in temporary
improvement of symptoms, but serial ABGs revealed worsening
alkalosis. He was transferred to the MICU for further
management.
.
In this first MICU stay, he was continued on vanco and levaquin
for pneumonia. The differential diagnosis considered included
atypical pneumonia, PCP, [**Name10 (NameIs) 1902**], vasculitis, diffuse alveolar
hemorrhage. He was on BiPAP for an unspecified period of time.
He was also given nebs and started on solumedrol. Coumadin was
held. By the next day he was much improved and was called out to
the floor that night. He was on 2L nc at that time, and was
satting 95-96% on room air by the following morning.
.
On [**2105-2-14**], after transfer to the floor, he was lying on his L
side in bed and coughing up thick mucus when he suddenly became
acutely short of breath. Initially, O2sat 85% on 2L, 87% on 5L,
not much improved on face mask, and low 90s on NRB. He was given
nebs without improvement. He was suctioned by respiratory, but
only small amounts secretions suctioned. Chest PT was tried (as
the patient had a strong cough) with some success. He was also
treated with nitro, morphine, and lasix with some improvement.
.
On arrival back to the MICU, he was started on broad
antimicrobials (vanco, zosyn, Bactrim, and voriconazole). With
his immunosuppression from MM in the setting of an acute
infection, he was given 2 doses of IVIG. On [**2105-2-15**], he was
intubated in anticipation of inability to sustain high minute
ventilation. Bronchoscopy and BAL were performed and were
positive for influenza A by DFA. Serial bronchial lavages were
increasingly blood-tinged, raising concern for alveolar
hemorrhage. He was given vitamin K to reverse his INR, and his
Hct was monitored closely. DFA returned positive for influenza
A. BAL bacterial and fungal cultures were negative, so all
antimicrobials were discontinued on [**2105-2-17**]. He was diuresed
with improvement in his oxygenation and was extubated on [**2105-2-22**].
Since, he has had continued improvement in his respiratory
status, currently breathing well on 3L/min nasal cannula. Of
note, he has had some hallucinations while in the ICU which have
been treated with prn haloperidol.
.
He was transferred back to the floor on [**2105-2-25**] where he was
weaned off of his supplemental oxygen. He was cleared by PT/OT
for discharge home with home PT. Due to his continued
hemoptysis and the patient's concern, his warfarin continued to
be held and he was not put on a heparin drip (since his only
risk factor for thromboembolization was a-fib); he will discuss
resuming this with his PCP.
Medications on Admission:
- Aspirin 81 mg Tablet
- Metoprolol Tartrate 12.5 mg [**Hospital1 **]
- Warfarin 5 mg Tablet PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR); 7.5MG
3X/WEEK(TU,TH,SA)
- Amlodipine 2.5 mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
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. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
5. Toprol XL 25 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis: influenza viral pneumonia with subsequent
ARDS
.
Secondary diagnoses: multiple myeloma, history of bladder
cancer, atrial fibrillation, hypertension, COPD, coronary artery
disease, B12 deficiency with resultant macrocytic anemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with a severe viral pneumonia
from influenza requiring intubation. Your breathing has
improved markedly throughout your hospitalization, but due to
your deconditioning, you are being sent to rehab to help regain
your strength. Several medication changes were made to your
outpatient regimen, so please take careful note of the
medication list included in your discharge paperwork.
.
Please take all medications as prescribed. Please attend all
follow up appointments.
.
If you experience high fevers, shortness of breath, chest pain,
loss of consciousness, or other concerning symptoms, then you
need to seek medical attention.
.
Since you kept coughing up bloody sputum, we temporarily stopped
you Coumadin (warfarin). You should discuss resuming this with
Dr. [**Last Name (STitle) 665**] since your atrial fibrillation puts you at risk for
a stroke; Coumadin will reduce this risk.
Followup Instructions:
Please call Dr.[**Name (NI) 666**] office ([**Telephone/Fax (1) 250**]) to schedule a
follow up appointment for sometime in the next 1-2 weeks.
.
Please call Dr.[**Name (NI) 3930**] office ([**Telephone/Fax (1) 3237**]) to schedule a
follow up appointment for sometime in the next 1-2 weeks.
.
Provider: [**Name10 (NameIs) 3242**] CHAIR 1 Date/Time:[**2105-3-4**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9573**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2105-3-4**]
9:00
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC Date/Time:[**2105-3-26**] 10:20
|
[
"V10.51",
"441.4",
"786.3",
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"281.1",
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"276.2",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.14",
"99.07",
"96.6",
"99.04",
"96.04",
"96.72",
"93.90",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
7769, 7827
|
4048, 6894
|
337, 362
|
8119, 8128
|
3171, 4025
|
9099, 9712
|
2382, 2624
|
7132, 7746
|
7848, 7848
|
6920, 7109
|
8152, 9076
|
2639, 3152
|
7937, 8098
|
274, 299
|
390, 1330
|
7867, 7916
|
1352, 1974
|
1990, 2366
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,329
| 120,274
|
49870
|
Discharge summary
|
report
|
Admission Date: [**2129-11-14**] Discharge Date: [**2129-12-1**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
woman originally admitted to the Medical Service with a
remote history of breast cancer and six weeks of midthoracic
back pain radiating to bilateral flanks, worse with movement.
She was treated with Percocet but continued with significant
back pain, abdominal pain and constipation. She denied
numbness, tingling, or weakness.
PAST MEDICAL HISTORY: Hypertension. Hypercholesterolemia.
Anxiety and depression. History of breast cancer in [**2112**],
status post lumpectomy and radiation therapy.
MEDICATIONS ON ADMISSION: Lescol 40 mg, Xanax, Prozac 20 mg
q.d., Aspirin 81 q.d., Percocet p.r.n., Evista 60 mg q.d.
ALLERGIES: PENICILLIN.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.7??????, blood
pressure 149/100, heart rate 91, respirations 20, oxygen
saturation 93% on room air. General: The patient was an
elderly woman in moderate pain. HEENT: Pupils equal, round
and reactive to light. Extraocular movements intact.
Oropharynx clear. Neck: Supple. No jugular venous
distention. Pulmonary: Chest clear to auscultation.
Cardiovascular: Regular, rate and rhythm. No murmurs, rubs,
or gallops. Abdomen: Soft, nontender, nondistended.
Rectum: Normal rectal tone. Guaiac negative stool. Back:
There was positive midthoracic tenderness. Extremities: No
clubbing, cyanosis, or edema. Neurological: The patient was
awake, alert and oriented times three. Cranial nerves II-XII
intact. Strength was 5 out of 5 in all muscle groups.
Sensation intact to light touch and pinprick. Reflexes were
1+ at the biceps patella, and Achilles.
The patient was seen by the Neurosurgery Service who noted a
compression fracture at T9 on plain films. MRI of thoracic
spine revealed a large right paraspinal mass at 3 x 5 x 3 cm
and T9 anterior wedge compression fracture with retropulsed
segment compressing the cord. There was evidence of
metastases at C7, T1, T4, T8, T11, and T12.
They recommended bone scan and repeat MRI scan.
CT Surgery was consulted to rule out paraspinal mass in the
thoracic region. Dr. [**Last Name (STitle) 1327**] recommended T9 vertebrectomy
with T8-T10 arthrodesis for stabilization, for palliation and
relief of pain.
This most likely represented a primary lung cancer with
direct extension to the T9 vertebrae with paraspinal soft
tissue mass.
Bone scan results showed multifocal osseous metastatic
disease. Head CT showed no lesions.
Chest, abdomen and pelvis CT showed right lower lobe mass
with a lung mediastinal hilar lymphadenopathy and compression
fracture of T9.
She underwent embolization of the tumor on [**2129-11-17**],
without complications. She tolerated the procedure well.
She was followed by the Oncology Service, as well as
Radiation Oncology and Surgical Service.
On [**2129-11-21**], the patient underwent T9 vertebrectomy
with thoracic stabilization for palliation. The patient
tolerated the procedure well. There were no intraoperative
complications.
Postoperatively the patient was monitored in the Surgical
Intensive Care Unit. She remained intubated and sedated.
She was then awake off Propofol. She did not follow
commands. She was moving all extremities spontaneously. She
flexed bilateral legs at the hips and knees.
Chest tube put out a total of 500 cc postoperatively. The
patient remained intubated.
On [**11-23**], the patient was localizing to pain on the
right, and withdrew the right lower extremity. She did not
follow commands. Dressing was clean, dry, and intact. No
drainage. Chest tube continued to be in place.
The plan was to wean the ventilator and extubated the patient
if possible. On [**2129-11-28**], the patient opened her
eyes. Gaze was conjugate. Pupils were 3 down to 2 mm. She
was not following commands. She withdrew with antigravity
strength in lower extremities. Incision was clean, dry, and
intact.
Her LFTs began to rise. She had a liver and gallbladder
ultrasound which showed multiple metastatic lesions with no
ductal dilatation and no cholelithiasis.
She continued to not follow commands. Toes were downgoing.
She had sluggish movement of the upper extremities and
withdrew the lower extremities. LFTs continued to rise.
Gastrointestinal was consulted. The abdomen showed an
increase in size of all lesions, right lung base,
gallbladder, and biliary system.
A family meeting on [**2129-12-1**], made the patient DNR.
The patient's condition continued to deteriorate, and the
family decided on [**2129-12-1**], to make the patient
comfort measures. The patient was extubated on [**2129-12-1**], and expired.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2130-1-31**] 13:24
T: [**2130-1-31**] 13:25
JOB#: [**Job Number 104194**]
|
[
"578.9",
"198.7",
"733.13",
"197.7",
"162.5",
"198.5",
"415.19",
"518.5",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.04",
"88.44",
"96.6",
"38.91",
"80.51",
"99.04",
"81.62",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
715, 833
|
856, 5018
|
156, 516
|
539, 688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
408
| 173,910
|
8387
|
Discharge summary
|
report
|
Admission Date: [**2188-10-27**] Discharge Date: [**2189-1-11**]
Service:
HISTORY OF THE PRESENT ILLNESS: This is one of several [**Hospital3 **] Hospital admissions for this elderly male.
The history of this admission goes back to a previous
admission in [**2188-9-14**] when the patient was admitted
for repair of an incarcerated paraileostomal hernia in the
setting of a prior hernia repair. This operation itself
followed a panproctocolectomy for Crohn's disease.
Following that operation, the patient appeared to be doing
well and was, however, readmitted to the hospital on [**2188-10-13**]
until [**2188-10-21**] with what appeared to be left upper quadrant
pain and a hematoma but there was nothing that appeared to
warrant surgery. He was consequently discharged home on
[**2188-10-21**] but then readmitted on [**2188-10-27**] which is the date of
this admission.
The reason for this readmission was that the patient
continued to have developed temperatures and a high white
cell count while an outpatient and developed increasing left
upper quadrant pain. On this occasion, he was readmitted and
CAT scanned and a fluid collection which was not evident on
the previous admission was drained. He was then admitted to
the floor for further follow-up.
PRIOR MEDICAL HISTORY: Status post panproctocolectomy for
Crohn's disease.
PHYSICAL EXAMINATION: General: The physical examination
revealed an elderly male. HEENT: Normal. Heart and lungs:
Clear. Abdomen: Well-healed midline incision, an ostomy on
the left lower quadrant and a drain site in the right upper
quadrant.
HOSPITAL COURSE: The patient's condition appears to have
evolved following his admission in that he developed a
clear-cut enterocutaneous fistula which began to necessitate
via the midline incision. Much thought was given to how to
deal with this including consultations with other surgeons.
He was, therefore, placed on intravenous elementation in the
hopes that this fistula would either be controlled on its own
or that his metabolic state would allow us to reenter his
abdomen and try to address the situation.
On [**2188-12-6**], he was taken back to the Operating Room in hopes
of being able to create an ileostomy proximal to the fistula.
However, this operation proved to be impossible owing to
dense adhesions within the abdomen. Nothing further was done
and he was, therefore, returned to the floor for further
intravenous elementation, antibiotics, and all supportive
care. Despite this, however, the patient continued to
dwindle and he finally died on [**2189-1-11**].
FINAL DIAGNOSIS: Enterocutaneous fistula.
OPERATION PERFORMED: Exploratory laparotomy.
DISPOSITION: The patient died.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**]
Dictated By:[**Last Name (NamePattern4) 22919**]
MEDQUIST36
D: [**2189-5-17**] 04:17
T: [**2189-5-21**] 20:04
JOB#: [**Job Number 29622**]
|
[
"428.0",
"998.59",
"038.8",
"280.0",
"584.9",
"276.2",
"518.81",
"569.81",
"117.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"54.12",
"96.6",
"54.91",
"99.15",
"96.72",
"38.91",
"54.92",
"54.25",
"38.93",
"93.59",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
1624, 2593
|
2611, 2992
|
1378, 1606
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,082
| 178,322
|
12185
|
Discharge summary
|
report
|
Admission Date: [**2122-4-7**] Discharge Date: [**2122-4-16**]
Date of Birth: [**2056-4-27**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Zolpidem / Tramadol / Ketorolac / Cyclobenzaprine
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Transfer for question of RCA "found down" at OSH on cardiac
catheterization
Major Surgical or Invasive Procedure:
[**4-7**] Cardiac catheterization with placement of BMS to the Left
Circumflex
Removal of Intraaortic balloon pump
History of Present Illness:
65 y.o. with prior cath [**10-11**] with 50% LCx and RCA totally
occluded treated with RCA cypher DES 2.5 x 8 mm, RCA PCI [**2119**],
recently admitted to [**Hospital 46**] Hosp with diastolic heart failure
about a month ago and sent to [**Location (un) 169**] rehab for long stay.
Finally returned home on [**3-30**]. She was home for two days and was
found down by VNA with blood sugar of 490. Per the pt she fell
becasue of feeling dizzy and was only down for a few minutes.
Negative Head CT. She went back to [**Hospital1 46**] and ruled in for small
NSTEMI with a Trop peak of 1.16 and cpk mb of 8.5. She declined
cath initally. Her mental status has been labile, paranoid at
times, and overall questionable. Her right to consent had been
revoked and her daughter [**Name (NI) 38129**] [**Name (NI) **] consented for cath. BS
today 120's. At cath they first engaged the left and found LCx
with 80% mid lestion. Noted STE in 2, 3 and AVF on EKG. Moved
over to the RCA but not actually engaged and found to be down.
She became bradycardic to the 40's. She did not receive
Atropine. She was started on IV nitro at 60mcg/mn and IV heparin
4000 unit bolus/1400 unit gtt. IABP was placed via 7 french
atrial sheath for ?chest pain. Also has 7 french venous sheath
all on the right. STE improved. 60cc contrast. Fentanyl and
Versed will be totalled when she leaves their labs. She was
awake and minimally agitated on transfer. Last Lovenox last
evening. BP now improved 140/70.
.
Labs at OSH notable for wbc 5.6, hgb 11.2, hct 32.2, plt 188, na
142, k 3.5 repleted earlier 40meq, cl 106, co2 26, bun 9, cr
0.93 (1.49 prior to hydration), iNR on [**4-2**] 1.02 ptt 23.1.
.
The patient came to [**Hospital1 18**] via Med Flight and went straight to
the cath lab. At this point, she was CP free and EKGs had
settled. Initial access was attempted from rt radial but pt had
spasm so they went in through the left radial initially with
diagnostic catheter which was later switched to PCI catheter.
RCA was found to be widely patent with previous stent in place.
Mid circ 80% lesion was intervened on with BMS. She was
transferred to the floor on heparin gtt and IABP with VSS of HR
60 BP 122/52 satting 99% on RA.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. S/he
denies recent fevers, chills or rigors. S/he denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
- CARDIAC HISTORY: Diastolic Heart Failure, +Insulin dependent
Diabetes, +Dyslipidemia, +Hypertension, s/p cth [**10-11**] with 50%
LCx, 100% PDA and 90% RCA treated with ptca/cypher DES 2.5 x 8
mm stent, has a hx of inferior wall scar
.
- OTHER PAST MEDICAL HISTORY:
Anxiety Disorder
Morbid obesity
elevated left sided filling pressures
pancreatitis
peripheral neuropathy
s/p tonsillectomy/adeniodectomy
bilateral hip replacement
partial thyroidectomy
Social History:
pt lives at home w/ son. Uses a walker but can only go a few
feet before getting sob. uses three pillows at night.
- Tobacco history: no
- ETOH: no
- Illicit drugs: no
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: 99.5 130/76 74 18 96%
General: AAOx2, cooperative
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: warm and dry
reflexes biceps, brachioradialis, patellar, ankle.
Pertinent Results:
[**2122-4-14**] 06:05AM BLOOD WBC-7.3 RBC-3.01* Hgb-9.1* Hct-26.6*
MCV-89 MCH-30.2 MCHC-34.2 RDW-16.2* Plt Ct-209
[**2122-4-14**] 06:05AM BLOOD Glucose-248* UreaN-15 Creat-0.6 Na-144
K-3.9 Cl-108 HCO3-26 AnGap-14
[**2122-4-10**] 12:56AM BLOOD calTIBC-250* Hapto-51 Ferritn-254*
TRF-192*
[**2122-4-9**] 10:10AM BLOOD TSH-5.6*
Cardiac enzymes:
[**2122-4-7**] 10:01PM BLOOD CK-MB-2
[**2122-4-7**] 10:01PM BLOOD CK(CPK)-27*
Other notable labs:
[**2122-4-9**] 10:10AM BLOOD VitB12-1125*
[**2122-4-10**] 12:56AM BLOOD calTIBC-250* Hapto-51 Ferritn-254*
TRF-192*
[**2122-4-9**] 10:10AM BLOOD TSH-5.6*
[**2122-4-9**] 10:10AM BLOOD Free T4-1.5
Coronary angiography: right dominant
LMCA: No angiographically-apparent CAD.
LAD: Mild luminal irregularities with 50% stenosis distally.
LCX: 80% diffuse into moderate sized OM1.
RCA: proximal 30%. Widely patent stent. Chronically occluded
PL unchanged from prior and fills distally from LCA
LCX:
2.5 x 18 mmIntegriti stent and postdilated to 2.5 mm with an NC
balloon
Echo [**2122-4-9**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with inferior and
inferolateral hypokinesis. The remaining segments contract
normally (LVEF = 40%). 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 (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation
Brief Hospital Course:
65F w/ prior RCA stent, HTN, IDDM, anxiety disorder who was
flown in from [**Hospital3 **] after suspicion of acute occlusion
of RCA during elective cath for NSTEMI. Underwent cath here and
was found to have patent RCA, but got BMS to 80% LCX. Had
balloon pump removed which was placed at OSH presumably for for
chest pain.
.
#NSTEMI at OSH/CAD/patent at [**Hospital1 18**]: Patient transferred to the
[**Hospital1 18**] catheterization laboratory after the patient developed
chest pain, bradycardia and STE during diagnostic
catheterization at [**Hospital3 3583**]. During injections of the
LCA, the patient developed chest pain and inferior STE.
Nonselective angiography at that hospital demonstrated occlusion
of the RCA proximally. An IABP was inserted and she was
transferred to [**Hospital1 18**] for confirmatory angiography and possible
PCI of the RCA. The patient arrived without chest pain. Pt was
found to have patent RCA in [**Hospital1 18**] unlike report from OSH where
she was thought to have acute occlusion. Given report of
inferior STE changes, pt most likely had transient occlusion of
the RCA resulting from an air or other embolus. Pt did have 80%
lesion of LCX which was stented with BMS. Pt had balloon pump
weaned and removed without complication with no subsequent chest
pain or drop in pressure. Pt should be on Plavix (clopidogrel)
75 mg daily X 1 month uninterrupted and preferably 9 months
total, aspirin indefinitely,and Metoprolol XL 50 mg.
Atorvastatin was also started.
.
# Anxiety/Delirium: Long and significant hx of anxiety, panic
attacks etc. She was started on PRN benzos for severe agitation,
as well as haldol and olanzapine as needed. Psych was consulted,
and felt this was hospital induced delirium. Benzos were weaned
then stopped as were PRN anti-psychotics. She continued on
olanzapine 7.5 qHS with good effect. Her orientation improved to
oriented times three at the time of discharge. However, she
remains intermittently agitated, often worse later in the day,
although is redirectable.
.
# Acute on chronic systolic and diastolic CHF: Patient had
recent admission for DHF in [**Hospital1 46**]. Last EF 45%. Here she was
found to have inferior and inferolateral hypokinesis and LVEF of
40%. Pt had no signs of acute failure here. She will continue
with lisinopril, metoprolol. She was dry on exam here and thus
her home lasix 20 mg was held. Continued on discharge.
.
# DM2: pt reports blood sugars not well controlled. BS range
50-450 over last 1 month. She was on about 50 units of glargine,
which was reduced then held when patient was confused and not
eating. After starting eating, blood sugars were high. Restarted
lantus 25 units, with sliding scale. Discharged on this dose,
which can be increased as needed at rehab.
.
# Hyperlipidemia: [**2119-9-26**] chol 161, HDL 38, LDL 54, trig 433.
She was started on atorvastatin 80mg.
.
# Hypertension: stable. Continued metoprolol and lisinopril.
TRANSITIONAL ISSUES
- It is unclear what the patient's baseline mental status is now
after multiple admissions and multiple episodes of delirium.
While there are no obvious acute issues, she should undergo an
outpatient workup for dementia. TSH and folate wnl. No B12
deficiency.
- Rehab stay anticipated to be less than 30 days
Medications on Admission:
Plavix 75mg daily
ASA 325mg daily
MVI daily
Humalog SS AC/HS
Klonapin 0.5mg [**Hospital1 **]
Lantus 80 q12
Ativan 0.25 prn
Ferous sulfate 325
Lamictal 150mg daily
Neurotin 300mg daily
Paxil 30mg daily
Toprol 50mg daily
Zestril 20mg daily
Lasix 20mg qd
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lamotrigine 150 mg Tablet Sig: One (1) Tablet PO once a day.
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. insulin glargine 100 unit/mL Cartridge Sig: Twenty Five (25)
units Subcutaneous at bedtime.
11. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day: Breakfast/Lunch/Dinner
120-159 - 2 units (0 units qHS)
160-199 - 6 units (2 units qHS)
200-239 - 9 units (4 units qHS)
240-279 - 12 units (6 units qHS)
280-319 - 15 units (8 units qHS)
320-359 - 18 units (10 units qHS)
360-399 - 21 units (12 units qHS)
> 400 - 24 units (14 units qHS).
12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - [**Location (un) 11792**] - [**Location (un) 7740**]
Discharge Diagnosis:
NSTEMI
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:
Ms. [**Known lastname 38130**],
You were admitted to the hospital for concern of a heart attack,
and underwent a cardiac catheterization with stenting of any
artery. You will be transferred to rehab care to help improve
your strength.
Medication changes:
Start atorvastatin 80mg daily
Start olanzapine 7.5mg at bedtime
Stop klonopin and ativan
Reduce insulin lantus to 25mg daily
Increase paxil to 40mg daily
Followup Instructions:
Please contact your primary care physician for [**Name9 (PRE) 702**] after
you have left rehab.
|
[
"333.85",
"292.81",
"348.30",
"250.92",
"401.1",
"278.01",
"272.4",
"V43.64",
"V45.82",
"410.71",
"345.90",
"V58.67",
"414.01",
"E939.4",
"E939.2",
"428.32",
"356.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.40",
"36.06",
"00.45",
"97.44",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
10966, 11076
|
6172, 9463
|
395, 511
|
11127, 11127
|
4351, 4677
|
11739, 11838
|
3755, 3870
|
9766, 10943
|
11097, 11106
|
9489, 9743
|
11304, 11541
|
3885, 4332
|
4694, 6149
|
11561, 11716
|
280, 357
|
539, 3075
|
11142, 11280
|
3366, 3552
|
3568, 3739
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,370
| 136,676
|
39244
|
Discharge summary
|
report
|
Admission Date: [**2105-3-18**] Discharge Date: [**2105-3-25**]
Date of Birth: [**2031-10-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2105-3-19**]
1. Coronary artery bypass grafting x3 with a reverse
saphenous vein graft from the aorta to the first obtuse
marginal coronary artery; reverse saphenous vein graft
from the aorta to the left anterior descending coronary
artery; reverse vein graft from the aorta to the distal
right coronary artery.
2. Repair of postinfarct ventricular septal defect with a
bovine pericardial patch technique ([**First Name8 (NamePattern2) 84634**] [**Last Name (NamePattern1) **]).
History of Present Illness:
73 y/o female with IDDM presented to [**Hospital3 934**] Hospital
with h/o SOB since noon. Progressive. Denied chest pain.
Taken
to ER by ambulance at 1830. Severely SOB/diaphoretic on
arrival.
Required intubation. EKG RBBB. Troponin 2.57. Given 324 mg
ASA, Plavix 300 mg. Cath at Caritas showed 50% LM, 90% prox
LAD,
diffuse disease in circumflex, 80% prox RCA. BP on cath 70/54.
IABP placed. Patient with wide open MR on LV gram. Stepup in
saturation (58% RA vs 78% PA.) Accepted by CCU. Patient
medievaced. No inotropes in transit.
Past Medical History:
insulin dependent diabetes mellitus
breast cancer s/p bilateral mastectomies
Social History:
tobacco: smokes 6 cigarettes per day
Family History:
non-contributory
Physical Exam:
T 97.2 BP 166/50 HR 80 (SR) IABP 1:1 Sat 100%
General - intubated, has moved all extremities
HEENT - pupils pin point
Neck - supple
Lungs - rales/rhonchi
Cardio - difficult to hear secondary to balloon
Abd - soft, obese
Ext - IABP left groin, Swan right groin
DP and PT pulses present by doppler
Pertinent Results:
Pre-op
[**2105-3-18**] 11:39PM PT-13.2 PTT-150* INR(PT)-1.1
[**2105-3-18**] 11:39PM PLT COUNT-367
[**2105-3-18**] 11:39PM WBC-12.1* RBC-3.74* HGB-11.5* HCT-35.0*
MCV-94 MCH-30.7 MCHC-32.8 RDW-13.2
[**2105-3-18**] 11:39PM ALBUMIN-3.1* CALCIUM-8.1* PHOSPHATE-5.7*
MAGNESIUM-2.0
[**2105-3-18**] 11:39PM CK-MB-18* MB INDX-6.4* cTropnT-1.53*
[**2105-3-18**] 11:39PM ALT(SGPT)-30 AST(SGOT)-12 LD(LDH)-117
CK(CPK)-281* ALK PHOS-72 TOT BILI-0.3
[**2105-3-18**] 11:39PM GLUCOSE-485* UREA N-14 CREAT-0.4 SODIUM-143
POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-19
Discharge
[**2105-3-24**] 05:55AM BLOOD WBC-11.3* RBC-3.77* Hgb-11.8* Hct-34.4*
MCV-91 MCH-31.4 MCHC-34.4 RDW-14.2 Plt Ct-316
[**2105-3-21**] 02:42AM BLOOD PT-11.6 PTT-28.2 INR(PT)-1.0
[**2105-3-24**] 05:55AM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-136
K-4.1 Cl-92* HCO3-36* AnGap-12
Intra-op echo
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild regional left ventricular systolic dysfunction with severe
hypokinesis of the distal infero and anteroseptal walls. There
is a muscular ventricular septal defect (VSD located in the mid
to distal inferior septum.. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). There is an
intra-aortic balloon pump catheter well positioned in the
descending thoracic aorta
POSTBYPASS
Left ventricular systolic function remains unchanged compared to
pre-bypass. RV systolic function remains normal. Color flow
Doppler is no longer seen across the interventcicular septum.
The study is otherwise unchanged from pre-bypass.
CHEST (PA & LAT) [**2105-3-24**] 3:22 PM
[**Hospital 93**] MEDICAL CONDITION: 73 year old woman with s/p cabg
REASON FOR THIS EXAMINATION: evaluate for effusion
Final Report
INDICATION: 73-year-old female post-CABG.
CHEST, AP: Moderate bilateral effusions are likely unchanged,
given
differences in positioning. Mild interstitial edema persists.
Left lower
lobe atelectasis is stable. The right lung is clear. The
cardiomediastinal
and hilar contours have a normal post-CABG appearance. Right
venous
introduction sheath has been removed. There is no pneumothorax.
IMPRESSION: Stable bilateral effusions.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 10307**] HO
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Brief Hospital Course:
Ms [**Known lastname 805**] presented to [**Hospital **] hospital with chest paina and
shortness of breath. She was brought emergently to the cardiac
catheterization lab and found to have 3 vessel CAD wide open
mitral regurgitation and a VSD. She was intubated and an IABP
was placed. She was then transferred to [**Hospital1 18**] for further care.
Once at [**Hospital1 18**] she was evaluated by cardiac surgery and brought
to the oerating room for: 1. Coronary artery bypass grafting x3
with a reverse saphenous vein graft from the aorta to the first
obtuse marginal coronary artery; reverse saphenous vein graft
from the aorta to the left anterior descending coronary artery;
reverse vein graft from the aorta to the distal right coronary
artery. 2. Repair of postinfarct ventricular septal defect with
a bovine pericardial patch technique ([**First Name8 (NamePattern2) 84634**] [**Last Name (NamePattern1) **]). Her bypass
time was 144 minutes with a cross clamp of 120 minutes. Please
see OR report for details.
She tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
She was kept sedated on the day of surgerey, on POD1 her IABP
was weaned and removed. Following the removal of the IABP
sedation was stopped, she woke neurologically intact, was weaned
from the ventilator and extubated. Over the next several days
she was weaned from all iv medications, all tubes lines and all
drains were removed per cardiac surgery protocols. On POD4 she
was transferred from the ICU to the stepdown floor for continued
care and recovery. She continued to make slow progress in her
physical activity and on POD6 she was cleared for transfer to
rehabilitation at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) **].
Medications on Admission:
insulin and oral diabetic meds
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-13**]
Puffs Inhalation Q6H (every 6 hours) as needed for
bronchospasm/wheezing.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous QAM.
15. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale units Injection QAC&HS.
16. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
acute myocardial infarction
coronary artery disease s/p coronary bypass grafting
ventricular septal defect s/p closure
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal wound 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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call with any questions or concerns [**Telephone/Fax (1) 170**],
provider will be paged during off-hours
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name (STitle) 4223**] in [**12-13**] weeks [**Telephone/Fax (1) 8506**]
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**2105-4-2**] 1:15pm
[**Telephone/Fax (1) 8506**], [**Location (un) **] office of DMA
Completed by:[**2105-3-25**]
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50,628
| 163,915
|
42019
|
Discharge summary
|
report
|
Admission Date: [**2175-9-29**] Discharge Date: [**2175-10-7**]
Date of Birth: [**2093-11-3**] Sex: M
Service: MEDICINE
Allergies:
Flagyl / Rofecoxib
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
dyspnea and melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
81 yo M w/ h/o bladder ca s/p surgery and L nephrectomy, lung
tumor s/p resection, CHF (EF 20%), CAD s/p multiple stents, BPH
who initially presented to OSH for dyspnea and melena, found to
hct 21 and troponin I elevation transferred from [**Hospital1 **] for
managment of GIB and demand ischemia.
.
Per patient, he initially presented to OSH for dyspnea on
exertion and black stools for several days. He denies abdominal
pain or hematemesis.
.
On admission to the OSH, his labs were notable for: hct of 21,
plts 112, trop I of <0.06, Cr 1.1, nl LFTs, BNP 216, INR 1.5.
His dyspnea was thought to be multifactorial: anemia, CHF. His
hct trend was: 21 ([**9-27**])-> 25 ([**9-28**]) -> 29 ([**9-29**]). Per
discharge summary patient received 6-7 units of pRBC throughout
his stay, he received 5 units on [**9-29**] and 2 units prior to
transfer on [**9-30**]. GI consulted and thought UGIB likely. He
was started on a ppi ggt and planned for possible endoscopy.
His hospital course was further complicated by troponin I leak
to 25. His ECG showed q's inferiorly and precordial chest
leads, and patient was not complaining of chest pain. He
developed episodes of hypotension that improved w/ holding coreg
and reducing imdur from 60 to 30 and blood transfusions. He had
a CTA was neg for PE. He was seen by cards, who suggested to
d/c plavix, but continue aspirin. His troponin elevated due to
acute event vs demand ischemia and ultimately he was not scoped.
He also developed urinary retention and cr elevated from 1.1 on
admission to 1.4. Urology was consulted. A renal US did not
show hydronephrosis. His retention was thought to be secondary
to BPH and a foley was placed.
.
Currently, he denies chest pain, abdominal pain, nausea,
vomiting. He states his dyspnea has improved.
.
Of note, patient states that he had an episode of BRBPR a few
years ago. His [**Month/Year (2) 802**] states that this was secondary to
diverticulosis. He may have had a colonoscopy within this time
period, but they are uncertain.
Past Medical History:
s/p AAA repair
s/p left nephrectomy for encapsulated tumor
s/p surgery for bladder cancer
osteoarthritis
s/p lung tumor resection
hip fracture s/p ORIF
CEA
diverticulosis
CHF w/ EF of 20%
Aspiration pneumonia after a surgery
CAD s/p multiple stents - per daughter last MI in [**2174-4-16**] w/ "4
blockages"
BPH s/p TUMT [**2-/2175**]
Fe deficiency anemia
Social History:
Lives with [**Year (4 digits) 802**].
- Tobacco: smoked 1ppd for "many years" but quit smoking 40 yrs
ago
- Alcohol: used to drink socially on the weekends
- Illicits: denies
Family History:
CAD, DM, strokes
Physical Exam:
ADMISSION EXAM
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 9-10cm, no LAD
CV: Regular rate and rhythm, normal S1, 3/6SEM, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
Vitals: T: 98.3 BP: 100-124/50-64 (80-88/50-64) P: 55-63 R: 18
O2: >95% RA [**Telephone/Fax (1) 91216**]/600
General: pleasant elderly gentleman sitting up in bed, alert,
oriented, no acute distress, appears comfortable
HEENT: NCAT, Sclera anicteric, MMM, oropharynx clear
Neck: supple, no JVD
CV: Regular rate and rhythm, normal S1, 3/6 systolic
crescendo-decrescendo murmur loudest at RUSB with radiation to
clavicle, no rubs, murmer throughout systole with obliteration
of S2
Lungs: no use of access mm, minor crackles bibasilar L>R, no
wheezes, good air movement.
Abdomen: NABS, soft, non-tender, non-distended, no rebound or
guarding
Ext: warm, dry, no edema
Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities,
no gross deficits
Pertinent Results:
ADMISSION LABS
[**2175-9-29**] 08:42PM BLOOD WBC-9.6 RBC-4.00* Hgb-12.0* Hct-34.6*
MCV-87 MCH-30.0 MCHC-34.7 RDW-15.5 Plt Ct-111*
[**2175-9-29**] 08:42PM BLOOD Neuts-74.7* Lymphs-17.4* Monos-4.5
Eos-3.0 Baso-0.3
[**2175-9-29**] 08:42PM BLOOD PT-13.7* PTT-28.9 INR(PT)-1.2*
[**2175-9-29**] 08:42PM BLOOD Glucose-91 UreaN-49* Creat-1.3* Na-145
K-3.9 Cl-113* HCO3-24 AnGap-12
[**2175-9-29**] 08:42PM BLOOD ALT-22 AST-44* CK(CPK)-119 AlkPhos-60
TotBili-1.5
[**2175-9-29**] 08:42PM BLOOD CK-MB-10 MB Indx-8.4* cTropnT-1.81*
[**2175-9-29**] 08:42PM BLOOD Calcium-8.5 Phos-3.9 Mg-2.0
PERTINENT STUDIES
TTE [**2175-9-30**]:
Conclusions
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is moderate regional left
ventricular systolic dysfunction with focal akinesis and
thinning/aneurysm of the basal inferolateral and inferior wall.
There is hypokinesis of the mid-inferolateral and distal lateral
wall and the true apex. The remaining segments contract normally
(LVEF = 35 %). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). The mitral valve
leaflets are moderately thickened. There is moderate thickening
of the mitral valve chordae. Moderate (2+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is a very small
pericardial effusion.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
multivessel CAD as detailed above. Moderate left ventricular
hypertrophy and cavity dilation. Severe aortic stenosis. Severe
pulmonary hypertension. Moderate tricuspid and mitral
regurgitation. Mildly dilated thoracic aorta.
.
CXR [**2175-9-29**]:
Heart size is enlarged, in particular left ventricle.
Mediastinum is
relatively wide although it might be explained by the portable
study
character. Multifocal linear densities projecting over the lungs
most likely represent calcified pleural plaques. No appreciable
pulmonary edema is seen.
The evaluation is limited due to the presence of pulmonary
nodules given superimposed pleural plaques and if clinically
warranted, correlation with chest CT might be considered
.
EGD [**2175-10-1**]:
Normal mucosa in the esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow up per inpatient GI team recommendations
The findings do not account for the symptoms, patient should
undergo elective colonoscopy while inpatient within the next few
days. He will need MAC anesthesia for this as well.
.
Colonoscopy [**2175-10-3**]: Multiple diverticula were seen in the
sigmoid. Diverticulosis appeared to be of moderate severity.
Impression: Diverticulosis of the sigmoid
Otherwise normal colonoscopy to cecum
Recommendations: No cause of GI bleeding found.
.
CT abdomen and pelvis: [**2175-10-3**] 1. No CT evidence for active
gastrointestinal bleeding or aortoenteric fistula.
2. Small pericardial effusion and bilateral pleural effusions
.
CXR [**2175-10-4**]: In comparison with the study of [**9-29**], there is
continued enlargement of the cardiac silhouette with left
ventricular prominence. It is difficult to assess the widening
of the mediastinum due to obliquity of the patient.
Indistinctness of pulmonary vessels is consistent with elevated
pulmonary venous pressure. Retrocardiac opacification is
consistent with some volume loss in the left lower lobe. Pleural
plaques and some nodularity again are noted.
.
Capsule study [**2175-10-5**]
1) No bleeding source identified throughout the small bowel.
2) Suboptimal preparation of the small bowel.
3) A single, non-bleeding red spot vs. angioectasia in the
proximal small bowel.
Summary: No bleeding in the small bowel. Suboptimal preparation,
therefore small underlying lesions may have been missed.
Recommendations: Follow-up with GI consult service and PCP. [**Name10 (NameIs) **]
consider repeat capsule as outpatient if bleeding persists.
.
CXR [**10-7**] Moderate cardiomegaly is unchanged since [**9-29**].
Lungs are clear of any focal abnormality, and there is little if
any vascular redistribution. Tiny pleural effusions layer
posteriorly. Asbestos-related pleural calcifications noted.
.
DISCHARGE LABS
[**2175-10-7**] 06:43AM BLOOD WBC-9.6 RBC-3.32* Hgb-10.1* Hct-28.5*
MCV-86 MCH-30.5 MCHC-35.5* RDW-15.8* Plt Ct-182
[**2175-10-7**] 06:43AM BLOOD Plt Ct-182
[**2175-10-7**] 06:43AM BLOOD Glucose-101* UreaN-11 Creat-1.2 Na-139
K-3.6 Cl-106 HCO3-24 AnGap-13
[**2175-10-7**] 06:43AM BLOOD Calcium-7.8* Phos-3.9 Mg-2.2
Brief Hospital Course:
Pt is an 81 yo M w/ h/o bladder ca s/p surgery and L
nephrectomy, lung tumor s/p resection, CHF (EF 20%), CAD s/p
multiple stents, BPH, who presented with melena and demand
ischemia. He has now had negative EGD, colonoscopy and capsule
study without source of bleeding identified.
.
ACUTE CARE:
# GIB: The patient initially presented from OSH with GIB and
demand-ischemia. On presentation to [**Hospital1 18**] MICU, he was
hemodynamically stable. GI was consulted and performed an EGD
that did not reveal abnormality or source of bleed. The patient
was then transferred to the floor and underwent colonoscopy,
which was also non revealing of active bleeding. The
differential diagnosis did include AVMs due to the patient's
severe AS (Heydes Syndrome) so the aptient underwent capsule
study, which was unfortunately a suboptimal prep but did not
reveal a source of bleeding. There was a small red dot in the
duodenum that could have been the source. The patient also had a
CT abdomen to rule out aortoenteric fistula (again related to
his severe AS this was in the ddx), which was negative. The
patient had a guaic-negative stool prior to discharge and
remained HDS throughout his stay. If he is to rebleed, he should
undergo repeat EGD and capsule study. He was discharged with
repeat hematocrit checks next week and an appointment with [**Hospital1 18**]
GI to follow up these numbers, as his GI physician did not have
an appointment soon. Discharged on PPI.
.
# Demand Ischemia: On presentation to the MICU, his troponins
were elevated and MBI was also elevated. The troponin trend was
the following: 1.8->2.1->2.01. He was continued on aspirin 81mg
(from 325mg). GI and cardiology were consulted. Cardioogy
recommended restarting some of his anti-hypertensive medications
and performing echocardiogram, which revealed severe AS,
moderate TR/MR and severe pulmonary hypertension, LV systolic
dysfunction consistent with multi-vessel CAD. Cardiology felt
that his "demand ischemia in setting of UGI bleed in context of
severe multivessel CAD, infarct-mediated cardiomyopathy, and
severe aortic stenosis," and that his troponin elevation were
"related to prior episode of silent ischemia with kidney injury
leading to decreased clearance." The patient's EKGs did not
reveal new changes. At time of discharge, Lasix, Plavix and
Imdur were being held. His doses of carvedilol and lisinopril
had been significantly decreased; and his aspirin dose was also
decreased, these medication changes need to be addressed in f/u.
.
# urinary retention: the patient had muliple voiding trials
which he failed. He was continued on finesteride and was unable
to tolerate both tamsulosin and doxazosin, due to hypotension.
He was discharged on doxazosin only and was advised to discuss
reinitiation of tamsulosin in the outpatient setting. He was
discharged with a foley catheter, which will be managed by VNA.
He has follow up with urology to discuss management of his
urinary retention, which is likely secondary to BPH but he does
have a history of bladder cancer which encased the kidney.
.
# hypotension: the patient was hypotensive on trial of
reinitiation of carvedilol 12.5mg [**Hospital1 **]; lisinopril 2.5mg and
doxazosin and tamsulosin. He also did receive lasix 20mg PO and
he was hypotensive with this. The patient requires adequate
preload given his severe AS but hypertension should be avoided
because his EF is low and he could be at risk for flash
pulmonary edema. The patient's blood pressure must be carefully
monitored at home to maintain ideal control and his medications
should be titrated accordingly. VNA has been instructed to
monitor BP carefully and discuss management with his PCP.
.
# cough: the patient c/o productive cough for the 2 days prior
to d/c. He had two chest xrays which revealed clear lungs
without edema or pneumonia. There were small pleural effusions
and plaques consistent with asbestos exposure, which should be
followed up. He was afebrile and did not have an elevated white
count, so suspicion for pna was very low. He was not started on
abx and he was not diuresed, as suspicion for pulmonary edema
was similarly low.
.
# Chronic systolic heart failure: Previous EF 20% per OSH
records prior to transfer to MICU. Recent TTE obtained while in
MICU reported EF of 35% with left ventricular dysfunction
suggestive of multi-vessel disease. Pt without evidence of
decompensation. As above, his cardiac medications were changed
and/or discontinued and need to be added back on at follow up.
VNA will be monitoring the patient's blood pressures and weights
carefully and will be communicating with his PCP. [**Name10 (NameIs) 21067**] of his
low EF, the patient is at risk for flash pulmonary edema if his
BP is too high but also requires good preload due to his severe
AS, so the VNA will have to carefully monitor his blood
pressures and communicate these to his PCP to ensure that his
blood pressure is ideally monitored in the outpatient setting.
.
# Acute renal failure: Pt with mild Cr bump at OSH, thought to
be pre-renal, with renal u/s at OSH with no evidence of
hydropnephrosis. Cr 1.1-1.2.
.
# Severe AS: As documented by TTE and clinical findings.
However, difficult to assess pt's syx given pt with recent bleed
and SOB, etc. most likely attributed to recent bleed. The
patient was advised to follow up with his cardiologist to
discuss surgical vs nonsurgical management of severe AS.
.
# Thrombocytopenia: Plts 111 on admission, unclear if acute or
chronic. Given severe AS, possible destruction of platelets due
to shearing effect. Plts remained stable, and increased to 198
prior to discharge.
.
# social issues: the patient's [**Name10 (NameIs) 802**], his HCP, wanted the
patient to be discharged to rehab. The patient was cleared for
home with PT by physical therapy consult and was not accepted by
rehab facility. He was offered elder services, which he
declined, and social work called the [**Name10 (NameIs) 802**] to explain options
for care of the patient.
.
ISSUES OF TRANSITIONS IN CARE:
# Communication: Patient, [**Name (NI) **] [**Doctor Last Name 8214**] - HCP cell [**Telephone/Fax (1) 91217**],
home [**Telephone/Fax (1) 91218**])
# Code: DNR/DNI - confirmed
# PENDING STUDIES AT TIME OF DISCHARGE: none
# ISSUES TO ADDRESS AT FOLLOW UP:
-If his hematocrit decreases again, the patient should have
repeat EGD and capsule study.
-Pleural plaques noted; can be assessed in future
-Please address the discontinuation or adjustment in dose of the
following medications: Plavix, Imdur, Lasix, Lisinopril,
Carvedilol, Aspirin.
-Please address the patient's severe aortic stenosis.
-Please address management of this patient's blood pressure so
that it is ideally managed.
Medications on Admission:
Home Medications: per MICU note
tamuslosin 0.4mg daily
atorvastatin 80mg daily
lisinopril 10mg daily
clopidogrel 75mg daily
furosemide 20 mg daily
doxazosin 4mg daily
colchicine 0.6mg daily
carvedilol 25mg [**Hospital1 **]
Omeprazole 20mg daily
ferrous sulfate 325mg daily
aspirin 325mg daily
docusate 100mg [**Hospital1 **] prn
finasteride 5mg daily
fluticasone 110mcg inh [**Hospital1 **]
lidocaine patch daily prn
Isosorbide mononitrate 60mg daily
Senna 1 tab [**Hospital1 **] prn
.
Medications on transfer: per MICU note
imdur 30mg daily
flomax 0.4mg daily
lidoderm patch
finasteride 5mg daily
asa 325mg daily
colchicine 0.6mg daily
doxazosin 4mg daily
atorvastatin 80mg daily
fluticasone
protonix gtt
zofran prn
.
Medications on transfer to medicine floors:
Atorvastatin 80mg daily
ASA 81 daily
Carvedilol 12.5mg [**Hospital1 **]
Finasteride 5mg daily
Lidocaine Patch
Zofran 4mg prn
Pantoprazole gtt --> plan per MICU team to switch to IV BID
overnight
Discharge Medications:
1. Outpatient Lab Work
Please check hematocrit and hemoglobin on [**10-27**] and have
results sent to your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Telephone/Fax (1) 91219**].
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. carvedilol 12.5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*0*
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place
on source of pain for 12 hours and then remove for 12 hours per
day.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. doxazosin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 701**] VNA
Discharge Diagnosis:
primary: gastrointestinal bleed
secondary: congestive heart failure, 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 91220**],
It was a pleasure taking care of you. You were admitted for a
bleed from your gastrointestinal tract but it is still unclear
where the bleed was coming from. You underwent colonoscopy,
capsule study and scope down your esophagus, so your whole GI
tract was visualized and no source of bleeding was found.
Please be sure to follow up with your physicians.
Please note the following changes to your medications:
- STOP plavix, please discuss restarting this with your
cardiologist
- STOP imdur, please discuss restarting this with your
cardiologist
- STOP Lasix, please discuss restarting this with your
cardiologist
- DECREASE your lisinopril to 2.5mg from 10mg, discuss this
change with your cardiologist
- DECREASE carvedilol from 25mg twice a day to 12.5mg once a day
and discuss this change with your cardiologist.
- DECREASE aspirin from 325mg daily to 81mg daily and discuss
this change with your cardiologist
- STOP colchicine
- STOP iron and discuss restarting this medication with your
physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] docusate and senna
- STOP omeprazole
- START Pantoprazole twice per day
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2175-10-10**] at 2:00 PM
With: [**Name6 (MD) 11170**] [**Last Name (NamePattern4) 11171**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Name: [**Last Name (LF) 53169**],[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1105**]
Specialty: Internal Medicine
Address: [**Street Address(2) **], Ste#106 [**Hospital1 **], [**Numeric Identifier 4474**]
Phone: [**Telephone/Fax (1) 91221**]
Appointment: Monday [**10-16**] at 10:10AM
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2175-10-18**] at 9:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Specialty: Cardiology
Address: [**Apartment Address(1) 91222**], [**Location (un) **],[**Numeric Identifier 60377**]
Phone: [**Telephone/Fax (1) 84266**]
Appointment: Wednesday [**10-25**] at 2PM
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: Gastroenterology
Address: [**Apartment Address(1) 91223**], [**Location (un) **],[**Numeric Identifier 91224**]
Phone: [**Telephone/Fax (1) 54080**]
Appointment: WEDNESDAY [**12-13**] AT 11:30AM
**Your Dr [**Last Name (STitle) 44381**] to please call them once you are discharged so
you can talk to Dr [**Last Name (STitle) **] to see if there are any cancellations.**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
|
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icd9cm
|
[
[
[]
]
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[
"45.23",
"45.13",
"45.19"
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icd9pcs
|
[
[
[]
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|
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|
298, 303
|
18323, 18323
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,999
| 156,853
|
29046
|
Discharge summary
|
report
|
Admission Date: [**2152-11-3**] Discharge Date: [**2152-11-8**]
Date of Birth: [**2084-9-21**] Sex: M
Service: MEDICINE
Allergies:
Epinephrine
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization without intervention
History of Present Illness:
Patient is a 68M h/o CAD s/p CABG, DM2, CRI presented to OSH
[**2152-11-2**] with chest pain. Initially noted intermittent 'shooting'
pains in his chest on [**10-31**] that radiated throughout body. On
[**11-2**] at 10am, developed [**10-10**] substernal chest pressure while
defecating that radiated to the neck. Associated with
diaphoresis and nausea but no SOB. He took SL nitro x 3 without
improvement and called EMS.
At OSH, ECG revealed sub-mm ST elevations and TWIs in V5-[**Street Address(2) 69974**] depressions V1-V4. Cardiac enzymes were positive (CK 409, MB
17, MBI 4, TnT 2.4). Given aspirin 325mg, plavix 600mg load, IV
lopressor, and heparin gtt. He became pain free on nitro gtt and
morphine prn. BNP 4300 with normal CXR. On [**11-3**] early AM, he
was found to be in AF with RVR 120's. No prior h/o AF or
palpitations per his report. Transferred to [**Hospital1 18**] for cath.
Received pre-cath hydration. Cath revealed totally occluded
native vessels, fresh thrombus in SVG->OM, and occluded stubs in
the SVG->diag and SVG->RCA; the SVG->PDA and LIMA->LAD were
patent. No intervention given >48hrs since event. Right heart
cath was not performed. While in holding area s/p cath, became
increasingly dyspnic. Noted to be in AF with HR 110's. Denies
palpitations. Also somnolent s/p fentanyl with observed apneic
episodes. Chest pain free.
On ROS, reports claudication for years. Currently can walk only
10 feet without pain, resolves with rest. No resting
claudication. Denies PND and ankle edema. Recent worsened
orthopnea (1->2 pillow). No abdominal pain, nausea, vomiting,
diarrhea, melena, hematochezia, headache, fevers, or chills.
Past Medical History:
1) CAD s/p CABG ([**2140**])
- LIMA->LAD
- SVG->OM
- SVG->diag
- SVG->RCA
- SVG->PDA
2) IMI ([**9-/2150**]) c/b transient complete heart block
3) HTN
4) Hypercholesterolemia
5) Tobacco abuse
6) DM2 with nephropathy, neuropathy
7) Obesity
8) CRI
9) PVD h/o right femoral artery occlusion
10) Cataracts
11) Low back pain
Social History:
Retired, lives alone. Current smoker, 50 pack-year history. [**1-3**]
glasses wine with dinner. No illicits.
Family History:
Mother with MI (died 62). Father with DM2 and metastatic
prostate CA.
Physical Exam:
vitals T 97.0 HR 107 irregular BP 121/72 RR 16 SaO2 97% RA
Weight 93kg
General: WDWN, mild tachypnea
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no LAD, unable to assess JVP, no
bruits
Cardiac: irregularly irregular, s1s2 normal, no m/r/g
Pulmonary: crackles left base, scattered mild expiratory wheeze
Abdomen: +BS, soft, obese, voluntary guarding, no rebound, no
HSM
Extremities: cool, 1+ DP pulses, no edema
Neuro: somnolent but arousable, oriented, speech clear, follows
commands, CNII-XII intact, [**4-5**] grip strength upper extremities,
5/5 strength lower extremities, FTN intact, DTRs 2+ biceps and
patellar, downgoing toes bilaterally
Pertinent Results:
Laboratory Results:
[**2152-11-3**] 01:42PM WBC-10.8 RBC-4.68 HGB-15.1 HCT-42.2 MCV-90
MCH-32.2* MCHC-35.8* RDW-13.7
[**2152-11-3**] 01:42PM PLT COUNT-197
[**2152-11-3**] 01:42PM PT-12.0 PTT-25.5 INR(PT)-1.0
[**2152-11-3**] 01:42PM GLUCOSE-269* UREA N-39* CREAT-1.7* SODIUM-139
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-29 ANION GAP-17
[**2152-11-3**] 01:42PM ALT(SGPT)-32 AST(SGOT)-48* LD(LDH)-583*
CK(CPK)-283* ALK PHOS-71 AMYLASE-42 TOT BILI-1.4
[**2152-11-3**] 01:42PM LIPASE-20
[**2152-11-3**] 01:42PM CK-MB-12* MB INDX-4.2 cTropnT-2.56*
[**2152-11-3**] 01:42PM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-2.3
[**2152-11-3**] 01:42PM TSH-1.7
[**2152-11-5**] 07:00AM BLOOD WBC-12.6* RBC-4.10* Hgb-13.2* Hct-36.5*
MCV-89 MCH-32.2* MCHC-36.1* RDW-13.8 Plt Ct-199
[**2152-11-5**] 10:20AM BLOOD PT-13.7* PTT-112.4* INR(PT)-1.2*
[**2152-11-5**] 07:00AM BLOOD Glucose-72 UreaN-42* Creat-1.5* Na-141
K-3.6 Cl-100 HCO3-27 AnGap-18
.
ECG ([**11-3**]): atrial fibrillation, 109 bpm, normal axis and
intervals, sub-mm STE and TWI V5-6, STD V1-V4
.
Relevant Imaging:
1)Cardiac cath ([**2152-11-3**]): 1. Coronary angiography in this right
dominant system demonstrated LMCA without angiographically
significant disease. The LAD, LCX and RCA were all proximally
occluded, as previously known.
2. The LIMA to LAD graft was widely patent and the distal LAD
was
satisfactory. The SVG to PDA was patent. The SVG to R-PL and the
SVG to
OM were totally occluded stubs. The SVG to diagonal was freshly
occluded
with thrombus present. 3. Limited resting hemodynamics revealed
systemic arterial pressure of 98 mmHg systoic and 66 mmHg at
diastole.
4. Recommend medical therapy; SVG to diagonal not suitable for
PCI or
thrombolytics.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA to LAD and SVG to R-PDA. Occluded SVGs to OM,
diagonal
and R-PL.
.
2)ECHO([**11-3**]):1. The left atrium is markedly dilated. The right
atrium is moderately dilated. 2. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed. Inferior and lateral hypokinesis to
akinesis is present.
3. The aortic root is mildly dilated. The ascending aorta is
mildly dilated. 4. The aortic valve leaflets are mildly
thickened.
5. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-3**]+) mitral regurgitation is seen. 6. There is mild
pulmonary artery systolic hypertension. 7. There is a small to
moderate sized pericardial effusion.
.
3)CXR ([**11-3**]):Mild cardiomegaly. Cannot exclude small pleural
effusion.
.
4)CXR ([**11-6**]): 1. Interval development of infiltrate in right
lower lobe worrisome for pneumonia. 2. Pulmonary vascular
engorgnent with bilateral pleural effusions in the setting of
cardiomegaly, likely representing CHF.
Brief Hospital Course:
A/P: 68M h/o CAD s/p CABG presents with STEMI, new-onset AF with
RVR, and dyspnea.
.
# CAD: The patient was taken to cardiac cath which revealed
fresh thrombus in SVG->OM graft and likely old totally occlusion
of SVG->RCA and SVG->diag grafts. The SVG->OM and LIMA->LAD
grafts were patent. No intervention was performed given that the
patient presented >48 hours from symptom onset and infarction
completed. TTE revealed new lateral wall hypokinesis and
diminished systolic function c/w recent infarct. He was given
aspirin, plavix, statin, beta-blocker; however plavix was
discontinued prior to discharge given no PCI. He will f/u with
his cardiologist.
.
# CHF: EF 35%. Initially volume overloaded but diuresed with
lasix and euvolemic at discharge; started on toprol XL and
lisinopril. 2gm Na diet.
.
# Atrial fibrillation: paroxysmal. AF with RVR at presentation,
spontaneously converted to sinus rhythm and then back into AF.
Loaded with amiodarone (normal QTc, TFTs, and LFTs; he will need
outpatient PFTs) and cont on beta-blocker for rate control.
Heparin gtt started and bridged to coumadin with goal INR [**2-4**].
He was given [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor at discharge.
.
# Chest/neck pain: Multiple episodes of sharp migratory stabbing
pains during admission. DDx included pericarditis,
musculoskeletal pain, or rate relate angina. atypical for
angina, no specific ECG changes, and cardiac enzymes cont to
trend down. He was given tylenol prn with good response.
.
# Anemia: Hct decreased likely due to blood loss during cath and
dilutional componenent from pre-cath fluids. Remained stable. No
groin hematoma/bleeding and RP bleed unlikely. Will need
outpatient Hct check by PCP.
.
# Dyspnea: likely [**2-3**] volume overload from pre-cath hydration
for IV contrast nephropathy prophylaxis. CXR revealed small left
effusion, RLL opacity. Low-grade fevers and mild elevation WBC;
started ceftriaxone and azithromycin. Discharged to complete
course of augmentin.
.
# Pericardial effusion: small volume, noted incidentally on
echocardiogram. possibly post-MI. no evidence tamponade
physiology. Pulsus ~ 7. suggest outpatient f/u echo to assess
resolution.
.
# Acute on CRI: baseline Cre ~1.4; initially increased to 1.7
but returned baseline prior to discharge. likely pre-renal.
received pre-cath hydration for IV contrast nephropathy
prophylaxis.
.
# DM: hyperglycemic at presentation with daytime blood sugars
200's. cont regimen regimen of NPH/humalog and FS qid with HISS.
.
# Altered mental status: Pt somewhat confused intially. DDx
includes sundowning vs. toxic-metabolic [**2-3**] peri-cath
medications and hypercarbia, however given AF of unclear
duration there was initial concern for embolic disease. Neuro
consulted who believed low likelihood CVA. CT head with no
bleed, mass effect but did reveal old lacunar infarcts. U/A neg,
culture pending. Mental status cleared.
.
# Abnormal LFTs: elevated AST likely [**2-3**] passive hepatic
congestion due to volume overload.
.
# Hypercholesterolemia: cont statin
.
# Respiratory alkalosis: Resolved. probable hyperventilation due
to pain in setting of bicarb infusion for renal protection. pt
is likely CO2 retainer from OSA.
.
# Low back pain: no acute issues, tylenol prn
.
# ?Sleep apnea: Noted to have apnic periods during admission.
Obese body habitus. Would recommend outpatient sleep study for
OSA.
.
Medications on Admission:
At home:
Imdur 30mg qd
Folate 1mg qd
Lipitor 20mg qd
Lopressor 25mg [**Hospital1 **]
NPH insulin 16 qam 45qpm
Humalog insulin 10 qam 18 qpm
On transfer:
Aspirin 325mg qd
Plavix 75mg qd
Lipitor 80mg qd
Lopressor 25mg [**Hospital1 **]
Nitropaste 1" q6h
Colace 100mg qd
Folate 1mg qd
Insulin
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: 1-2 Tablets PO BID (2 times a
day): Please take one pill twice a day for 14 days, then take
one pill once a day ongoing.
Disp:*90 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: start
on [**2152-11-9**].
Disp:*30 Tablet(s)* Refills:*2*
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
months supply Subcutaneous twice a day: 16 units qam
45 units qpm.
10. Humalog 100 unit/mL Solution Sig: One (1) months supply
Subcutaneous twice a day: 10 units qam
18 units qpm.
11. Augmentin XR 1,000-62.5 mg Tablet Sustained Release 12HR
Sig: Two (2) Tablet Sustained Release 12HR PO twice a day for 7
days.
Disp:*28 Tablet Sustained Release 12HR(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial infarction
Atrial fibrillation
Discharge Condition:
Good
Discharge Instructions:
Please return to the hospital or call your PCP if you experience
any shortness of breath, chest pain, lightheadedness, or any
other symptoms that concern you.
.
You have been started on several new medications during this
admission. Please make sure to take all medications as
prescribed.
.
New medications: amiodarone, augmentin, lisinopril, coumadin,
aspirin, toprol XL, nitroglycerin
Discontinued medications: imdur, lopressor
Changed medications: lipitor
.
Note, you have been started on coumadin. You must have your INR
checked regularly by your PCP. [**Name10 (NameIs) 357**] follow up with all
appointments that have been made for you.
.
You have been diagnosed with atrial fibrillation. You are on a
medication called amiodarone which will help keep your heart
beating in normal sinus rhythm. This medication must be
monitored. You will need to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
for your atrial fibrillation and amiodarone dosage. Please keep
this appointment.
Followup Instructions:
You need to have your INR (coumadin) level checked at your PCP's
lab on Friday [**2152-11-10**]. They will call you with a time. Call
[**Telephone/Fax (1) 40489**] for your appointment time if you have not heard
from them by [**2152-11-9**].
.
You have an post-discharge f/u appointment with your PCP, [**First Name8 (NamePattern2) 1692**]
[**Last Name (NamePattern1) **], at 2:30pm on [**2152-11-15**]. Phone: [**Telephone/Fax (1) 40489**].
.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5686**] on [**2152-11-16**] at
1:15pm.
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], ([**Telephone/Fax (1) 9530**], [**Hospital Ward Name 12837**], [**Hospital Ward Name **]-4 on [**2152-12-15**] at 1:20pm.
.
|
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icd9cm
|
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[
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[
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icd9pcs
|
[
[
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]
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|
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|
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,451
| 170,498
|
20180
|
Discharge summary
|
report
|
Admission Date: [**2185-11-30**] Discharge Date: [**2185-12-13**]
Date of Birth: [**2121-8-30**] Sex: M
Service: MICU
CHIEF COMPLAINT: Transferred for further management.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old man
admitted to the [**Hospital3 26615**] Hospital on [**2185-11-22**] with
gallstone pancreatitis. He underwent unsuccessful endoscopic
retrograde cholangiopancreatiography there, and was briefly
transferred to the [**Hospital6 256**] on
[**2185-11-25**] for repeat ERCP. Successful sphincterotomy
and stone extraction was performed.
He returned to the [**Hospital3 26615**] Hospital where his course was
marked by the development of pancreatitis, hypoxic
respiratory failure, hypotension, and progressive abdominal
distention. He was intubated, received aggressive fluid
resuscitation, and was started on broad-spectrum antibiotics,
as well as total parenteral nutrition. He had interval
imaging of the abdomen, as summarized below, which showed
necrotizing pancreatitis, and he was transferred to the [**Hospital6 1760**] for further management.
ALLERGIES: None known.
MEDICATIONS ON TRANSFER:
1. Imipenem 500 mg intravenously q 6 h.
2. Levothyroxine 0.0625 mg q 24 h intravenously.
3. Pantoprazole 40 mg intravenously q 12 h.
4. Regular insulin infusion [**4-20**] U/h continuously.
5. Lorazepam 0.5-2 mg q h prn.
6. Morphine sulfate prn.
PAST MEDICAL HISTORY:
1. Gallstone pancreatis, as described above.
2. Type 2 diabetes mellitus, unknown complications.
3. Hypothyroidism, on stable replacement.
4. Osteoarthritis and leg cramps treated with quinine and a
[**Doctor Last Name **]-II inhibitor.
5. Cerebrovascular accident in [**2181**] with right hand numbness.
6. Hypertension, on an ACE inhibitor as an outpatient.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: As reported on transfer, the patient smokes
[**5-21**] cigars per day. He does not drink alcohol or use drugs.
PHYSICAL EXAMINATION: Temperature 99.5, heart rate 120,
blood pressure 161/73. He was intubated. The ventilator was
set to volume supported assist control with fractional
inspired oxygen of 0.7, tidal volume 700 cu cm, respiratory
rate 14, SPO2 97%.
GENERALLY: He was ill-appearing.
HEENT: Normocephalic, atraumatic, anicteric, normal
conjunctivae. Pupils equal, round and reactive to light from
2.5 mm to 1.0 mm.
NECK: Jugulovenous distention was 4 cm. There was no
carotid bruit. There was no thyromegaly. A nasogastric tube
and an endotracheal tube were in place.
NODES: There was no anterior cervical, posterior cervical,
supra or infraclavicular, axillary or inguinal adenopathy.
HEART: The PMI was in the fifth rib space in midclavicular
line. It was tachycardia. There was a normal S1 and S2.
There was no S3, S4, murmurs, rubs or gallops.
LUNGS: Rhonchi bilaterally extending from the bases
anteriorly approximately halfway up both fields.
ABDOMEN: Distended, decreased bowel sounds, tympanitic with
percussion splash, but no shifting dullness. He was too
heavily sedated to assess for tenderness. There was
reducible umbilical hernia. Scrotal edema was also
appreciated.
BACK: Not assessed initially; however, there were no skin
lesions appreciated throughout his hospital course.
VASCULAR: The carotid and femoral pulses were brisk and
equal.
EXTREMITIES: There was no rash, clubbing, or cyanosis.
There was +2 edema in the lower extremities from the toes to
the midcalves, and from the fingertips to the midforearms.
NEUROLOGIC - Mental status: Sedated, intubated.
Cranial nerves: I not tested formally; II, III, IV, VI
normal, as above. The corneal reflex was present. V and VII
symmetric with intact sensation. VIII not tested formally.
IX, X, XII - gag to manipulation of the ETT. [**Doctor First Name 81**] not tested.
Motor: Normal bulk and tone.
Upper extremities and lower extremities: He was paralyzed
for transport, but he was able to move all four extremities
spontaneously following transfer, as well as prior to
transfer.
Sensory: Not assessed.
Coordination: Not assessed.
Deep tendon reflexes: Not assessed.
LABORATORY EVALUATION AM OF TRANSFER: White blood cell count
8.3, hemoglobin 9.7, hematocrit 28.8, platelets 143.
Chemistry - sodium 143, potassium 4.4, chloride 116,
bicarbonate 16, blood urea nitrogen 20, creatinine 1.4,
glucose 263, calcium 9.1, albumin 3.4, ALT 71, AST 125,
alkaline phosphatase 91, total bilirubin 4.6, thyroid
bilirubin 3.7, INR 1.2. Arterial blood gas - pH 7.37, PCO2
35, PO2 114, SAO2 97% on volume supported assist control with
an FIO2 of 0.5, tidal volume 700, rate 14.
Lipase last recorded on [**11-25**] was 320, amylase
100--last recorded on [**11-28**].
ECG taken on [**2185-11-22**]: Sinus at 64, PR interval less
than 0.2, QT 0.4, axis +30, with normal R wave progression,
right bundle branch block that was stable from a previous
tracing of [**2180-1-1**] by report. There was no evidence of
ischemia, injury or infarction.
Chest x-ray from [**11-29**]: Hazy bibasilar densities, left
greater than right, both with pleural effusions.
Abdominal ultrasound on [**11-24**]: Showed multiple
gallstones without evidence of ductal dilation. Splenomegaly
(16.5 cm diameter) was also appreciated.
Computed tomographic angiogram of chest: Did not reveal
proximal emboli.
Abdominal CT from [**11-24**]: Showed bibasilar pulmonary
densities, likely reflecting scarring or atelectasis. There
was cholelithiasis without evidence of cholecystitis.
Splenomegaly was also noted. The pancreatic margins were
indistinct.
Interval CT of the abdomen on [**11-28**]: Showed evidence of
greater than 50% necrosis of the pancreas. There was no
abscess or free air identified.
Please see the LMR for the findings of his ERCP.
HOSPITAL COURSE BY PROBLEMS - 1) PANCREATITIS: The patient's
imipenem was continued. In addition, he received a 10-day
course of fluconazole. Aggressive volume resuscitation was
required, and at its peak the patient was 35 kg positive (He
went from 101 at baseline to 137.). For the first 4 days,
adequate urine output, oxygenation and ventilation were
maintained. However, he had persistent fevers and several
episodes of hypotension, culminating in oliguria and
ultimately anuria.
He had a CT-guided fine needle aspiration of the
peripancreatic fluid collection which was acellular and
sterile. Total parenteral nutrition was started, and liberal
calcium, magnesium and potassium repletion was required.
2) RENAL FAILURE: As described above, the patient became
oliguric. He was started on continuous venovenous
hemofiltration, largely to remove the third space fluid that
had accumulated in his resuscitation, but also to provide
some clearance of metabolites. His CVVHF was complicated by
repeated clotting of the filter, as well as episodes of
hypotension following large volume removal. On hospital day
#13, CVVHF was discontinued.
Coincident with this termination, the patient became
progressively more febrile, although his cultures, as
described above, remained sterile. He was also hypotensive,
hypoxic and slightly hypercarbic.
3) TYPE 2 DIABETES: The patient's glycemia was controlled
adequately with continuous insulin infusion with the dose
depending on the presence or absence of total parenteral
nutrition administration.
4) HYPOTHYROIDISM: The patient received half of his usual
oral dose parenterally. An interval TSH level was normal.
After two weeks, the patient did not show improvement, and
his daughter, [**Name (NI) **] [**Name (NI) 54239**], was contact[**Name (NI) **] regarding the goals
of his care. She stated that the patient has a Living Will
and expressly does not want aggressive measures pursued if
they mean that his quality of life will be compromised. She
specifically stated that he does not want a gastrostomy or
tracheostomy. After discussion with the surgical service
regarding the very high morbidity and mortality of possible
debridement of his necrotic pancreas, she stated that it was
her family's wish to withdraw care. Comfort measures were
then pursued.
DISCHARGE DIAGNOSES:
1. Gallstone pancreatitis.
2. Type 2 diabetes mellitus, unknown complications.
3. Hypothyroidism, on stable replacement.
4. Osteoarthritis and leg cramps treated with quinine and a
[**Doctor Last Name **]-II inhibitor.
5. Cerebrovascular accident in [**2181**] with right hand numbness.
6. Hypertension, on an ACE inhibitor as an outpatient.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2185-12-13**] 11:45
T: [**2185-12-13**] 13:35
JOB#: [**Job Number 54240**]
|
[
"995.92",
"276.6",
"560.1",
"577.0",
"427.5",
"518.83",
"584.5",
"280.0",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"54.91",
"38.95",
"99.04",
"99.15",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
1804, 1822
|
8115, 8719
|
1975, 3515
|
157, 194
|
223, 1132
|
3568, 8094
|
3531, 3551
|
1157, 1404
|
1426, 1787
|
1839, 1952
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,586
| 145,697
|
53711
|
Discharge summary
|
report
|
Admission Date: [**2127-4-27**] Discharge Date: [**2127-4-28**]
Date of Birth: [**2051-5-6**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Intracranial Hemorrhage
Major Surgical or Invasive Procedure:
Mechanical Intubation and Ventilation
History of Present Illness:
Patient is a 75 year old female who presents with AMS. Per EMS
report, patient became acutely altered at 1630. A report of a
fall without headstrike was obtained after family arrived. EMS
found patient grabbing left side of head. She remained flacid on
right side. Upon arrival to [**Hospital3 **] FS in 130's. Exam
demonstrated withdrawal on right side and some spontaneous
movement on left. She had disconjugate gaze and symmetric and
reactive pupils at 2 mm. CT head obtained demonstrating large
left sided intraparenchymal hemorrhage with substantial
subfalcine herniation. Patient with INR of 2.8, anticoagulated
for valve and AF. Patient given 100 mg of Lidocaine IV x 1 and
intubated with Etomidate 20 and Succ 120. She was given Mannitol
50 g IV x 1 and placed on Propofol for sedation. CXR showed
right main stem intubation and tube adjusted. After family
arrived, history of fall obtained and collar placed. CT c-spine
was not imaged at [**Hospital3 15402**] do to time constraints. Vent
settings TV 400 mL, PEEP 5, Rate 16 and FIO2 of 100%. Patient
given Vitamin K 10 mg IV x 1 and 2 units FFP here. No beriplex
or profilnine available.
.
In the ED, both neurosurgery and neurology were consulted.
Neurosurgery felt this was likely hypertensive bleed or
hemorrhagic conversion of infarct. STAT repeat head CT shows
progression of the bleed and now shows casted 4th ventricle and
developing hydrocephalus in the setting of significantly
enlarging Left IPH with worsening MLS and herniation. No options
for surgical intervention due to devastating injury. Neurology
also felt that these findings were not survivable.
Past Medical History:
afib
valve replacement
Social History:
unable to confirm
Family History:
unable to confirm
Physical Exam:
PHYSICAL EXAM
Vitals: 96.7 159/65 79 99%
General: intubated, sedated, non-responive to verbal or tactile
stimuli
HEENT: intubated. pupils 1mm sluggishly reactive
Neck: supple, JVP not elevated, no LAD
CV: irreg irreg rhthym, normal rate
Lungs: Clear to auscultation anteriorly
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, echymoses over left leg
Neuro: sedated, not awakening. Not responsive noxious stimuli
(sternal rub, nail bed pressure). Pupils are equal and 1mm
slugishly reactive. No spontaneous movements
Pertinent Results:
LABS
[**2127-4-27**] 08:24PM BLOOD Type-ART Rates-17/ Tidal V-400 PEEP-5
FiO2-100 pO2-430* pCO2-36 pH-7.41 calTCO2-24 Base XS-0 AADO2-244
REQ O2-48 -ASSIST/CON
Intubat-INTUBATED
IMAGING
CXR [**5-4**]
FINDINGS: Single semi-erect AP portable view of the chest was
obtained.
Endotracheal tube is seen, terminating approximately 3 cm above
the level of the carina. A nasogastric tube is seen coursing
below the level of the
diaphragm, side port not seen, although distal aspect projecting
over the
expected location of the proximal stomach. There is moderate
pulmonary edema. Left base opacity is seen, which could relate
to overlapping soft tissues and edema, although underlying
consolidation or atelectasis and small effusion are not entirely
excluded. The patient is status post median sternotomy and
cardiac valve replacement. No pneumothorax seen. Aortic knob
calcification.
CT scan head w/o contrast
FINDINGS: A large left frontal hematoma arising from the left
basal ganglia measures up to 8.0 x 4.7 cm axially and has
enlarged since the [**2127-4-27**] 5:02 p.m. reference study.
There has been interval slight worsening of rightward midline
shift, now to 12 mm. Blood products are seen within the left
lateral ventricle, which is nearly completely effaced. There is
increased layering blood along the left lateral occipital [**Doctor Last Name 534**]
(2:12). There is mild effacement of the left aspect of the
suprasellar cistern (2:9). The quadrigeminal cistern remains
preserved. There is soft tissue crowding at the foramen magnum
(2:1), also seen on the reference examination. There is
worsening sulcal effacement of the left vertex (2:22).
There is no acute fracture. The middle ear cavities, mastoid air
cells, and included views of the paranasal sinuses are clear.
IMPRESSION: Enlarging left frontal intraparenchymal hematoma
with worsening mass effect, including increased rightward
midline shift, early left suprasellar cistern effacement,
tonsillar fullness at the foramen magnum, and left vertex sulcal
effacement.
The study and the report were reviewed by the staff radiologist.
CT C-Spine
FINDINGS: There is no acute fracture or traumatic malalignment
of the
cervical spine. Mild multilevel degenerative changes are
present, worst at
C5/6 and C6/7, where there is endplate sclerosis and anterior
and posterior
osteophytosis, but no appreciable narrowing of the thecal sac.
There is no
prevertebral soft tissue abnormality. The patient is
post-intubation and
orogastric tube placement. Included views of the lung apices are
clear. The
thyroid is normal.
IMPRESSION: No acute fracture or traumatic malalignment of the
cervical
spine.
Brief Hospital Course:
ICH: Injury deemed non-survivable by neurology/neurosurgery.
Unclear if bleed precipitated or was result of fall. Admitted
to ICU intubated. After family meeting, patient made CMO, was
extubated, and passed away several hours later.
Medications on Admission:
patient deceased
Discharge Medications:
patient deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
patient deceased
Discharge Condition:
patient deceased
Discharge Instructions:
patient deceased
Followup Instructions:
patient deceased
|
[
"E888.9",
"V58.61",
"853.01",
"414.00",
"348.4",
"V45.81",
"427.31",
"434.91",
"V43.3",
"331.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5786, 5795
|
5438, 5678
|
309, 348
|
5855, 5873
|
2753, 5415
|
5938, 5957
|
2104, 2124
|
5745, 5763
|
5816, 5834
|
5704, 5722
|
5897, 5915
|
2139, 2734
|
246, 271
|
376, 2005
|
2027, 2052
|
2068, 2088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,767
| 173,368
|
50129+59232
|
Discharge summary
|
report+addendum
|
Admission Date: [**2115-8-29**] Discharge Date:
Date of Birth: [**2069-2-27**] Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 46 year old
female with a complicated past medical history, admitted on
[**2115-8-28**] for a chief complaint of stridor. She
presented with a three day history of shortness of breath,
noisy breathing, upper respiratory infection symptoms and
odynophagia. On a recent hospital, between [**2115-4-26**] and
[**2115-6-28**], the patient was intubated for aspiration
pneumonia which led to acute respiratory distress syndrome.
The patient subsequently underwent tracheostomy on [**2115-5-25**] and decannulated seven weeks prior to this admission.
The patient has a history of bilateral vocal cord paralysis
of unknown etiology. In the Emergency Room, the patient was
given steroids, racemic epinephrine and ceftriaxone times
one, with minimal improvement. She was taken to the
Operating Room for an emergent tracheostomy and transferred
to the Medical Intensive Care Unit for observation.
The patient's current issues include:
1. Infectious disease: On Unasyn for upper respiratory
infection/tracheobronchitis.
2. Coronary artery disease: Ruled out for a myocardial
infarction.
3. Congestive heart failure: Pulmonary edema on chest
x-ray, being diuresed with intravenous Lasix.
4. Hypertension: Blood pressure elevated post procedure.
5. Fluids, electrolytes and nutrition: The patient has
hyperkalemia.
Upon transfer to the floor, the patient is complaining of
mild head congestion, also complaining of double vision which
resolves when she covers one eye, either right or left. Her
diplopia started in [**Month (only) 205**] and has been worse over the past few
days. The patient is complaining of increased secretions
from her tracheostomy. The patient thinks it might be food
that she is aspirating. The patient denies shortness of
breath or chest pain.
PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus with
history of lupus nephritis, vasculitis and cerebritis,
diagnosed at age 27. 2. Hepatitis B. 3. Hypertension. 4.
Peptic ulcer disease. 5. Gout. 6. Transient ischemic
attacks in [**2104**]. 7. Congestive heart failure. 8. Chronic
renal insufficiency, previously on hemodialysis but not
currently. 9. History of recurrent urinary tract
infections. 10. History of liver mass, found to be benign
on liver biopsy in [**2114-7-10**]. 11. History of alcohol
abuse. 12. Status post L5-S1 and S2 diskectomies in [**2110**].
13. History of pancreatitis secondary to alcohol abuse. 14.
History of spontaneous bacterial peritonitis. 15. History
of Clostridium difficile colitis. 16. Depression. 17.
Splenectomy status post motor vehicle accident. 18.
Dysphagia with past history of tube feeds. 19.
Echocardiogram in [**2115-5-10**] showed dilated right atrium,
mildly dilated left atrium, systolic function with left
ventricular ejection fraction of 75%, right ventricular
hypertrophy, bicuspid aortic valve, 2+ aortic regurgitation,
2+ mitral regurgitation, decreased right ventricular systolic
function.
MEDICATIONS ON ADMISSION: Prednisone 5 mg p.o.q.d., Prilosec
20 mg p.o.q.d., Lasix 40 mg p.o.q.d., Zoloft 100 mg p.o.q.d.,
Norvasc 10 mg p.o.q.d., Serax 15 mg p.o.q.h.s.p.r.n.; upon
transfer, Zofran 2 to 4 mg i.v.q.8h.p.r.n., Protonix 40 mg
p.o.q.d., Lasix 40 mg p.o.q.d., regular insulin sliding
scale, Unasyn 1.5 mg i.v.q.6h., thiamine 100 mg p.o.q.d.,
folate 1 mg p.o.q.d., Prednisone 5 mg p.o.q.d., Zoloft 100 mg
p.o.q.d., Norvasc 10 mg p.o.q.d., Serax 10 mg
p.o.q.h.s.p.r.n., Dilaudid 2 to 4 mg p.o.q.6h.p.r.n.,
Lopressor 50 mg p.o.t.i.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient smokes one pack per day and has
a prior history of alcohol abuse.
LABORATORY DATA: Chest x-ray showed stable cardiomegaly with
increased congestive heart failure and increased left
effusion; ill-defined lucency along the left upper
mediastinum, possibly representing air in distended
esophagus, however, mediastinal air collection could not be
ruled out; recommend follow-up study.
PHYSICAL EXAMINATION: On physical examination, the patient
had a temperature of 98.7, pulse 80, respiratory rate 22,
blood pressure 157/93, and oxygen saturation 100% in room
air. General: Patient alert, in no acute distress. Head,
eyes, ears, nose and throat: Extraocular movements intact,
diplopia with downward gaze. Neck: Tracheostomy in place.
Cardiovascular: Regular rate and rhythm, II/VI systolic
ejection murmur at left upper sternal border. Lungs:
Minimal rales at bases. Abdomen: Soft, nontender,
nondistended, positive bowel sounds. Extremities: No edema.
Neurologic examination: Cranial nerves II through XII
intact, no nystagmus, diplopia disappears when either eye is
covered, made worse with downward gaze.
HOSPITAL COURSE: 1. Pulmonary: The tracheostomy remained
in place for the duration of the hospitalization. A repeat
chest x-ray was negative for air leak in mediastinum. The
patient is to follow up with otolaryngology upon discharge.
She is to continue Prednisone 5 mg daily.
2. Infectious disease/tracheobronchitis: Once an air leak
in the mediastinum was ruled out, intravenous Unasyn was
discontinued. Since the tracheobronchitis was likely viral,
antibiotics were not continued.
3. Congestive heart failure: The patient's congestive heart
failure stabilized after diuresis with intravenous Lasix.
The patient was continued on her home dose of oral Lasix.
4. Hypertension: The patient was restarted on her home
medications of Norvasc, atenolol and lisinopril. The
lisinopril was titrated upward to a dose of 30 mg daily.
5. Gastrointestinal: An initial swallow study revealed mild
aspiration with all consistencies. The patient was allowed
to continue taking orals and her diet was advanced as
tolerated. No repeat swallow study was done.
6. Fluids, electrolytes and nutrition: The patient's
potassium returned to [**Location 213**] after one dose of Kayexalate.
7. Neurology: A neurology consult was obtained to evaluate
the patient's diplopia. Neurology felt that she had partial
cranial nerve palsy secondary to past multiple strokes. They
did not feel that [**Last Name **] problem was acute and recommended
follow-up in clinic as an outpatient.
CONDITION AT DISCHARGE: Satisfactory.
DISCHARGE STATUS: The patient will be discharged to a
rehabilitation facility.
DISCHARGE MEDICATIONS:
Protonix 20 mg p.o.q.d.
Lasix 20 mg p.o.q.d.
Prednisone 5 mg p.o.q.d.
Zoloft 100 mg p.o.q.d.
Norvasc 10 mg p.o.q.d.
Atenolol 100 mg p.o.q.d.
Lisinopril 30 mg p.o.q.d.
Ultram 100 mg p.o.q.6h.p.r.n.
Dilaudid 2 mg p.o.q.6h.p.r.n.
Serax 15 mg p.o.q.h.s.p.r.n.
DISCHARGE DIAGNOSIS:
Upper respiratory infection leading to stridor, requiring
tracheostomy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22604**], M.D. [**MD Number(1) 22605**]
Dictated By:[**Name8 (MD) 7112**]
MEDQUIST36
D: [**2115-9-6**] 10:50
T: [**2115-9-6**] 11:40
JOB#: [**Job Number 104634**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 16982**]
Admission Date: [**2115-8-29**] Discharge Date: [**2115-9-12**]
Date of Birth: [**2069-2-27**] Sex: F
Service: General Internal Medicine [**Company 112**] Firm
ADDENDUM: Please see full discharge summary for hospital
course. Since then, the patient remained for another week in
the hospital, mainly for teaching of her tracheostomy care
and teaching of a Passy-Muir valve. At first the patient did
not seem to be attaining this new information well, however,
with continued teaching as well as involvement of her partner
she was able to learn how to sufficiently take care of her
trach as well as the contraindications for use of the
Passy-Muir valve. The patient continued to refuse
rehabilitation placement and insisted on going home from
here. At that point the case management looked into VNA
nursing for her, however, this required much consideration
given the complexity of her health. The patient was seen by
the ENT team on [**9-11**] for possible decannulation of her trach,
however, they decided that it would be best for the patient
to keep her trach in place for several more weeks and
possibly even change it to a different type of tracheostomy
called [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] before decannulation. The patient is to
follow-up at [**Hospital **] clinic within the next week or two. In
addition, in the last week of hospitalization the patient did
have a high white blood cell count of up to 25. She remained
afebrile. Her urinalysis showed 100 of protein, however,
this resolved within a few days and her white blood cell
count came down. She had no other signs of lupus flare to
necessitate a rheumatology consult and the patient was
discharged home on [**9-12**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home.
DISCHARGE MEDICATIONS: Lasix 40 mg po q d, Prednisone 5 mg
po q a.m., Zoloft 150 mg po q d, Norvasc 10 mg po q d,
Atenolol 100 mg po q d, Lisinopril 30 mg po q d, Ultram 100
mg po q 6 hours prn, Dilaudid 2 mg po q 6 hours prn, Serax 15
mg po q h.s. prn, Amitriptyline 50-100 mg po q h.s. prn,
Prilosec 20 mg po q d.
DISCHARGE DIAGNOSIS:
1. History of aspiration pneumonia leading to ARDS,
requiring tracheostomy.
2. Lupus with nephritis, vasculitis and cerebritis since age
of 27.
3. Hepatitis C.
4. Hypertension.
5. Peptic ulcer disease.
6. Gout.
7. TIAs [**2104**].
8. Congestive heart failure.
9. Chronic renal insufficiency.
10. Recurrent urinary tract infections.
11. Liver mass, benign, on biopsy [**7-/2114**].
12. Alcohol abuse.
13. Status post L5,S1,S2 discectomies [**2110**].
14. History of pancreatitis secondary to alcohol.
15. History of SBP.
16. History of C. diff colitis.
17. Depression.
18. Splenectomy, status post MVA.
19. Dysphagia, history of tube feeds.
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 17002**], M.D. [**MD Number(1) 17003**]
Dictated By:[**Last Name (NamePattern1) 1875**]
MEDQUIST36
D: [**2115-9-12**] 18:48
T: [**2115-9-13**] 10:25
JOB#: [**Job Number 17004**]
|
[
"466.0",
"478.34",
"357.5",
"786.1",
"710.0",
"276.7",
"428.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
9067, 9361
|
9382, 10314
|
3165, 3738
|
4908, 6383
|
4175, 4733
|
6398, 6494
|
158, 1953
|
4758, 4890
|
1976, 3138
|
3755, 4152
|
9008, 9043
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,711
| 147,808
|
54386
|
Discharge summary
|
report
|
Admission Date: [**2112-2-23**] Discharge Date: [**2112-3-1**]
Date of Birth: [**2056-1-27**] Sex: F
Service: MEDICINE
Allergies:
Morphine Sulfate / Pronestyl / Quinidine-Quinine Analogues /
Mexiletine / Captopril / Sulfa (Sulfonamide Antibiotics) / Latex
/ Nitrofurantoin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
progressive dyspnea
Major Surgical or Invasive Procedure:
right heart cath
PICC placement
History of Present Illness:
Mrs. [**Known lastname 111334**] is a 56 year old woman with a history of severe
dilated cardiomyopathy with an EF of [**10-24**]% (?viral vs
post-partum) s/p ICD placement who was admitted on [**2112-2-23**] for
severe shortness of breath and PND, presumably due to worsening
congestive heart failure. Given the lack of edema or hypoxia,
the patient was continued on her home regimen fo torsemide 30mg
PO QAM and 10mg PO QPM. Notable findings during her stay
included a BNP >4000 (baseline of 1000), trigger for severe
dyspnea/orthopnea, and an echo that showed profoundly worsened
EF now down to 5% from 10-15%, with severe dilation of the LV.
At the behest of her cardiologist, Dr. [**First Name (STitle) 437**], she underwent a
right heart cath with plans for a trial of milrinone therapy.
RHC revealed markedly elevated left and right heart filling
pressures that significantly improved with milrinone infusion.
If this milrinone trial fails, she would likely be transferred
to [**Hospital1 3278**] for a heart transplant evaluation.
.
On arrival to the CCU, the patient subjectively felt much better
after milrinone infusion. She had by that point made nearly
700cc of urine.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- Idiopathic vs post partum cardiomyopathy atleast since [**2092**],
EF of [**10-24**]%
- 64 year old female with post-partum dilated cardiomyopathy s/p
abdominal ICD implantation for NSVT and inducible VT in EP study
in [**2092**]. She had an abdominal ICD generator change on [**2096-2-8**].
In [**4-/2098**] she had abdominal ICD explantation and lead capping
due to discomfort. She had first transvenous ICD implant on
[**2098-5-29**] in the L pectoral region and had a device change
[**2103-3-7**]. Implantation of a [**Company 1543**] Secura VR Single Chamber
ICD in [**2108-9-14**].
3. OTHER PAST MEDICAL HISTORY:
- Incidental finding noted on chest CT scan of a 6 mm nodule,
mild restriction on PFTs
- status post cholecystectomy, status post appendectomy, two
C-sections
- remote asthma and multiple allergies
- anxiety
- ovarian cysts
- Lyme disease seeing specialists in [**State 531**].
Social History:
[**Known firstname **] is married, lives with her husband and has two daughters.
She smoked cigarettes in her 20s and has not smoked tobacco
since. Occasional wine.
Family History:
Father died suddenly at age 74. She reports he may have had a
heart attack and had diabetes near the end of his life. Mother
is alive and fairly healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.8 HR 90 BP 95/63 RR 25 O2 95%RA
GENERAL: Chronically ill appearing woman in NAD, AOx3 and
appropriate but mildly drowsy
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD
CARDIAC: large palpable precordial heave RRR, normal S1, S2. No
m/r/g. 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: Warm extremities with good cap refill. No c/c/e
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PHYSICAL EXAM ON DISCHARGE:
VS: T97.4, HR:95, BP99/50, RR18, O2sat:97%RA
General: less drowsiness
Extremities: PICC in place
Exam otherwise unchanged from admission
Pertinent Results:
ADMISSION LABS:
WBC-8.9 RBC-4.82 Hgb-14.3 Hct-42.6 MCV-88 MCH-29.7 MCHC-33.6
RDW-13.1 Plt Ct-275
Neuts-74.3* Lymphs-21.1 Monos-3.1 Eos-0.7 Baso-0.7
Glucose-120* UreaN-27* Creat-0.9 Na-140 K-3.4 Cl-98 HCO3-31
AnGap-14
proBNP-4779*
cTropnT-<0.01
.
STUDIES:
.
CXR ([**2112-2-23**]): PA and lateral views of the chest are compared to
previous exam from [**2111-8-10**]. Again seen is cardiomegaly
which is essentially stable from prior. The lungs remain clear.
There is a small left pleural effusion. Pacemaker wires are in
stable position. There are surgical clips in the upper abdomen,
potentially from prior cholecystectomy.
IMPRESSION: Small left pleural effusion. Stable cardiomegaly.
.
RIGHT HEART CATH ([**2112-2-24**]):
1. Resting hemodynamics revealed severely elevated filling
pressures
with a mean PCPW of 39mmHg and an RVEDP of 25mmHg. There was
severe
pulmonary hypertension with a PA pressure of 71/41mmHg. Cardiac
output
was diminished at 2.4L/min with an index of 1.3L/min/m2.
2. Following milrinone bolus and infusion of 0.5mcg/kg/min,
PCWP
decreased to mean of 30mmHg. PA pressure fell to 60/42mmHg, and
cardiac
output increased to 3.4L/min with an index of 1.9L/min/m2.
FINAL DIAGNOSIS:
1. Severe right- and left-sided heart failure with elevated
filling
pressures at rest.
2. Positive response to milrinone infusion with decrease in PA
pressure,
PCWP, and increase in cardiac output.
.
ECHO ([**2112-2-24**]):
Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is profoundly depressed (LVEF= 5 %). The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with severe global free wall hypokinesis. The
mitral valve leaflets are structurally normal. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. AT LEAST
moderate [2+] tricuspid regurgitation is seen. [Due to acoustic
shadowing from the ICD coil, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is no
pericardial effusion.
Compared to the prior study of [**2111-4-20**], the left
ventricular ejection fraction is even further reduced, and now
severe right ventricular contractile dysfunction is present,
with markedly increased tricuspid regurgitation and at least
moderate pulmonary hypertension.
.
LENIs ([**2112-2-24**]): Normal appearance of the deep venous structures
of the right and left lower extremities. No evidence of deep
venous thrombosis.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2112-2-25**] 7:30
AM
FINDINGS: As compared to the previous radiograph, the patient
has received a right internal jugular vein device, in addition
to the left pacemaker.
The size of the cardiac silhouette is still substantially
enlarged and the
presence of a small pleural effusion on the left cannot be
excluded.
Otherwise, there are signs of minimal fluid overload but no
overt pulmonary edema with no evidence of pneumonia. Unchanged
retrocardiac atelectasis.
.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2112-2-25**] 2:00 PM
Radiology Report -77 BY DIFFERENT PHYSICIAN [**Name9 (PRE) 2221**] Date of
[**2112-2-25**] 2:00 PM
The right PICC line tip is at the level of cavoatrial junction.
Right
internal jugular line tip is at the level of superior SVC. The
rest of the
findings are unchanged.
.
Cardiovascular Report ECG Study Date of [**2112-2-26**] 10:29:02 AM
Sinus rhythm with ventricular premature depolarizations.
Compared to the
previous tracing heart rate is reduced. Otherwise, no
significant change.
TRACING #2
.
Cardiovascular Report ECG Study Date of [**2112-2-26**] 9:53:36 AM
Sinus tachycardia. Left atrial abnormality. Non-specific QRS
widening. Left axis deviation. Left anterior fascicular block.
Diffuse non-diagnostic repolarization abnormalities. Compared to
the previous tracing of [**2112-2-24**] heart rate is increased.
Otherwise, no diagnostic change.
TRACING #1
.
Lab Results on Discharge:
[**2112-2-29**] 07:38AM BLOOD WBC-6.3 RBC-3.98* Hgb-11.8* Hct-34.9*
MCV-88 MCH-29.7 MCHC-33.9 RDW-13.2 Plt Ct-213
[**2112-2-24**] 05:50AM BLOOD Neuts-72.7* Lymphs-21.5 Monos-3.8 Eos-1.3
Baso-0.5
[**2112-3-1**] 09:00AM BLOOD PT-15.1* PTT-28.4 INR(PT)-1.4*
[**2112-3-1**] 09:00AM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-136
K-3.5 Cl-102 HCO3-28 AnGap-10
[**2112-2-26**] 04:47AM BLOOD ALT-59* AST-29 AlkPhos-85 TotBili-0.4
[**2112-2-24**] 11:00AM BLOOD CK-MB-1 cTropnT-<0.01
[**2112-2-29**] 07:38AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.2
[**2112-2-26**] 12:30AM BLOOD Type-ART pO2-91 pCO2-38 pH-7.49*
calTCO2-30 Base XS-5 Intubat-NOT INTUBA
[**2112-2-26**] 12:30AM BLOOD Glucose-105 Lactate-1.7 Na-137 K-3.5
Cl-100
[**2112-2-25**] 05:19AM BLOOD Hgb-12.4 calcHCT-37 O2 Sat-64
[**2112-2-26**] 12:30AM BLOOD freeCa-1.20
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 56 year old
woman with a history of severe dilated cardiomyopathy with an EF
of 5% (?viral vs. post-partum) s/p ICD placement who was
admitted on [**2112-2-23**] for severe SOB and PND, secondary to
worsening chronic systolic CHF. She was started on milrinone
drip and had improvement in symptoms and functional capacity
in-house. She was discharged home on milrinone drip with
follow-up with transplant cardiology at [**Hospital 3278**] Medical Center.
.
ACUTE CARE:
1. Chronic Systolic CHF: Patient presented with severe
dypspnea/orthopnea. This was especially bad at night when she
would have paroxysms of symptoms. Her EF was found to be 5%, BNP
elevated to 4000 from baseline of 1000, and left and right sided
pressures were markedly elevated (40s and 70s systolic
respectively) on right cath performed on admission. Patient was
subsequently admitted to CCU for initiation of milrinone. She
improved significantly on milrinone 0.5/hr infusion: CI rose
from 1 to 1.9, CO improved and trans-pulmonary gradient
decreased, which dramatically improved her pulmonary
hypertension. She was transiently hypotensive on milrinone [**2-11**]
milrinone's vasodilatory effects, which subsequently resolved
with MAPs consistently >55 afterward. Given her profoundly
reduced LV function, she was also started on Coumadin. Home
torsemide was restarted once pt was normotensive. Beta blocker
was initiated per patient's cardiologist. PICC was placed for
home milrinone infusion. She was transferred back to the floor,
where PT eval on milrinone showed asymptomatic during ADL's and
even climbing stairs. She was discharged home on the milrinone
drip. Patient will ultimately require heart transplant at [**Hospital1 3278**]
after optimization of hemodynamics with milrinone.
.
# ARRYTHMIA: Patient went into multifocal ATach on HD#4 likely
[**2-11**] discontinuation of her beta blocker after initiation of
milrinone. This resolved and she returned to NSR after
metoprolol 5mg IV. Per patient request and with her
cardiologist's permission, she was restarted on low-dose
metoprolol without recurrence of MAT.
.
# Left wrist Superficial Thrombophlebitis: Patient developed
superficial thrombophelbitis of left wrist since peripheral line
removal in the ICU. There was a superficial 3x3cm area of
erythema, warmth, and tenderness to palpation with a palpable
cord on the lateral aspect of patient's left wrist. This
initally improved with warm packs and elevation alone, but then
developed increasing erythema, tenderness, and induration. She
was started on a 7-day course of keflex to complete at home but
noted some improvement after 2 days on antibitics in the
hospital.
.
CHRONIC CARE
1. H/O LYME DISEASE, FUNGAL INFECTIONS: Per patient report, she
has history of chronic Lyme disease for which she is followed by
integrative medicine specialist at an OSH. She also reports h/o
fungal infections (no further details available). Per ID
consult, no further workup needed at this time as these issues
are unlikely related to her chronic heart failure.
.
2. ABNORMAL LFTs: Most likely secondary to congestive
hepatopathy. Iron studies and hepatitis viral studies WNL. They
were downtrending to normal range and monitoring was stopped
when they approached normal.
.
3. DEPRESSION/ANXIETY: Patient endorsed depression and SI
without a plan in the ED. She later denied suicidality. She
underwent psych eval in CCU where she was found to be mildly
delirious and it was recommended that home benzos be limited.
They also feel that she would benefit from talk therapy and
possibly antidepressant therapy as an outpatient. Also followed
by social work. Her mood and affect improved on HD#2, although
she did remain significantly anxious requiring frequent
reassurance and low-dose klonopin throughout.
.
4. ASTHMA: Patient has a remote history of asthma and is on prn
ipratropium at home. This was continued during hospitalization
with no issues.
.
TRANSITIONS IN CARE:
1. Medication Changes:
1. START milrinone infusion at home. The rate is
0.5mcg/kg/minute.
2. START cephalexin 500mg by mouth every 6 hours for six days
3. START saline nasal spray and fluticasone nasal spray as
directed while having nasal congestion.
4. START warfarin 5mg by mouth daily and adjust for INR under
direction of the [**Hospital3 **]. This medication is
important in lowering the risk of stroke.
5. START a daily multivitamin
6. START acyclovir 5% ointment. Apply to the affected area on
the lips every two hours while awake for three days.
7. START metoprolol succinate 50mg by mouth once daily
8. STOP taking metoprolol tartrate
9. STOP taking losartan as your blood pressure is not
tolerating this medication
10. CHANGE torsemide dosing to 40mg by mouth once daily.
11. START fexofenadine 60mg by mouth twice daily.
12. STOP nattokinase
13. START potassium chloride 20meq by mouth daily
2. FOLLOW-UP:
You will be contact[**Name (NI) **] by [**Name8 (MD) **] NP that works with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Hospital 3278**] Medical Center for an initial appointment in
evaluation for heart transplant. If you do not hear from them
within a week, they can be reached at: [**Telephone/Fax (1) 72785**]
Please keep the following other appointments:
Department: CARDIAC SERVICES
When: MONDAY [**2112-3-7**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2112-3-14**] at 12:00 PM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
Department: CARDIAC SERVICES
When: MONDAY [**2112-6-13**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please make an appointment to see your PCP [**Name Initial (PRE) 176**] 2 weeks of
discharge.
3. OUTSTANDING CLINICAL ISSUES:
-maintenance of coumadin therapy
-evaluation for heart transplant
-follow-up TTE's
-titration of milrinone with cardiologist
Medications on Admission:
Active Medication list as of [**2112-2-23**]:
Medications - Prescription
CLONAZEPAM - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 1 mg Tablet - 1/2-1 Tablet(s) by mouth three times a
day as needed
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol Inhaler - 1-2 puffs inhaled twice a day for wheezing
LOSARTAN [COZAAR] - 25 mg Tablet - one Tablet(s) by mouth twice
a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth two
times a day
NATTOKINASE - (Prescribed by Other Provider) - - one capsule
twice a day
NYSTATIN - 100,000 unit/gram Powder - apply to inflammed area
twice a day
TERCONAZOLE [TERAZOL 7] - 0.4 % Cream - insert in vagina once a
day
TORSEMIDE - 20 mg Tablet - 1.5 Tablet(s) by mouth every morning,
0.5 tablets by mouth every evening
Medications - OTC
ASPIRIN - (Prescribed by Other Provider; OTC) (Not Taking as
Prescribed: forgets) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day (not taking because she forgets)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth
COENZYME Q10 [CO Q-10] - (Prescribed by Other Provider; OTC;
Dose adjustment - no new Rx) - 300 mg Capsule - 1 Capsule(s) by
mouth twice a day
Discharge Medications:
1. milrinone in D5W 40 mg/200 mL Piggyback Sig: 0.5 mcg/kg/min
Intravenous continuous: OK to substitute 400mcg/mL strength
formulation.
[**2-29**] weight:74.8kg.
Disp:*30 day supply* Refills:*5*
2. clonazepam 1 mg Tablet Sig: 0.5-1 Tablet PO three times a day
as needed for anxiety: do not drive or operate machinery while
taking this medication.
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation [**Hospital1 **] (2 times a day) as needed for wheezing.
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*28 Capsule(s)* Refills:*0*
7. nystatin 100,000 unit/g Powder Sig: One (1) application
Topical twice a day.
8. terconazole 0.4 % Cream Sig: One (1) Appl Vaginal DAILY
(Daily) as needed for vaginal itching for 7 days.
9. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Vitamin D-3 2,000 unit Capsule Sig: One (1) Capsule PO once
a day.
11. coenzyme Q10 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
12. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day) as needed for nasal congestion.
Disp:*1 bottle* Refills:*2*
13. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
QID (4 times a day) as needed for dryness.
Disp:*1 bottle* Refills:*5*
14. acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS
DIRECTED) for 3 days: apply to affected area on lip every two
hours while awake for four days.
Disp:*1 unit* Refills:*0*
15. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
16. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
17. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2*
18. Outpatient Lab Work
Chem-10, PT/INR on [**2112-3-2**]
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary: Chronic Systolic Heart Failure
Secondary: Chronic pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 111334**],
It was a pleasure taking part in your care. You were admitted
for shortness of breath. You underwent cardiac catheterization
which showed worsening heart failure. We started some new
medications and adjusted others and your symptoms improved. You
also developed skin infection in your forearm for which we
started antibiotics. You are now discharged home to await
evaluation for heart transplant.
.
Please make the following changes to your medications:
.
1. START milrinone infusion at home. The rate is
0.5mcg/kg/minute.
2. START cephalexin 500mg by mouth every 6 hours for six days
3. START saline nasal spray and fluticasone nasal spray as
directed while having nasal congestion.
4. START warfarin 5mg by mouth daily and adjust for INR under
direction of the [**Hospital3 **]. This medication is
important in lowering the risk of stroke.
5. START a daily multivitamin
6. START acyclovir 5% ointment. Apply to the affected area on
the lips every two hours while awake for three days.
7. START metoprolol succinate 50mg by mouth once daily
8. STOP taking metoprolol tartrate
9. STOP taking losartan as your blood pressure is not tolerating
this medication
10. CHANGE torsemide dosing to 40mg by mouth once daily.
11. START fexofenadine 60mg by mouth twice daily.
12. STOP nattokinase
13. START potassium chloride 20meq by mouth daily
.
Please take all other medications as prescribed
.
Please keep all follow-up appointments.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You will be contact[**Name (NI) **] by [**Name8 (MD) **] NP that works with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Hospital 3278**] Medical Center for an initial appointment in
evaluation for heart transplant. If you do not hear from them
within a week, they can be reached at: [**Telephone/Fax (1) 72785**]
Please keep the following other appointments:
Department: CARDIAC SERVICES
When: MONDAY [**2112-3-7**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2112-3-14**] at 12:00 PM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None
Department: CARDIAC SERVICES
When: MONDAY [**2112-6-13**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please make an appointment to see your PCP [**Name Initial (PRE) 176**] 2 weeks of
discharge.
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,741
| 161,560
|
1976+55337
|
Discharge summary
|
report+addendum
|
Admission Date: [**2175-2-20**] Discharge Date: [**2175-2-26**]
Date of Birth: [**2090-10-31**] Sex: M
Service: SURGERY
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 year old male with past medical history of interstitial
pulmonary fibrosis on 3L home oxygen, COPD, hypertension, CKD
Stage 4 (baseline Cr 3-3.5), hypertension, severe peripheral
artery disease s/p multiple [**First Name3 (LF) 1106**] procedures, osteoarthritis
who presented with respiratory distress. The patient had
recently been admitted to [**First Name3 (LF) **] Surgery [**2175-2-8**] for his
ongoing iliac artery aneurysm that has been difficult to
intervene upon. He presented this morning with chief compliant
of lower back pain in addition to progressive shortness of
breath for one day.
Per the patient's wife at his last pulmonary office visit
([**2175-1-9**]), the patient at baseline spends most of his day in
bed, getting up only for meals and doctor's appointments. He
uses 3L NC supplemental oxygen at home but intermittently, when
he should be using it continuously. He develops exertional
shortness of breath even with minimal activity. He had been in
his otherwise normal state of health, but complained of sudden
onset lower back pain in the evening prior to admission. He
eventually asked to go to the ER as a result. He was not having
much trouble breathing at that juncture.
.
In the ED, initial vitals were [**11-8**] abdominal pain from
chronic, HR 62, BP 195/86, RR 48, pOx 80 on room air with
respirations at 42 /min. He was triggered and immediately put on
non-rebreather, then BiPAP. During this time, the patient was
visibly tachypneic, speaking two word phrases only. CXR showed
LLL pneumonia so he was given zofran 4mg, Vancomycin 1 gram and
Ceftriaxone 1 gram for HCAP. He was also given duonebs. Prelim
CXR impression by radiology was bibasilar opacities likely
represenative of chronic fibrosis and bronchiectasis with
thoracoabdominal aortic ectasia again noted.
His respiratory distress subsided significantly and he was
transitioned to Venturi face mask (35%). ABG was 7.47/26/323/19
on CPAP. He also received morphine 4mg IV for pain relief and
albuterol/ipratropium nebs. On physical exam, reportedly no JVD
or pitting edema, no CHF history. As he is a significant
vasculopath, blood cultures could not be obtained and Chem 10
was too hemolyzed to run. One of his two PIVs blew and had to be
replaced. Chem panel was performed on the floor with Na 137, K
4.5, Cl 106, BUN 34, Cr 3.2 (baseline 3.0-3.5), HCO3 17, Glc
143. Other labs showing Troponin 0.14, CK-MB 4, Lactate 2.7.
On transfer, afebrile, HR62, BP 195/86, RR20, 100% on Venturi
face mask (35%). His wife is with him in the [**Name (NI) **] and he was
confirmed full code.
ECG also performed showing NSR at 60 bpm with PR prolongation
(226 ms), IVCD (QRS 108 ms), QTc 472 ms, leftward axis,
non-specific inferior ST-T changes similar to prior ECG.
.
On arrival to the ICU, patient was examined at bedside. He was
speaking complete sentences, appeared comfortable although
respiratory rate in high 20s. Patient was complaining of [**7-9**]
mid-line lower back pain.
Past Medical History:
* Idiopathic pulmonary fibrosis (on home oxygen, 3L NC) -
diagnosed [**2165**] by radiographic imaging and PFTs
- Most recent PFTs [**2176-1-10**]
* Mild to moderate COPD
* Chronic renal insufficiency (baseline 3.5), s/p RUE AVF
placement ([**3-/2174**])
* Hypertension
* Osteoarthritis
* Right eye cataract surgery
* Head injury s/p assault ([**2136**])
* Peripheral artery disease:
- Right hypogastric aneurysm s/p angiogram ([**2175-2-8**])
- Right hypogastric aneurysm s/p coil embolization, complicated
by bradycardia ([**2175-1-10**])
- ([**2174-12-19**])
- Bilateral iliac artery aneurysms s/p aortobi-iliac bypass
([**2158**])
- AAA repair ([**2158**])
- Ischemic left foot secondary to thrombosed popliteal artery
aneurysm s/p thrombectomy of femoral artery, SFA-PT bypass, left
leg fasciotomy of posterior deep compartment([**3-/2172**])
- Right distal SFA to below knee popliteal bypass graft with
RGSV ligation above and below aneurysm ([**4-/2172**])
- Left calf debridement ([**5-/2172**])
Social History:
Worked as a nurse previously, lives with wife and family. Quit
smoking 24 years ago (~30 pack year history) and occasional
alcohol use ([**3-3**] drinks/day when he does drink). Denies
illicits.
Family History:
Mother had diabetes, no family history of coronary artery
disease/sudden cardiac death.
Physical Exam:
Admission Exam:
Vitals: BP 179/82, HR 67, RR 28 pOx 100 on 35 % VM
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral [**Month/Day (3) **]: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : [**Hospital1 **]-basilar, Diminished: bases), RUE fistula + bruit
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Warm
Neurologic: Attentive, Responds to commands
Pertinent Results:
[**2175-2-20**] CTA torso: 1. Type B dissection of the thoracic aorta
extending into the abdominal aorta
terminating superior to the level of the aortobiiliac stent.
Dissection is seen involving the origin of the celiac axis and
SMA. The right renal artery is coming off the false lumen with
hypoenhancement of the right adrenal gland and kidney compared
to the left.
2. Slight interval increase in size of right hypogastric artery
aneurysm. Stable left hypogastric artery aneurysm.
3. Slight interval increase in right popliteal artery aneurysm
compared to previous angiogram from [**2172-4-3**].
4. Patent superficial femoral artery to below-knee grafts.
[**2175-2-24**] 05:51AM BLOOD
WBC-7.3 RBC-3.37* Hgb-9.4* Hct-29.9* MCV-89 MCH-27.7 MCHC-31.3
RDW-15.3 Plt Ct-144*
[**2175-2-23**] 04:08AM BLOOD
WBC-8.6 RBC-3.28* Hgb-9.2* Hct-29.1* MCV-89 MCH-28.0 MCHC-31.6
RDW-15.4 Plt Ct-151
[**2175-2-22**] 02:26AM BLOOD
WBC-10.9 RBC-3.59* Hgb-10.3* Hct-31.1* MCV-87 MCH-28.5 MCHC-33.0
RDW-15.8* Plt Ct-134*
[**2175-2-22**] 02:26AM BLOOD
PT-13.7* PTT-32.8 INR(PT)-1.3*
[**2175-2-24**] 05:51AM BLOOD
UreaN-45* Creat-4.5* Na-141 K-4.0 Cl-109* HCO3-23 AnGap-13
[**2175-2-23**] 04:08AM BLOOD
Glucose-105* UreaN-44* Creat-4.6* Na-139 K-4.0 Cl-106 HCO3-22
AnGap-15
[**2175-2-22**] 05:04PM BLOOD
Glucose-119* UreaN-41* Creat-4.1* Na-138 K-4.2 Cl-105 HCO3-23
AnGap-14
[**2175-2-22**] 02:26AM BLOOD
Glucose-100 UreaN-38* Creat-3.6* Na-137 K-4.4 Cl-105 HCO3-23
AnGap-13
[**2175-2-24**] 05:51AM BLOOD
Calcium-8.5 Phos-5.3* Mg-2.2
[**2175-2-23**] 04:08AM BLOOD
Calcium-7.5* Phos-5.7* Mg-2.1
[**2175-2-20**] 06:10AM
URINE Color-YELLOW Appear-Clear Sp [**Last Name (un) **]-1.011
URINE RBC-5* WBC-<1 Bacteri-NONE Yeast-NONE Epi-0
Brief Hospital Course:
84-year-old male with past medical history of oxygen-dependent
interstitial pulmonary fibrosis, COPD, hypertension, CKD Stage
4, hypertension, severe peripheral artery disease s/p multiple
[**Last Name (un) 1106**] procedures, osteoarthritis who presented with acute
onset back pain.
Acute Issues:
# Low back pain: Type B Dissection) Patient presented to the ED
with acute onset lower lumbar back pain. Given known history of
[**Last Name (un) 1106**] issues and elevated blood pressure, some concern for
[**Last Name (un) 1106**] process. CTA of the torso showed a type B aortic
dissection. [**Last Name (un) **] surgery was consulted and transferred the
patient to the Surgical ICU for further monitoring and tight
blood pressure control. Initially on IV medications. He was
transfered to his PO medications and transferred to the VICU for
further care. Mr. [**Known lastname 1968**] remained HD stable since transfer the
the [**Known lastname 1106**] service, with good blood pressure and heart rate
control, and no further episodes of back pain.
# Troponin elevation: On admission, troponin was 0.14 and repeat
was rising (0.48), likely caused by aortic dissection. Blood
pressures were closely controlled and trops were trended
0.14->0.48->0.62-> 0.85->.75, the rise was attributed to his
acute on chronic renal failure. A cardiac consult was obtained.
See Below for consultation:
EKG
[**2-20**] 05:31 sinus at 60, 1mm J point elevation in V2 with
minimally biphasic T wave in anterior precordial leads both
unchanged from previously. LAD, IVCD.
[**2-21**] 00:42 sinus at 61, otherwise as above
[**2-21**] 07:39 sinus at 59, otherwise as above
TELEMETRY
Sinus with rates high 50 to low 60s, no tachy- or
bradyarrhythmias
ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The descending thoracic aorta is
markedly dilated, measuring 3.6 to 5.2 centimeters. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
symmetric left ventricular hypertrophy and preserved global and
regional biventricular systolic function. Mildly dilated
ascending aorta. Markedly dilated descending thoracic aorta.
Mild aortic regurgitation. Indeterminate pulmonary artery
systolic pressure.
Compared with the prior study (images unavailable for review) of
[**2173-5-12**], a markedly dilated descending thoracic aorta
measuring up to 5.2 centimeters in greatest dimension is now
appreciated (previously mildly dilated at 3.3 centimeters, but
not consistently well-visualized or commented upon). The
ascending aorta is now mildly dilated. The severity of aortic
regurgitation has increased minimally and is now mild.
ASSESSMENT
Patient has elevated troponins in this setting on account of
LVH, prior systolic BP 200s with stage 4 CKD. MB flat and within
normal limits. No symptoms c/w acute coronary syndrome. ECG
unchanged from previously. No involvement of coronary arteries
with dissection stopping distal to L subclavian artery.
- Continue to trend enzymes until troponin coming down.
Completed. .85 - > .75
- No need for further w/u unless new symptoms, ECG changes, or
significant rise in enzymes suggestive of ischemia.
# Hypertension: Patient hypertensive on admission. Home norvasc
was continued with SBPs in the 120s. He also recieved his PO
lopressor. Blood pressure was monitored closely once dissection
was identified. On Dc his HTN was well controlled. He will have
VNA follow his BP, hs PCP will [**Name9 (PRE) **] his BP and adjust
medications as appropriate. His new home medication will be
Lopressor 50 [**Hospital1 **].
# Idiopathic pulmonary fibrosis and COPD: Patient is
oxygen-dependent with restrictive ventilatory defect. No
evidence of frank exacerbation at this time. Was noted to be
breathing at an increased respiratory rate on admission, and was
temporarily transferred to the [**Hospital Unit Name 153**] for management, however the
patient was satting mid-high 90s on 3L, which is his home oxygen
requirement.
# CKD Stage 4: Patient with Cr 3.1 at baseline, climbed to 4.8.
On DC 4.5. Renal was consulted, they follwed closely. On the
downtrend. Renal cleared for home. He has appointment with both
PCP and Nephrology. His creatinine will be follwed closely.
Medications on Admission:
- Simvastatin 10mg daily
- Amlodipine 10mg daily
- Citalopram 20mg daily
- Latanoprost 0.005% eye drops qHS
- Omeprazole 20mg daily
-Calcitriol 0.25mcg every other day
- Aspirin 81mg daily
-Codeine-guaifenesin 5-10mg q6hours PRN cough
- Senna/Colace PRN constipation
-Acetaminophen 650mg q6 hours PRN pain/fever
Discharge Medications:
1. Xalatan 0.005 % Drops Sig: One (1) Ophthalmic at bedtime.
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*11*
5. 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:*11*
6. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
10. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
Disp:*30 Capsule(s)* Refills:*2*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
13. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Type b dissection
Renal failure acute on chronic
PVD, IPF (on home O2), CRI (baseline 3.5), HTN, Osteoarthritis,
hypogastric aneurysm, thoracic aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Aortic Dissection
An aortic dissection is a dangerous condition. A tear develops
in the inner layer of the aorta, the large blood vessel
branching off the heart.
When an aortic dissection is detected early and treated
promptly, your chance of survival greatly improves. Because of
the complexity of this condition, only specialized [**Location (un) 1106**]
centers such as [**Hospital **] Hospital Center have the capability
to manage and successfully treat these conditions.
There are two types of aortic dissections and are known by where
the tear occurs:
Type A. This is the more common and dangerous type of aortic
dissection. It involves a tear in the ascending portion of the
aorta just where it exits the heart, or a tear extending from
the ascending portion down to the descending portion of the
aorta. This tear may extend into the abdomen.
Type B. This type involves a tear in the descending aorta only,
which also may extend into the abdomen.
You have a type B dissection
Causes of Aortic Dissection
Aortic dissection occurs in a weakened area of the aortic wall.
Risk factors may include:
Chronic high blood pressure
Inherited conditions associated with a weakened and enlarged
aorta
Trauma
Please call if you have any symptoms listed below
Symptoms of Aortic Dissection
Symptoms of Aortic dissection are similar to those of a heart
attack.
They include:
Sudden severe chest or upper back pain, often described as a
tearing, ripping or shearing sensation, that radiates down the
back
Loss of consciousness (fainting)
Abdominal pain
Sudden onset of leg pain with compromised blood flow
Call 911 immediatly if you experience the above symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2175-3-9**] 3:00 Renal
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2175-7-3**] 10:40
Please go to the office 1 hr before to have you creatine
checked. You should go to the lab to have this done, This is in
the same building as Dr [**First Name (STitle) **]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**],
MD Phone:[**Telephone/Fax (1) 608**] Date/Time:[**2175-2-27**] 2:30
Dr [**Last Name (STitle) **] as below:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2175-4-11**] 8:00
Completed by:[**2175-2-25**] Name: [**Known lastname 447**],[**Known firstname 1503**] Unit No: [**Numeric Identifier 1504**]
Admission Date: [**2175-2-20**] Discharge Date: [**2175-2-26**]
Date of Birth: [**2090-10-31**] Sex: M
Service: SURGERY
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 270**]
Addendum:
Addendum [**2175-2-26**] - patient stayed one more day due to transient
desaturation to 80%s when ambulating with physical therapy.
Incentive spirometry was encouraged, and today he is at baseline
95% on 3L. He is discharged to home in stable condition with
home O2, visiting nursing, and home PT.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2175-2-26**]
|
[
"724.2",
"443.22",
"447.73",
"V15.82",
"516.31",
"494.0",
"440.31",
"366.9",
"V46.2",
"790.5",
"584.9",
"491.21",
"403.90",
"486",
"715.90",
"585.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17303, 17515
|
7136, 11880
|
279, 286
|
13923, 13923
|
5381, 7113
|
15770, 17280
|
4545, 4635
|
12242, 13638
|
13739, 13902
|
11906, 12219
|
14074, 15747
|
4650, 5362
|
230, 241
|
314, 3289
|
13938, 14050
|
3311, 4316
|
4332, 4529
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,861
| 113,971
|
4278
|
Discharge summary
|
report
|
Admission Date: [**2136-1-15**] [**Year/Month/Day **] Date: [**2136-1-25**]
Date of Birth: [**2064-2-24**] Sex: F
Service: MEDICINE
Allergies:
Streptomycin / Versed / Fentanyl
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: 71 YO Russian-speaking F with recent
admission for LBP presenting with LBP and chest pain (similar to
her last admission. LBP: [**10-14**], sharp, mid-right side of back
and down her legs. Nothing makes it better or worse. Tried
tylenol and did not help much. It is constant. No loss of bowel
or bladder function. H/o of recent diarrhea. No leg weakness, no
recent trauma. Has had this problem for 2 years, but in the past
couple of months has gotten worse. MRI performed in [**3-13**] showed
No evidence of cord compression or cord signal abnormality abd
multiple vertebral body compression fractures, none of which
appear acute
CP is left breast radiating to back and right side, [**7-14**], sharp
and has gotten better with percocet. No ekg changes noted and
patient states she has had this pain before. last admission, not
found to be cardiac. p-Mibi done in [**10-13**] showed normal cardiac
perfusion.
.
Initial VS in the ED: 98 67 128/78 14 100%. Was tachypneic on
exam. CXR and BNP elevated. Given percocet, asa and lasix.
Baseline anemia and chronic renal failure. VS upon transfer:
120/61 72 97% 2L 15. Pt reports she wears 2L O2 at home for
sleep.
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied
palpitations. Denied nausea, vomiting, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denied arthralgias or myalgias
Past Medical History:
1. Atrial fibrillation
2. Hypertension
3. Dyslipidemia
4. Obstructive sleep apnea with secondary pulmonary HTN
5. Chronic diastolic heart failure
6. Type 2 Diabetes Mellitus
- [**2135-1-31**] HbA1c 7.9
7. Chronic Renal Failure
8. S/p lap appy ([**9-11**])
9. Diabetic neuropathy
10. Osteoporosis
11. h/o cataract surgery
Social History:
Home: lives with her husband
Occupation:
EtOH: Denies
Drugs: Denies
Tobacco: Denies
Family History:
non-contributory.
Physical Exam:
Vitals: T: 95.5 BP: 100/62 P: 64 R: 16 O2: 99% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact/ 5/5 strength in BUE/BLE, sensation in
tact
M/S: TTP in middle right back
Pertinent Results:
Admission Labs:
[**2136-1-15**] 02:46AM PT-39.2* PTT-31.0 INR(PT)-4.1*
[**2136-1-15**] 02:19AM GLUCOSE-310* UREA N-22* CREAT-1.4* SODIUM-135
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-30 ANION GAP-10
[**2136-1-15**] 02:19AM estGFR-Using this
[**2136-1-15**] 02:19AM cTropnT-<0.01
[**2136-1-15**] 02:19AM proBNP-1545*
[**2136-1-15**] 02:19AM WBC-8.7 RBC-3.43* HGB-8.5* HCT-30.0* MCV-88
MCH-24.8* MCHC-28.3* RDW-16.8*
[**2136-1-15**] 02:19AM NEUTS-76.3* LYMPHS-17.6* MONOS-4.6 EOS-1.2
BASOS-0.3
[**2136-1-15**] 02:19AM PLT COUNT-193
CXR:
IMPRESSION:
1. Cardiomegaly, with mild fluid overload.
2. Stable multiple compression deformities of the thoracolumbar
spine
T spine/L spine: pending
Brief Hospital Course:
Assessment and Plan: 71 yo F h/o LBP with compression fractures
presenting with 10/10 back pain.
.
# Lower Back Pain: Likely related to compression fractures as
seen on x-ray. Initially admitted for pain control. Given her
serious allergies, she was not given strong pain medication. She
was given acetaminophen, lidocaine [**Last Name (LF) 18539**], [**First Name3 (LF) **] gay and 25 mg of
ultram every six hours as needed. This appeared to moderately
control her pain. On the first night of admission, she was
started on Gabapentin 300 mg given this may be related to
neuropathic pain. The following morning, the patient appeared
confused and at times lethargic. An ABG showed patient had
hypercapnic respiratory failure. Patient with known history of
OSA with pulmonary hypertension. Patient stated on admission she
did not use CPAP at night, but on further questioning with
family the following day, she does use this machine. It was felt
that the combination of not using CPAP the night prior and
possibly Gabapentin could have contributed to this event. She
was transferred to the MICU for BiPAP. During her MICU course,
she developed fever and found to have Moraxella pneumonia
confirmed by sputum culture. She was started on levofloxacin.
Her respiratory status improved, she was weaned off of BiPAP and
transferred back to the medical floor. She continued to use CPAP
at night and did not have further episodes of this.
# Atrial Fibrillation: Patient was noted to have three episodes
of afib with RVR to 150s. Each time she was given 10 mg IV dilt
x 2 which broke her fast rate. Diltiazem was uptitrated to 90 mg
[**First Name3 (LF) **]. She was noted the night of this uptitration to have brief
rates into the 20s-30s. She was asymptomatic and asleep during
these episodes. Upon waking, her HR improved. Since her heart
rate ranged from bradycardia to tachycardia, and a concern for
further intervention may need to be pursued EP was consulted. It
was felt no intervention should be done during this
hospitalization, since she does have an active infection. She
was continued on metoprolol and diltiazem, and will follow up
closely with Dr. [**Last Name (STitle) 171**] in the outpatient. She was noted to
have a supratherapeutic INR (4.1) and coumadin was held while
until her INR was at goal. Of note, she became subtherapeutic to
1.8 [**1-19**], but once warfarin was restarted, she became
therapeutic throughout the rest of the hospitalization.
# Acute on Chronic diastolic CHF: Upon ambulation her O2sats
would decrease to 88% on Room air. Crackles notable on exam and
chest x-ray consistent with marked pulmonary edema. This was
felt due diastolic dysfunction. This may have been exacerbated
in the setting of afib with RVR. Her home lasix dosage was
increased to 80 [**Hospital1 **] and she would intermittently receive 80 IV
lasix to help with further diuresis. Upon [**Hospital1 **] she was
breathing at room air in the mid-90s and upon ambulation
saturate 90% on room air. She was felt to be euvolemic.
# Acute on Chronic Kidney Disease: With aggressive diuresis, her
creatinine increased to 1.8, but upon [**Hospital1 **] decreased to
1.3, which is in her baseline range.
# DMT2: continue 70/30 40 units q AM and 25 units q hs plus
HISS. Glipizide was held while inpatient, but restarted upon
[**Hospital1 **].
# HTN: Stable. Continued metoprolol and diltiazem as above.
# Hypothyroidism: Continued levothyroxine.
# HLD: Continued lipitor and fenofibrate.
Medications on Admission:
Lipitor 10 mg q.d.,
omeprazole 20 mg q.d.,
levothyroxine 100 mcg p.o. q.d.,
amitriptyline 10 mg 2 tablets at h.s.,
folic acid 1 mg p.o. q.d.,
fenofibrate 145 mg p.o. q.d.,
Coumadin 5 mg q.d.,
Lasix 80 mg q.d.,
Toprol-XL 50 mg 2 tablets q.d.,
Cartia XT 240 mg p.o. q.d.,
glipizide 5 mg 2 tablets b.i.d.,
Humulin insulin 70/30 40 units q.a.m. and 25 units at h.s.
Senna and Colace are on hold.
[**Hospital1 **] Medications:
1. Methyl Salicylate-Menthol Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed for Back Pain.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Tramadol 50 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for to back.
Disp:*12 Adhesive Patch, Medicated(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for back pain: Do not exceed more than 4
grams in 24 hours.
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime.
11. Fenofibrate Nanocrystallized 145 mg Tablet Sig: One (1)
Tablet PO once a day.
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: One (1)
Subcutaneous twice a day: 40 Units q AM and 25 Units q HS.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
16. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
17. Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO q AM.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
18. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
[**Hospital1 **] Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
[**Hospital1 **] Diagnosis:
Primary:
Pneumonia
Lower Back Pain
Atrial Fibrillation
Obstructive Sleep Apnea
Acute on Chronic Diastolic Heart Failure
Secondary:
Diabetes Type 2
Hypertension
Hyperlipidemia
[**Hospital1 **] Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
[**Hospital1 **] Instructions:
You were initially admitted because you were having lower back
pain. You were pain controlled with Tylenol, lidocaine [**Hospital1 18539**],
and very small doses of ultram. Due to your allergies, you are
limited to what you can take for pain. You felt this regimen
helped your pain.
During your hospitalization, you were having difficulty
breathing. You were transferred to the intensive care unit for
BiPaP. This helped your breathing. You were found to have
Pneumonia. Your difficulty breathing was likely due to a
combination of things: Not using your CPAP machine for one night
prior, an infection in your lungs, some fluid overload meaning
blood backing into your lungs from your heart, and possibly a
sedating medications for pain that was given to you, Gabapentin.
To solve these problems, you used your CPAP every night while
in the hospital. You were given antibiotics for your lung
infection. You were given lasix through your veins to remove
some of the excess fluid in your lungs, and you were not given
Gabapentin any more while in the hospital. Your breathing
improved.
You also had episodes where your heart rate would become very
fast (into the 150s-160s). This is due to your atrial
fibrillation. Sometimes, with atrial fibrillation, your heart
rate can get very fast. You were given IV Diltiazem to slow your
heart rate. Since this occurred repeatedly, we increased your
diltiazem to a higher dosage. We asked Dr.[**Name (NI) 5103**] colleagues
to evaluate your heart rate and it was felt you should continue
these medications and follow up with your cardiologist in the
outpatient. Your appointments are below.
Since you continued to need oxygen during the day to breathe.
We repeated a chest x-ray that showed you had a lot of fluid in
your lungs. This is from your congestive heart failure. We gave
you more lasix through the IV to get rid of the extra fluid in
your lungs and your breathing improved. We increased your home
lasix dose to 80 mg twice a day. You will follow up with your
primary care doctor for further management of this medication.
On your last day of [**Name (NI) **], upon walking your oxygen level
was 89-90% on Room air. Your weight on the day of [**Name (NI) **] is
86.9 kg (191 lbs). This is very close to your "dry weight." This
information is very important for your cardiologist and primary
doctor to know. you should tell them this when you see them.
Your Medication changes include:
1. Diltiazem XR 360 mg daily to be taken every morning. (This is
an increase from your home dosage of 240 mg daily)
2. Ultram 25-50 mg to be taken once every 6 hours as needed for
pain.
3. Lasix 80 mg to be taken twice a day. (This is an increase
from your home medication of lasix 80 mg once a day)
You should contact your primary care doctor or go directly to
the emergency room if you experience shortness of breath, chest
pain, a very fast heart rate, severe back pain, inability to
walk or any other symptom that is concerning to you.
Followup Instructions:
Your follow up appointments are scheduled below:
Appointment #1:
PRIMARY CARE:
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8682**]
Date/ Time: Thursday, [**1-26**] at 10:45am
Location: [**Street Address(2) 3375**], [**Location (un) **], MA
Phone number: [**Telephone/Fax (1) 133**]
Special instructions for patient: This appt was already
scheduled for follow up for your [**2136-1-10**] visit with Dr [**Last Name (STitle) 8682**].
Be sure to discuss your hospital stay.
Appointment #2:
CARDIOLOGY
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2136-2-13**] 1:40
Appointment #3:
SLEEP/PULMONARY MEDICINE
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]/DR. [**Last Name (STitle) **]
Phone:[**Telephone/Fax (1) 612**]
Date/Time: [**2136-2-7**] 10:00
|
[
"518.84",
"276.2",
"733.00",
"250.60",
"428.33",
"724.2",
"585.9",
"482.83",
"416.8",
"327.23",
"272.4",
"427.31",
"357.2",
"403.90",
"428.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3742, 7229
|
314, 320
|
3019, 3019
|
13043, 13924
|
2366, 2385
|
7255, 7649
|
2400, 3000
|
1558, 1902
|
265, 276
|
9559, 9645
|
7679, 9529
|
376, 1539
|
3036, 3719
|
9893, 10000
|
9673, 9879
|
1924, 2247
|
2263, 2350
|
10033, 13020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,086
| 182,160
|
45450
|
Discharge summary
|
report
|
Admission Date: [**2196-11-2**] Discharge Date: [**2196-11-10**]
Date of Birth: [**2115-2-9**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Abdominal aortic aneurysm.
Major Surgical or Invasive Procedure:
Resection and repair of abdominal aortic aneurysm with 18 mm
Dacron tube graft
History of Present Illness:
This 81-year-old lady has a 6.4 cm infrarenal abdominal aortic
aneurysm. She had a 7 cm thoracic aneurysm which was treated
with an [**First Name3 (LF) 96989**] about 3 months ago. She is now having repair
of her second aneurysm
Past Medical History:
Thoracic and Abdominal Aortic Aneurysms
Hypertension
Diverticulosis
Chronic Back Pain(L1 collapse)
Arthritis
s/p Cataract Surgery
s/p Appendectomy
s/p Cholecystectomy
s/p Mole removals
s/p D&C
Social History:
Active smoker, 50 pack year history. Denies ETOH. She is
widowed, currently lives with her 22 year old granddaughter. She
is retired.
Family History:
Denies history of premature coronary disease.
Physical Exam:
PE: VS: Tm 101.1, Tc 100.0, BP 107/50(106-151/46-68), MAPs
67-99,
RR 24-40, SaO2 96%/FT
Genl: appears to be in some distress, moving around in bed
frequently, tachypneic
HEENT: NCAT, eyes closed, sl dry MM
CV: RRR, nl S1, S2
Chest: tachypneic, some resp distress, but lungs clear
anteriorly
Abd: soft, retroperitoneal C/D/I
Ext: all distal pulses palp
Neurologic examination:
Mental status: eyes closed, tries to open them to command,
follows command to open eyes or stick out tongue to daughter's
command, can also squeeze and release intermittently to
daughter's command. Minimal vocalizations to questions - "what"
or "[**Last Name (un) 46536**]", seems somewhat appropriate but not very interactive.
Cranial nerves: pupils equal and reactive, blinks to visual
threat b/l, L>R, +corneal reflexes. ?mild facial droop at rest
on
right, but no real NLF flattening and definite full excursion
bilaterally with grimace. Tongue midline.
Motor: moves all extremities spontaneously, symmetrically.
Strong
when resisting (not tested by command).
Sensory: withdraws to noxious stim in all extremities
DTRs: reflexes normal and symmetric throughout BUE, decreased in
BLE but symmetric. R toe mute, L toe upgoing.
Pertinent Results:
[**2196-11-10**] 06:00AM BLOOD
WBC-10.8 RBC-3.31* Hgb-9.5* Hct-28.4* MCV-86 MCH-28.6 MCHC-33.5
RDW-16.3* Plt Ct-289#
[**2196-11-9**] 02:11AM BLOOD
PT-12.7 PTT-29.4 INR(PT)-1.1
[**2196-11-10**] 06:00AM BLOOD
Glucose-81 UreaN-38* Creat-1.6* Na-141 K-4.4 Cl-105 HCO3-26
AnGap-14
[**2196-11-9**] 02:11AM BLOOD
Calcium-8.0* Phos-3.6 Mg-2.2
[**2196-11-4**] 01:24AM
URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR
Bilirub-NEG URINE RBC-[**3-13**]* WBC-[**6-18**]* Bacteri-NONE Yeast-NONE
Epi-0
[**2196-11-7**] 8:59 am MRSA SCREEN Site: RECTAL
MRSA SCREEN (Final [**2196-11-9**]): NO STAPHYLOCOCCUS AUREUS
ISOLATED.
[**2196-11-6**] 10:10 AM
CHEST PORT. LINE PLACEMENT
One portable view. Comparison with the previous study done
[**2196-11-5**]. There is interval improvement in bilateral pleural
effusions. The heart and mediastinal structures are unchanged. A
vascular stent is in place in the descending aorta as before. An
endotracheal tube and nasogastric tube remain in place. A
Swan-Ganz catheter has been withdrawn. A right internal jugular
catheter has been inserted and terminates in the superior vena
cava.
IMPRESSION: Interval improvement and bilateral pleural
effusions. Line placement as described.
[**2196-11-4**] 2:10 PM
CT HEAD W/O CONTRAST
FINDINGS: There is no acute intracranial hemorrhage, shift of
normally midline structures, or hydrocephalus. [**Doctor Last Name **]-white matter
differentiation is preserved. Soft tissues and osseous
structures are normal. The visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION: No acute intracranial hemorrhage
[**2196-11-4**] 4:00 PM
RENAL U.S.
FINDINGS: The study is recent postop with extensive surgical
dressings, particularly over the left flank. The patient was
intubated and not able to comply with technologist's directions.
Limited imaging of the right kidney demonstrates a length of
approximately 10 cm. The echotexture is grossly unremarkable.
There is no hydronephrosis or stone identified. Visualization of
the left kidney was moderately compromised. The length is
approximately 9 cm. Again no gross hydronephrosis is seen. The
echotexture cannot be adequately evaluated. No stone is seen.
The patient was catheterized prior to arrival at Radiology. No
fluid is identified in the bladder. Despite multiple attempts,
visualization of the Foley catheter balloon was also not
possible.
IMPRESSION: Markedly limited study. Renal sizes are grossly
within normal limits and symmetric. No gross hydronephrosis is
identified. No stones are seen.
Cardiology Report ECHO Study Date of [**2196-11-2**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 0.7 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Diastolic Dimension: 5.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: 0.29 (nl >= 0.29)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aortic Valve - Valve Area: *2.7 cm2 (nl >= 3.0 cm2)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.33
Pericardium - Effusion Size: 0.7 cm
INTERPRETATION:
Findings:
Rotated heart secondary to COPD, limited and suboptimal
transesophageal and transgastric views. Normal LV systolic
function without any focal abnormalities. LV circumflex area
during diastole started with 14cmsq and was same after the cross
clamp came off. No wall motion abnormalities detected at the
time of cross clamping of the aorta that was suprarenal for
22min and then for another 40 minutes for infrarenal clamp.
Echodense shadow seen in the descending thoracic aorta
consistent with aortic stent no endoleak seen at the graft
sight. Mild to slightly moderate TR The PA systolic pressure
estimated from TR equal to 40 mm of Hg that correlates with the
PA systolic pressure tracing from the PA cath. Propagation
velocity remained within the normal range before the cross clamp
and after the cross clamp.
LEFT ATRIUM: Normal LA size. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
All four
pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is
normal in diameter with appropriate phasic respirator
variation.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thicknesses and cavity
size. Overall normal LVEF (>55%). TVI E/e' >15, suggesting
PCWP>18mmHg. No resting LVOT gradient.
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal; mid inferoseptal - normal; basal
inferior - normal; mid inferior - normal; basal inferolateral -
normal; mid inferolateral - normal; basal anterolateral -
normal; mid anterolateral - normal; anterior apex - normal;
septal apex - normal; inferior apex - normal; lateral apex -
normal; apex - normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
Three aortic valve leaflets.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**1-11**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Small pericardial effusion.
Conclusions:
The left atrium is normal in size. No mass/thrombus is seen in
the left atrium or left atrial appendage. Left ventricular wall
thicknesses and cavity size are normal. Overall left
ventricular systolic function is normal (LVEF>55%). The
calculated myocardial performance index was 0.34 (MPI A =528 ms;
MPI B = 394ms). Tissue velocity imaging E/e' is elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. There are three aortic valve leaflets. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The transmitral flow propagation velocity is 47c
m/s (nl <=0.45m/s) There is a small pericardial effusion.
Brief Hospital Course:
Pt admitted on [**2196-11-2**]
Underwent a Resection and repair of abdominal aortic aneurysm
with 18 mm Dacron tube graft. There were no complications. Pt
was extubated in the OR.
Transfered to the VICU in stable condition
Pt had increase in creat / ARF / responded to gentle hydration.
On admission creat was 1.0 / On DC 1.6 / Pt high creat 2.3. Pt
also recieve an US of kidneys / limited study / essentially
negative.
In the above workup pt was found to have UTI / treated with
levofloxacin.
Pt became agitated post operative - CIWA scale. Pt recieved
ativan, became hypercarbic. STAT code called. Pt intubated on
the floor. Found to be acidotic with increase lactate.
Transfered to the TICU.
Also during this time questionable facial droop / nuerology
consulted / head CT negative
Pt remaind intubated for 3 days. Pt extubated.
Post extubation pt transfered to the rehular floor.
PT cleared for home with vna
pt anmbulkating / taking po / urinating / pos bm
Medications on Admission:
crestor 10', ASA 81', toprol 25'
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed: prn for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
retroperitoneal AAA
hypercarbia secondary to ativan - requiring intubation
Alcohol Withdrawal
UTI
ARF postoperative with normalization befor DC
Post operative hypovolemia
Right facial droop - sedating medications
Metabolic acidosis
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING AORTIC SURGERY
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are no specific restrictions on activity other than no
lifting an object heavier than twenty-five (25) pounds for the
first three (3) months. Gradually increase your level of
activity back to normal depending on how you feel. Fatigue is
normal, especially for the first month postoperative. Resume
driving when you feel strong enough and comfortable enough
without needing pain medication.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Severe and worsening abdominal pain .
Pain or swelling in one of your legs.
Increasing pain, redness or drainage related to your incision(s)
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 8 weeks.
Resume driving when you feel strong enough and comfortable
enough without needing pain medication .
No heavy lifting greater than 20 pounds for 8 weeks.
Avoid excessive bending at the hips and stooping for 4 weeks.
BATHING/SHOWERING:
You may shower immediately if the incision is dry upon coming
home. No baths until sutures / staples are removed. Dissolving
sutures may have been used. In either case, you can wash your
incision gently with soap and water.
WOUND CARE:
Suture / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
When the sutures / staples are removed the doctor may or may not
place pieces of tape called steri-strips over the incision.
These will stay on about a week and you may shower with them on.
If these do not fall off after 10 days, you may peel them off
with warm water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
two weeks after surgery.
MEDICATIONS:
You may resume taking medication you were on prior to your
surgery unless specifically instructed otherwise by your
physician [**Name9 (PRE) **] will be given a new prescription for pain
medication, which should be taken every three (3) to four (4)
hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid heavy lifting (over 20 pounds) for 8 weeks after surgery.
No strenuous activity for 4-6 weeks after surgery.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.
Followup Instructions:
Calll Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**]. Schedule an
apppointment for 2 weeks
Completed by:[**2196-11-10**]
|
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icd9cm
|
[
[
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[
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|
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|
703, 897
|
913, 1049
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,459
| 186,218
|
47436
|
Discharge summary
|
report
|
Admission Date: [**2176-2-24**] Discharge Date: [**2176-3-7**]
Date of Birth: [**2105-11-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
upper GI bleed.
Major Surgical or Invasive Procedure:
1. Placement of right arm PICC line [**2-28**] (tip in SVC),
discontinued on [**2176-3-7**] after antibiotics course complete.
History of Present Illness:
70 YO woman with MR p/w with coffee ground emesis x2 (250cc
/episode) while at [**Hospital3 **] today. Denied abd pain,
diarrhea, brbpr.
ED: in ED T 96.7 HR 85 BP 119/62 RR 20 Satting 94% on oxygen.
NG tube placed 250 black coffee ground emeis noted, lavaged with
500cc NS. 2 IV placed. Infused 1 U PRBC with 20 lasix. Given a
total of 2L NS and 1 U PRBC in the ED and started on a protonix
drip 8mg/hr. GI was consulted and initially planned to perform
EGD in am, though this was deferred as Hct stabilized and she
would have had to undergo intubation to complete the
colonoscopy. She was transferred to the [**Hospital 332**] Medical ICU for
mgmt of her respiratory failure thought [**2-1**] aspiration pna and
for mgmt of her UGIB.
Past Medical History:
- Mental retardation moderate-to-severe, lives in assisted group
facility.
- Bibasilar PNA in [**12-3**] s/p 12 dy course of levoquin
- Hypertension.
- B12 deficiency.
- History of hypercalcemia secondary to hyperparathyroidism.
- Hyperamylase. Last amylase was 372 in [**2171-12-31**].
- History of iron deficiency anemia.
- Left cataract.
- Eczema.
- Status post ORIF of the left femur and left tibia secondary to
two falls.
- History of gastritis with positive H. pylori
- Hepatits B
- Pulmonary fibrosis - last evaluated by Dr. [**Last Name (STitle) 575**] in
[**11/2172**] who did not think that she was a candidate for
prednisone or O2 [**2-1**] to concerns about her tripping over the
cord.
Social History:
She lives in a group home at [**Last Name (NamePattern1) 100346**] with phone
number [**Telephone/Fax (1) **]. There is no history of tobacco or alcohol
in the history. She uses a walker at baseline. HCP is [**Name (NI) **]
[**Name (NI) **] [**Telephone/Fax (1) 72440**].
Family History:
NC
Physical Exam:
T 98.8 P 95 BP 151/61 RR 25 O2Sat 94% 4L NC
GENERAL:thin well appearing female, NAD. Interactive, pleasant.
HEENT: NC/AT, PERRL, EOMI, dry MM, NG tube in place
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Diffuse bilat crackles [**2-2**] way up posteriorly
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Black stool but guiac positive per ED
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses b/l.
Contracted lower extremities.
Skin: no rashes or lesions noted.
Neuro: alert, interactive, able to communicate small
phrases/wishes in garbled speech. Does not consistently obey
commands.
Pertinent Results:
----------
Reports:
.
[**2176-2-24**] EKG:
Sinus rhythm
Conduction defect of LBBB type
No change from previous
.
CXR [**2176-2-24**]: Left lower lobe infiltrate, which could represent
pneumonia.
Left pleural effusion. Faint opacity in the right lower lobe
may represent an early infiltrate.
.
CXR [**2176-2-27**]: The heart is enlarged but stable in size. There
are persistent diffuse bilateral alveolar opacities with
relative sparing of the left upper lobe, superimposed upon
baseline areas of fibrosis. This may reflect edema or diffuse
infection. There are probable small bilateral pleural effusions.
.
CXR [**2176-3-4**]: Evaluation of the lung apices is limited by head
positioning. Compared to prior study there appears to be minimal
change in diffuse interstitial infiltrate within the right lung.
Otherwise, cardiac and mediastinal silhouettes are unchanged.
There may be a small amount of volume loss within the left lung.
.
[**2176-2-27**] Swallow Study:
RECOMMENDATIONS:
1. Suggest pt be made NPO with alternate means of nutrition and
hydration, as there were no safe consistencies to recommend
based
on today's evaluation.
2. Pt is not a candidate for an objective swallowing evaluation
(videoswallow or FEES) as the pt is not expected to participate
in either.
3. Suggest a family discussion to weigh the options/risks for
nutrition regarding continued PO intake vs alternate means of
nutrition and hydration.
4. Should the family health care proxy decide to continue with
PO
intake, would suggest a PO diet of honey thick liquids and
pureed
consistency solids, knowing pt is at high risk to aspirate all
consistencies.
*** it was decided by HCP that pt should continue with PO diet,
as per #4 above.
----------
Labs:
[**2176-2-23**] 10:45PM BLOOD WBC-13.2* RBC-2.69* Hgb-8.7* Hct-26.5*
MCV-99* MCH-32.2* MCHC-32.6 RDW-18.4* Plt Ct-419
[**2176-3-7**] 07:30AM BLOOD WBC-11.1* RBC-3.59* Hgb-11.4* Hct-34.0*
MCV-95 MCH-31.7 MCHC-33.5 RDW-16.2* Plt Ct-496*
[**2176-2-23**] 10:45PM BLOOD Neuts-77.1* Lymphs-15.4* Monos-5.0
Eos-1.8 Baso-0.7
[**2176-3-5**] 10:30AM BLOOD PT-11.4 PTT-22.5 INR(PT)-1.0
[**2176-2-23**] 10:45PM BLOOD Glucose-129* UreaN-52* Creat-1.2* Na-134
K-5.5* Cl-95* HCO3-30 AnGap-15
[**2176-3-7**] 07:30AM BLOOD Glucose-102 UreaN-18 Creat-0.9 Na-137
K-4.8 Cl-102 HCO3-31 AnGap-9
[**2176-3-7**] 07:30AM BLOOD Calcium-9.9 Phos-2.5* Mg-1.8
[**2176-3-5**] 10:30AM BLOOD Vanco-13.9*
[**2176-3-6**] 07:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2176-3-6**] 07:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
----------
Micro:
[**2176-3-6**] URINE URINE CULTURE-PENDING INPATIENT
[**2176-3-6**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2176-3-6**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2176-3-1**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2176-2-29**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2176-2-28**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2176-2-27**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {AEROCOCCUS
VIRIDANS}; ANAEROBIC BOTTLE-FINAL {AEROCOCCUS VIRIDANS}
INPATIENT
Sensativities unable to be performed by Micro lab, though likely
sensative to beta lactams and vanc per Micro lab director, Dr.
[**First Name (STitle) 3077**]
[**2176-2-27**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.}
AMPICILLIN------------ <=2 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
VANCOMYCIN------------ <=1 S
[**2176-2-24**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2176-2-24**] urine/serology Legionella Urinary Antigen -FINAL
INPATIENT
[**2176-2-24**] URINE URINE CULTURE-FINAL
Brief Hospital Course:
A/P: 70 yo F with PMH of Mental Retardation, IPL, Grade II
gastritis from [**2169**] EGD on ASA daily who presents with 2
episodes of coffee ground emesis and heme + melena. She was seen
in ED by GI for possible scope.
.
1. GI bleed: Given her presentation and coffee ground emesis
this thought to be consistent with a GI bleed. She received IVF
and 2 units of pRBCs and her Hct stabilized. She was also
started on protonix and her aspirin was held. GI was consulted
but since she no longer had emesis and her hematocrit was stable
an endoscopy was not performed. Her Hct remained stable
throughout the remainder of the hospitalization.
.
2. Pulmonary: LLL infiltrate with possible RLL infiltrate and
possible L pleural effusion, in setting of chronic IPF. Pt.
currently continues to need chronic O2, she desaturates to 70s
on room air. Pt needs to be frequently reminded to keep oxygen
on. She has a h/o CHF (EF 20%), last CXR on [**2-28**] with mod pulm
edema, CXR on [**3-3**] showed ground glass R>L, increased cardiac
silhouette. Lasix 20mg IV given for several episodes of
desaturation, then transition to PO lasix and also started on
aldactone given her depressed EF. Difficult to measure Is/Os
[**2-1**] incontinence, but subjectively Pt. appeared more comfortable
and interactive at the time of d/c, with clearer lungs and less
work of breathing. Will need K monitored closely given
aldactone/lasix.
.
3. ID: Enterococcus UTI, Aerococcus bacteremia. Blood cx was
obtained from femoral site, very dirty appearing, suspect
Aerococcus was contaminant. Subsequent cx's NGTD. Urine cx
grew enterococcus resistant to [**Last Name (LF) 64983**], [**First Name3 (LF) **] treated with vanco.
Pt. completed 14-day course of vancomycin and remained afebrile,
with normalization of WBC count.
.
4. CHF: Her most recent echo from '[**70**] showed an LVEF of 20%.
She was intermittently given IV lasix during her hospital stay,
maintained on her ACEI and beta-blocker regimen. Spironolactone
and PO lasix were started prior to discharge.
.
5. Mental retardation: She was continued on fluvoxamine. 1:1
sitter with her at all times.
.
6. Left upper extremity DVT: During her PICC placement, she was
noted to have a left upper extremity DVT, likely from a previous
IV line placement. Anti-coagulation was considered but given
her recent history of a GI bleed, this was not initiated. Should
not have catheters in this extremity.
.
7. FEN: She was initially kept NPO for a potential procedure and
was maintained on this once she was found to be aspirating. A
regular (soft-solid) diet was started after a meeting with her
legal gaurdian (see below).
.
8. Dispo: A meeting with her legal gaurdian and multiple people
involved in her care at her living facility was held on [**2-29**]. At
this meeting, it was decided to re-initiate her diet (although
she was shown to aspirate on her food, she clearly enjoys eating
and a PEG tube is contra-indicated given the high likelihood
that she would pull it out). It was also decided not to
anti-coagulate her for her DVT. This was considered in the
setting of her recent GI bleed. Endoscopy was considered but
due to her lung disease and desaturation, this was thought to be
a risky procedure that might require intubation. At the
conclusion of the discussion it was decided to change her code
status to DNR/DNI. Due to her tendency to aspirate and poor
lung disease at baseline, she is likely to develop respiratory
distress at some point but it was decided that aggressive
interventions would be inappropriate. She requires constant
supplementary oxygen.
Medications on Admission:
Atenolol 25mg QD
Ferrous Sulfate 325 QD
Fluvoxamine 50mg qam
Fluvoxamine 50 qhs
lisnopril 20mg qd
aspirin 325 mg qd
atorvastatin 80 mg qd
docusate 100mg qd
senna
tylenol
rantitidine
Discharge Medications:
1. Fluvoxamine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO once a day.
9. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-1**] Sprays Nasal
QID (4 times a day) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Marguarat
Discharge Diagnosis:
1. Upper GI bleed, stabilized without EGD.
2. Aspiration pneumonia.
3. LUE DVT.
4. Congestive heart failure
Discharge Condition:
Hemodynamically stable, still requiring 4L NC to keep oxygen
saturations in the mid-90s%.
Discharge Instructions:
You are being discharged to a group home with care attendants to
help you. Please take your medications as prescribed, cooperate
with your healthcare providers, and come to your follow-up
appointments.
Followup Instructions:
Please have your healthcare providers schedule a follow up
appointment with your Primary Care Physician in the next week,
to be re-evaluated after this hospitalization.
You should have your electrolytes, in particular your potassium
and phosphate levels, checked within the next 3 days and
frequently thereafter until stable. You were started on
spironolactone, furosemide and Neutra-Phos, all of which can
effect your potassium levels. You may need these medications
adjusted based on the results of these tests.
|
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"578.0",
"318.0",
"280.9",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.34",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11937, 11973
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6758, 10366
|
288, 417
|
12125, 12217
|
2936, 6735
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11994, 12104
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2233, 2917
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233, 250
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445, 1186
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1208, 1907
|
1923, 2198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,941
| 109,675
|
3799
|
Discharge summary
|
report
|
Admission Date: [**2189-6-21**] Discharge Date: [**2189-6-29**]
Date of Birth: [**2136-12-24**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Iodine; Iodine Containing / Tape / Ibuprofen /
Levofloxacin
Attending:[**First Name3 (LF) 15247**]
Chief Complaint:
Difficulty breathing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
52 F with history of sarcoidosis complicated by prior airway
obstruction and chronic trach, DM1 and triopathy, CABG, HTN, MI,
morbid obesity, most recent discharge [**5-20**], here with SOB x half
day. SOB started gradually earlier this afternoon with vomiting,
diaphoresis, and with her usual migraine. In the ED, she was
noted to be 87% on RA with increased work of breathing, 97% on
10L trach mask. CXR LLL infiltrate, small L>R effusion. EKG
unchanged, cardiac enzymes negative, no CP, not like previous
MI. BNP 34. Has WBC 14.6, received levaquin and had local
erythema raised with pruritus so was switched to Ceftriaxone and
Azithromycin. Received 60 methylprednisolone, reglan, zofran,
morphine.
.
MICU course: Patient had urine culture grow pseudomonas, ddimer
was positive so they were planning on a CTA to be done before
transfer. Respiratory therapy reported that patient does have
thick secretions with trach suctioning. Patient reported pain
with coughing.
Past Medical History:
1. DM-TI - age 16 diagnosis (c/b neuropathy, gastroparesis)
2. Sarcodosis ([**2175**])
3. Tracheostomy - [**3-13**] upper airway obstruction, sarcoid.
4. Arthritis - wheel chair bound
5. Neurogenic bladder
6. Sleep apnea
7. Asthma
8. Hypertension
9. Cardiomyopathy - diastolic dysfunction
10. Pulmonary hypertension
11. Hyperlipidemia
12. CAD s/p CABG (SVG to OM1, OM2, and LIMA to LAD, cath [**2183**])
13. VRE, MRSA - unknown sources
14. s/p cholecystectomy
[**97**]. s/p appendectomy
16. Chronic low back pain
17. Morbid obesity
Social History:
Lives alone, has monogamous partner lives 15min away, denies
ethanol, tobacco use.
Family History:
No hx of CAD, diabetes in cousin and uncle
Father had MI in his 60s
Physical Exam:
98.9 / 100 / 18 / 155/83 / 97% on 14L 0.6 trach mask
GEN: Alert, oriented x3, obese, to speak patient covers the
opening of her trach.
HEENT: No scleral icterus, PERRL, OP dry and clear, trach with
no erythema/edema/secretions, no carotid bruits
LUNGS: Difficult to hear because of body habitus, but no rales
appreciated
HEART: RRR, no m/r/g, distant heart sounds
ABD: Soft, +BS, ND NT
EXTR: 2+ pitting edema bilaterally
NEURO: [**6-13**] motor
Pertinent Results:
Admission Labs [**2189-6-20**] 11:40PM :
GLUCOSE-135* UREA N-37* CREAT-1.2* SODIUM-140 POTASSIUM-3.9
CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
[**2189-6-20**] 11:40PM CK(CPK)-89 CK-MB-4 cTropnT-<0.01 proBNP-1384*
WBC-14.6*# RBC-4.20 HGB-13.3 HCT-39.4 MCV-94 MCH-31.6 MCHC-33.7
RDW-14.2 PLT SMR-NORMAL PLT COUNT-184
NEUTS-90.2* BANDS-0 LYMPHS-7.7* MONOS-1.5* EOS-0.5 BASOS-0
.
PT-11.1 PTT-20.2* INR(PT)-0.9
.
[**2189-6-21**] 06:12AM URINE
COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-1000 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-OCC EPI-0-2
.
[**2189-6-21**] 07:28PM D-DIMER-1169*
.
[**2189-6-21**] 07:28PM CK(CPK)-292* CK-MB-13* MB INDX-4.5
cTropnT-0.12*
.
[**6-21**] CXR PA and lat:
1. Mild/moderate pulmonary edema
2. Patchy area of consolidation in left lower lobe - atelectasis
or pneumonia.
.
[**6-22**] bilateral lower ext u/s:
Very limited study secondary to patient body habitus. No
definite evidence of DVT is identified.
.
[**6-23**] CT chest/abd:
1. Bibasilar atelectasis and small bilateral pleural effusions.
2. Markedly limited examination due to patient's body habitus.
No definite stones seen within the renal collecting systems. No
evidence of hydronephrosis. Periumbilical hernia and small left
ventral wall hernia containing omental fat. No evidence of bowel
obstruction.
.
[**6-23**] Echo:
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
inferior/inferolateral
akinesis/hypokinesis (however views are technically suboptimal
for assessment
of regional wall motion). Estimated left ventricular ejection
fraction ?55%.
Right ventricular chamber size and free wall motion are probably
normal. The
aortic valve is not well seen. There is no aortic valve
stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No
mitral regurgitation is seen. There is no pericardial effusion.
No significant
aortic or mitral regurgitation is detected but views are
technically
suboptimal.
Brief Hospital Course:
52 F with history of sarcoidosis complicated by prior airway
obstruction and chronic trach, DM1 and triopathy, CABG, HTN, MI,
morbid obesity, most recent discharge [**5-20**], here with SOB which
is improved.
.
# SOB: Likely associated with acute on chronic underlying
restrictive defect, obesity hypoventilation, pulmonary
hypertension, and LLL infiltrate. She has not taken steroids PO
for her sarcoidosis in years. She completed a 5 day course of
azithromycin for Community acquired pneumonia. She will
complete a 10 day course of cefpodoxime for combo treatement of
CAP and complicated pseudomonas UTI. Case was discussed with
sleep/pulm and thought that she likely had nighttime hypoxia
secondary to obesity. We discharged her with home oxygen and
for a home overnight oximetry in 1 monthto evaluate and follow
up with Dr. [**Last Name (STitle) 575**].
.
# N/V: Patient was treated for constipation with good result.
She was treated for gastroparesis with return to home reglan
doses and antiemetics prn. On benzotropine for effects of
reglan.
.
# Cardiac:
Ischemia: NSTEMI on [**6-21**] by enzymes and ruled out on [**6-26**] for
nausea. She has history of CABG, MI. Case was discussed with
cardiologist, Dr. [**Last Name (STitle) **] on [**6-22**], and recommended medical
management; continued ASA, metoprolol (slightly lower dose than
admission) and statin. Echo was suboptimal.
Pump: Has diastolic dysfunction with EF 55%
.
# ARF: Cr improved with IVF. FeNa <1, c/w pre-renal azotemia.
Urine Eos + rash with levo possible AIN.
.
# UTI (complicated): patient has chronic indwelling foley and
pseudomonas in urine. Initially treated with ceftaz starting
[**6-23**] and transitioned to cefpodoxime to complete 10 day course.
.
# DM1: Has had since age 16. Patient is on glargine 64 QHS on
home regimen, started at 40 and increased to 60 day of discharge
and discharged on home regimen.
.
# Chronic pain and anxiety issues:
- On Vicodin, Ativan, and Fioricet.
.
FEN: No IVF, replete K/Mg, DM diet
PPX: PPI [**Hospital1 **], heparin sc
CODE: Full
Contact: partner, [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 17063**]
Medications on Admission:
1. Celexa 20mg qd
2. Lopressor 25mg [**Hospital1 **]
3. Cozaar 25mg qd
4. Colace 100 [**Hospital1 **]
5. Multivitamin [**Hospital1 **]
6. Tums ultra 1000 [**Hospital1 **]
7. Zofran 8mg [**Hospital1 **] prn
8. Compazine 25mg prn, no more than [**Hospital1 **]
9. Nystop 100,000units per gram to affected area [**Hospital1 **]
10. Fiorcet - 325/40/50 (no more than 2 per day)
11. Aspirin 325 qd
12. Lipitor 10 qd
13. Hydrocodone-Acetaminophen 5-500mg prn
14. Salmeterol 21 mcg/Dose disk prn
15. Albuterol 90 mcg 1-2puffs [**Hospital1 **] prn
16. Prilosec 20mg qd
17. Fluticasone 110 mcg 2 puffs [**Hospital1 **]
18. Glargine - 64 qhs
19. Insulin - regular - sliding scale
20. Metoclopramide 10mg - 2 with breakfast, 1 with lunch, two
with dinner, 1 at dinner (increase to 20 qid when ill)
21. Gabapentin 600 qd
22. Lorazepam 1 mg [**Hospital1 **] prn
23. Mag oxide [**Hospital1 **]
24. Benztropine 1mg tid
25. Hctz 25 mg qd
26. Protonix 40 [**Hospital1 **]
Discharge Medications:
1. Benztropine 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 days: To be completed on [**7-6**] .
Disp:*28 Tablet(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
7. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
15. Zofran 8 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for nausea.
Disp:*22 Tablet(s)* Refills:*0*
16. Nystop 100,000 unit/g Powder Sig: One (1) Topical twice a
day: To affected area.
17. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO every twelve (12) hours as needed for headache: No
more than 2 per day.
18. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
19. Continuous oxygen
Please use continuous oxygen via trach mask to maintain oxygen
saturations above 92%.
.
Please have the oxygen company do an overnight oximetry in 1
month for evaluation and send results to Dr. [**Last Name (STitle) 575**] at ([**Telephone/Fax (1) 514**].
20. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Hold while taking your antibiotics.
21. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-10**] Inhalation
twice a day.
22. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Metoclopramide 10 mg Tablet Sig: 1-2 Tablets PO QIDACHS (4
times a day (before meals and at bedtime)): On dosing schedule
of 20 QAM, 10 Qnoon, 20 QPM, 10 QHS. .
24. Insulin Glargine 100 unit/mL Solution Sig: Sixty Four (64)
units Subcutaneous at bedtime.
25. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig:
Variable units Subcutaneous four times a day: As per home
sliding scale.
26. Metamucil Powder Sig: One (1) packet PO twice a day as
needed for constipation.
Disp:*60 packets* Refills:*2*
27. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**2-10**]
Tablet, Delayed Release (E.C.)s PO once a day as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
Community acquired pneumonia
Urinary tract infection
NSTEMI
Diabetes mellitus
Acute interstitial nephritis/acute renal failure
Sarcoidosis
Morbid obesity
Gastroparesis
Discharge Condition:
Stable, requiring oxygen.
Discharge Instructions:
You were admitted with a pneumonia. You also had a urinary
tract infection. You were treated with antibiotics for both of
these infections. You will continue on an oral antibiotic as an
outpatient until [**7-6**].
.
You had some difficulty breathing on admission, which was felt
to be due to multiple problems, including obesity, pulmonary
hypertension, and pneumonia. You continued to have low oxygen
saturations intermittently, so you will be discharged with
oxygen for you to use at home as needed.
.
You also had an NSTEMI on admission, which may have been due to
demand ischemia. You should continue on your aspirin, bblocker
(lopressor), statin (lipitor) and [**Last Name (un) **] (cozaar) for medical
management of your heart disease.
.
Please keep all your follow-up appointments.
.
Please take all your medications as prescribed.
1) You have a new antibiotic, cefpodoxime, which you should
continue taking until [**7-6**].
2) Your dose of metoprolol has been reduced to 12.5mg twice a
day. This dose should be titrated up as an outpatient.
3) You are NO LONGER taking hydrochlorothiazide.
.
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever, chills, shortness of breath,
lightheadedness, dizziness, difficulty breathing, chest pain,
nausea, vomiting, inability to tolerate your oral medications,
or any other worrisome symptoms.
Followup Instructions:
Please keep the following appointments:
.
[**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2189-7-8**]
1:40
.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2189-7-9**]
9:00
.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2189-8-3**] 1:30
.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 6197**] Date/Time:[**2189-8-7**] 11:00am
.
[**First Name8 (NamePattern2) 1569**] [**Last Name (NamePattern1) **], MD Phone [**Telephone/Fax (1) 612**] Date/Time: [**2189-8-25**] at
8AM (spirometry first at 8AM on [**Location (un) 436**], then appt at 8:30AM)
.
Dr.[**Name (NI) 15921**] office will be calling you with an appointment time
for a repeat pMIBI (stress test for your heart). If you have not
heard from her office by Friday, please call to confirm the date
of your test.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 15248**]
|
[
"428.30",
"780.57",
"584.9",
"410.71",
"425.4",
"536.3",
"135",
"V45.81",
"041.7",
"599.0",
"596.54",
"300.00",
"564.09",
"V44.0",
"428.0",
"416.8",
"357.2",
"290.10",
"493.90",
"716.90",
"412",
"486",
"338.29",
"250.61",
"272.4",
"799.02",
"278.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.55"
] |
icd9pcs
|
[
[
[]
]
] |
10964, 11055
|
4803, 6947
|
356, 363
|
11267, 11295
|
2587, 4780
|
12729, 13890
|
2036, 2106
|
7953, 10941
|
11076, 11246
|
6973, 7930
|
11319, 12706
|
2121, 2568
|
296, 318
|
391, 1363
|
1385, 1919
|
1935, 2020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,334
| 198,005
|
6608
|
Discharge summary
|
report
|
Admission Date: [**2140-3-3**] Discharge Date: [**2140-3-15**]
Date of Birth: [**2078-9-23**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Left leg dry gangrene and ulcerations.
HISTORY OF PRESENT ILLNESS: Information was obtained from
discharge summaries and the patient. The patient is a
reliable historian.
The patient is a 61-year-old white male with extensive
cardiac history consisting of coronary artery disease,
ischemic and alcohol cardiomyopathy, who over the last four
months has been in hospitals and rehabilitation for cardiac
respiratory problems and has developed foot and leg
ulcerations which have not resolved with conservative
treatment.
The patient admitted to left greater than right leg
claudications since his mid 30s but has been wheelchair-bound
since [**Month (only) 116**] of last year. The patient has been hospitalized in
our institution from [**2140-2-13**], to [**2140-2-17**],
for congestive heart failure which has been compensated and
then on [**2-19**] to [**2140-2-23**], for urinary tract
infection which is treated. The patient returned for
intravenous antibiotics, wound care and vascular evaluation.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Combivent 2 puffs q.6 hours,
Lisinopril 5 mg q.d., Lasix 20 mg q.d., Thiamine 100 mg q.d.,
Folic Acid 100 mg q.d., Multivitamin 1 tab q.d., Zantac 150
mg b.i.d., Flovent 110 mcg 2 puffs b.i.d., Desipramine 30 mg
at h.s., Zoloft 200 mg q.d., Neurontin 300 mg b.i.d., Isordil
10 mg t.i.d., Lopressor 25 mg b.i.d., Aspirin 81 mg q.d.
PAST MEDICAL HISTORY: Alcohol abuse with history of delirium
tremens and questionable history of seizures. History of
hypertension. History of coronary artery disease with a
stress test in [**2131**]. Carotid disease. History of pneumonia.
History of left varicose veins with stasis ulcerations.
History of chronic obstructive pulmonary disease. History of
depression. History of intravenous drug abuse; has not used
intravenous drugs in the last 20 years. Recent compensated
congestive heart failure with an ejection fraction of 40%.
SOCIAL HISTORY: This is a 61-year-old, single male, who
lives alone. He has a 38 pack-year history of smoking. He
has not had any alcohol since [**2140-2-23**]. He has been
wheelchair and bed bound over the last 2-4 months.
PHYSICAL EXAMINATION: Vital signs: Afebrile. General:
Depressed, tearful male. HEENT: Unremarkable. Pulse:
Palpable carotids bilaterally, with diminished right carotid,
with a [**3-8**] right carotid bruit. The radial pulses were
palpable bilaterally. The femorals were palpable but
diminished in intensity. There were no femoral bruits.
Popliteal dorsalis pedis and posterior tibial pulses absent
by palpation. Chest: Lungs clear to auscultation with
increased AP diameter. Heart: Regular, rate and rhythm but
distant in auscultation. No murmurs, rubs, or gallops.
Abdomen: Soft with increased girth with increased venous
prominence with enlarged liver edge. No bruits or masses
were noted. Musculoskeletal: The left anterior tibial area
with linear excoriations with a clean base; no exudate or
odor. The left malleolar ulcer was with fibrinous base. The
left foot dorsal ulcer times two with fibrinous base. No
exudate or odor. There is muscle wasting of the upper and
lower extremities. Neurological: Unremarkable.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service. He was begun on Vancomycin, Levofloxacin and Flagyl
given that he had been hospitalized multiple times and
admitted to rehabilitation centers. PVRs were obtained on
[**2140-3-4**], which demonstrated significant bilateral
aorto-iliac arterial disease with no Dopplerable left
popliteal or pedal pulses. The metatarsal pressure on the
right was 4 mm and on the left 2 mm.
Labs included a CBC with a white count of 13.6, hematocrit
31.7, platelet count 33k; PT and INR were normal; BUN was 16,
creatinine 0.6, potassium 4.0; ............... were normal.
The wound cultures grew gram-positive cocci, pairs and
clusters, coag-positive, Staphylococcus aureus.
Cardiology was requested to see the patient for perioperative
risk assessment. Cardiology felt that the patient was in
intermediate risk factors for planned surgery and that we
should increase his Lopressor dosing to what his blood
pressure and pulse rate will tolerate and increase the
Lisinopril as tolerated for blood pressure. No other
interventions at this time.
After reconsideration and discussion with Cardiology, the
patient was amendable to a cardiac catheterization. He
underwent a right and left heart catheterization, coronary
angiography, abdominal aortic and right iliac femoral
angiography. The study demonstrated three-vessel disease not
easily amendable to high risk angioplasty intervention,
severe right iliac and femoral atherosclerotic disease. The
patient is not a candidate for intra-aortic balloon support
without PTA stenting of the iliac system. Severe pulmonary
arterial hypertension was found, in addition to decompensated
systolic and diastolic heart failure.
The patient was transferred to the Cardiac Unit for
management of his congestive failure. He was placed on
diuretics. He was afterload reduced with Nitroglycerin, and
ACE inhibitors were begun, in addition to beta-blockers.
The patient was transfused preoperatively for a hematocrit of
27. Postoperative transfusion hematocrit was 32.2.
Aspirin was held. The patient showed significant improvement
in his heart failure, and Cardiology felt we could proceed
with a leg amputation. The Nitroglycerin was weaned.
The patient underwent on [**2140-3-8**], a left AKA without
complication. Postoperative electrocardiogram was without
acute changes. Postoperative hematocrit was 28.5. BUN and
creatinine remained stable. Initial CK total was 130.
Postoperatively the patient was transferred to the SICU for
continued monitoring and care. The patient remained stable
over night. There were no acute events. He was transferred
to the VICU for continued monitoring and care.
After reevaluation of the patient, the [**Hospital 228**] transfer to
the VICU was held. He remained in the SICU to continue
cardiac monitoring and afterload reduction.
By postoperative day #2, the patient continued to diuresis on
oral agents. His diet was advanced as tolerated. His
hematocrit remained stable at 27.9.
The patient was transferred on postoperative day #2 to the
VICU for continued care. The patient required a second unit
of packed red blood cells. His posttransfusion hematocrit
was 30.6. This was given because of his significant cardiac
history. The patient continued to do well from a hemodynamic
standpoint. His congestive heart failure was compensated.
He was delined and transferred to the regular nursing floor
on postoperative day #3.
Social Service did see the patient for emotional support.
Psychiatry was requested to see the patient, and they felt
that the patient had multiple medical problems and had a
history of depression and polysubstance abuse. At the
present time, his mental status is currently more depressed
in context with the recent AKA and news regarding his cardiac
catheterization results, as well as the lack of social
support system. The patient does not verbalize suicidal
ideation and does not appear to be an acute safety issue.
His Zoloft dosing was continued at 200, as well as
Desipramine at 30 mg q.h.s. His Trazodone was increased to
200 at h.s.
Recommendations were made to be specific about treatment plan
and that once he is discharged, he should be followed by
Psychiatry at the rehabilitation facility he is transferred
to. At the time of discharge from the rehabilitation
facility, the institution should contact [**Hospital6 25259**] Center to arrange for appropriate psychiatric
follow-up. The patient's primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 25260**], has notified the [**Hospital 778**] Healthcare Service regarding
the [**Hospital 228**] transfer to rehabilitation.
At the time of discharge wounds were clean, dry, and intact.
Staples were intact. The patient was stable from a cardiac
standpoint.
FOLLOW-UP: Dry sterile dressing changes to left AKA q.d.
with Ace wrap. The patient should follow-up with Dr. [**Last Name (STitle) **]
in [**3-7**] weeks. He should follow-up with Cardiology and
primary care physician [**Last Name (NamePattern4) **] [**3-7**] weeks.
DISCHARGE MEDICATIONS: Trazodone 200 mg h.s. p.r.n.,
Desipramine 30 mg at h.s., Captopril 25 mg t.i.d., hold for
systolic blood pressure less than 90, Dulcolax tab 5-10 mg
q.d. p.r.n., Lasix 20 mg q.d., Oxycodone 10-15 mg q.4-6 hours
p.r.n., Metoprolol 50 mg b.i.d., hold for systolic blood
pressure less than 90, heart rate less than 60, Acetaminophen
325-650 mg q.4-6 hours p.r.n., Lorazepam 0.5-2.0 mg q.4-6
hours p.r.n. agitation or delirium tremors, Colace 100 mg
b.i.d., Dulcolax suppository p.r.n., Aspirin 81 mg q.d.,
Isosorbide Dinitrate 10 mg t.i.d., Multivitamin 1 tab q.d.,
Folic Acid 1 mg q.d., Thiamin 100 mg q.d., Albuterol
................ inhalers 1-2 puffs q.6 hours p.r.n.,
Percocet [**2-4**] tab q.4-6 hours p.r.n. pain.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease with impaired left ventricular
systolic/diastolic function.
2. Congestive heart failure, compensated.
3. Blood loss anemia, corrected.
4. Left leg gangrene secondary to ischemia status post left
above-knee amputation.
5. Depression, stable.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2140-3-15**] 11:12
T: [**2140-3-15**] 11:16
JOB#: [**Job Number 25261**]
|
[
"428.0",
"428.40",
"303.90",
"414.01",
"311",
"730.07",
"280.0",
"458.2",
"440.24"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.23",
"84.17",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
8510, 9229
|
9250, 9774
|
1232, 1564
|
3399, 8486
|
2360, 3381
|
158, 198
|
227, 1205
|
1587, 2108
|
2125, 2337
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,963
| 186,489
|
9152
|
Discharge summary
|
report
|
Admission Date: [**2183-9-23**] Discharge Date: [**2183-9-29**]
Date of Birth: [**2133-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD with banding and sclerotherapy
History of Present Illness:
50m with HIV, HCV cirrhosis with esophageal varices s/p numerous
banding presents with one episode of loose, dark stools the
morning of admission. He states he'd felt well the day before
admission but went to bed feeling [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] queasy. He awoke at four
AM, needing to move his bowels, and when he did the stool was
dark with some red streaking, loose but not exactly watery, and
somewhat sticky. He's had no further BM's, no abd pain, and no
n/v. He also denies LH, chest pain, or dyspnea. Denies f/c. He
says he's had approximately [**8-9**] variceal bleeds, all similar to
this; he's never had a colonoscopy. He denies swelling in his
legs or abdomen, no recent weight changes.
In the ED, he had a hct of 26, refused an NG lavage and was
started on an octreotide drip.
.
Pt admitted to MICU and received 4 units PRBC and underwent EGD
with banding and sclerotherapy. After EGD pt had N/V and found
to have ileus. Improved after stopping octreotide and increased
bowel regimen. HCT stabalized and pt transfered back to medicine
floor.
Past Medical History:
-- HIV/AIDS dx in [**2163**], CD4 nadir 95 in [**2179**]
-- H/o zoster
-- H/o positive toxo IgG in [**2180**]
-- H/o positive CMV IgG in [**2180**]
-- H/o positive Hep A ab in [**2183**]
-- H/o positive Hep B core AB in [**2183**] (with neg sAB, neg
antigen)
H/o negative RPR in [**2183**]
-- Negative PPD in [**2183**]
-- Osteomyelitis L knee 10 years ago [**3-6**] IVDA
-- Portal vein thrombosis seen on CT in [**2183**]
-- Hepatitis C, s/p varices, portal gastropathy, splenomegaly
-- Esophageal varices s/p banding
-- Gout (dx age 18; hx of tophi removal; on allopurinol in the
past. Was seen in [**Hospital **] Clinic [**2182-3-5**].)
-- Substance abuse (mostly IV heroin, benzos, cocaine)
[**Hospital **] Medical noncompliance
Social History:
Lives with girlfriend, on [**Name (NI) 31500**]. Smoked 2ppd x 20-30 yrs, no
etoh. H/o IVDA. Recent cocaine use (last 1 week ago), with
frequent 4-5d "binges." Occasional bzd abuse. Denies any etoh
use.
Family History:
Non-contributory
Physical Exam:
t 96.7, bp 112/67, hr 70, rr 14, spo2 99% 2lNC
GEN: alert and oriented x3.
HEENT: anicteric, no jvd/lad/thyromegaly, R IJ.
CV: rrr, s1s2, no m/r/g
RESP: moves air well, no w/r/r
ABD: soft, mild distention, active BS, non-tender. Tympany. No
fluid wave appreciated.
EXT: no cyanosis/edema, warm/dry, no clubbing, no pitting/color
changes/indentations. Occ healed lesions and l leg ecchymoses.
NEURO: a&ox3, no focal cn/motor deficits, no asterixis
Pertinent Results:
EGD [**6-/2183**]: 3 cords of grade I varices, gastropathy.
[**2183-9-23**] EGD:
Esophagus:
Protruding Lesions 2 cords of grade II varices were seen in the
lower third of the esophagus. There were stigmata of recent
bleeding on one varix with a cherry red spot.A single band was
placed at the lower third of esophagus near GE junction on this
varix.A second band was attempted when bleeding was noticed on
the banded varix.At this point, hemostasis was secured by
injecting a total of 6.5 cc of 50% Morrhuate sodium into 2
separate varices. Bleeding stopped.
.
[**2183-9-25**] KUB:
IMPRESSION: Ascites, but no obstruction.
.
[**2183-9-23**] ABD U/S:
LIVER DOPPLER ULTRASOUND STUDY: Extending from the left portal
vein to the main portal vein, there is a non-occlusive
retractile echogenic
filling defect consistent with thrombus. The hepatic veins are
patent. There is a small amount of ascites. A small
right-sided pleural effusion is seen. The IVC is patent. The
gallbladder is normal in appearance. No gallbladder wall edema
is seen. There is no intrahepatic or extrahepatic biliary ductal
dilatation, and the common bile duct measures 5 mm in diameter.
The spleen is enlarged measuring 18.5 cm.
.
[**2183-9-23**] ECG:
Sinus rhythm, Normal ECG
.
LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2183-9-27**] 06:00AM 1.2* 3.64* 9.4* 28.8* 79* 25.8* 32.7
19.0* 46*
[**2183-9-27**] 02:10AM 27.2*
[**2183-9-26**] 09:45PM 1.3* 3.44* 9.3* 27.5* 80* 27.1 34.0 18.6*
39*
[**2183-9-26**] 04:21AM 1.4* 3.93* 10.2* 31.1* 79* 26.0* 32.9
18.9* 56*
[**2183-9-25**] 03:25AM 1.6* 3.61* 9.8* 28.7* 80* 27.1 34.1 18.5*
53*
[**2183-9-24**] 06:18PM 31.8*
[**2183-9-24**] 11:52AM 28.7*
[**2183-9-24**] 02:39AM 1.5* 3.72* 9.9* 29.2* 79* 26.6* 33.8
18.5* 47*
[**2183-9-23**] 11:00PM 27.7*
[**2183-9-23**] 05:52PM 28.9*
[**2183-9-23**] 03:05PM 26.7*#
[**2183-9-23**] 09:43AM 20.3*
[**2183-9-23**] 05:00AM 2.7* 3.54* 8.6* 26.4* 75*#1 24.2*# 32.4
18.2* 79
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2183-9-27**] 06:00AM 89 10 1.1 141 3.5 104 29 12
.
LFTs:
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
[**2183-9-27**] 06:00AM 9 15 0.6
[**2183-9-26**] 04:21AM 14 19 118 57 0.7
COAGS:
PT PTT Plt Ct INR(PT)
[**2183-9-27**] 06:00AM 15.5* 29.4 1.4
.
TOX SCREEN:
ASA Ethanol Acetmnp Bnzodzp Barbitr Tricycl
[**2183-9-23**] 09:43AM NEG NEG1 NEG NEG NEG NEG
.
MICRO:
[**2183-9-23**] 5:50 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2183-9-24**]**
URINE CULTURE (Final [**2183-9-24**]): NO GROWTH.
.
Brief Hospital Course:
A/P: 50m with AIDS, HCV cirrhosis with known varices and prior
variceal bleeds presents with variceal bleed.
.
## GIB: Source variceal. Now s/p EGD with banding and
sclerotherapy. HCT stable. Pt was transfused 4U PRBCs in the
ICU. Pt remained hemodynamically stable and followed closely in
the ICU. Pt was kept NPO, initially started on an octreotide gtt
prior to EGD. Post banding and sclerotherapy pt remained
hemodynamically stable. Pt was continued on PPI [**Hospital1 **] IV intially
and transitioned to PO. He was continued on Sucralfate. He
tolerated sips well, then transitioned to POs without trouble.
His diet was advanced to regular without any difficulties. He
did have 1 small BM which was black and tarry while on the
medicine floor but was hemodynamically stable with stable
hematocrit.
.
## N/V/Ileus: Likely [**3-6**] octreotide and narcotics. Improved
after d/c meds and starting PO naloxone and reglan. KUB with no
evidence of obstrution. Pt did not have N/V and was tolerating
POs well with 1 BM. His methadone was continued as well as
reglan and PO naloxone. PO naloxone only affects gut mu
receptors therefore not affecting systemic narcotic levels.
.
## Cirrhosis: ascites per recent abdominal U/S, no asterixis and
oriented. His lactulose was restarted, had discussion with Dr.
[**Last Name (STitle) 497**] as pt was refusing lactulose initially and agreed to take.
His nadolol was held. His LFTs were wnl. He was continued on
Levoflox to complete a 7 day course, which he finished.
.
## HIV/AIDS: Pt has been off HAART for 4-5 months as well as
prophylactics.
He was restarted on his prophylaxis medications (azithro and
dapsone). Has ID appointment on Friday at 11 a.m.
.
## Substance abuse: He was continued on methadone, however he
was placed on IV then switched to 60mg daily. Per Dr. [**Last Name (STitle) 497**] and
pt his home regimen is 80mg daily, which he was switched to.
States no EtOH abuse recently, so held CIWA. No evidence of
withdrawal symptoms and did not need CIWA.
.
## Coagulopathy: Likely [**3-6**] to liver disease. No evidence of
consumptive process.
.
## Pancytopenia: likely [**3-6**] both HIV and liver disease. Cont to
follow. Became neutropenic. Thought to be seconday to HIV. Got
one dose of Neugapen.
.
## Smoking: Pt was provided with nicotine patch while in-house
and encouraged to quit.
.
## CODE: FULL
Medications on Admission:
(pt states only taking methadone, allopurinol, and prednisone)
Azithromycin 1200mg weekly
Dapsone 100mg DAILY
Nadolol 40mg DAILY
Paroxetine 10mg DAILY
Pantoprazole 40mg daily
Allopurinol 200mg daily
Lactulose 30cc TID
Methadone 80mg DAILY
Lopinavir-Ritonavir 200-50 mg [**Hospital1 **]
Abacavir 300mg [**Hospital1 **]
Lamivudine 150mg [**Hospital1 **]
Tenofovir Disoproxil Fumarate 300mg DAILY
Prednisone 5mg DAILY (for gout)
Discharge Medications:
1. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
4. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
take twice per day for 2 weeks, then take daily.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO once a
week.
Disp:*4 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Melena
Variceal bleeding
.
Secondary:
-HIV
-HCV Cirrhosis
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed and keep all your
follow up appointments.
.
If you notice bright red blood per rectum, vomiting red blood,
or black/tarry stools or other worisome symptoms, call your
physician and go to the emergency room.
Followup Instructions:
You have an appointment with Dr. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] on [**10-3**]
at 11 a.m.
.
You have an appointment with Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] on [**10-7**] at
11:30 a.m.
.
You have an appointment with Dr. [**First Name5 (NamePattern1) 9619**] [**Last Name (NamePattern1) 9620**] on
[**10-13**] at 10:30 a.m.
.
Dr.[**Name (NI) 948**] office will call you with an appointment for a
repeat EGD and variceal banding in about 2 weeks.
|
[
"070.70",
"305.1",
"V15.81",
"305.90",
"571.5",
"790.01",
"456.20",
"042",
"274.9",
"572.3",
"572.8",
"305.51",
"284.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9456, 9462
|
5691, 8055
|
288, 324
|
9573, 9582
|
2940, 5668
|
9882, 10407
|
2439, 2457
|
8531, 9433
|
9483, 9552
|
8081, 8508
|
9606, 9859
|
2472, 2921
|
242, 250
|
352, 1445
|
1467, 2202
|
2218, 2423
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,527
| 174,419
|
21006
|
Discharge summary
|
report
|
Admission Date: [**2115-7-10**] Discharge Date: [**2115-7-19**]
Date of Birth: [**2031-3-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing dyspnea on exertion
Major Surgical or Invasive Procedure:
[**7-10**] Cardiac catheterization
[**7-15**] Aortic Valve Replacement ([**Street Address(2) 6158**]. [**Hospital 923**] Medical Epic
Biocor tissue valve), Coronary artery bypass grafting x 1 with
reverse saphenous vein graft to the right coronary artery
History of Present Illness:
Ms. [**Known lastname 41323**] is an 84 year-old woman with history of atrial
fibrillation (not anticoagulated), aortic stenosis, CHF, COPD,
and pulmonary hypertension. For the past several months she has
been having increasing symptoms of dyspnea on exertion. In
[**4-30**], she was admitted to [**Hospital3 2737**] with a CHF
exacerbation in the context of an infection (pt unsure of nature
of infection). She received IV lasix and was discharged on PO
lasix. Two weeks ago, Ms. [**Known lastname 41323**] [**Last Name (Titles) 46101**] the NP who works
with her cardiologist (Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] and Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**]) who
recommended that she stop lasix given absence of peripheral
edema, and she planned to take it PRN which she has not
required.
Although she was previously able to ambulate through the grocery
store without difficulty, her current baseline respiratory
status is notable for dyspnea on exertion half-way across a room
in her home, causing her to sit down and rest. She has
previously led a very active lifestyle. Because her symptoms
were thought to be in large part secondary to her AS and
limiting her ADLs, she was referred for catheterization in
anticipation of possible AVR. She denies any recent chest pain,
light-headedness, or syncope. She further denies claudication,
LE edema, orthopnea, or PND.
.
She was taken for cath on [**7-10**] demonstrating an 80% ostial RCA
lesion and valve area 0.5 cm2. After the case the patient
developed bleeding from groin with hypotension 60s systolic, HR
40s - received fluids and atropine. After this her SBP rose
into the 130s with HR 70s. She was sent to the CCU for
observation overnight.
Past Medical History:
Meniere's disease
Leukemia in [**2097**] treated with Chemotherapy
Myelodysplastic syndrome
COPD
Paroxsymal Atrial Fibrillation - She did not know of this
diagnosis. Denied ever taking Coumadin.
Aortic Stenosis with valve area 0.7 cm2
Pulmonary Hypertension
Hemorrhoidectomy
Tonsillectomy
Appendectomy
GERD
Chronic Diarrhea
Frequent Urination
Previous UTI's
Degenerative Disc Disease
Social History:
Ms. [**Name14 (STitle) 55821**] alone in [**Location (un) 2498**] MA. She recently had a
visiting nurse [**First Name8 (NamePattern2) 767**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Health Agency for three weeks
after her hospitalization in [**Month (only) **]. Her contact person in her
stepson [**Name (NI) **] [**Name (NI) 41323**]; his home number is [**Telephone/Fax (1) 55822**]. The
patient still drives. She has bilateral hearing aides. She
occasionally uses a cane when she is out of her house and has to
go some distances.
Family History:
Mother died at 103 of old age. Father died with stomach CA.
Physical Exam:
VS: T= 94.6, BP= 143/79, HR=85, RR= 16, O2 sat=92%
GENERAL: appropriate, pleasant elderly woman lying flat on her
back
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP 7 cm
CARDIAC: normal PMI, irregular, harsh 4/6 systolic murmur heard
best at RUSB
LUNGS: lungs clear anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. DP pulses intact
bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Preop labs
[**2115-7-10**] 10:12PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2115-7-10**] 10:12PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2115-7-10**] 10:12PM URINE RBC-[**5-1**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2115-7-10**] 03:50PM HCT-29.7*
[**2115-7-10**] 12:45PM GLUCOSE-98 UREA N-26* CREAT-1.0 SODIUM-136
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-22 ANION GAP-12
[**2115-7-10**] 12:45PM ALT(SGPT)-14 AST(SGOT)-24 ALK PHOS-68
AMYLASE-73 TOT BILI-0.5 DIR BILI-0.1 INDIR BIL-0.4
[**2115-7-10**] 12:45PM ALBUMIN-4.0 CALCIUM-8.8 CHOLEST-113
[**2115-7-10**] 12:45PM %HbA1c-5.5
[**2115-7-10**] 12:45PM WBC-3.4* RBC-2.91* HGB-9.3* HCT-29.3*
MCV-101* MCH-32.1* MCHC-31.9 RDW-17.6*
[**2115-7-10**] 12:45PM PLT SMR-NORMAL PLT COUNT-344#
[**2115-7-10**] 12:45PM PT-14.7* PTT-83.8* INR(PT)-1.3*
Discharge labs
[**2115-7-18**] 04:55AM BLOOD WBC-7.8 RBC-3.21* Hgb-9.9* Hct-28.8*
MCV-90 MCH-30.7 MCHC-34.2 RDW-17.5* Plt Ct-213
[**2115-7-18**] 04:55AM BLOOD Plt Smr-NORMAL Plt Ct-213 LPlt-2+
[**2115-7-16**] 02:57AM BLOOD PT-16.1* PTT-39.9* INR(PT)-1.4*
[**2115-7-18**] 04:55AM BLOOD Glucose-106* UreaN-20 Creat-1.1 Na-136
K-4.5 Cl-102 HCO3-26 AnGap-13
[**2115-7-10**] Cardiac Catheterization: 1. Coronary angiography in this
right dominant system demonstrated single vessel coronary artery
disease. The LMCA had no angiographically apparent disease.
The LAD and the LCX had no angiographically significant
stenosis. The RCA had a 90% ostial calcified stenosis, and
supplied small PDA and PL arteries. The distal RCA before the
crux appears to be a good target for bypass. 2. Resting
hemodynamics revealed normal right atrial and right ventricular
filling pressures with mean RA pressure of 6 mmHg and
end-diastolic RV pressure of 5 mmHg. There was mild pulmonary
arterial hypertension with mean PA pressure of 26 mmHg and
elevated pulmonary vascular resistance of 150 dynes-sec/cm5.
The left ventricular filling pressure was slightly elevated with
mean PCW pressure of 17 mmHg. There was no evidence of mitral
stenosis. Severe aortic stenosis was present, with a peak
aortic gradient of 66 mmHg, mean gradient of 49 mmHg, and
estimated aortic valve area of 0.59 cm2. The cardiac output was
normal at 4.8 L/min. There was no evidence of a left-to-right
shunt based on oxygen saturation data.
[**2115-7-11**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
<40%
EKG: sinus at 75 bpm, NL axis, 1st degree AV block, no ST-T wave
changes
[**2115-7-15**] ECHO: PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). No atrial septal
defect is seen by 2D or color Doppler. Right ventricular chamber
size and free wall motion are normal. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-23**]+) mitral regurgitation is seen.
There is no prolapse of flailing [**Last Name (un) **] leaflets. There is no
pericardial effusion. Dr. [**Last Name (STitle) 55823**] was notified in person of the
results on Ms.[**Known lastname 41323**] at 8AM before incision. Post_Bypass:
Patient on infusion of epinephrine 0.04 mcg/kg/min, mild RV and
global LV hypokinesis. LVEF 45%. There is a bioprosthesis in the
native aortic position with stable and well functioning
leaflets. Thoracic aorta is intact. There is minimal MR.
Brief Hospital Course:
Ms. [**Known lastname 41323**] is an 84 year-old woman with aortic stenosis,
recent admission to outside hospital for CHF/flash pulmonary
edema with subsequent ongoing shortness of breath, now s/p
catheterization on [**7-10**] demonstrating 90% ostial RCA lesion and
[**Location (un) 109**] 0.5cm2. As mentioned in the HPI, she was hypotensive with
bleeding post-cath requiring fluids and atropine. CT abdomen
done en route to the CCU did not show any signs of
retroperitoneal bleeding. Cardiac surgery was consulted and she
underwent pore-operative work-up which included echo, carotid
u/s, vein mapping and usual lab studies. While awaiting surgery
she was medically managed. On [**7-15**] she was brought to the
operating room where she underwent a coronary artery bypass x 1
and aortic valve replacement. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU for invasive monitoring in stable condition.
Post-operatively she required large amount of fluid
resuscitation, transfusion, and pressors for bleeding and
hypotension. Repeat echo was performed and ruled out tamponade.
On post-operatively day one she was weaned off sedation, awoke
neurologically intact and extubated. Post-operative day two her
chest tubes were removed and she was transferred to the
telemetry floor for further care. Epicardial pacing wires were
removed on post-op day three. The remainder of her post-op
course was unremarkable and she worked with physical therapy for
strength and mobility. On post-op day four she was discharged to
rehab facility with appropriate follow-up appointments.
Medications on Admission:
Coreg 3.125 mg tablet [**Hospital1 **], Epogen 40,000 units SQ Bimonthly,
Folic Acid 1 mg tablet daily qhs, Combivent 90 mcg 2 puffs QID,
Meclizine 25 mg tablet [**Hospital1 **], Simvastatin 20 mg tablet qhs,
Multivitamin tablet daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Meclizine 25 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for dizziness.
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for shortness
of breath.
7. Epogen 40,000 unit/mL Solution Sig: One (1) injection
Injection every other Wednesday.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
13. Aspirin 81 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO
DAILY (Daily).
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Coronary artery Disease s/p Coronary Artery Bypass Graft x 1
Severe Aortic stenosis s/p Aortic Valve replacement
Chronic Diastolic congestive heart Failure EF 55%
Chronic Obstructive Pulmonary Disease
Past Medical History: Meniere's disease, Leukemia in [**2097**]
treated with Chemotherapy, Myelodysplastic syndrome, Atrial
Fibrillation, Pulmonary Hypertension, Gastroesophageal reflux
disease, Chronic Diarrhea, Previous UTI's, Degenerative Disc
Disease, CVA found by MRI in [**2099**], Anemia, Bilateral cataracts,
s/p Tonsillectomy, s/p Appendectomy, s/p Hemorrhoidectomy
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] (Cardiac Surgeon) in 4 weeks Phone: [**Telephone/Fax (1) 170**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] (Cardiology) in [**12-25**] weeks Phone: [**Telephone/Fax (1) **]
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] (Primary Care) in [**11-23**] weeks Phone: [**Telephone/Fax (1) 55824**]
Completed by:[**2115-7-19**]
|
[
"416.8",
"458.29",
"286.9",
"496",
"386.00",
"285.22",
"427.31",
"208.91",
"428.32",
"428.0",
"998.11",
"424.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"36.11",
"35.21",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11037, 11108
|
7897, 9518
|
305, 561
|
11727, 11734
|
4076, 7874
|
12245, 12656
|
3369, 3430
|
9803, 11014
|
11129, 11330
|
9544, 9780
|
11758, 12222
|
3445, 4057
|
235, 267
|
589, 2368
|
11352, 11706
|
2792, 3353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,031
| 111,628
|
1097
|
Discharge summary
|
report
|
Admission Date: [**2178-11-18**] Discharge Date: [**2178-12-2**]
Date of Birth: [**2109-5-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Paracentesis
Dynamic l.hip screw placement
History of Present Illness:
This is a 69 year old F h/o HCV cirrhosis, esophageal varices,
h/o falls, initially p/w encephalopathy and hip pain, now s/p
dynamic hip screw to L hip with difficulty extubating post op
requiring transfer to the MICU. Of note pt admitted [**Date range (1) 7136**]
s/p mechanical fall with L 5th digit fx. Pain noted in left hip
at the time but plain films negative. Pt d/c'd to [**Hospital 7137**].
.
She was readmitted on [**11-18**] after being noted to have fever to
100 at CH in association with abd pain. Pt noted to be
encephalopathic, which cleared with lactulose. Pt's fever
attibuted to pna (? right-sided consolidation) and treated with
levo (increased from home sbp dose)/flagyl. Once pt's mental
status more lucid, she was complaining of L hip pain. MRI
showing left intertrochanteric fracture.
.
On [**11-25**], [**Month/Year (2) **] took pt to OR for DHS. Pre-op CXR [**11-24**] showed
increased effusion on R and increased infiltrate on L. Intra-op,
spiked to 100.9, transiently on neosynephrine. [**Name (NI) **], pt
developed thick, copious secretions felt to preclude extubation.
Pt bronch'd in PACU: sputum cxs ultimately grew out MRSA.
.
Pt transferred to MICU with orthopedics following. Pt treated
initially with vanc/zosyn, narrowed to vanc with above cx
results. PT extubated [**11-26**] at 3 pm. She has been doing well
post-extubation. By report, evaluated by PT and is full weight
bearing, though no note in chart since [**11-25**]. She is transferred
to the medical floor for further evaluation and management.
.
Patient is comfortable on the floor on 3L NC. Without complaints
at this time.
Past Medical History:
-Hepatitis C: genotype 1b; acquired from blood transfusion;
complicated by cirrhosis, splenomegaly, ascites, variceal bleed,
partial portal vein thrombosis. s/p therapeutic tap [**2178-7-12**]
admission
-Diabetes Mellitus 2
-Esophageal varices secondary to portal hypertension s/p banding
after bleed in [**2171**]. Most recent EGD 5/06-2 cords of grade I
varices were seen in the middle third of the esophagus and lower
third of the esophagus non-bleeding and non-amenable to banding.
Also portal gastropathy seen.
-GERD
-HTN
-Asthma
-Depression/anxiety
-history of UTI urosepsis [**12-14**]
-s/p open CCY in [**Country 532**], [**2147**]
-s/p removal of ovary, [**2147**]
Social History:
Patient was admitted from [**Hospital3 2558**]. No EtOH, no tobacco,
no IVDU. Pt is a Holocaust survivor, she was living
independently prior to her last admission and her son was
spending nights with her.
Family History:
Patient was three when her parents were killed in the Holocaust.
Her son denies any health problems.
Physical Exam:
Vitals: T 97.8 BP 126/50, P 78, Resp 20 98% on 3L
General: Alert, no acute distress, no complaints
HEENT: PERRL, extraocular motions intact, sclera mildly icteric,
dry mucous membranes with some mucosal crusting
Neck: No JVD, no cervical lymphadenopathy
Chest: Decreased breath sounds R base, rhonchorous on L,
difficult to auscultate lower lobes due to positioning
CV: Normal S1/S2, RRR, no murmurs, rubs, or gallops
Abd: Soft, nontender, significant distention, hyperactive bowel
sounds
Extr: [**1-13**]+ pitting edema to knees b/l. 2+ DP pulses bilaterally.
L hand in splint, left leg with bruising of medial thigh,
patient propped on pillow for positioning of leg
Pertinent Results:
CXR ([**2178-11-18**]): There is elevation of the right hemidiaphragm
with blunting of the right costophrenic angle. There are
increased interstitial markings bilaterally with areas of
confluent opacities in the right middle lobe and right lower
lobe concerning for asymmetrical pulmonary edema and/or
aspiration. The cardiomediastinal and hilar contours are stable.
The osseous structures and soft tissues are normal.
.
CXR [**12-1**]: FINDINGS: In comparison with the study of [**2178-11-29**],
there is again prominence of interstitial markings consistent
with increased pulmonary venous pressure. Opacification at the
right base with preservation of pulmonary markings is consistent
with a large pleural effusion. Some underlying atelectatic
change may well be present.
.
The right IJ catheter has been removed. The left PICC line again
extends to the level of the carina.
.
Abdominal US: IMPRESSION: Findings compatible with cirrhosis and
portal hypertension. No evidence of portal vein thrombosis.
.
BLE US: IMPRESSION: No DVT, bilateral lower extremities
.
MRI: IMPRESSION:
1. Left intertrochanteric fracture with varus angulation and
marked surrounding muscular and soft tissue hematoma/edema
including a 2.7 x 4.3 x 4.0 cm fluid collection containing
hemorrhage posterior to the proximal left femur and contained
within the gluteus minimus muscle. Marked soft tissue swelling
of the left hip and subcutaneous edema extending
circumferentially around the proximal left thigh.
2. Not mentioned above, there is a focal area of increased
signal on STIR sequence with a ring and arc configuration most
consistent with enchondroma. This is seen distal to the fracture
line.
3. Marked pelvic ascites. Please correlate with patient's
previous medical history.
.
EXAMINATION: Left hip and pelvis.
One view of both hips and the pelvis and four views of the
proximal femur and two views of the distal left femur are
submitted showing a nonhealed nonacute intertrochanteric
fracture of the left femur with only mild superior overriding of
the distal fracture fragment, and no dislocation of the mildly
to moderately degenerated left hip joint. Pelvis is intact.
Distal left femur and knee are normal. There is no knee joint
effusion, and the pelvic ring is intact.
.
IMPRESSION: Study limited by overlying casting material. Mid
shaft fifth proximal phalanx fracture again seen.
.
ECHO: Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. There is no valvular aortic stenosis. The increased
transaortic velocity is likely related to high cardiac output.
Trace aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Moderate pulmonary hypertension.
.
Labs:
[**2178-11-18**] 08:00AM BLOOD WBC-12.6*# RBC-3.32*# Hgb-11.6*#
Hct-35.4*# MCV-107* MCH-34.9* MCHC-32.7 RDW-15.7* Plt Ct-208#
[**2178-12-1**] 01:53AM BLOOD WBC-7.0 RBC-2.60* Hgb-9.3* Hct-27.4*
MCV-106* MCH-35.6* MCHC-33.8 RDW-20.4* Plt Ct-137*
[**2178-11-18**] 08:00AM BLOOD Neuts-81.1* Lymphs-10.4* Monos-7.3
Eos-0.6 Baso-0.6
[**2178-11-28**] 12:46PM BLOOD Neuts-79.2* Lymphs-12.7* Monos-4.5
Eos-3.4 Baso-0.1
[**2178-11-18**] 08:00AM BLOOD PT-20.9* PTT-35.9* INR(PT)-2.0*
[**2178-12-1**] 01:53AM BLOOD PT-19.0* PTT-41.3* INR(PT)-1.8*
[**2178-11-18**] 08:00AM BLOOD Glucose-197* UreaN-20 Creat-0.9 Na-137
K-4.1 Cl-103 HCO3-27 AnGap-11
[**2178-11-29**] 07:00AM BLOOD Glucose-148* UreaN-18 Creat-0.9 Na-135
K-3.8 Cl-97 HCO3-34* AnGap-8
[**2178-11-30**] 03:29AM BLOOD Glucose-153* UreaN-23* Creat-1.2* Na-133
K-3.9 Cl-96 HCO3-33* AnGap-8
[**2178-12-1**] 01:53AM BLOOD Glucose-111* UreaN-25* Creat-1.3* Na-131*
K-4.0 Cl-95* HCO3-31 AnGap-9
[**2178-11-18**] 08:00AM BLOOD ALT-23 AST-31 LD(LDH)-319* AlkPhos-153*
Amylase-42 TotBili-7.6*
[**2178-11-28**] 08:24AM BLOOD ALT-11 AST-29 LD(LDH)-233 AlkPhos-140*
TotBili-6.3*
[**2178-11-18**] 08:00AM BLOOD TotProt-6.6
[**2178-12-1**] 01:53AM BLOOD Calcium-8.4 Phos-1.0* Mg-1.9
[**2178-11-18**] 09:20AM BLOOD Ammonia-60*
[**2178-11-20**] 06:20AM BLOOD Ammonia-69*
[**2178-12-1**] 01:53AM BLOOD Vanco-22.2*
Brief Hospital Course:
# PNA: Cx growing MRSA. Pt now afebrile, satting well on 1L NC.
Titrating off oxygen as tolerated. Patient's vanc trough was
supratherapeutic. We have been holding her vancomycin until it
returns to a normal range. She will need 14 days of vancomycin
total dose. PICC line in place. Vancomycin trough today 16.8.
Vanco dose held. Pt initally started on [**2178-11-25**]. She will need
treatment for a total of 14 days. Dose vanco if trough <15.
Check trough [**12-3**] am.
.
# Diarrhea: Patient was C. Diff positive in [**Month (only) **]. C. Diff
negative x3 here. On lactulose titrating to [**3-15**] loose stools
daily given her liver disease. Diarrhea has improved
considerably over the last few days.
.
# L hip fx: Patient was taken to the OR by [**Month/Day (3) **] for a dynamic
hip screw placement on [**11-25**]. She has been doing well
post-operatively. She is weight bearing and requires rehab for
physical therapy. On tylenol and prn morphine for pain control
Has some post-op edema in her L>R legs. She is on Lovenox and
will require 4 weeks as per [**Month/Year (2) **]. She should follow up with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP 2 weeks after dc ([**Telephone/Fax (1) 1228**]). Staples
are to be removed on post-operative day #14. She should follow
up with Dr. [**Last Name (STitle) **] one month after discharge.
.
# Hep C/Cirrhosis with known esophageal varices and ascites:
Patient had a diagnostic tap in the Emergency room prior to
admission that was negative for SBP. She has been continued on
her levofloxacin for SBP prophylaxis as well as her home
spironolactone and nadolol (was changed to Metoprolol pre-op but
then restarted nadolol afterwards). She has had evidence of
volume overload and has been diuresis with IV lasix, however,
has had a bump in her creatinine over the last few days. She
normally takes 40mg PO Lasix at home and 100mg aldactone.
.
# DM: On Lantus and insulin sliding scale. She should continue
this as an outpatient.
Sliding scale attached.
.
# Macrocytic Anemia: She has been anemic since surgery, but
stable. Her baseline Hct is 30. She has had multiple checks of
B12 and folate in the past, all have been normal. Thought to be
secondary to liver disease. Would continue to monitor.
.
# Hand Fracture: Left sided 5th digit fracture s/p fall. Patient
should continue to wear her ulnar gutter splint. She should
follow up in hand clinic 2 weeks after discharge. She was
evaluated by plastic surgery while in house.
.
# Pt discovered to have a UTI on [**2178-12-1**]. Culture thus far
shows no growth. Pt started on IV ceftriaxone for which she will
take for a total of 5 days. Last dose on [**2178-12-5**].
.
# GERD: Continued on outpatient PPI
.
# Depression/Anxiety: Continued on outpatient Citalopram
.
# PPX: Continued outpatient PPI, should have 4 weeks of Lovenox
as per orthopedic surgery.
.
# Access: PICC in place on Left.
.
# Contact: son [**Name (NI) **] 617*849*4375
.
# Full code
Medications on Admission:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for SEVERE pain for 10 days.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
10. Insulin Sliding Scale
Please continue Insulin sliding scale as directed, and perform
QID Fingersticks (QAC/HS). If NPO use the bedtime sliding
scale.
11. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO
every six (6) hours as needed for titrate to 3 bowel movements
daily: Please titrate administration to 3 bowel movements daily.
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. 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
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 3 loose stools daily.
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 4 total weeks:
Discontinue on [**2178-12-26**] (4 weeks total therapy).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): SBP prophylaxis.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. MS Contin 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day: hold for respiratory
depression, mental status changes.
14. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 3 days: total of
5 days. Day #1 [**12-1**] for UTI.
15. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 6 days: Day #1 [**11-25**]. Check trough [**12-3**] and give
dose if <15.
16. Insulin sliding scale
Insulin SC sliding scale-humalog as per attached scale.
finger sticks QACHS
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **]
Discharge Diagnosis:
Left intertrochanteric fracture
Left 5th digit fracture
Hepatitis C cirrhosis
DM2
HTN
asthma
depression/anxiety
MRSA pneumonia
UTI
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for fever, abdominal pain, confusion and L.hip
pain. You were found to have a fracture of your L.hip that was
repaired by orthopedic surgery. After surgery, you were in the
MICU for respiratory difficulties. You were also found to have a
MRSA pneumonia for which you are receiving antibiotics. You are
currently
being treated for a urinary tract infection with another
antibiotic.
.
If you develop shortness of breath, chest pain, severe abdominal
pain, severe leg pain,weakness, or numbness/tingling in your
leg, blood or burning on urination or other symptoms that
concern you, please call your doctor or go to the nearest
Emergency Room as soon as possible.
.
Please take your medications as prescribed and keep all follow
up appointments.
Followup Instructions:
You should follow up with your primary care doctor as soon as
possible. You can call [**Telephone/Fax (1) 589**] to set up this appointment.
.
In addition, you should follow up in the hand clinic for your L
finger fracture in 2 weeks. You should call ([**Telephone/Fax (1) 7138**] to
set up this appointment.
.
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 1228**] to schedule an
orthopedic follow up for your hip fracture in one month.
Your staples may be removed on POD 14. [**2178-12-7**] at rehab.
|
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58,782
| 134,708
|
40953
|
Discharge summary
|
report
|
Admission Date: [**2101-9-11**] [**Month/Day/Year **] Date: [**2101-9-19**]
Date of Birth: [**2065-6-5**] Sex: M
Service: MEDICINE
Allergies:
Chlorhexidine
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Neutropenic fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 36 year-old male with a history of AML (monocytic
differentiation (trisomy 15) diagnosed in [**4-27**] s/p induction
therapy and 4 cycles of consolidation with high dose cytarabine
presenting after syncopal event and referred from OSH for low
platelets. Pt states he has been having T to [**Age over 90 **]F over the last
2d and this am felt lightheaded, temp 103 and syncopized after
leaving the bathroom. Denies any prodromal symptoms and regained
consciousness before even hitting ground w/o loss of
bowel/bladder incontinence. Fell down hitting his Left
forehead. Of note, he was discharged [**8-29**] and has been seen
frequently in clinic. He has been neutropenic since [**2101-9-2**].
Presented to OSH and had a CT which per report did not show a
bleed or fx. His plt count was 18,000 and he was transfered here
for transfussion and further work-up. CXR there neg. He was
given 2g cefepime. He denies any n/v, cough, nasal [**Month/Day/Year **],
dysuria, HA, SOB, abd pain. Endorses 2-3 episodes per day x 3
days of loose stools nonbloody over that last week in context of
taking milk of magnesia for constipation as well as
Ciprofloxacin (started ~[**2101-9-2**]) per primary Oncologist for
prophylaxis. He also endorses sore throat today. At OSH he had
cultures and was transferred here for a plt count of 18. He says
he has been feeling "off" for the past 2 days. Has had some
loose stools, some sore throat.
.
ROS relevent for for right retro-orbital headache. Denies blurry
vision, dizziness, difficulty with speech, focal weakness.
Reports developing a sore throat on ride here. No cough,
shortness of breath, or chest pain. He has had diarrhea for past
2-3 days, 3 episodes of watery, nonbloody stool this AM. Has not
had dysuria, hematuria. Reports abdominal bloating, nausea
today. No vomiting. No stiff neck, joint pains, leg swelling,
rashes. Has had mild self-limited nosebleeds, no other sites of
bleeding.
.
ED Course: Febrile in the ED to 104, received Tyenol x 2. Was
tachycardic to 140's, given 7 L IVF, and HR came down to 125.
MAPs still less than 65, so CVL was placed. Satting 100% 3L but
tachypneic to high 20s. Bld Cx sent. WBC count is 0.2 with 7%
neutrophils. BMT saw him in the ED, and thought potential for C.
Diff infection. IV Vanc and flagyl added. He also got 2U of
plts, and had a non-con head CT and ABD CT. Head CT: no acute IC
pathology, ? mild max sinus thickening. Abdomen: IMPRESSION: 1.
Findings suggest acute appendicitis with new peri-appendiceal
fat-stranding about a dilated appendix.
2. No CT evidence of colitis. Liquid stool in the colon.
Past Medical History:
PMH:
Hepatosteatosis
Inguinal hernia
s/p concussion in [**2089**]
s/p periodontal surgery
.
PAST ONCOLOGIC HISTORY:
- [**2101-4-22**]: admitted after presenting to PCP/[**Hospital **] hospital c/o
malaise, fatigue, syncope, night sweats and weight loss and
found on labs to have WBC of 148K with blasts, Hct: 17. At [**Hospital1 18**]
admission, had 119K WBC and 48% blast, Hct 15.7, acute renal
failure with creat of 2.7 (secondary to lysozyme kidney injury).
- [**2101-4-22**]: Peripheral Flow Cytometry: AML w/ monocytic
differentiation
- [**2101-4-22**]: BMBx: markedly hypercellular marrow with extensive
involvement with AML with monocytic differentiation (58% blasts
seen on aspirate).
- [**2101-4-22**]: BMBx cytogenetics: trisomy 15 in 86/100 nuclei.
- [**Date range (1) 66812**]/11: received 7+3 induction chemotherapy - course
complicated by neutropenic fever, mastoiditis, and mild
mucositis.
- [**2101-4-24**]: NPM positive; FLT3 negative
- [**2101-5-6**]: Day 14 BMBx: chemoablated marrow. Overall cellularity
40%. Significant fibrosis seen and most likely present prior to
chemo.
- [**2101-5-6**]: BMBx cytogenetics: trisomy 15 in 21/100 nuclei.
- [**2101-5-12**]: Day 20 BMBx: hypocellular bone marrow for age with
prominent dysmegakaryopoiesis and scant left-shifted
myelopoiesis. Concern for underlying myelodysplasia. AML blasts
are not seen.
- [**2101-5-12**]: BMBx cytogenetics: Trisomy 15 in 5/100 nuclei.
- [**2101-5-18**]: JAK2 mutation analysis: Negative
- [**2101-5-25**]: Day 33 BMBx: Normocellular bone marrow for age with
maturing trilineage hematopoiesis and megakaryocytic clustering.
Diagnostic morphologic features of involvement by acute myeloid
leukemia are not seen.
- [**2101-5-25**]: BMBx cytogenetics: Trisomy 15 is not detected. NPM is
negative.
- [**2101-5-30**]: HIDAC cycle #1.
- [**2101-6-15**]: Admission for neutropenic fever.
- [**2101-6-29**]: HIDAC cycle #2.
- [**2101-7-31**]: HIDAC cycle #3.
- [**2101-8-28**]: HIDAC cycle #4.
Social History:
Works as a supervisor for [**Company 7546**], with exposure to many
chemicals and some solvents. He was previously in the Marines
from [**2084**]-[**2089**]. No smoking history, social alcohol drinker.
Patient endorses past casual use of cocaine, marijuana and
Ecstasy. His mother lives in the area. Patient recently got
engaged and fiancee lives in [**Location 19061**]. Other family in
[**Country 13622**] Republic.
Family History:
Breast cancer history on mother's side, including mother (dx
~60s), aunt. Ovarian cancer in patient's maternal aunt. There
is history of throat cancer and brain cancer in the patient's
father, who was a smoker. No family history of leukemia. One
cousin had lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 102.4 BP: 94/41 P: 123 R: 30 O2: 95 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx with obvious exudate,
4cm Frontal hematoma over L supraorbital rim with 2cm laceration
with crusting over.
Neck: supple, JVP not elevated, no LAD
Lungs: no wheezes, mild rales at bases bilaterally
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, mildly tympanitic, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: II-XII grossly intact, no gross motor or sensory
deficitis in B/L upper and lower ext.
.
[**Country 894**] PHYSICAL EXAM:
VS Tm 98.9, BP 120s/80s, HR 100-110s, RR 20, O2sats >96% RA
General: Alert, oriented, no acute distress
Lungs: no wheezes, mild rales at bases bilaterally
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, no rebound tenderness or guarding,
no organomegaly
Pertinent Results:
ADMISSION LABS:
[**2101-9-10**] 08:30AM WBC-0.5* RBC-2.45* HGB-7.9* HCT-20.7* MCV-85
MCH-32.1* MCHC-38.0* RDW-15.7*
[**2101-9-10**] 08:30AM NEUTS-1* BANDS-0 LYMPHS-99* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2101-9-10**] 08:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2101-9-10**] 08:30AM PLT COUNT-19*
[**2101-9-10**] 08:30AM GRAN CT-5*
[**2101-9-10**] 08:30AM GLUCOSE-190* UREA N-13 CREAT-1.1 SODIUM-136
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16
.
During hosptitalization:
[**2101-9-11**] 04:23PM BLOOD WBC-0.2*# RBC-2.37* Hgb-7.6* Hct-19.9*
MCV-84 MCH-32.1* MCHC-38.4* RDW-15.4 Plt Ct-14*
[**2101-9-12**] 06:10AM BLOOD WBC-0.2* RBC-2.38* Hgb-7.5* Hct-19.6*
MCV-82 MCH-31.6 MCHC-38.4* RDW-14.6 Plt Ct-47*
[**2101-9-13**] 01:18AM BLOOD WBC-0.2* RBC-2.74* Hgb-8.7* Hct-22.2*
MCV-81* MCH-31.6 MCHC-39.0* RDW-14.9 Plt Ct-41*
[**2101-9-12**] 06:10AM BLOOD Neuts-0* Bands-0 Lymphs-100* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2101-9-10**] 08:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2101-9-13**] 01:18AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Spheroc-2+ Ovalocy-1+
[**2101-9-11**] 04:23PM BLOOD PT-16.6* PTT-25.2 INR(PT)-1.5*
[**2101-9-12**] 01:01AM BLOOD PT-17.6* PTT-30.4 INR(PT)-1.6*
[**2101-9-12**] 06:10AM BLOOD PT-16.4* PTT-28.9 INR(PT)-1.4*
[**2101-9-12**] 06:10AM BLOOD Gran Ct-0*
[**2101-9-13**] 01:18AM BLOOD Gran Ct-0*
[**2101-9-14**] 12:00AM BLOOD Gran Ct-40*
[**2101-9-11**] 04:23PM BLOOD Glucose-221* UreaN-15 Creat-1.4* Na-129*
K-3.6 Cl-93* HCO3-24 AnGap-16
[**2101-9-12**] 01:01AM BLOOD Glucose-225* UreaN-11 Creat-1.3* Na-132*
K-3.5 Cl-99 HCO3-23 AnGap-14
[**2101-9-13**] 01:18AM BLOOD Glucose-187* UreaN-10 Creat-1.1 Na-133
K-3.2* Cl-99 HCO3-25 AnGap-12
[**2101-9-11**] 04:23PM BLOOD ALT-40 AST-33 AlkPhos-59 TotBili-0.8
DirBili-0.2 IndBili-0.6
[**2101-9-11**] 04:23PM BLOOD Lipase-12
[**2101-9-11**] 04:23PM BLOOD cTropnT-<0.01
[**2101-9-12**] 01:01AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8
[**2101-9-13**] 01:18AM BLOOD Calcium-8.1* Phos-1.9* Mg-2.0
[**2101-9-14**] 12:00AM BLOOD Albumin-3.0* Calcium-8.0* Phos-2.6*
Mg-1.9
[**2101-9-13**] 06:07AM BLOOD Vanco-6.1*
[**2101-9-11**] 10:24PM BLOOD Type-MIX pO2-35* pCO2-31* pH-7.45
calTCO2-22 Base XS-0
[**2101-9-11**] 04:32PM BLOOD Glucose-215* Lactate-1.9 K-3.7
[**2101-9-11**] 04:32PM BLOOD Hgb-7.8* calcHCT-23
[**2101-9-13**] 11:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2101-9-13**] 11:15PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
[**2101-9-13**] 11:15PM URINE RBC-<1 WBC-5 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
.
[**Month/Day/Year 894**] LABS:
[**2101-9-19**] 12:00AM BLOOD WBC-9.4# RBC-3.09* Hgb-9.9* Hct-27.5*
MCV-89 MCH-32.0 MCHC-35.9* RDW-15.4 Plt Ct-55*
[**2101-9-19**] 12:00AM BLOOD Gran Ct-4794
[**2101-9-19**] 12:00AM BLOOD Glucose-179* UreaN-15 Creat-1.0 Na-138
K-3.5 Cl-101 HCO3-27 AnGap-14
[**2101-9-19**] 12:00AM BLOOD Albumin-3.5 Calcium-8.9 Phos-4.5 Mg-1.8
.
IMAGES:
[**2101-9-13**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) **],[**First Name3 (LF) **] R.
In comparison with the study of [**9-12**], there is less prominence
of
the cardiac silhouette and no evidence of vascular congestion,
pleural
effusion, or acute pneumonia. Right IJ catheter extends to the
upper portion of the SVC.
.
[**2101-9-12**] Radiology CT CHEST W/O CONTRAST [**Last Name (LF) **],[**First Name3 (LF) **] R.
Multifocal ground glass opacities bilaterally (right > left)
with mild to
moderate simple right pleural effusion suggests infective
etiology. Findings are not specific for any particular type of
infection
.
[**2101-9-12**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) 2437**],[**First Name3 (LF) **]
In comparison with the study of [**9-11**], there are lower lung
volumes.
There is an area of increased opacification at the right base
medially. It is unclear whether this represents merely crowding
of normal pulmonary vessels or possibly a developing focus of
consolidation. The left lung is essentially clear.
.
[**2101-9-12**] Cardiology ECHO [**2101-9-12**] [**Last Name (LF) 2437**],[**First Name3 (LF) **] Finalized
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). There is no ventricular septal
defect. There is abnormal septal motion/position. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion
.
[**2101-9-11**] Radiology CHEST PORT. LINE [**First Name9 (NamePattern2) **] [**Last Name (LF) 2437**],[**First Name3 (LF) **]
There is a right IJ catheter that extends to about the level of
the junction with the subclavian vein. No evidence of acute
cardiopulmonary disease
.
[**2101-9-11**] Radiology CT HEAD W/O CONTRAST [**Doctor Last Name **],CZARINA
1. No acute intracranial process. Specifically, no intracranial
hemorrhage.
2. Mild bimaxillary sinus mucosal thickening.
3. Scattered left mastoid air cell opacification, stable
.
[**2101-9-11**] Radiology CT ABD & PELVIS WITH CO [**Doctor Last Name **],CZARINA
1. Findings suggest acute appendicitis with new peri-appendiceal
fat-stranding about a dilated appendix.
2. No CT evidence of colitis. Liquid stool in the colon.
.
[**2101-9-11**] Cardiology ECG [**2101-9-13**] [**Last Name (LF) **],[**First Name3 (LF) **] R.
Sinus tachycardia. RSR' pattern in lead V1. Non-specific ST-T
wave
abnormalities. Compared to the previous tracing of [**2101-5-10**] no
diagnostic
interval change.
.
MICRO:
[**9-14**] SPUTUM CULTURE NEGATIVE
[**9-13**] URINE CULTURE NEGATIVE
[**9-13**], 26, 25 BLOOD CULTURE NO GROWTH TO DATE
[**9-12**] STREP THROAT CULTURE NEGATIVE
[**9-12**] RESPIRATORY VIRAL PANEL NEGATIVE
[**9-12**] CDIFF NEGATIVE
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
Mr. [**Known lastname 89379**] is a 36 year-old male with a history of AML
(monocytic differentiation (trisomy 15) diagnosed in [**4-27**] status
post induction therapy and 4 cycles of consolidation with high
dose cytarabine presenting after syncopal event and referred
from OSH for low platelets in the context of neutropenic fever
and concern for septic shock.
.
ACTIVE PROBLEMS
# Febrile Neutropenia: His symptoms prior to admission were
abdominal pain and diarrhea. He denied symptoms of respiratory
illness, however, his CT chest was suggestive of a bilateral
ground glass pneumonia. His legionella and respiratory viral
panel were negative. CT abdomen was also suggestive of acute
appendicitis and he had melanotic diarrhea for a few days prior
to admission. His C.diff was negative. Patient was empirically
started on vancomycin (did not have a port), cefepime
(neutropenic fever regimen), levofloxacin (atypical bilateral
pneumonia coverage), and flagyl (intra-abdominal infection
coverage). He was continued on fluconazole prophylaxis. He also
recieved one dose of oseltamivir. The vancomycin and cefepime
were discontinued without further fevers. He was discharged to
complete a 14 day course of levofloxacin/flagyl for neutropenic
fever and appendicitis.
.
# Sepsis: Upon admission, he met criteria for sepsis, but
responded to volume resusitation with resolution of his
hypotension. TTE ruled out cardiac vegetations. Lactate was
normal. He persisted with tachycardia after his blood pressure
was normal. With transfusion of red blood cells for his anemia,
his tachycardia improved.
.
# Acute kidney injury: Creatinine at 1.4 on admission. This was
consistent with a pre-renal picture in context of
hypotension/sepsis. Creatine improved to 1.0 after volume
resucitation.
.
# Coagulopathy: INR 1.6 on admission. Suspectd to be due to
nutrition. PTT is normal and had low suspicion for other process
like DIC. Received Vitamin K po x1.
.
# Pancytopenia: Likely due to chemotherapy with contributing
factor of sepsis and possible GI blood loss. Transfused total
of 4 units pRBC and 1 unit platelets while in the ICU. He was
continued on antifungal and antibiotic coverage for neutropenia.
.
# Syncope: Fell and hit his head quite hard at home. CT head
negative for intracranial hemorrhage. Syncope likely due to
hypovolemia given history of diarrhea and malaise with poor PO
intake, elevated creatinine and fevers he undoubtedly had
increased insensible losses. TTE showed no evidence of
structural disease leading to sycope and patient was monitored
on telemetry without arrthymia events.
.
# AML: Monocytic differentiation, s/p 7+3 induction and finished
consolidation with HiDAC, Cycle 4. Antibiotics were administered
as above, and fluconazole ppx was continued until he was no
longer neutropenic. Further management per primary heme/onc team
as an outpatient.
.
# Hyperglycemia: A1c during admission 6.8%. Hyperglycemia
during this admission was likely related to sepsis and resolved
prior to [**Date Range **]. Patient is already working on diet and
exercise.
.
TRANSITIONAL ISSUES:
- Please ensure that his counts stay normal now that treatment
for his AML is complete
- Please follow up fasting blood glucose levels once he is no
longer in the stress phase of illness. His A1c was normal,
however, he had elevated FBS and may need therapy in the future.
He is already working on diet and exercise for weight loss
Medications on Admission:
ciprofloxacin 500 mg [**Hospital1 **]
fluconazole 200 mg daily
ondansetron 8 mg q8h prn nausea
[**Hospital1 **] Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. ondansetron 8 mg Film Sig: One (1) tab PO every eight (8)
hours as needed for nausea.
3. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for dyspepsia,
heartburn.
Disp:*30 ML(s)* Refills:*0*
4. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Take for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever>100.4, headache.
Disp:*30 Tablet(s)* Refills:*0*
[**Hospital1 **] Disposition:
Home
[**Hospital1 **] Diagnosis:
PRIMARY DIAGNOSIS:
Neutropenic fever
.
SECONDARY DIAGNOSIS:
Acute myelocytic leukemia
Normocytic anemia
[**Hospital1 **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Hospital1 **] Instructions:
Dear Mr. [**Known lastname 89379**],
.
You were admitted to the hospital because you were having fevers
and had very low white blood cell counts--called neutropenic
fever. This is a concerning condition because your body's
defenses against infection are low due to chemotherapy. You
were found to have inflammation in your appendix suggestive of
an infection and also possible pneumonia. You were treated with
antibiotics. You should continue the antibiotics (levofloxacin
and metronidazole) for 7 more days.
.
You also had low red blood cell counts in the hospital--called
anemia. This is common with chemotherapy, however, you may have
had some bleeding in your GI tract which made this worse.
Bleeding in your GI tract causes black tarry stools and can
result in a fast heart rate and low blood pressure like you
experienced. You underwent red blood cell and platelet
transfusions for this.
.
The following changes were made to your medications:
YOU SHOULD START TAKING THE FOLLOWING MEDICATIONS:
- Levofloxacin 750 mg daily until [**9-26**]
- Metronidazole 500 mg three times a day until [**9-26**]. You
should
not drink alcohol while you are taking this medication.
- You can use acetaminophen for pain control
- You can use Maalox as needed for abdominal
bloating/heartburn
.
It is also very important that you keep all of the follow-up
appointments listed below.
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2101-9-30**] at 2:30 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"285.3",
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"785.0",
"278.00",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13222, 16349
|
301, 307
|
6765, 6765
|
19323, 19587
|
5405, 5678
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|
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244, 263
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|
17581, 17601
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17711, 17823
|
17562, 17562
|
2968, 4949
|
4965, 5389
|
17854, 19300
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,904
| 173,746
|
6745
|
Discharge summary
|
report
|
Admission Date: [**2140-11-27**] Discharge Date: [**2140-12-5**]
Date of Birth: [**2061-6-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Horse Blood Extract
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 79yoM with h/o IDDM, CAD who presents from his [**Hospital1 1501**]
with hyperglycemia. He is followed by Dr. [**First Name (STitle) **] at [**Last Name (un) **]
Diabetes Center, and has had multiple admissions in recent
months related to labile blood sugars. Most recent admission
from [**Date range (3) 25659**] for hypoglycemia, and since that time his
insulin regimen was changed from 18u [**Hospital1 **] of Humalog 75/25 to a
humalog sliding scale with meals and 4u Lantus qAM. Per [**Hospital1 1501**]
blood glucose log from this week, his blood sugars have
generally been high, frequently >400. This AM his blood sugar
was >500 on multiple checks. The staff called Dr. [**Last Name (STitle) 10088**] at
[**Last Name (un) **], who was covering for Dr. [**First Name (STitle) **] and recommended pt go to
ED for further eval.
In the ED, initial VS were T 97.9, HR 68, BP 120/68, RR 16,
O2sat 98% RA. Labs were notable for FBS 431, AG 17, HCO3 21,
+urine ketones. He was started on insulin gtt @ 6u/hr with 6u
bolus and IV NS with 20mEqK at 250cc/hr. He was admitted to MICU
for continued management on insulin gtt.
On arrival to the MICU, he reports feeling well. Endorses
labile blood sugars recently, but is uncertain of the cause.
Denies HA, lightheadedness/dizziness, visual changes, CP/SOB,
abdominal pain, N/V, diarrhea.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Hypertension.
CAD s/p NSTEMI [**10-2**] tx with medical management
DMI recently labile blood sugars, on insulin pump in past,
followed by [**Last Name (un) **]
Glaucoma
h/o colon adenocarcinoma, resected
Social History:
Lives at [**Location (un) 169**] facility. He quit tobacco 38 years ago,
but his smoking exposure was very minimal. He drinks wine very
seldomly. He is a retired computer scientist. He has 3 children,
son [**Name (NI) 3979**] is HCP, has daughter [**Name (NI) **], and another child. Wife
died several yrs ago.
Family History:
Father had a question of coronary artery disease and had a
pacemaker and died at the age of 81. His mother died of CA,
unknown.
Physical Exam:
In ICU:
General: Pleasant, frail-appearing elderly male in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Neuro: AAOx3, CNII-XII grossly intact, no focal deficits
On Floor:
Vitals: T: 99.5, BP: 132/52, P: 103, R: 20, SaO2: 98% RA
General: Pleasant, elderly, cachectic male, no apparent
distress, AOx3, days of week backwards
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Regular rhythm (frequent PACs), tachycardic to 100s, normal
S1 + S2, no murmurs, rubs, gallops appreciated
Lungs: Left base with crackles
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Neuro: 4+ strength throughout, sensation grossly intact, grossly
nonfocal
Pertinent Results:
[**2140-12-5**] 07:35AM BLOOD WBC-12.7* RBC-3.48* Hgb-11.1* Hct-33.1*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.1 Plt Ct-514*
[**2140-12-5**] 07:35AM BLOOD Glucose-85 UreaN-21* Creat-0.9 Na-138
K-3.8 Cl-102 HCO3-29 AnGap-11
[**2140-11-27**] 07:05PM BLOOD CK-MB-3 cTropnT-0.01
[**2140-12-5**] 07:35AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8
[**2140-11-29**] 06:50AM BLOOD TSH-14*
[**2140-11-27**] 01:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Blood culture and urine cultures negative.
MRSA screen positive
CXR: Though there is new mild volume loss in the left lower
lobe, there is enough irregular consolidation accompanied by a
new small left pleural effusion to raise concern for pneumonia,
particularly due to aspiration. A smaller region of vague
opacity in the right upper lung at the level of the second
anterior interspace and third rib is larger than it was in
[**10-2**] and [**11-27**]. The nature of this abnormality is
unclear.
Brief Hospital Course:
DKA: The patient presented with DKA and was started on an
insulin drip and admitted to the ICU. [**Last Name (un) **] diabetes consult
was called and he was transitioned to SC insulin. He was
transferred to the floor where he was found to have a pneumonia.
His insulin levels were titrated by [**Last Name (un) **]. He will follow up
with Dr. [**First Name (STitle) **] at [**Last Name (un) **].
Pneumonia, aspiratoin: The patient has risk factors for HCAP
however on symptoms and CXR it was thought his pneumonia was
consistent with aspiration pneumonia. He was treated with
levofloxacin and metronidazole. His fevers and white blood cell
count improved on this regimen.
Encephalopathy: He was confused in the ICU with visual
hallucinations. Upon treating his hyperglycemia and infection
his mental status improved. It was thought to be most consistent
with metabolic encephalopathy. It continued to improve through
the hospital course.
HTN: Stable and continued on home medications.
CAD: Stable and continued on home medications.
Glaucoma: Stable and continued on home medications.
Code status: DNR/DNI
Transitional Issues:
f/u CXR for lesion noted on [**2140-11-29**]
titration of insulin regimen
complete antibiotic course - monitor mental status
Medications on Admission:
-ASA 81mg chewable PO daily
-Brimonidine 0.15% ophth solution 1 drop to each eye twice daily
-Xalatan 0.005% ophth 1 drop each eye qhs
-prune juice prn: constipation
-Milk of Magnesia 30mL PO daily prn constipation
-Dulcolax 10mg PR qhs prn constipation
-Plavix 75mg PO daily
-Lipitor 80mg PO daily
-Metoprolol tartrate 37.5mg PO BID
-Albuterol sulfate neb q6hours prn SOB/wheezing
-Glucerna [**1-24**] can PO TID
-Lisinopril 2.5mg PO BID
-Insulin
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml
PO once a day as needed for constipation.
5. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO at bedtime as needed for
constipation.
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/wheezing.
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 days.
13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 2 days.
14. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous twice a day.
15. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous as directed: please see attached insulin sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 8162**]-[**Location (un) 8163**] Village - [**Location (un) **]
Discharge Diagnosis:
Diabetic ketoacidosis
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr [**Known lastname **],
You were admitted to the hospital with diabetic ketoacidosis.
You were treated in the ICU with an insulin drip and then
converted to subcutaneous insulin. You blood sugar levels
improved. [**Last Name (un) **] Diabetes Center was consulted and helped in
titrating your insulin. You were found to have a pneumonia and
were treated with antibiotics. You were slightly confused
throughout your say which was thought to be due to the
pneumonia. This should continue to improve with treatment of
your pneumonia. You should continue antibiotics through
[**2140-12-7**].
You were found to have a low functioning thyroid. You were
started on a low dose of medication for this called
levothyroxine.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
When: Monday, [**2139-12-13**]:00 AM
|
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|
[
[
[]
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[] |
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|
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308, 315
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22,242
| 117,764
|
17810
|
Discharge summary
|
report
|
Admission Date: [**2149-3-15**] Discharge Date: [**2149-3-28**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
male with a history of coronary artery disease, CABG in [**2136**],
hypertension, and GERD, who presented to an outside hospital
on [**2149-3-14**] with chest pain occurring at rest. The
chest pain was substernal radiating to the jaw, and as well
to both arms. He denied nausea, vomiting or diaphoresis. As
well, he denied shortness of breath. At the outside
hospital, he received aspirin, Nitroglycerin x 5, morphine 2
mg IV, and the chest pain resolved. However, he did have
persistent neck and arm pain. The patient was started on
heparin and received Nitro spray.
At the outside hospital, his vitals were blood pressure
96/62, pulse 79, respiratory rate 20, 99% on 2 liters. Labs
at the outside hospital revealed a CK of 144, MB 7.9, index
5.5, as well as troponin of 0.5. His EKG, by report, was
normal sinus rhythm, poor R wave progression, nonspecific
ST-T wave changes. No changes compared to an EKG on [**2149-3-9**]. The chest x-ray showed an elevated left hemidiaphragm
which had been seen on the previous chest x-ray since
[**2148-12-1**]. The patient reports being relatively
pain-free since his CABG. His last episode of chest pain was
approximately one year ago.
Upon arrival at [**Hospital1 18**], blood pressure 106/60, pulse 73. He
was given Lopressor 25 po x 1, sublingual Nitroglycerin x 1,
heparin drip, nitropaste. His chest pain went from being
[**1-10**] on arrival to being chest pain-free. His EKG showed a
normal sinus rhythm, left axis deviation, poor R wave
progression, T wave inversions in III, T wave flattening in
II and AVS.
The patient was admitted with unstable angina, non-ST
elevation MI. He was continued on aspirin, beta blocker, IV
Nitroglycerin, nitropaste, heparin drip, and started on
Integrelin.
PAST MEDICAL HISTORY: CAD, status post CABG x 4 in [**2136**],
hypertension, GERD complicated by Barrett's esophagus,
Paget's disease, DJD, trigeminal neuralgia, frequent falls,
restless leg syndrome.
MEDICATIONS ON ADMISSION: 1) aspirin 325 qd, 2) Lipitor, 3)
calcium, 4) Klonopin, 5) thiazide, 6) Celexa, 7)
multivitamin, 8) vicodin, 9) Prilosec, 10) valium 2.5 [**Hospital1 **].
MEDICATIONS ON TRANSFER FROM CT SURGERY SERVICE TO THE CCU
SERVICE: 1) albuterol nebs q 6 prn, 2) calcium carbonate
1,000 [**Hospital1 **], 3) Haldol 2 mg IV q 4 prn, 4) heparin IV, 5)
regular sliding scale insulin, 6) pantoprazole 40 qd, 7)
amiodarone 1 mg qd, 8) metoprolol 25 [**Hospital1 **], 9) furosemide 40 IV
bid, 10) Neo drip, 11) aspirin 325 qd, 12) albuterol MDI, 13)
colace 100 [**Hospital1 **], 14) Plavix 75 mg qd, 15) percocet.
SOCIAL HISTORY: He is retired. He has two children. He is
a lawyer whose healthcare proxy is [**Name (NI) **] [**Name (NI) 49438**], his lawyer.
The patient smokes a pipe. No alcohol use or illicit drug
use.
PHYSICAL EXAM ON ADMISSION: Heart rate 73, 106/61 blood
pressure, 12 respiratory rate, 92%/2 liters. A&Ox3. Cranial
nerves II through XII intact. Bilateral surgical pupils,
anicteric. OP clear. Moist mucous membranes. No JVD
appreciated. Lungs clear to auscultation. Cardiovascular -
regular rate and rhythm, no murmurs, rubs or gallops.
Abdomen - nontender, nondistended, positive bowel sounds.
Stool guaiac negative. Extremities - no edema, clubbing or
cyanosis, [**5-5**] lower extremity strength and upper extremity
strength.
LABS ON ADMISSION: Hematocrit 33.7, hemoglobin 11.2, white
count 6.6, platelets 224, sodium 141, potassium 4.3, chloride
103, bicarb 30, BUN 25, creatinine 1.1, glucose 138, CK 144,
MB 7.94, MB 5.5, troponin .........
IMPRESSION: This is an 85-year-old male admitted with
unstable angina with a significant CAD history, for non-ST
elevation MI.
HOSPITAL COURSE: The patient was continued on aspirin, beta
blocker, nitropaste, heparin drip, and started on Integrelin.
He remained chest pain-free, and on the [**2149-3-17**], he
underwent a cardiac catheterization. His peak CK was 617, MB
3, index 13.5, troponin 34.9. These were from the [**2149-3-15**].
On cardiac catheterization, he had a right atrial pressure of
20, mid RCA 100% lesion, acute marginal 60% lesion, proximal
LAD 100%, midcircumflex 60%, OM 80%. His grafts, SVG1 to the
PDA had a 90% discrete midlesion. The SVG2 to OM, as well as
the left LAD to LIMA, were patent.
The patient underwent PCI of the SVG to PDA. The procedure
was complicated by perforation of the SVG/RV. A GelMed stent
was placed in the perforated region. The patient continued
to leak dye distal to the GelMed stent. An additional GelMed
stent was placed distally. The graft was occluded using a 3
mm balloon.
At that time, the patient was noted to have severe chest
pain, and also became hypotensive. STAT echo revealed a
hemopericardium with pericardial tamponade. Physiology
pericardiocentesis performed, complicated by RV perforation.
The patient was intubated and went emergently to cardiac
surgery on dopamine and neo-synephrine. The surgery portion
of the vein from the lower leg was harvested.
Stroke monitoring was performed and a moderate amount of
blood from the RA was drained. There was no bleeding found
from the RA graft with perforation present in the lower
aspect of the RV which was cauterized. Two drains were
placed. The patient had severe biventricular failure despite
inotropic support. He spiked a temperature to 101.8 on
[**3-18**]. He was started on vancomycin, as well as heparin and
Plavix. He was weaned off pressors. Epi was weaned on
[**3-19**]. Levo was weaned on [**3-20**]. He was extubated on [**3-19**].
Chest tube removed [**3-21**].
Per nurse's report, the patient's course has been complicated
by delirium in the Cardiothoracic Unit. He had atrial
fibrillation on the 20th. He was started on amiodarone drip
and heparin and converted to normal sinus rhythm on the 21.
He had 18 hours total of atrial fibrillation. He had another
episode the evening of the 23 into the 24 that lasted four
hours. Since then, he has been in normal sinus rhythm. He
was transferred to the CCU for management on the [**3-21**].
PHYSICAL EXAMINATION: On the day of discharge, the patient's
exam revealed a blood pressure of 112/57, heart rate 70, 96%
on 5 liters nasal cannula. He was in no acute distress,
sitting up in chair, answering questions appropriately, A&O x
3. Surgical pupils. EOMI. Poor dentition. Dobbhoff NG tube
in left nostril. JVD approximately 8-9 cm. Cardiovascular -
regular rate and rhythm, distant heart sounds, no murmurs,
rubs or gallops. Crackles - one a quarter the way up
bilaterally. Abdomen - soft, normoactive bowel sounds, no
tenderness. Extremities - no edema. His left leg harvest
site had mild erythema. Cranial nerves II through XII were
intact. He had 4/5 strength. Able to ambulate a small
number of steps with assistance from bed to chair.
LAB DATA DAY OF DISCHARGE: Hematocrit 33.9, hemoglobin 11.3,
platelets 199, white blood cell 8.3, sodium 135, potassium
3.7, chloride 107, bicarb 28, BUN 25, creatinine 0.9, calcium
7.8, phosphorus 3.3, magnesium 1.8. The patient had a
negative HIT antibody.
The patient had blood cultures on the 21 and urine cultures
on the 21 that have no growth. One out of four bottles on
the blood culture showed the Staph epi. The patient has been
afebrile since his transfer to the CCU, with a normal white
count.
An echocardiogram on [**3-24**] showed a 5x2 cm mass extending to
the left atrium that was compressing the left atrium. The
left atrium was mildly dilated. The right atrium was normal
size. Mild depressed LV. No reliable measure of EF. Right
ventricular chamber size was normal. Trivial MR and 1+ TR.
No tamponade. No effusion. The patient had oropharyngeal
swallowing study on the [**3-25**]. Nonfunctional
swallowing ability with aspiration of pureed foods and nectar
thickened liquids after the swallow.
It is anticipated that when the patient gets a little bit
stronger and gets out of the unit, can safely swallow on
clear and secretions, he should be able to eat and swallow.
Reassessment should be done at that time. Recommendations of
tube feeds and videoscope in which the patient was found to
just have problems clearing secretions and collecting
secretions, with likely ability to improve his function in a
short period of time.
The patient is an 85-year-old male with CAD, status post
coronary artery bypass graft in [**2136**], hypertension,
hypercholesterolemia who presents with non-ST elevation
myocardial infarction, status post SVG perforation, RV
perforation, with pericardial tamponade requiring emergent
cardiac surgery for drainage. Postop atrial fibrillation
approximately x 8 hours. Currently in normal sinus rhythm,
....................ischemia. He was continued on aspirin
and Plavix, as well as beta blocker. Blood pressure ran low
at times, as low as maps around 60 to high-50s. The patient
never required pressors, although his Lopressor dose was
decreased to 12.5 [**Hospital1 **] with his heart rate steadily in the
60s-70s.....................
The patient had a cycle in the CCU of being volume overloaded
and then being aggressively diuresed with 40 lasix IV bid and
then being dehydrated with low blood pressure. The echo, as
previously stated, showed mildly depressed EF without
specific EF. This should probably be followed up as an
outpatient with a repeat echo at a later date. On the [**3-24**], the patient had a Swan placed, a right IJ Cordis and
Swan. The patient was A&O x 3 and was consented for the
Swan. This was done without complication. CVP was
approximately 12, RV pressure was approximately 40/18, PA was
approximately 38/26, and his wedge was approximately 18.
On the day of discharge, the patient was being converted to
two-day medicine staggered, Zestril 2.5 pm, Toprol XL 25 q am
with 40 po lasix qd. This will allow for maximization of his
blood pressure while placing him on cardioprotective and
anti-CHF medication. On the day of discharge, the patient is
in mild, compensated fluid overload. He is receiving 20 of
IV lasix. The patient should have weights qd and strict in's
and out's to the best of his ability, and be followed up at
the [**Hospital 1902**] Clinic here at [**Hospital1 **], and have his
regimen adjusted based on his weights.
RHYTHM: The patient had 18 hours of atrial fibrillation
postop. He has been normal sinus rhythm. He has had guaiac
positive stools. The heparin was DC'd, as well as the
amiodarone. He has maintained normal sinus rhythm with the
exception of four hours on the evening of the 23. He is
maintained with beta blocker to help control his heart rate.
ID: Despite the episode of fever prior to his transfer to
the CCU, the patient had no leukocytosis, no fever during his
time in the ICU, and no clear tissue source of infection. He
was empirically treated with Levaquin for seven days. It is
unclear whether the patient had pneumonia, and he also was
being treated with clindamycin for a course of 10 days for
cellulitis around his vein harvest site. On the day of
discharge, the site was much improved. The patient was
afebrile with a normal white count. The patient should have
periodic stools sent for C. diff following the use of the
clindamycin. If he should develop diarrhea, a C. diff test
should be sent and treated with Flagyl appropriately.
GI: The patient was continued on Protonix for GERD.
MENTAL STATUS: Although the patient was experiencing
delirium prior to his transfer to the CCU, his course has
been one of generally improving mental status, and on the
days prior to admission the patient was alert and oriented x
3, sitting up in a chair, joking, and resembling himself
prior to his hospitalization.
PSYCH: He gets Klonopin for restless leg syndrome and
Celexa. The patient did not require Haldol at all for
agitation in the CCU.
FLUIDS, ELECTROLYTES AND NUTRITION: The patient had a low
albumin, but also had the failed swallowing study secondary
to secretions. He had an NG tube placed with tube feeds.
The patient was receiving ....................with fiber 70
cc/h and has reached his goals. He has a Dobbhoff feeding
tube. The patient will require a follow-up swallowing study.
I anticipate that within a week he should be able to return
to PO.
HEME: The patient has had guaiac positive stools. His
hematocrit has been stable since he has been off the heparin.
The guaiac positive stools were in the context of
anticoagulation. He will require follow-up in this matter.
As an outpatient his hematocrit has been stable since
receiving a transfusion.
DISCHARGE DIAGNOSES: 1) Coronary artery disease status post
coronary artery bypass graft. 2) Non-ST elevation myocardial
infarction, status post catheterization with perforation of
his saphenous vein graft and puncture of his right ventricle
resulting in tamponade and requiring open surgical
intervention. 3) Hypertension. 4) Gastroesophageal reflux
disease complicated by Barrett's esophagitis. 5) Paget's
disease. 6) Degenerative joint disease. 7) Trigeminal
neuralgia. 8) Restless leg syndrome. 9) Frequent fall
history.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS: 1) lasix 40 mg po qd, 2) lisinopril
2.5 mg po q pm, 3) metoprolol XL 25 mg po q am, 4)
lansoprazole oral solution 30 mg po NG qd now and when the
patient is taking POs this can be converted to a pill; 5)
clindamycin 300 mg po q 6 h should be continued until [**4-1**], 6) aspirin 325 qd, 7) heparin 5,000 U subcu q 12 h and
this may be discontinued when the patient is ambulating, 8)
Flovent 110 mcg 2 puffs inhaled [**Hospital1 **], 9) salmeterol 1-2 puffs
inhaled [**Hospital1 **], 10) Dorzolam 2%, timolol 0.5% ophthalmic drops 1
drop OU [**Hospital1 **], 11) clonazepam 0.5 mg po tid, 12) Atrovent nebs
1 neb q 6 h and held prn shortness of breath; he is currently
getting them q 6 h, 13) Pravachol 20 mg po qd, 14) calcium
carbonate 1,000 mg po bid, 15) colace 100 mg po bid, 16)
Plavix 75 mg po/NG qd, 17) Tylenol 325-650 mg po/q 4-6 h prn.
FOLLOW-UP: The patient should have follow-up with the [**Hospital 1902**]
Clinic approximately one week following discharge. He should
have daily weights, and I's and O's to the best of his
ability tracked to monitor the patient's fluid status. The
patient should have a swallowing study repeated within the
week after his discharge to rehabilitation to see if he is
able to resume po intake. He will require nutritional
supplements for calories and protein. The patient will also
require follow-up with CT surgery. The number will be
enclosed, and a call should be made to follow-up.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Last Name (NamePattern1) 1659**]
MEDQUIST36
D: [**2149-3-28**] 12:28
T: [**2149-3-28**] 11:28
JOB#: [**Job Number 49439**]
|
[
"276.5",
"998.2",
"428.0",
"427.31",
"998.59",
"410.71",
"423.0",
"997.1",
"785.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.55",
"89.64",
"88.53",
"37.31",
"37.0",
"96.71",
"36.01",
"36.06",
"96.04",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
13273, 13280
|
12738, 13251
|
13304, 15019
|
2134, 2735
|
3855, 6207
|
6230, 11530
|
113, 1904
|
3508, 3837
|
11546, 12716
|
1927, 2107
|
2752, 2962
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,523
| 110,303
|
10313
|
Discharge summary
|
report
|
Admission Date: [**2171-10-30**] Discharge Date: [**2171-11-18**]
Date of Birth: [**2110-4-16**] Sex: M
HISTORY OF PRESENT ILLNESS: This 61-year-old male with a
history of chronic obstructive pulmonary disease was admitted
to [**Hospital6 33**] on [**2171-10-20**], for an
exacerbation of her pulmonary problems. [**Name (NI) **] underwent an
substernal chest pain; however, he was only able to complete
two minutes on [**Doctor First Name **] protocol before having ST depressions
and chest pain. On [**10-24**], he underwent cardiac
catheterization which revealed a 60% to 70% stenosis of his
left main, as well as greater than 90% stenosis of his right
coronary artery, and greater than 60% of his left circumflex.
[**2171-10-25**], where he underwent coronary artery bypass
graft times three. His postoperative course was somewhat
complicated by his chronic obstructive pulmonary disease;
however, he was managed with bronchodilators and antibiotics
for a left lower lobe consolidation and positive sputum for
hemophilus.
On [**2171-10-29**], the patient was discharged to a
rehabilitation facility in stable condition. While at that
facility, the patient and his wife were not satisfied with
the quality of care being provided there, and was brought to
[**Hospital3 417**] Hospital's Emergency Department with
complaints of chest discomfort which was exacerbated with
movement and coughing. The Emergency Department evaluation
felt that his pain was due to his sternotomy incision and had
planned to discharge him back to the rehabilitation facility.
However, the patient and his wife did not agree to that.
Since there was some questionable cellulitis of his right
lower extremity, the patient was transferred to [**Hospital1 346**]. He had complained of low-grade
fever but denied chills, sweats, or any discharge from his
incision.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease with multiple
hospitalizations and previous steroid use.
2. Hypertension.
3. Sleep apnea.
4. Gout.
5. Status post methicillin-resistant Staphylococcus aureus
pneumonia.
6. Status post appendectomy.
7. Status post umbilical herniorrhaphy.
MEDICATIONS ON ADMISSION: Medications upon admission to the
hospital were Lopressor 12.5 mg p.o. b.i.d., Lasix 40 mg p.o.
t.i.d., potassium chloride 20 mEq p.o. b.i.d., aspirin 81 mg
p.o. q.d., levofloxacin 500 mg p.o. q.d. times eight days,
Percocet one to two tablets p.o. q.3-4h. p.r.n. for pain,
Colace 100 mg p.o. b.i.d., Paxil 20 mg p.o. q.d.,
allopurinol 100 mg p.o. q.d., Singulair 10 mg p.o. q.d.,
Serevent inhaler 1 puff to 2 puffs q.4h. p.r.n., and
albuterol nebulizer treatment q.i.d. p.r.n.
PHYSICAL EXAMINATION ON ADMISSION: Upon admission to the
hospital temperature was 99.2, pulse 76, normal sinus rhythm,
blood pressure 129/67, respiratory rate 20, oxygen saturation
91% on room air. The patient was a 61-year-old male in no
apparent distress, was alert and oriented times three. His
neck was supple with no bruits noted. Lungs revealed wheezes
bilaterally. His sternum was stable. His incision was
clean, dry, and intact. Coronary examination revealed a
regular rate and rhythm, with no murmurs, rubs or gallops.
The abdomen was soft, nontender, and nondistended. His
extremities were warm and well perfused. His incision was
clean, dry, and intact with no purulent discharge of
significant erythema.
LABORATORY DATA ON ADMISSION: Laboratory values upon
admission to the hospital were white blood cell count 16.8,
hematocrit 28.4. Potassium 4.6, BUN 18, creatinine 0.8.
HOSPITAL COURSE: The patient was admitted to the hospital
for physical therapy as well as wound checks and pulmonary
toilet.
In the early morning on hospital day two ([**2171-10-31**]), the patient had some problems with disorientation
after receiving Ambien for sleep. The patient did receive
some Haldol to treat this. The patient remained
hemodynamically stable, and the patient was monitored by a
one-to-one sitter in his room. Later in the day the patient
was alert and oriented, in no apparent distress. He remained
to be wheezing bilaterally, but otherwise had an unremarkable
physical examination.
On [**2171-11-1**], the patient continued to have
intermittent periods of delirium. It was noted upon physical
examination that day that there was a small sternal click at
the inferior portion of his sternum which was elicited with
coughing. The patient's incision had remained clean, dry,
and intact. His white blood cell count had risen to 18.6,
and the patient was fully cultured at that time. Two blood
cultures which were obtained on [**2171-11-1**], revealed
coagulase-negative Staphylococcus aureus. Sputum culture on
that same day was unremarkable.
Over the next few days, the patient had a low-grade fever
between 99 degrees and 101 degrees and continued to have a
sternal click without wound drainage or erythema. The
patient was empirically started on vancomycin on
[**2171-11-2**], due to Staphylococcus species. At that
time the cultures were not finalized; however, they
ultimately proved to oxacillin-resistant Staphylococcus
aureus.
On [**2171-11-3**], on hospital day five, postoperative
nine, the patient complained of a clicking painful sensation
in his chest. This persisted throughout the next day as
well, on [**11-4**], when he continued to complain of
sternal discomfort. The patient had completed his course of
levofloxacin and was on day three of vancomycin at that time.
On [**2171-11-5**], the patient continued to have a
sternal click with pain at the site and positive blood
cultures. The patient was taken to the operating room on
[**2171-11-5**], due to sternal dehiscence. He underwent
a sternal wound debridement with a Robicsek weave of his
sternum by Dr. [**Last Name (STitle) 70**]. Please see the Operative Report
for full details of surgical procedure.
The patient was extubated and brought to the Intensive Care
Unit where he remained for approximately 24 hours. He
remained hemodynamically stable. His white blood cell count
had dropped to 9.2. On [**11-6**], his pulmonary status
was stable. His creatinine had elevated slightly from a
baseline of 1.1 to 1.4 at this time. He had adequate urine
output at the time and was transferred from the Intensive
Care Unit to the telemetry floor, [**Hospital Ward Name 121**] Six, on [**2171-11-6**].
On [**11-7**], on postoperative day two, the patient still
had complaints of pain; however, was hemodynamically stable.
His white blood cell count at that time was 13.5. The
patient had remained essentially afebrile to having a
low-grade fever of about 100 degrees. His oxygen saturation
was adequate, and his vital signs were stable. The patient
was noted to have some serosanguineous drainage from the
middle portion of his sternal wound at that time. The
patient was maintained on intravenous vancomycin for the
methicillin-resistant Staphylococcus aureus which was noted
in his previous blood cultures. He was given morphine for
pain control. He was on Lopressor and was continuing to
diuresed.
On [**2171-11-8**], a peripherally inserted central
catheter line was inserted in the Interventional Radiology
Department because it was felt that the patient would need to
continue on a full 4-week to 6-week course of vancomycin. On
[**2171-11-8**], the patient remained hemodynamically
stable; although, he was beginning to have an elevated fever
to 101.2, and he continued to complain of sternal pain. He
was noted to still have mild amounts of serosanguineous
drainage fro his sternal incision.
On [**11-9**], on postoperative day four, the patient was
more comfortable. He had been given Dilaudid for pain
control. He was noted to have some degree of peri-incisional
erythema of his sternotomy incision. His sternum was stable
at that time. The patient had no other significant
complaints. His white blood cell count was 12.4. His
creatinine had risen again to 1.5 at this time. He was still
being continued on vancomycin. On [**2171-11-9**], the
house officer was called to see the patient due to agitation.
Upon arrival for examination the patient was alert and
oriented; however, he did state that he felt confused
earlier, but this had resolved. This was felt likely to be a
complication of the narcotics which he had been given for
pain control. The narcotics were discontinued at this time,
and he was started on Ultram and Toradol for pain control.
On [**2171-11-10**], the patient's creatinine was noted to
have risen from 1.4 on the previous day to 2.3. This was
felt to be attributable to the Toradol which was discontinued
at that time. The patient remained alert. His sternum
remained dry with some peri-incisional erythema present. The
patient stated he felt better.
On [**2171-11-11**], a Renal Medicine consultation was
obtained due to continued rise in creatinine which was 3.8 on
[**11-11**]. It was their feeling that the patient had been
exposed to nephrotoxic drugs, specifically nonsteroidal
antiinflammatory drugs such as ibuprofen, Toradol, Celebrex,
and Vioxx over the past number of days, and it was their
recommendation to repeat urinalysis as well as urine
cultures, to hold all nephrotoxic drugs, to follow the
patient's electrolytes on a daily basis, to maintain a
systolic blood pressure of 110, and to renally dose all of
his medications as well as to follow strict measurements of
intake and output.
On [**2171-11-12**], the patient's creatinine continued to
rise and was at 4.4. The patient's vancomycin level was
33.3, and his vancomycin was held with the plan of daily
levels to be drawn, and for him not to be dosed again until
his level dropped below 15. The patient was transfused
packed red blood cells for a hematocrit which had drifted
down over the previous two days to 21.1. It was the Renal
Service's feeling that there was no indication for dialysis
but to continue the treatments which had been initiated; that
was to continue to hold all nonsteroidal drugs, and to
renally dose medications, and to continue to follow
electrolytes, urine output, and creatinine daily. The
patient continued to receive bronchodilator treatments due to
his underlying pulmonary disease.
On [**2171-11-13**], the patient remained with a low-grade
fever of about 100. His creatinine had leveled off at 4.5.
He remained with no sternal drainage. His sternum was stable
with no click; however, he continued to have some erythema of
the sternal incision.
On [**2171-11-14**], the patient had progressed somewhat with
level of ambulation. His pain was fairly well controlled.
His creatinine had stabilized at 4.5. While there was no
drainage, there remained erythema at the sternal incision.
The patient was started on levofloxacin empirically for what
was presumed a sternal wound cellulitis. On [**2171-11-14**],
the patient was noted to have more episodes of agitation and
disorientation. The patient also began to start complaining
of increased sternal pain exacerbated with cough and deep
breathing which he had been encouraged to do because of his
pulmonary status, and history of chronic obstructive
pulmonary disease, and need for bronchodilators, and
pulmonary toilet.
On [**2171-11-15**], the patient was noted to have some
increasing erythema over his sternal incision, and a Plastic
Surgery consultation was obtained on [**2171-11-15**]. It was
their assessment that the patient should return to the
operating room for sternal wound debridement and
vacuum-assisted dressing placement. On [**11-15**], the
patient was also noted to have a slight increase in his
creatinine despite holding of nephrotoxic drugs. He was up
to 4.8 at this time; although, it was still felt that there
was no indication to initiate dialysis since the patient was
not acidemic nor hyperkalemic at that time. On [**2171-11-14**], the patient was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13797**] (plastic
surgeon). It was his recommendation at that time to consider
a chest CT scan to rule out mediastinitis due to the
continued erythema with the plan of taking him for surgical
debridement if his erythema had not improved or had increased
over the next few days.
On [**2171-11-16**], the patient was noted to have increased
erythema with some serosanguineous drainage beginning to come
from the sternal incision, and this was sent for culture, and
the Gram stain revealed Staphylococcus species at this time.
Dr. [**First Name (STitle) **] from the Plastic Surgery Service did evaluate the
patient on [**2171-11-16**]. He reported that the CT scan
showed no retrosternal collection, and he felt there was no
urgency to do anything other than conservative treatment at
that time. It was his recommendation that if the patient had
increased draining or became febrile that he may need to
return to the operating room for a wound debridement. On
[**11-16**], the patient's serum creatinine had risen to 5.1,
and while his renal function had been deteriorating there was
still no indication for renal replacement therapy at that
time. An Infectious Disease consultation was obtained on
[**2171-11-16**]. Their recommendation was to continue
treating the patient with intravenous vancomycin to be dosed
by levels and to add gram-negative coverage only if there was
a change in the patient's clinical status.
On [**2171-11-17**], the patient was noted to have an
increased amount of drainage from the middle portion of his
sternal incision. The staples in that area had been removed,
and there was continued erythema. Wet-to-dry normal saline
dressings had been initiated. On [**2171-11-17**], the
Plastic Surgery Service recommended at that time that the
patient be taken to the operating room for an operative
washout of his sternal incision. This was due to continued
erythema and drainage. The patient's creatinine at this time
had started to decline and was down to 4.3 on [**2171-11-18**], and his urine output had also begun to increase.
The patient was taken to operating room on [**2171-11-18**],
due to continued sternal wound erythema and drainage. The
patient underwent a sternal debridement by Dr. [**Last Name (STitle) 70**] and Dr.
[**Last Name (STitle) 72**] as well as placement
of a vacuum device by plastic surgerye. Please
see the Operative Report for full details of the surgical
procedure. The patient was transported from the operating
room to the Intensive Care Unit, extubated, and
hemodynamically stable with a vacuum-assist device in place
to the sternal wound. At approximately 9:20 that evening,
the patient had a strong cough and the suction container
attached to the vacuum-assist device began to fill with blood
quickly. The house officers were called and responded to the
bedside within minutes. The vacuum dressing was removed, and
the patient's chest was opened completely, and it was noted
at that time that there was a tear in the right ventricle
that was felt to be possibly secondary to adhesions following
the coughing.
The patient did suffer a full cardiopulmonary arrest at that
time. He was intubated, but he was unable to be
resuscitated. Dr. [**Last Name (STitle) 70**] was notified and came to the
hospital and spoke with the family at that time at length to
notify them of the events which had occurred. The patient
did expire on [**2171-11-18**]. Permission for autopsy was
granted and arrangements for the autopsy were made.
CONDITION AT DISCHARGE: Expired.
DISCHARGE DIAGNOSES: Right ventricular rupture, status post
sternal wound infection/dehiscence/sternal debridement.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2171-11-29**] 13:41
T: [**2171-11-30**] 05:13
JOB#: [**Job Number 34287**]
(cclist)
|
[
"401.9",
"998.3",
"730.08",
"E878.2",
"496",
"780.57",
"427.5",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.91",
"34.01",
"34.79",
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] |
icd9pcs
|
[
[
[]
]
] |
15542, 15938
|
2201, 2701
|
3598, 15494
|
15509, 15519
|
149, 1865
|
3438, 3579
|
1887, 2174
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,296
| 186,066
|
18924
|
Discharge summary
|
report
|
Admission Date: [**2161-1-28**] Discharge Date: [**2161-2-1**]
Date of Birth: [**2080-11-20**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Tetracycline Analogues / Aspirin / Bactrim /
Prednisone
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Abdominal pain, fever, transferred for ERCP
Major Surgical or Invasive Procedure:
[**1-28**] ERCP
ERCP with sphincterotomy
History of Present Illness:
80YOF with dementia, TIA, DM, HLD, CAD (MI s/p CABG), pAFIB
(CHADS of 6, on atenolol, coumadin), ambulla of vater adenoma
c/b cholangitis/pancreatitis s/p 15 ERCP since [**2155**], transferred
from [**Hospital1 **] for epigastric pain and fever. At OSH, CT showed
intra-hepatic ductal dilation/PD dilation. Labs at OSH
significant for WBC 14.6, AST/ALT 149/289, lipase 78, T bili
1.5. Pt has a h/o cholangitis and pancreatitis s/p biliary
stent placement. She is a poor historian - on pain medication,
demented at baseline per husband, [**Name (NI) **], who is HCP. [**Name (NI) **]
husband, she is full code. At [**Hospital1 **] got 1L NS, IV levofloxacin
750mg, po flagyl 500mg, and home anti-hypertensive medications.
.
In the ED inital vitals were, 98 88 118/66 16 99% ra, then
desated to 93%, she was put on 2L of NC. Her exam was
significant for abdominal tenderness, slightly jaundice in
appearance. Labs were notable for lactate of 4.1, wbc of 21, plt
of 144, alt/ast = 236/298, tbili of 2.9, coags are pending. She
was given zosyn and 1L of NS. Surgery and ERCP are aware. EKG
noted for rate of 70, afib, with no ST changes. ACCESS: 18G on
R (placed in ED), 20G on L (placed at OSH). most recent vitals
97.4, 109/64, 75, 27, 99% 2.5L
Past Medical History:
- dementia
- TIA at [**Hospital3 **] [**2159-4-5**] started on plavix per dtr.
- adenoma of the ampulla of Vater c/b cholangitis, pancreatitis
- s/p stent placement in biliary tract
- MI, s/p CABG
- hyperlipidemia
- DVT
- paroxismal Afib
- s/p bilateral knee replacements
- s/p partial colon resection with recurrent strictures and
adhesions
- s/p left ovarian surgery (reason?)
- diverticulitis, resulting in intraabdominal abcess
- s/p cholecystectomy
- osteomyelitis R-knee; long term Abx
- lumbar spinal stenosis, s/p spinal fusion L3-5
- h/o Bells palsy R-facial
- Gout
- Diabetes mellitus, type 2, on insulin
Social History:
Lives at home with her husband. She has difficulty walking since
a fall several years ago and uses a cane/walker to ambulate. She
requires assistance with showering. Husband cooks and does the
shopping. Daughter comes once per week to do the cleaning. Pt
does the bills. She was a homemaker for many years and then
worked as a bankteller. She then did office work for her son's
business for 20 years before retiring about 10 years ago. No
EtOH or tobacco use.
Family History:
Mother and father without known medical problems. [**Name (NI) 6419**]
deceased.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.4 BP: 130/80 P: 80 R: 18 O2: 97% RA
General: Alert, oriented x2, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~[**8-13**], no LAD
Lungs: Inspiratory crackles in bilateral bases, no wheezes,
rhonchi
CV: irregularly irregular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, mildly tender in epigastrium, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace lower extremity edema
Pertinent Results:
Admission labs:
[**2161-1-28**] 08:00AM BLOOD WBC-21.1*# RBC-4.32 Hgb-13.1 Hct-37.3
MCV-86 MCH-30.4 MCHC-35.2* RDW-13.9 Plt Ct-144*
[**2161-1-28**] 08:00AM BLOOD Neuts-89* Bands-2 Lymphs-2* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2161-1-28**] 08:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2161-1-28**] 08:00AM BLOOD Plt Smr-LOW Plt Ct-144*
[**2161-1-28**] 08:00AM BLOOD Glucose-238* UreaN-20 Creat-0.8 Na-135
K-4.5 Cl-100 HCO3-21* AnGap-19
[**2161-1-28**] 08:00AM BLOOD ALT-236* AST-295* AlkPhos-127*
TotBili-2.9* DirBili-2.2* IndBili-0.7
[**2161-1-28**] 08:00AM BLOOD Lipase-46
[**2161-1-28**] 08:00AM BLOOD cTropnT-<0.01
[**2161-1-28**] 03:27PM BLOOD CK-MB-2
[**2161-1-28**] 08:00AM BLOOD Calcium-9.8 Phos-2.2* Mg-1.5*
[**2161-1-28**] 09:03PM BLOOD Type-ART pO2-86 pCO2-32* pH-7.49*
calTCO2-25 Base XS-1
[**2161-1-28**] 08:14AM BLOOD Lactate-4.1*
[**2161-1-28**] 09:03PM BLOOD Lactate-1.5
[**2161-1-28**] 09:03PM BLOOD O2 Sat-96
[**2161-1-28**] 2:30:00 PM - ercp report
S/P Sphincterotomy and papillotomy. Previously placed biliary
and pancreatic stents noted Previously placed biliary plastic
stent was removed using a snare Cannulation of the biliary duct
was successful and deep after a guidewire was placed A severe
dilation was seen at the main biliary tree. An irregular filling
defect, consistent with a sludge was noted at distal CBD. Small
amount of sludge and pus extracted successfully using a balloon.
A 7cm by 10FR biliary stent was placed successfully with good
bile drainage. Recommendations: Continue antibiotics Repeat ERCP
with Dr. [**Last Name (STitle) **] on [**2161-3-31**] Follow up LFTs
[**2161-1-28**] Radiology CHEST (PORTABLE AP)
IMPRESSION: Pulmonary vascular engorgement, mild pulmonary
vascular
congestion.
Brief Hospital Course:
80 yo F with pAFIB (CHADS of 6, rate controlled on coumadin and
digoxin), DM, MI s/p CABG, demetia, TIA, ampulla of vater
adenoma c/b cholangitis/pancreatitis s/p 15 ERCP since [**2155**],
admitted for cholangitis now s/p ERCP doing well.
.
# Depsis due to Cholangitis: she had gotten levoflox/flagyl at
[**Hospital1 **], then switched to zosyn here for treatment of presumed
cholangitis. Pt had an ERCP with sphincterotomy on [**1-28**], when
she had a biliary stent replacement and drainage of sludge and
pus. Pt has remained afebrile w/ stable hemodynamics. WBC and
LFTs trending down. Blood cultures have shown No growth. Per
ERCP and GI, she needs a repeat ERCP with Dr. [**Last Name (STitle) **] on
[**2161-3-31**], and continue zosyn for now until cultures return (hold
dicloxacillin while on zosyn). Her diet was advanced to clears
on [**1-30**].
- She was discharged on Augmentin to complete her 14 day course
- She will continue her chronic dicloxacillin
# Paroxysmal Afib: confirmed medications with PCP, CHADS2 of 6,
on atenolol and dig with coumadin for anticoagulation. Dig was
initially held due to slightly supratherapeutic level 2.3,
repeat digoxin level 1.4 on [**1-29**], and dig was restarted on a
lower dose of 0.125mg. Warfarin was held on [**1-28**]-26
peri-procedurally. Per ERCP, coumadin was restarted at 50% home
dose. Her home spironolactone, and atenolol were held in the
setting of cholangitis, but these were restarted at her home
dose on [**1-29**] due to clinical stability post procedure. Her
warfarin was resumed at home dose on [**1-31**].
- She is to take her usual 2.5mg on sunday, then resume 5mg
starting [**Month/Year (2) 766**]
- She will require an INR check on [**2161-2-3**]
# dementia: stable, continue to monitor. Continued home
risperidone, namenda.
# MI, s/p CABG: stable, continue to monitor. Her home
spironolactone, furosemide, and atenolol were held in the
setting of cholangitis, but these were restarted at her home
dose on [**1-29**] due to clinical stability post procedure.
.
# hyperlipidemia: continued statins
# Chronic rhinitis: continue cetirizine
# Gout: continue allopurinol
# Diabetes mellitus, type 2, on insulin. Held home
glyburide/metformin; on insulin sliding scale while inpatient.
Continued home gabapentin, tramadol for dm neuropathy. Her FSBG
were high on a lower dose of Lantus given she was not eating as
much.
- oral agents restarted on discharge. Her lantus was restarted
at her home dose of 25-30 units qAM at discharge. They will
call her endocrinologist on [**Month (only) 766**] to confirm an adequate dose.
Medications on Admission:
Medications: (per PCP)
- Allopurinol 100 mg Tablet PO DAILY
- Atenolol 50 mg Tablet PO DAILY
- Aldactone 25 mg PO daily
- Lasix 40mg daily
- Coumadin 5mg po QD except [**1-5**] tab on Sat, Sun QHS
- Digoxin 0.25mg QOD
- Risperidone 0.25mg [**Hospital1 **]
- Namenda 10mg [**Hospital1 **]
- Tramadol HCL 25mg Q6H PRN pain
- Gabapentin 300mg 1cap [**Hospital1 **], 2cap qhs
- Dicloxacillin 500mg Q6H for life long infected knee joint
- Tylenol 1g PRN
- ProAir 108(90) MCG/ACT 2 puff q4h prn
- Glyburide 5mg [**Hospital1 **]
- Metformin 500mg [**Hospital1 **]
- Simvastatin 40mg daily
- Lisinopril 2.5mg daily
- Lantus 10u QAM
- Cetirizine HCL 10mg po qhs
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. atenolol 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. warfarin 5 mg Tablet Sig: 0.5-1 Tablet PO Once Daily at 4 PM:
5mg Mon-Fri
2.5mg Sat, Sun.
6. digoxin 125 mcg Tablet Sig: Two (2) Tablet PO every other
day.
7. risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO every
six (6) hours.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
13. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
14. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
15. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
17. Lantus 100 unit/mL Solution Sig: 25-30 units Subcutaneous
once a day: please call the doctor [**First Name (Titles) **] [**Last Name (Titles) 766**] to adjust.
18. cetirizine 10 mg Tablet Sig: One (1) Tablet PO qhs ().
19. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 11 days: through [**2-11**].
Disp:*22 Tablet(s)* Refills:*0*
20. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
21. Outpatient [**Name (NI) **] Work
PT/INR, AST, ALT, Alk phos, T. bili
- please check on [**2161-2-3**], fax to PCP:
[**Name Initial (NameIs) 7274**]: [**Last Name (LF) **], [**Name6 (MD) **] [**Name8 (MD) **] MD
Phone: [**Telephone/Fax (1) 9332**]
Fax: [**Telephone/Fax (1) 31204**]
Discharge Disposition:
Home With Service
Facility:
Steward Home Care
Discharge Diagnosis:
Acute cholangitis
Biliary obstruction
Atrial fibrillation
h/o TIA
Type 2 diabetes mellitus, uncontrolled
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Patient admitted with abdominal pain and obstructive jaundice.
Found to have acute cholangitis. She underwent ERCP with
sphincterotomy and stent replacement. She did well with
antibiotics after that. She continued to improve and was
transitioned to oral antibiotics.
Her warfarin dose was decreased briefly, then resumed at home
dose. Please have INR checked within the next few days. Her
digoxin was decreased slightly to every other day. Please take
all medications as prescribed and keep all follow up
appointments.
Please note that your digoxin was decreased to 0.25mg every
other day.
Please resume her home Lantus at 25-30 units and call her
diabetes doctor
Followup Instructions:
PCP: [**Name10 (NameIs) 9328**],[**First Name3 (LF) **] [**Doctor First Name 9329**] [**Telephone/Fax (1) 9332**]
- Please follow up within the next week
Department: ENDO SUITES
When: TUESDAY [**2161-3-31**] at 7:30 AM
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2161-3-31**] at 7:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
|
[
"V45.4",
"V43.65",
"274.9",
"250.02",
"412",
"V58.61",
"272.4",
"576.2",
"294.20",
"V45.81",
"995.91",
"576.1",
"472.0",
"782.4",
"427.31",
"038.9",
"V45.82",
"V12.51",
"V12.54",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
10669, 10717
|
5358, 7959
|
371, 414
|
10866, 10866
|
3515, 3515
|
11748, 12381
|
2833, 2917
|
8663, 10646
|
10738, 10845
|
7985, 8640
|
11051, 11725
|
2957, 3496
|
288, 333
|
442, 1700
|
3531, 5335
|
10881, 11027
|
1722, 2339
|
2355, 2817
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,627
| 172,555
|
12856
|
Discharge summary
|
report
|
Admission Date: [**2131-12-22**] Discharge Date: [**2132-1-8**]
Date of Birth: [**2053-11-20**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
headache and weakness
Major Surgical or Invasive Procedure:
EVD placement
History of Present Illness:
78 yo RHM with history of left parietal stroke in [**2129**],
aflutter s/p ablation, on coumadin, pacer, HTN, DM, OSA,
presenting with one day history of headache and generalized
weakness. As per patient's wife, he was in his usual state of
health yesterday until bedtime, around 10 PM when he had a mild
bifrontal headache and had difficulty getting in and out of bed.
Neither he nor his wife noted any lateralizing weakness, and he
went to bed and again had difficulty, requiring assistance when
going to use the bathroom, needing to hold onto the wall, but
did
not fall. He had a mild headache this AM and felt diffusely
weak
and went to [**Location (un) 2274**] and there he was recommended to go to ED for
further evaluation.
Upon arrival, he was mildly drowsy and with a mild bifrontal
headache. A CT head revealed an acute right basal ganglia,
anterior thalamus, choroid plexus and intraventricular
hemorrhage
with layering in the occipital horns with mild ventricular
dilatation, and a neurological consult was requested after the
imaging study was performed. Since returning from CT, the wife
notes the patient has been more drowsy and confused, frequently
falling off to sleep and appearing more disoriented. His blood
pressure has been more elevated as well (140s-160s systolic
prior
to CT and since has been 180s-200s despite 10 mg hydralazine).
ROS negative for visual changes, dizziness, speech changes,
lateralizing weakness or sensory changes, bowel or bladder
changes. No recent fevers, chills, cough, chest pain, shortness
of breath, diaphoresis, nausea, vomiting, diarrhea, or
constipation.
Past Medical History:
PMHx;
-left parietal stroke in [**2129**] with resulting cognitive changes
such as difficulty with numbers, word retrieval, and occasional
stuttering as well as right lower quadrantsonopia. Patient had
small bleed upon initiation of anticoagulation after stroke.
-seizures in [**6-3**] and [**12-4**] presumed to be secondary to stroke-
one GTC and one with unilateral shaking and speech arrest
followed by weakness (wife unaware of which side). Second
seizure occurred in setting of AED wean and none since resumed
at
prior dose
-aflutter s/p ablation, on coumadin
-pacemaker
-DM
-HTN
-GERD
-OSA on CPAP
-glaucoma
Social History:
Social History;
-catholic priest, had been a social worker, quit after stroke in
[**2129**]. No history of tobacco or etoh. Lives with wife, [**Name (NI) 1439**]
[**Name (NI) 27328**], [**Telephone/Fax (1) 39546**] or [**Telephone/Fax (1) 39547**]
Family History:
Family History;
-brother with stroke in late 60s, father with [**Name (NI) 5895**]
disease
Physical Exam:
Physical Examination;
VS; BP 202/154 P 67 RR 21 96% on 2L
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM, oropharynx clear
Neck: No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Drowsy, requiring frequent stimulation to remain
awake, and repeatedly closing eyes. States date is [**2100-11-10**] is [**Hospital1 2177**] ED. Can do DOY forward but not backwards.
Perseverative at times. Speech mildly slurred but able to
repeat
a sentence. Occasional paraphasic errors and names [**3-30**] objects
correctly. Unable to state which holiday occurred last week.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Blinks to threat in all
quadrants.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: L NLF flattening and decreased activation on L with smile
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. Uncooperative with formal strength testing but able
to maintain all extremities antigravity against resistance.
-Sensory: Intact to light touch and pinprick throughout.
-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 extensor on left, mute on right.
-Coordination: No dysmetria on FNF b/l.
-Gait: deferred
Pertinent Results:
[**2131-12-22**] 03:02PM PLT COUNT-190
[**2131-12-22**] 03:02PM NEUTS-53.6 LYMPHS-37.7 MONOS-5.8 EOS-2.5
BASOS-0.4
[**2131-12-22**] 03:02PM WBC-6.0 RBC-4.48* HGB-13.8* HCT-39.0* MCV-87
MCH-30.8 MCHC-35.4* RDW-13.6
[**2131-12-22**] 03:02PM cTropnT-<0.01
[**2131-12-22**] 03:02PM CK(CPK)-87
[**2131-12-22**] 11:39PM PT-20.3* PTT-23.9 INR(PT)-1.9*
[**2131-12-22**] 11:44PM LACTATE-2.3*
[**2131-12-22**] 11:44PM TYPE-ART PO2-187* PCO2-40 PH-7.40 TOTAL
CO2-26 BASE XS-0
Brief Hospital Course:
78 yo RHM with history of left parietal
stroke in [**2129**], aflutter s/p ablation, on coumadin, pacer, HTN,
DM, OSA, presenting with one day history of headache and
generalized weakness, and found to have acute right basal
ganglia
hemorrhage on CT head with IVH in 3rd ventricle, layering of
occipital horns, and moderate ventricular dilitation. The
hemorrhage may have been secondary to hypertension in setting of
anti-coagulation. INR was reversed with 2 units FFP and 10 mg
vit K in ED. Shortly after initial CT head, he was found to
become more drowsy, requiring frequent stimulation to maintain
arousal, and hypertensive (>200 systolic), requiring nicardipine
drip. Repeat CT head did not show significant change, with mild
improvmeent in alertness after blood pressure control, however
constellation of symptoms as well as CT head were concerning for
possible obstructive hydrocephalus; patient had an EVD placed
and removed; his repeat head CT showed hydrocephalus which
neurosurgery decided not to further intervene on as patient was
clinically stable; hydrocephalus remained stable.
HOSPITAL COURSE BY SYSTEM:
Neurologic: Patient's CT consistent with R basal ganglia
hemorrhage on CT head s/p EVD placement. Patient was kept on q
1 neuro checks then q 2 hour. Patient was maintained
HOB>30degrees. SBP goal <160. Patient was started on keppra for
seizure with past seizure history. Drain pulled on [**1-1**].
Repeat NCHCT was stable initially; . Transferred to floor on
[**1-1**]. Head CT showed hydrocephalus which neurosurgery decided
not to further intervene on as patient was clinically stable;
hydrocephalus remained stable.
Cardiovascular: h/o atrial flutter, hypertension. Started on On
PO digoxin and PO cardizem for rate control. Dig level 0.7 on
[**2132-1-3**]. His BP should not be higher than 170; may give IV
hydralizine PRN
Pulmonary: Initially intubated for worsening mental status,
extubated on [**2131-12-27**]. Requiring lasix gtt for a short period.
No new complaints.
Gastrointestinal / Abdomen: no acute issues, was extubated on
[**2131-12-27**]. S/S evaluated that he needed nectar thickened liquids.
Renal: Lasix gtt d/c'd, goal to stay euvolemic, may restart if
needed.
Hematology: INR 2.5 s/p 2U FFP and vitamin K in the emergency
room. Hold anticoagulants. He was started on aspirin days after
admission.
Endocrine: H/o DM. RISS for now, adjust for goal FS<150
ID: MRSA+. No acute issues. He spiked to 101.3 while in ICU, he
was on vanc/ceftaz for 5 day course (started [**12-25**]); complete.
He has been afebrile for several days. Cultures were negative.
Medications on Admission:
-keppra 750 mg [**Hospital1 **]
-diltiazem CD 180 daily
-coumadin 5 mg daily
-metformin 500 mg [**Hospital1 **]
-gabapentin 100 mg qhs
-omeprazole 20 mg daily
-zoloft 100 mg daily
-cosopt both eyes in AM
-xalatan both eyes in PM
Discharge Medications:
1. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic QAM (once a day (in the morning)).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
6. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
10. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
right basal ganglia
hemorrhage with intraventricular extension
Discharge Condition:
awake, sometimes not oriented to time, left arm and leg weakness
Discharge Instructions:
You were presented to the hospital with headaches. Your head
images showed an acute right basal ganglia
hemorrhage with intraventricular extension that was thought to
have been secondary to hypertension in setting of
anti-coagulation. You had a ventricular shunt temporarily
placed. You were in ICU for a few days before being transferred
to the floor.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2132-2-19**] 4:00
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2132-1-8**]
|
[
"041.12",
"274.01",
"401.9",
"276.69",
"427.32",
"250.00",
"368.46",
"V53.31",
"276.3",
"997.31",
"530.81",
"365.9",
"438.83",
"V58.61",
"331.4",
"345.10",
"518.81",
"431",
"427.69",
"438.89",
"327.23",
"348.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.24",
"33.29",
"02.39",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9164, 9234
|
5209, 6308
|
328, 344
|
9341, 9408
|
4704, 5186
|
9809, 10109
|
2921, 3014
|
8109, 9141
|
9255, 9320
|
7855, 8086
|
9432, 9786
|
6336, 7829
|
3774, 4685
|
3029, 3356
|
267, 290
|
372, 1994
|
3371, 3757
|
2016, 2636
|
2652, 2905
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,110
| 131,817
|
42480
|
Discharge summary
|
report
|
Admission Date: [**2123-2-3**] Discharge Date: [**2123-2-13**]
Date of Birth: [**2046-5-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 91946**] is a 76 yo M with h/o CAD s/p CABG, DM, HTN, CKD
(baseline Cr ~3), CHF with EF 45%, PVD with chronic right 3rd
toe ulceration, s/p bioprosthetic aortic valve replacement, who
is being transferred from OSH for shortness of breath, found to
have pneumonia and CHF exacerbation. Patient was recently
discharged from [**Hospital3 **] to rehab (Newbridge on the
[**Doctor Last Name **]) after admission for falls and uncontrolled diabetes.
Prior to that he had been living independently at home. During
hospitalization at Sturdy, his ACE inhibitor and Bumex were
stopped due to worsening renal function. While in rehab, he
subsequently developed respiratory distress and hypoxia to 82%
on RA. He was admitted to [**Hospital1 18**] [**Location (un) 620**], where he was found to
have worsening respiratory failure possibly due to pneumonia or
CHF. CXR showed likely multifocal BL pneumonia, +/- pulmonary
edema. Echo showed LVEF 40%, moderately depressed LV systolic
function, hypokinesis/near-akinesis of at least basal and
mid-anteroseptal segments, moderate MR. [**Name14 (STitle) 16835**] negative (CPK
100, MB 2.3, Trop T 0.129 -> 0.138). EKG unremarkable. BNP
[**Numeric Identifier 91947**]. Lasix gtt @ 5cc/hr was started with good diuresis
(-1300cc on [**2-2**], -1500cc on [**2-3**]) but limited improvement in
oxygenation. Patient received dose of vanc/azithro/ceftriaxone
in [**Location (un) 620**] ED, then started on azithro and ceftriaxone as
inpatient. On transfer to [**Hospital1 18**], he is on 100% nonrebreather
satting in the 80s, antibiotics and Lasix gtt. He is currently
normotensive.
.
On arrival to the CCU, patient is hemodynamically stable,
satting in low 90's on 100% NRB. He complains of "weakness" but
denies dyspnea.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-CHF (EF 45%), requiring hosp 2 yrs ago
-CAD s/p CABG ~10 yrs ago
-s/p bioprosthetic aortic valve replacement ([**2121**])
-CKD (baseline Cr 3)
-PVD with chronic right 3rd toe ulceration
-HTN
-HLD
-IDDM
-Anemia requiring multiple blood transfusions, details unknown
-Frequent falls
-Hypothyroidism
Social History:
Prior to hospitalization and rehab, patient continued to work at
the Bay [**Location (un) 47997**] teaching appliance maintenance and
refrigeration. He has not smoked for more than 50 years. He
lives independently with his girlfriend.
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: elderly M in NAD, AAOx2.5, slightly confused, poor
historian, somewhat tachypneic when talking with examiner
HEENT: PERRL, sclera anicteric, MMM, oropharynx clear
Neck: JVD 6-7cm above clavicle, with positive hepatojugular
reflux, carotid pulsations normal
Lungs: Crackles 1/3 up bases without wheezes or rhonchi
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: 1+ bilateral lower extremity edema warm, well perfused, 2+
pulses, no clubbing, cyanosis. +bruising in BUE.
Neuro: CN??????s [**2-14**] grossly intact. +BLE flexor/extensor weakness.
Patient somewhat confused with word finding difficulties.
.
Discharge Physical Exam:
Deceased.
Pertinent Results:
ADMISSION LABS:
WBC-12.8* RBC-2.49* Hgb-7.7* Hct-23.6* MCV-95 MCH-31.1 MCHC-32.8
RDW-16.0* Plt Ct-235
PT-14.5* PTT-29.7 INR(PT)-1.4*
Glucose-209* UreaN-81* Creat-2.9* Na-142 K-4.1 Cl-105 HCO3-18*
AnGap-23*
ALT-65* AST-42* CK(CPK)-83 AlkPhos-182* TotBili-0.4
CK-MB-5 cTropnT-0.13*
Calcium-8.4 Phos-5.0* Mg-2.5
VBG: pO2-46* pCO2-30* pH-7.40 calTCO2-19* Base XS--4
Lactate-2.0
.
Labs on admission to [**Hospital1 18**] [**Location (un) 620**] ([**2-2**]):
Na 132, K 4.9, Cl 99, HCO3 18, BUN 79, Cr 3.0, glucose 348, Ca
8.1
WBC 12.3 (92% PMNs), HCT 21.6 (baseline ~25), MCV 97
INR 1.1
ALT 92, AST 92, AP 254, Tbili 0.77, albumin 2.6
Lactate 2.1
BNP 38,000
CPK 100, MB 2.3, Trop T 0.129 -> 0.138 (5:30am on [**2123-2-3**])
UA: trace blood, protein 30, glucose 100, no WBCs
A1C recently 9.0
ABG ([**2123-2-3**], 5:50 PM): 26/62/18.5
.
CXR ([**2123-2-2**], [**Location (un) 620**]): The patient is status-post CABG and
median sternotomy wires are intact. There is diffuse air space
opacity overlying the right hemithorax and portions of the left
hemithorax with sparing of the left lung apex and upper lobe.
The opacity obscures the cardiomediastinal silhouette. There is
no pneumothorax or large pleural effusion.
IMPRESSION: BILATERAL AIR SPACE OPACITIES, WORSE ON THE RIGHT.
IN THE PROPER CLINICAL SCENARIO, THESE ARE CONSISTENT WITH
MULTIFOCAL PNEUMONIA. LESS LIKELY, THIS WOULD REPRESENT
PULMONARY EDEMA.
.
CXR ([**2123-2-3**]): bilateral pulmonary edema and possible bilateral
infiltrates, pleural effusion on left.
.
EKG ([**2123-2-2**], [**Location (un) 620**]): NSR at a rate of 74 beats per minute,
normal axis, QTC of 495, minimal ST depression in V5 alone.
.
EKG ([**2123-2-3**]): ST depressions V4-V6
.
ECHO ([**2123-2-3**], [**Location (un) 620**]): [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. RA moderately
dilated. Normal LV wall thickness and cavity size. Mild/moderate
regional LV systolic dysfunction with hypokinesis of the basal
and mid anteroseptal segments. Due to suboptimal technical
quality, additonal focal wall motion abnormalities cannot be
fully excluded. Overall LV systolic function is moderately
depressed (LVEF= 40 %). There is abnormal septal
motion/position. A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. Trace
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is severe mitral annular
calcification. Moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Biatrial enlargement. Normal left ventricular cavity
size and wall thickness with moderately depressed left
ventricular systolic function and hypokinesis/near-akinesis of
at least the basal and mid anteroseptal segments. Right
ventricle not well-visualized. Well-seated, normally functioning
bioprosthetic aortic valve. At least moderate mitral
regurgitation in the setting of severe mitral annular
calcification. Mild pulmonary artery systolic pressure.
.
EEG ([**2123-2-11**]):
IMPRESSION: This is an abnormal continuous ICU video EEG because
of
frequent bursts of generalized periodic epileptiform discharges
at 1-1.5
Hz in the beginning of the recording which became prolonged
induration
by the afternoon. These do not have any clinical correlation. In
between bursts of GPEDs, the background remains slow and
disorganized at
a maximum of 5 Hz posteriorly indicative of moderate diffuse
encephalopathy. During the recording, frequent right arm and leg
writhing movements that are sometimes generalized are seen,
associated
with grunting at times, and do not have any electrographic
correlate or
clear association with GPEDs. No clear electrographic seizures
are
present in this recording. Compared to the previous day, there
is no
significant change.
Brief Hospital Course:
Primary Reason for Hospitalization: 76 yo M with h/o CABG, DM,
HTN, CKD (baseline Cr ~3), systolic CHF with EF 40-45% who is
being transferred from OSH for shortness of breath, found to
have pneumonia and CHF exacerbation thought to be due to
pneumonia and cessation of Lasix.
Active Diagnoses:
# s/p PEA arrest: Cardiac arrest most likely occurred in the
setting of hypoxia; he was pulseless for about 5 minutes.
Cooling protocol started overnight on [**2-5**], goal temperature
reached at 23:30, rewarming started [**2-5**] at 23:30 and complete on
[**2-7**] at 3pm - will be able to get a better idea of neurological
prognosis now that pt is warmed and off all sedation. Currently
he opens eyes to voice, intermittently responds to commands, has
brisk cough/gag reflexes. Pressors have been weaned down and pt
is now only on minimal dose of levophed (have been unable to
entirely wean as MAPs drop to 50s when levophed is stopped). He
was extubated 3 days s/p arrest. His neurologic status however
continued to decline, with increased epileptiform activity and
increased seizure activity, despite being on 2 antiepileptics.
#.HYPOXIA/RESPIRATORY DISTRESS: CT chest on [**2-5**] consistent with
ddx of multifocal PNA vs CHF given pulmonary edema and
effusions. On broad spectrum abx for HCAP. Echo c/w prior from
[**Location (un) 620**] report (EF 50-55%). Had been on NRB, but after hypoxic
PEA arrest, was intubated. Lasix gtt and torsemide were
discontinued due to creatinine bump (now 4 up from baseline 3).
Also started on isordil for afterload reduction on [**2-5**]. Patient
was ventilating and oxygenating well on on spontaneous breathing
trial, so was then extubated. He was continued on IV Vancomycin,
Levoquin and Cefepime for possible multifocal pneumonia and
finished an 8 day course, after which he was started on
vanc/zosyn because he spiked a temperature to 102F despite abx.
Respiratory status continued to worsen after extubation with
respiratory alkalosis. After family meeting, it was decided
based on overall prognosis that it would be best to not
intubate. He passed away the day after making him CMO.
#.CAD s/p CABG: Troponin was mildly elevated on admission and
stable, likely [**2-4**] CKD and demand ischemia from underlying
infection. Rechecked on [**2-5**] in setting of PEA arrest, mildly
elevated at 0.09. He was maintained on ASA 325mg PO daily,
Atorvastatin 40mg per outpatient cardiologist. His carvedilol
was held in the setting of hypotension.
#.Metabolic derangements: Pt had primary respiratory alkalosis
with metabolic compensation after PEA arrest; normalized once
respiratory rate normalized. Pt also hyperphosphatemic today [**2-4**]
[**Last Name (un) **]. Had AG, but could be from renal failure and uremia.
#.CKD: Creatinine 4s throughout (baseline 3.0). His ACEi was
held.
#.ANEMIA: Etiology unclear, thought initially to be transfusion
dependent per report, but pt, his partner and son deny any
transfusions for 2 years. Baseline HCT ~25. Transfused 2 units
PRBC on [**2-5**] for Hgb 7, guaiac neg stools.
#.IDDM: blood sugars difficult to control, was on insulin gtt
prior to code and now less likely to absorb sc insulin given
cooling so insulin gtt restarted. His insulin drip was
increased while he was getting D5W.
#.HYPERTENSION: holding antihypertensives while on pressors.
Patient is on hydralazine, amlodipine, and accupril at home.
#.HYPOTHYROIDISM: continued home Levoxyl.
Patient passed away at 8:33am [**2123-2-13**], seen asystolic on
telemetry. No heart sounds or breath sounds, pupils
nonreactive. Family notified, autopsy declinded, death
certificate filled out.
Medications on Admission:
HOME MEDS:
Amiodarone 100 mg daily.
Amlodipine 5 mg daily.
Calcium 1300 mg daily.
Vitamin D3 1000 units daily.
Lantus 10 units at bedtime.
Humalog insulin sliding scale.
Levoxyl 75 mcg daily.
Tylenol 650 mg q.4 h.
Bisacodyl rectal suppository daily.
Senna 2 tablets daily.
.
MEDS ON TRANSFER:
Lasix gtt @ 5cc/hr
Azithromycin 250mg IV daily (start date [**2123-2-3**])
Ceftriaxone 1g IV q24 hrs (start date [**2123-2-2**])
Novolog
Senna 2 tabs PO daily
Vitamin D 1000 U PO daily
Calcium carbonate 500mg PO daily
Amlodipine (Norvasc) 5mg PO daily
ASA 325mg PO daily
Heparin 5000mg SC TID
Lantus
Novolog
Levothyroxine 75 mcg PO daily
Amiodarone 200mg PO daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
Completed by:[**2123-2-13**]
|
[
"250.00",
"403.90",
"440.23",
"585.9",
"707.15",
"V58.67",
"428.0",
"276.2",
"V42.2",
"244.9",
"486",
"780.39",
"428.23",
"518.81",
"348.30",
"584.9",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12208, 12217
|
7820, 8099
|
323, 329
|
12264, 12269
|
3781, 3781
|
12321, 12448
|
2900, 2917
|
12180, 12185
|
12238, 12243
|
11499, 11774
|
12293, 12298
|
2957, 3726
|
264, 285
|
357, 2309
|
3797, 7797
|
8117, 11473
|
2331, 2631
|
2647, 2884
|
11792, 12157
|
3751, 3762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,050
| 135,473
|
8864
|
Discharge summary
|
report
|
Admission Date: [**2149-10-20**] Discharge Date: [**2149-10-23**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Fatigue and Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 30834**] is an 88 year old Spanish-communicating lady with a
PMH AS s/p AVR, CAD s/p CABG, HTN, and recent hip fracture
[**2149-10-9**] with admission to [**Hospital1 2177**] for ORIF, sent from nursing home
due to anemia, now with hypotension that was responsive to IV
fludis in the ED. Patient was discharged from [**Hospital1 2177**] to nursing
home one week prior to this admission. Over the course of that
week, she complained intermittently of chest pain, shortness of
breath and orthostasis. On [**10-19**] at the nursing home, she was
noted to have a hematocrit of 21, which was 15 points below a
baseline in [**2149-5-13**]. On [**2149-10-19**], she vomited once, but had no
hematemesis, melena, hematochezia or hematuria. She has also had
several episodes of non-bloody diarrhea over the last 2-3 days,
improved today.
In the ED, initial VS were: T 98.5 BP 99/45 HR 86 RR 20 SaO2 95%
RA. While in the ED, BPs trended 81-104/39-50, HR trended 80-95.
Her surgical site looked clean and intact, with no evidence of
hematoma. She was Hemeoccult negative on rectal exam. Labs were
notable for Hgb 6.7 / Hct 20.4, Plts 492, Na 131, BUN 52, Cr
1.5. Patient was given three 1L NS boluses, all of which
effectively increased her blood pressure. CXR was notable for:
EKG showed NSR at 86 with a RBBB. Patient was ordered for a
blood transfusion, but she has difficult to match antibodies.
She has two 18-gauge PIVs.
She was admitted to the MICU for further blood pressure
monitoring, as well as management and evaluation of her
hypotension.
Vitals on transfer were T 98 BP 100/46 HR 83 100% 2L.
On arrival to the MICU, Pt is comfortable and notes persistent
faitgue. She states via daughter that her SOB and CP have
resolved. She has no other complaints.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
s/p AVR, CABG [**2147-11-27**]
Hypertension
osteoporosis
hearing loss
mild dementia
kidney stone
leg cramps
cataracts
abdominal hernia
Past Surgical History:
s/p bilateral knee replacements [**2145**]
cataract surgery 6 years ago
Social History:
Widowed, lives alone. Spanish Speaking, 8 children. Several of
her children are live locally, are supportive. No smoking, no
alcohol, no illicit drug use. Has home health aide and friend
who assists with cleaning, household tasks.
Family History:
Mother died of MI ? age, Father - unknown, 8 children with no
known medical issues
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE EXAM:
VS: 99.2 124/68 84 20 94RA
General: Sleeping comfortably, no acute distress
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, flow murmur over
RUSB, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, no guarding or rebound tenderness, tenderness to
palpation slightly improved, non-distended, bowel sounds
present, no organomegaly
Ext: L hip incision C/D/I, warm, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CN II-XII grossly intact, strength and sensation grossly
normal, gait not assessed
Pertinent Results:
ADMISSION LABS:
[**2149-10-20**] 06:11PM WBC-5.7 RBC-2.17*# HGB-6.7*# HCT-20.4*#
MCV-94 MCH-30.8 MCHC-32.8 RDW-14.6
[**2149-10-20**] 06:11PM NEUTS-71.8* LYMPHS-19.0 MONOS-3.9 EOS-5.1*
BASOS-0.2
[**2149-10-20**] 06:11PM PLT COUNT-492*#
[**2149-10-20**] 06:11PM PT-10.6 PTT-24.1* INR(PT)-1.0
[**2149-10-20**] 11:11PM WBC-4.2 RBC-1.93* HGB-6.0* HCT-18.3* MCV-95
MCH-31.3 MCHC-33.1 RDW-14.9
[**2149-10-20**] 11:11PM NEUTS-59.5 LYMPHS-29.6 MONOS-3.9 EOS-6.8*
BASOS-0.2
[**2149-10-20**] 11:11PM PLT COUNT-482*
[**2149-10-20**] 11:11PM HAPTOGLOB-<5*
[**2149-10-20**] 11:11PM ALBUMIN-3.3* CALCIUM-8.1* PHOSPHATE-3.0
MAGNESIUM-1.7
[**2149-10-20**] 11:11PM ALT(SGPT)-13 AST(SGOT)-34 LD(LDH)-608*
CK(CPK)-40 ALK PHOS-85 TOT BILI-0.9
[**2149-10-20**] 06:11PM GLUCOSE-149* UREA N-52* CREAT-1.5*
SODIUM-131* POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13
CXR [**2149-10-21**]:
FINDINGS: Single semi-erect AP portable view of the chest was
obtained. The patient is status post median sternotomy and
CABG. Again the patient's trachea is deviated to the right with
a left-sided density consistent with enlarged thyroid.
Questionable blunting of the left costophrenic angle is felt to
most likely be due to overlying soft tissue. No definite focal
consolidation. The cardiac and mediastinal silhouettes are
stable. There is minimal pulmonary vascular congestion.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2483**]
Xray Pelvis/L Femur [**2149-10-21**]:
FINDINGS: No previous images. Metallic fixation device is seen
about prior fracture of the proximal femur with separation of
the lesser trochanter. Skin staples are in place.
The total knee arthroplasty is present, though not optimally
seen on views presented.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
CT abdomen/pelvis [**2149-10-22**]:
1. No evidence of retroperitoneal hematoma or other
intraabdominal fluid
collection.
2. Status post left femur ORIF. Small 1.7 x 1.0 cm low density
collection
adjacent to the superior aspect of the left greater trochanter
is compatible with a post-operative collection. Left lesser
trochanter fragment is medially displaced. Streak artifact
limits evaluation but no evidence of hardware complication is
identified.
3. Other findings include superior and inferior endplate
compression
deformities of L3, 2.8 cm liver segment VI cyst with small rim
calcification,
4.0 cm left renal midpole cystic structure compatible with
simple cyst, right anterior abdominal wall surgical clips which
may represent prior hernia repair, atherosclerotic calcification
of the abdominal aorta.
DISCHARGE LABS:
[**2149-10-23**] 06:00AM BLOOD WBC-6.4 RBC-2.73* Hgb-8.5* Hct-25.2*
MCV-92 MCH-31.1 MCHC-33.7 RDW-15.3 Plt Ct-627*
[**2149-10-22**] 05:40AM BLOOD Ret Aut-3.4*
[**2149-10-23**] 06:00AM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-139
K-4.6 Cl-106 HCO3-26 AnGap-12
[**2149-10-21**] 05:07AM BLOOD CK-MB-2 cTropnT-<0.01
[**2149-10-20**] 11:11PM BLOOD CK-MB-2 cTropnT-<0.01
[**2149-10-20**] 06:11PM BLOOD cTropnT-0.01
[**2149-10-23**] 06:00AM BLOOD Albumin-PND Calcium-9.2 Phos-3.9 Mg-1.7
(s/p transfusion PRBCs) [**2149-10-22**] 05:40AM BLOOD calTIBC-212*
Hapto-21* Ferritn-1467* TRF-163*
[**2149-10-22**]: COOMBs - NEGATIVE
Brief Hospital Course:
Ms. [**Known lastname 30834**] is an 88 year old Spanish-communicating lady with a
PMH AS s/p AVR, CAD s/p CABG, HTN, and recent hip fracture
[**2149-10-9**] with admission to [**Hospital1 2177**] for ORIF, sent from nursing home
due to anemia, now with hypotension that was responsive to IV
fludis in the ED.
#Hypotension: Most likely secondary to combination of anemia and
hypovolemia following recent ORIF. Infection less likely as pt
remained AF and WBC was not elevated. CXR with no signs of
infiltrate or consolidaton. CE not elevated and ECG unchanged
from baseline lowering suspicion for cardiac etiology. Blood
and urine cultures were no growth to date of discharge. Patient
was transfused with 2 units of PRBC and received 3 L of NS with
improvement in BP. Her home anti-hypertensive meds were held and
slowly restarted prior to discharge. We restarted Metoprolol and
HCTZ, but did not restart Lisinopril. This can be restarted PRN
at rehab.
#Anemia: Uncertain etiology but improved with 2 blood
transfusions in the MICU and HCT remained stable. No signs of
hematoma at surgical site or active bleeding. Guaiac neg in ED
and recent colonscopy with only a few polyps found make GI
etilogy less likely. Considered anemia secondary to lysis as pt
has antibodies to several blood antigens and it is unclear if
she was transfused during recent ortho procedure. LDH was
elevated and haptoglobin less than five however bilirubin was
not elevated. Direct coombs was negative as well, reticulocyte
count was appropriately elevated to 3.2. X-rays of the hip were
negative for fluid collection, and CT abdomen was negative for
intraabdominal process. Her HCT stabilized over the next 48hrs
and at discharge, her HCT was 25.2. Although there was no
evidence of bleeding, because of profound anemia on
presentation, her Lovenox was discontinued and this decision
will be communicated to her Orthopedic surgeon at [**Hospital1 2177**] as well.
#Respiratory Distress: Patient noted SOB over several days
leading up to admission. Most likely secondary to anemia in
setting of unremarkable infectous and cardio work up. She had
good oxygenation on admission and did no require supplemental
O2.
#CAD: Pt is s/p CABG and AVR. Pt did note CP earlier in the weak
which may be chronic vs. secondary to anemia. Cardiac enzymes
were negative x3 and patient's ECG was at baseline. Her home BB
and antihypertensives were held in MICU in setting of low BP,
but restarted slowly prior to discharge. Plavix was also held
in setting of possible bleeding source for anemia, but was
restarted prior to discharge.
#Left Hip: Patient was seen and evaluated by orthopedics who did
not think she needed any intervention. Her staples were removed
and she was treated with pain medication as needed. She
received PT when stable and should continue to have PT at rehab
upon discharge. She will f/u with Ortho at [**Hospital1 2177**] as outlined
below.
Transitional issues:
1.Pt should follow up with [**Hospital1 2177**] ortho with Dr. [**Last Name (STitle) 30885**] on
[**2149-10-28**] at 8:30am.
2.Lisinopril was not restarted prior to discharge, given
relative normotension during the admission. This can be
restarted when appropriate in the outpatient setting.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Donepezil 10 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Senior Vitamin *NF* (multivitamin-minerals-lutein) 1 tab Oral
daily
5. ammonium lactate *NF* 12 % Topical daily
6. Calcium 600 with Vitamin D3 *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral [**Hospital1 **]
7. Diphenoxylate-Atropine 1 TAB PO BID:PRN diarrhea
8. Gabapentin 600 mg PO HS
9. Hydrochlorothiazide 25 mg PO DAILY
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
12. Metoprolol Succinate XL 12.5 mg PO DAILY
13. Mirtazapine 30 mg PO HS
14. Ranitidine 150 mg PO BID
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Donepezil 10 mg PO DAILY
4. Gabapentin 600 mg PO HS
5. Hydrochlorothiazide 25 mg PO DAILY
6. Mirtazapine 30 mg PO HS
7. Ranitidine 150 mg PO BID
8. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN pain
9. OxycoDONE (Immediate Release) 2.5-5.0 mg PO Q4H:PRN pain
Hold for sedation, RR<12
RX *oxycodone 5 mg 1/2-1 tablet(s) by mouth every 4-6 hours Disp
#*40 Tablet Refills:*0
10. ammonium lactate *NF* 12 % Topical daily
11. Calcium 600 with Vitamin D3 *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral [**Hospital1 **]
12. Diphenoxylate-Atropine 1 TAB PO BID:PRN diarrhea
13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
14. Metoprolol Succinate XL 12.5 mg PO DAILY
15. Senior Vitamin *NF* (multivitamin-minerals-lutein) 1 tab
Oral daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Anemia
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:
Ms. [**Known lastname 30834**] you were admitted to [**Hospital1 1170**] after presenting with fatigue and short of breath. You
were found to have low blood counts (you were anemic). You had
multiple blood tests x-rays of your hip and a CT scan of your
abdomen which did not show that you were bleeding. In addition,
we tested your stool which did not have blood in it either. We
think that you were anemic because you just had a large
operation on your hip and your body is taking time to recover.
You were given a transfusion of blood and fluids through an IV
and we monitored your hemoglobin levels which remained stable.
We decided not to restart your blood thinner (Fragmin) because
this put you at increased risk of bleeding. We will communicate
this decision to your orthopedic surgery Dr. [**Last Name (STitle) 30885**] as well.
We stopped your blood pressure medication (Lisinopril) because
your blood pressure was low. You should not restart this unless
instructed by a physician.
While at Rehab, you will be followed by a physician [**Name Initial (PRE) **].
However, after you are discharged from Rehab please see Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] for additional medical care.
It was a pleasure caring for you and we wish you a speedy
recovery!
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2150-1-30**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"285.9",
"V45.81",
"V54.13",
"294.20",
"V43.65",
"733.00",
"276.52",
"401.9",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12238, 12321
|
7329, 10267
|
249, 255
|
12371, 12371
|
3957, 3957
|
13875, 14172
|
2620, 2704
|
11378, 12215
|
12342, 12350
|
10608, 11355
|
12549, 13852
|
6688, 7306
|
2281, 2355
|
2719, 3329
|
3345, 3938
|
10288, 10582
|
178, 211
|
283, 2061
|
3973, 6671
|
12386, 12525
|
2083, 2258
|
2371, 2604
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,263
| 195,108
|
5197
|
Discharge summary
|
report
|
Admission Date: [**2165-12-21**] Discharge Date: [**2165-12-28**]
Date of Birth: [**2100-3-13**] Sex: F
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
male with no significant medical history who presented with
one week of chest pain with ambulation relieved by rest. The
patient told her primary care physician who scheduled an
exercise treadmill test which was positive. The patient
while at home for a few days prior to admission started
developing pressure like sternal discomfort at rest, no
radiation, felt some nausea. She had a MIBI on [**2165-12-19**],
which showed reversible defect. The patient was admitted to
Cape Point Hospital, was scheduled for a catheterization,
however, the patient requested transfer to [**Hospital1 346**]. The patient was transferred to
[**Hospital1 69**] for further evaluation
and management.
PAST MEDICAL HISTORY:
1. Status post total abdominal hysterectomy at age 52.
2. Status post arthroscopy right knee.
3. Coronary artery disease.
ALLERGIES: Codeine - nausea and vomiting.
SOCIAL HISTORY: The patient lives with husband and two kids.
Occasional ETOH. She denies tobacco use.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. once daily.
2. Plavix 75 mg p.o. once daily.
3. Lovenox 80 mg subcutaneous twice a day.
4. Zocor 20 mg once daily.
5. Protonix 40 mg once daily.
6. Morphine Sulfate p.r.n.
7. Atenolol p.r.n.
8. Ambien p.r.n.
PHYSICAL EXAMINATION: The patient is a pleasant, cooperative
female in no acute distress. Temperature is 98.6, blood
pressure 100/68, pulse 65, respiratory rate 18, 98% in room
air. Mucous membranes are moist. Lungs are clear to
auscultation bilaterally. The heart is regular rate and
rhythm. The abdomen is soft, nontender, nondistended, no
edema.
HOSPITAL COURSE: The patient was admitted to the cardiology
team. She underwent catheterization on [**2165-12-23**], which
showed 90% left main disease with catheter damping. The
patient had intra-aortic balloon pump placed intraoperatively
and was referred for urgent cardiothoracic service
consultation. Given the patient's significant disease, the
patient was taken to the operating room on [**2165-12-23**], where
emergency coronary artery bypass graft times two with left
internal mammary artery to left anterior descending and
saphenous vein graft to obtuse marginal was performed.
Please see operative note for details. The patient tolerated
the procedure well and was transferred to cardiothoracic care
unit in no acute distress.
On hospital day one, the patient is afebrile and vital signs
are stable. Her intra-aortic balloon pump was discontinued.
On postoperative day number two, the patient is afebrile with
stable vital signs. Her chest tubes were discontinued. She
was started on Lopressor and beginning to ambulate,
tolerating regular diet. The patient was transferred to the
floor. On the floor, the patient remained afebrile and vital
signs were stable. Her wires were removed. She is
ambulating without help. The wound is clean, dry and intact.
No dyspnea, no active issues at this time.
CONDITION ON DISCHARGE: Good.
DISPOSITION: The patient is discharged home. The weight
will follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks and Dr. [**Last Name (STitle) 21235**] in
four weeks and Dr. [**Last Name (STitle) 11586**] in two weeks.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Aspirin 325 mg p.o. once daily.
3. Percocet one to two tablets p.o. q4-6hours p.r.n.
4. Tylenol 650 mg p.r.n.
5. Milk of Magnesia q6hours p.r.n.
6. Bisacodyl suppository p.r.n.
7. Protonix 40 mg p.o. once daily.
8. Lopressor 75 mg p.o. twice a day.
9. Vitamin C one tablet p.o. twice a day.
10. Iron 150 mg p.o. once daily.
11. Lasix 20 mg p.o. twice a day for two weeks.
12. Potassium Chloride 20 meq p.o. twice a day for two weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft.
2. Status post total abdominal hysterectomy.
3. Postoperative anemia.
4. Hypokalemia.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 15509**]
MEDQUIST36
D: [**2165-12-28**] 09:38
T: [**2165-12-28**] 10:11
JOB#: [**Job Number 21236**]
|
[
"E878.2",
"285.1",
"998.11",
"276.8",
"413.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"36.15",
"37.61",
"97.44",
"39.61",
"88.53",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
3931, 4377
|
3428, 3910
|
1219, 1459
|
1833, 3137
|
1482, 1815
|
179, 896
|
918, 1088
|
1105, 1193
|
3162, 3402
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,482
| 162,870
|
34476
|
Discharge summary
|
report
|
Admission Date: [**2174-9-29**] Discharge Date: [**2174-10-7**]
Date of Birth: [**2151-9-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Dyspnea, syncope, and hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient suffered a right 5th metatarsal fracture [**2174-9-14**] due to
"rolling on it". Originally patient had a splint but reported
significant swelling/pain and was changed to an air cast 2 weeks
ago. Other than resting at home for two days following the
injury, patient has been walking and going to work (denies
immobilization). On Wednesday night she felt dizzy while
cleaning her room. The dizziness did not resolve and she started
seeing black/yellow spots. At one point she felt she "blacked
out" (+ LOC) and had to rest on her bed. She experienced SOB
with mild exertion (walking to bathroom). She also describes
significant pleuritic pain. She tried drinking fluids because
she thought she was dehydrated. The patient drank more fluids
and slept with her feet elevated, but woke up on thursday still
feeling unwell. The patient does not have a PCP, [**Name10 (NameIs) **] she went to
the urgent care clinic at [**Hospital1 18**] and was sent to the ED in an
ambulance.
.
Denies recent surgery, history of blood clots. Denies current
use of OCP, did use OCP for a "couple months last year". Urine
HCG negative in ED. No recent bleeding, surgery, or head injury.
Denies history of easy bleeding, unsure if bruises easily.
.
ED course reviewed in admission note: VS on arrival to ED (10:42
a.m.): T 99.4 HR 95 BP 118/78 RR 17 Sat 98%/RA. In the ED, the
patient's BP ranged 84-111/47-77, with heart rate 95-131. The
patient received 2L NS, without resolution of tachycardia. CTA
showed extensive bilateral PE. Started on heparin protocol:
heparin 4900 units IV bolus, the heparin gtt 1100 units/hr.
.
ROS: No fever, chills. +dizziness. +pleuritic pain. No chest
pain except with deep inspiration. +DOE. No cough. No
abdominal pain, nausea, or vomiting. Occasional diarrhea since
parasitic infection. No dysuria. LMP [**2174-9-13**]. Pain in right
toe. Otherwise no extremity pain. No rash.
Past Medical History:
-anorexia nervosa in high school, resolved per pt
-parasitic infection, acquired during 2-month trip to [**Country 48229**] in
summer [**2173**], treated with antiparasitics, complete [**10/2173**], some
residual diarrhea
-right 5th metatarsal fracture [**2174-9-14**]
-right radius/ulna fracture, complicated by delayed [**Hospital1 **]
requiring bone stimulator
-seasonal allergies
-headaches
-s/p hymenectomy
-s/p wisdom tooth extraction
Social History:
SH: Denies smoking, drug use. Drinks 1 beer every other night.
Currently lives with roommates and works in public health.
Family History:
FH: Maternal grandmother had superficial colt in 40s. Maternal
uncle had PE in 50s, however was obese with significant venous
stasis disease.
Physical Exam:
VS: 99.5 108 111/63 19 98%/2L NC
Gen: NAD. Young woman lying comfortably in bed.
HEENT: Anicteric. PERRL. Moist oral mucosa.
Neck: JVP elevated to 10 cm.
Resp: Normal respiratory effort. Symmetric with good
expansion. CTAB.
CV: Tachycardic. Regular rhythm. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. Non-distended. Non-tender.
Ext: Echymosis over right 5th metatarsal. Trace edema RLE.
Peripheral vascular: Extremities warm and well perfused.
Radial, PT, and DP pulses 2+ bilaterally.
Neuro: Alert and oriented x 3. Speech normal. PERRL. EOMI.
Face symmetric. Palate elevates in midline. Tongue midline.
Moving all 4 extremities. Sensation intact distally in all 4
extremities.
Lines: PIV 18-gauge RUE.
Pertinent Results:
CT-PE protocol: Bilateral massive pulmonary emboli are present,
involving lobar, segmental and subsegmental arteries. Leftward
bowing of the ventricular septum suggests right heart strain.
Minimal atelectasis noted in the right lung base, otherwise, the
lungs are clear. No other abnormalities noted.
Cardiac Echo: Dilated RV cavity size with RV systolic
dysfunction. In the setting of a pulmonary embolism this is
consistent with RV strain.
LENI: DVT of the right popliteal vein, extending into the
proximal
superficial veins of the calf.
139 103 7
--------------< 92
3.8 25 0.7
HCG:<5 (Negative)
273
13.5 >------< 273
38.3
N:87.6 L:8.7 M:3.4 E:0 Bas:0.3
PT: 12.7 PTT: 23.8 INR: 1.1
Brief Hospital Course:
23 year old female with recent right metatarsal fracture,
treated with immobilization presents with pulmonary embolism,
causing pleuritic pain, DOE, tachycardia, and syncopal episode.
.
# Pulmonary embolism: Presenting symptoms included tachycardia,
syncope, and hypotension. Pulmonary embolism was diagnosed by
CT-A. Following fluid resuscitation in ER, patient was
hemodynamically stable on admission to MICU. Thrombolysis was
discussed but felt to have an unfavorable risk-benefit ratio
given clinical stability. Anticoagulation with heparin was
initiated per weight-based protocol. Echocardiogram showed RV
heart strain. LENI demonstrated DVT of the right popliteal vein,
extending into the proximal superficial veins of the calf. IVC
filter would have significant comorbidity at this age. Patient
transferred to the floor and started on Coumadin with Heparin
bridge. Bridged on Heparin drip for 24 hours when Coumadin
reached therapeutic INR [**2-13**]. Patient to remain on
anti-coagulation for 6 months followed by [**Hospital 191**] clinic. Primary
care provider can consider hypercoagulable work-up due to young
age, however patient did have risk factor of right metatarsal
fracture with tight splint fit. No significant family history.
.
# Right 5th metatarsal fracture: Weight as tolerated with air
cast and crutches. Patient to follow up with orthopedics.
# Syncope: She presented with syncope, likely related to her
pulmonary embolism. She had no further episodes.
Medications on Admission:
Tylenol PRN foot pain
Ibuprofen PRN foot pain
Discharge Medications:
1. Warfarin 2.5 mg Tablet Sig: 2-3 Tablets PO at bedtime: Friday
7.5 mg (3 tablets), Saturday 5 mg (2 tablets), Sunday 7.5mg (3
tablets). On Monday have your INR checked at [**Hospital 191**] clinic. Adjust
as needed per Dr.[**Name (NI) 29792**] office [**Telephone/Fax (1) 250**] or [**Hospital 191**] [**Hospital **]
clinic([**Telephone/Fax (1) 10844**].
Disp:*90 Tablet(s)* Refills:*2*
2. Outpatient Lab Work
INR check Monday morning [**2174-10-10**] at [**Hospital 191**] clinic. Call Dr. [**Name (NI) 79228**] office [**Telephone/Fax (1) 250**] with the results and adjust
coumadin as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pulmonary Embolism
Deep [**Last Name (un) **] thrombosis
Secondary:
Metatrasal fracture
Discharge Condition:
Good, ambulating with stable vitals.
Discharge Instructions:
You were admitted for a pulmonary embolism due to a deep vein
thrombosis. This was most likely caused by your metatrasal
injury, but please discuss with your primary care provider
whether [**Name Initial (PRE) **] hypercoagulability work-up is indicated. You need to
be on coumadin for 6 months for therapeutic INR [**2-13**]. Please
follow-up with orthopedics regarding your metatrasal injury,
until then walk using an air cast.
We are discharging you on Coumadin. It is very important to
follow your INR level. You will be followed by the [**Hospital 191**]
[**Hospital **] clinic their phone number is ([**Telephone/Fax (1) 10844**]
starting on Tuesday, before then Dr. [**Last Name (STitle) 13959**].
1) Go to [**Company 191**] Associates to have your INR drawn on Monday morning
[**2174-10-10**]. I have printed out a script. They will forward the
results to Dr.[**Name (NI) 29792**] office and he will contact you if you
need to adjust your coumadin dose. On Tuesday [**Hospital 191**]
[**Hospital 2786**] clinic will follow your INR.
2) Take Coumadin 7.5 mg Friday, 5mg Sat, 7.5 mg Sunday until
told otherwise by Dr.[**Name (NI) 29792**] office.
Return to the ER if you experience shortness of breath, chest
pain, bleeding or any other concerning symptoms.
Followup Instructions:
We have made the following appointments:
1) Go to [**Company 191**] Associates to have your INR drawn on Monday
[**2174-10-10**]. I have printed out a script. They will forward the
results to Dr.[**Name (NI) 29792**] office and he will contact you if you
need to adjust your coumadin dose. On Tuesday [**Hospital 191**]
[**Hospital 2786**] clinic will follow your INR.
2) [**Hospital6 733**] [**Hospital **] Clinic ([**Telephone/Fax (1) 10844**]
will be following your INR on Tuesday. They will be contacting
you on Tuesday.
3) Primary Care Doctor: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13960**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2174-10-20**] 12:00. [**Hospital **].
4) Orthopedic Surgeon: [**Name6 (MD) 13978**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2174-10-20**] 1:50
Completed by:[**2174-10-12**]
|
[
"790.92",
"453.42",
"453.41",
"415.19",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6773, 6779
|
4568, 6053
|
349, 357
|
6921, 6960
|
3831, 4545
|
8275, 9153
|
2916, 3059
|
6150, 6750
|
6800, 6900
|
6079, 6127
|
6984, 8252
|
3074, 3812
|
276, 311
|
385, 2296
|
2318, 2761
|
2777, 2900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,807
| 152,277
|
9846
|
Discharge summary
|
report
|
Admission Date: [**2145-6-28**] Discharge Date: [**2145-7-7**]
Date of Birth: [**2104-11-11**] Sex: F
Service: Acove
HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old
female with a history of C3-C4 quadriplegia, chronic adrenal
insufficiency and history of Methicillin resistant
Staphylococcus aureus pneumonia presenting to the Emergency
Room with mental status changes. Of note, she had recently
been admitted for hypoxia and similar symptoms. At
rehabilitation, the patient was found to be very lethargic
with O2 saturations at 80% and she was sent to the Emergency
Room where she received Narcan and immediately improved with
her mental status. She complained of pain all over and was
given 4 mg of morphine and became unresponsive again and was
once again improved with Narcan. She was noted to have left
basilar opacity and left pleural effusion on chest x-ray.
PAST MEDICAL HISTORY:
1. C3-C4 spinal cord injury, status post secondary to motor
vehicle accident in [**2139**]
2. Quadriplegia
3. History of gastroesophageal reflux disease
4. History of depression
5. Chronic adrenal insufficiency
6. Chronic pain
7. History of Methicillin resistant Staphylococcus aureus
pneumonia
ALLERGIES: PENICILLIN AND SULFA
Of note, the patient has been intubated multiple times over
the past several months and required hospital admissions for
this.
PHYSICAL EXAM:
VITAL SIGNS: The patient presented to the Emergency Room
with a temperature of 98.9??????, heart rate 70, blood pressure
100/52, respiratory rate 90, oxygen saturation 90% on room
air.
GENERAL: She initially was responsive to voice.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light. Extraocular muscles were intact. Neck
was supple.
LUNGS: Diffusely rancorous bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, slightly distended with guaiac negative
stools.
EXTREMITIES: Lower extremities were without any edema. The
patient had two notable ulcers. The first was fourth degree
pressure ulcer over the sacral region which is approximately
2 inches deep and 4 inches wide with mostly granulation
tissue covering the wound surface. There is no appreciable
fluctuance or a closed cavity. There is no area of
surrounding cellulitis. The patient's left shoulder had a
second degree pressure ulcer with an eschar over it.
ADMISSION LABS: The patient had white count of 7.2 with 73%
neutrophils, 19% lymphocytes. Hematocrit was 38.6 and
platelets were 309. Chem-7 was within normal limits.
Admission chest x-ray showed the presence of a left basilar
opacity which was new as well as a small left pleural
effusion. Urinalysis showed large blood, positive nitrites,
6 to 10 red blood cells and greater than 50 white blood
cells. Admission head CT was negative for intracranial
hemorrhage. Admission abdominal KUB showed there was no
evidence of intestinal obstruction or fecal impaction.
HOSPITAL COURSE BY SYSTEM:
1. Pulmonary: The patient presented with history of C3-C4
quadriplegia presenting with decreased oxygen saturations.
The decrease oxygen saturation is likely secondary to causes
including oversedation due to her pain medications as causing
decreased respiratory drive as well as left lower lobe
pneumonia. The patient has had a sputum culture during this
hospital admission which grew out coagulase positive
Staphylococcus. The Staphylococcus was resistant to
oxacillin. Therefore, the patient was treated with a 14 day
course of vancomycin. Aggressive chest physical therapy was
continued during her hospital admission. Also of note on the
patient's pain regimen, she was responsive without episodes
of oversedation.
2. Endocrine: The patient has a history of adrenal
insufficiency and was treated with high doses of
hydrocortisone in the Emergency Room and her prednisone was
continued throughout the hospital admission.
3. Infectious disease: The patient has etiologies of
infection including pneumonia given chest x-ray. Also, the
patient had a urinalysis which was notable for greater than
50 white cells. However, her Foley was changed on the [**5-31**]. The repeat urinalysis was unremarkable and the
cultures for the urinalysis showed no growth. The patient
also had wound swabs which were performed and the wound swabs
were notable for 1+ polymorphonuclear leukocytes as well as
2+ gram negative rods. The gram negative rods grew out
greater than four colonial morphologies. The wound culture
also grew out Pseudomonas which was sensitive to cefepime and
intermediate to ceftazidine. The patient is to complete a
seven day course of antibiotics for the Pseudomonas. The
patient during the hospital admission was hemodynamically
stable and afebrile.
4. Pain: The patient was seen by the pain control services
during this admission. They recommended a possible trial of
baclofen intrathecal injection in the future. In addition,
the patient's pain medications including the OxyContin,
oxycodone and Neurontin were continued. The patient's
baclofen was continued and Zanaflex was added to the
patient's anti-muscle spasm medication. The patient has a
follow up with the pain clinic on [**8-31**] for a trial of
the baclofen injection.
5. Wound ulcers: The patient has a history of the sacral
decubitus ulcer as well as the grade 2 ulcer on the right
chest wall. She was seen by the plastic surgery team during
this admission. The plastic surgery team felt that there is
no acute evidence of cellulitis and there is not a need for
debridement or reconstruction at the time. However, she may
follow up as needed for future consideration for possible
reconstructive measures in the plastic surgery clinic. They
recommended continuing current wet to dry dressing changes,
as well as preventing pressure with frequent position
changes.
DISPOSITION: Patient to return to [**Hospital3 20374**]. The patient's
follow up appointments are as follows: The patient has the
pain service follow up appointment on [**8-31**] on a
Tuesday at 12:40 p.m., phone number [**Pager number **]. The patient
has a plastics appointment on [**7-13**] at 9:15 a.m. which
has the phone number of [**Telephone/Fax (1) **].
DISCHARGE CONDITION: Good
DISCHARGE DIAGNOSES:
1. History of C3-C4 spinal cord injury
2. History sacra decubitus ulcers
3. History of chronic pain
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gm intravenous [**Hospital1 **] x5 days
2. Baclofen 30 mg po qid
3. Subcutaneous heparin 5000 units subcutaneous [**Hospital1 **]
4. Klonopin 1 mg po bid
5. OxyContin 20 mg po bid
6. Zanaflex 4 mg po tid
7. Atrovent metered dose inhaler 2 puffs q6h
8. Reglan 10 mg po qid
9. Albuterol metered dose inhaler 2 puffs q6h
10. Colace 100 mg po tid
11. Zinc 220 mg po bid
12. Estraderm pad 0.05 mg q 72 hours
13. Magnesium citrate 1 bottle every other day
14. Lactulose 30 cc po tid
15. Neurontin 900 mg po tid
16. Lidoderm patch to skin on at 9 a.m., off at 9 p.m.
17. Prednisone 5 mg po q day
18. Oxycodone 5 mg po q 3 to 4 hours prn
19. Protonix 40 mg po q day
20. Ditropan 5 mg po bid
21. Iron 325 mg po tid
22. Zoloft 50 mg po q day
23. Multivitamins 1 po q day
24. Gas-X 40 mg po qid prn
25. Levofloxacin 500 mg po q day x6 days
26. Cefepime 2 gm intravenous x7 days [**Hospital1 **]
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 27308**]
MEDQUIST36
D: [**2145-7-7**] 12:45
T: [**2145-7-7**] 13:53
JOB#: [**Job Number 18842**]
|
[
"799.0",
"507.0",
"V09.0",
"255.4",
"344.00",
"E940.1",
"707.0",
"482.41",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6232, 6238
|
6259, 6363
|
6386, 7541
|
2969, 6210
|
1404, 2372
|
167, 902
|
2389, 2942
|
924, 1389
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,713
| 199,175
|
50312
|
Discharge summary
|
report
|
Admission Date: [**2148-5-29**] Discharge Date: [**2148-5-31**]
Date of Birth: [**2096-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 yo woman h/o T1-T2 paraplegia following MVC [**1-4**], chronic
obstructive pulmonary disease and recent admission [**Date range (1) 49732**] for
COPD exacerbation (t/w rapid prednisone taper and 7-day course
of levofloxacin) who is admitted to the ICU for respiratory
distress and hypotension. History was taken from patient and her
friend [**Name (NI) **], who was present during the majority of the
interview.
.
Per patient, she was in her USOH until morning of admission.
When she awoke she felt "foggy" mentally, and she was coughing
up large amounts of clear sputum. She came to the ED where her
inital vitals were remarkable for hypotension to 90/60,
afebrile, with HR 55. She required non-rebreather to maintain
sats in the 90s. CXR was done which showed RLL pneumonia. Due to
the fact that she had difficult access and was hypotensive, a
right IJ was placed. She was given vancomycin, ceftriaxone and
levofloxacin, and she was started on norepinephrine drip. Prior
to transfer to MICU, she had received about 2L IVF.
.
By the time she arrived to the MICU, she felt much better from a
respiratory standpoint. She denied chest pain or pressure,
lightheadedness, dizziness, headache, nausea or vomiting. She
denied abdominal pain, diarrhea, dysuria or hematuria. She
denied joint pain, fever, or chills. Per patient and friend, her
mental status overall was much improved.
.
REVIEW OF SYSTEMS: as per HPI above.
Past Medical History:
- T1-T2 paraplegia following MVC [**1-4**]
- Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
- HCV, viral load suppressed
- H/o recurrent PNAs: MRSA, pan-sensitive Kleb
- Anxiety
- DVT in [**2142**] -IVC filter placed in [**2142**]
- Pulmonary nodules
- Hypothyroidism
- Chronic pain
- Chronic gastritis
- H/o obstructive lung disease
- Anemia of chronic disease
- S/p PEA arrest during last hospitalization in [**2147-10-3**]
Social History:
Social History:
- Lives at home wiht her husband and 2 adolescent children
- Tobacco: 35 pack years, no longer smoking
- etOH: Denies
- Illicits: Denies
.
Family History:
Family History:
- No history of lung disease
.
Physical Exam:
T 95.7, HR 72, BP 100/66, RR 17-24, sat 100% on venti mask 50%
Total in: 4L
Total out: 1L urine output
General: awake, alert and oriented x3, no distress. Attention
normal.
Lungs: diffuse expiratory wheezes and coarse inspiratory sounds
anterior fields.
Heart: RRR, normal s1/s2, no murmurs
[**Last Name (un) **]: soft, non-tender
Extremities: trace PE to ankles, warm and well-perfused
Pertinent Results:
[**2148-5-29**] 07:30PM BLOOD WBC-6.1 RBC-3.31* Hgb-9.2* Hct-28.7*
MCV-87 MCH-27.7 MCHC-31.9 RDW-15.1 Plt Ct-157
[**2148-5-30**] 05:31AM BLOOD WBC-4.9 RBC-2.94* Hgb-8.4* Hct-26.1*
MCV-89 MCH-28.6 MCHC-32.2 RDW-14.9 Plt Ct-113*
[**2148-5-29**] 07:30PM BLOOD Neuts-65.3 Lymphs-26.6 Monos-3.1 Eos-4.3*
Baso-0.7
[**2148-5-30**] 05:31AM BLOOD Plt Ct-113*
[**2148-5-30**] 05:31AM BLOOD PT-13.2 PTT-31.8 INR(PT)-1.1
[**2148-5-30**] 05:31AM BLOOD Glucose-97 UreaN-8 Creat-0.2* Na-144
K-3.9 Cl-111* HCO3-30 AnGap-7*
[**2148-5-29**] 07:30PM BLOOD Glucose-100 UreaN-8 Creat-0.3* Na-141
K-4.0 Cl-100 HCO3-35* AnGap-10
[**2148-5-30**] 05:31AM BLOOD proBNP-852*
[**2148-5-30**] 05:31AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.6
[**2148-5-29**] 09:27PM BLOOD Lactate-0.5
.
Wed [**5-29**]: IMPRESSION:
1. Increased right base opacity with blunting of the right
costophrenic angle may represent a combination of pleural fluid
and right lower lobe pneumonia. Patchy lateral left lung
opacity may reflect atelectasis. 2. Persistently enlarged
cardiac silhouette could be due to cardiomyopathy and/or
pericardial effusion.
Brief Hospital Course:
51 yo F with COPD, h/o recurrent pneumonias, presents with
respiratory distress, hypoxia, hypotension, and altered mental
status in setting of likely RLL pneumonia
.
# Respiratory distress - differential includes pneumonia vs
bronchitis/bronchospasm. Rapid improvement after nebs in the
emergency room would be more consistent with the latter.
Patient initially admitted to ICU given hypotension. Was
transiently on a norepinephrine drip, but was quickly weaned
off. Received IV vanc, ceftriaxone, and levofloxacin in the ICU
but was transitioned to just PO levafloxacin on call out to the
floor. Patient tested negative for Legionella. Anxiety also
likely played a large part in her shortness of breath as she
went up in her O2 requirement every time she became anxious on
this admission. Patient was discharged to complete a 7 day
course of oral levofloxacin and a fast prednisone taper.
Patient will continue on her home regimen of inhalers.
.
# Altered mental status - resolved following nebulizers, likely
secondary to hypoxemia/hypercarbia from respiratory distress
.
# Hypotension - required norepi drip while in the ICU, but
quickly weaned off. Patient was discharged to complete a 7 day
course of levofloxacin.
.
# Chronic pain - patient was continued on methadone, oxycodone,
and pregabalin per home regimen
.
# Hypothyroidism - patient continued on levothyroxine
.
# Chronic gastritis - patient continued on omeprazole
.
# Anxiety - patient continued on citalopram and klonopin
.
# Smoking history - patient continued on nicotine patch
Medications on Admission:
- albuterol nebs q4-6h prn
- baclofen 10 mg up to 5 tabs daily
- citalopram 40 mg daily
- clonazepam 1 mg ([**2-3**] at night for insomnia)
- Combivent 2 puffs tid
- levothyroxine 75 mcg qday
- lidocaine patch qday
- methadone 5 mg tid
- omeprazole 20 mg [**Hospital1 **]
- oxybutynin 5 mg up to five tabs daily
- oxycodone 5 mg tid prn
- pregabalin 150 mg tid
- sucralfate 1 g qid
- trazodone 200 mg qhs
- calcium carbonate 500 mg [**Hospital1 **]
- loratadine 10 mg daily prn
- nicotine patch 21 mg daily
- polyethylene glycol prn
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for shortness of breath or wheezing.
2. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
3. Citalopram 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
4. Clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime as
needed for insomnia.
5. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation three times a day.
6. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. Methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
11. Pregabalin 75 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3
times a day).
12. Sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times
a day).
13. Trazodone 100 mg Tablet [**Hospital1 **]: Two (2) Tablet PO at bedtime.
14. Calcium 500 500 mg (1,250 mg) Tablet [**Hospital1 **]: One (1) Tablet PO
twice a day.
15. Loratadine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day as
needed for allergy symptoms.
16. Miralax 17 gram/dose Powder [**Hospital1 **]: Seventeen (17) grams PO
once a day as needed for constipation.
17. Nicotine 7 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) patch
Transdermal once a day.
Disp:*30 patches* Refills:*0*
18. Prednisone 20 mg Tablet [**Hospital1 **]: as directed Tablet PO DAILY
(Daily) for 6 days: [**Date range (1) **] - 3 tablets daily
[**Date range (1) 18023**] - 2 tablets daily
[**Date range (1) 55074**] - 1 tablet daily.
Disp:*12 Tablet(s)* Refills:*0*
19. Levofloxacin 250 mg Tablet [**Date range (1) **]: Three (3) Tablet PO DAILY
(Daily) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary diagnosis:
- Pneumonia
Secondary Diagnosis:
- T1-T2 paraplegia following MVC [**1-4**]
- Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
- HCV, viral load suppressed
- H/o recurrent PNAs: MRSA, pan-sensitive Kleb
- Anxiety
- DVT in [**2142**] -IVC filter placed in [**2142**]
- Pulmonary nodules
- Hypothyroidism
- Chronic pain
- Chronic gastritis
- H/o obstructive lung disease
- Anemia of chronic disease
- S/p PEA arrest during last hospitalization in [**2147-10-3**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with shortness of breath and confusion. You
were found to have a pneumonia, which we treated with
antibiotics. You will need to complete a course of antibiotics
after discharge from the hospital.
The following changes were made to your medications:
- new: levofloxacin (levaquin) 750 mg daily for 6 days
- new: prednisone - please take as detailed below:
[**Date range (1) **] - 60 mg daily
[**Date range (1) 18023**] - 40 mg daily
[**Date range (1) 55074**] - 20 mg daily
- please decrease your nicotine patch from 21 mg to 7 mg daily
The rest of your medications have not changed. Please continue
to take them as originally prescribed.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2148-6-5**] at 1:30 PM
With: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"E929.0",
"285.8",
"458.9",
"V12.51",
"338.29",
"344.1",
"305.1",
"535.10",
"518.89",
"V13.02",
"070.54",
"300.00",
"493.20",
"244.9",
"907.2",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8332, 8387
|
4034, 5588
|
337, 343
|
8916, 8916
|
2911, 4011
|
9752, 10056
|
2455, 2488
|
6172, 8309
|
8408, 8408
|
5614, 6149
|
9067, 9729
|
2503, 2892
|
1773, 1793
|
277, 299
|
371, 1754
|
8460, 8895
|
8427, 8439
|
8931, 9043
|
1815, 2250
|
2282, 2423
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,412
| 101,380
|
50962+59301
|
Discharge summary
|
report+addendum
|
Admission Date: [**2176-3-22**] Discharge Date: [**2176-5-19**]
Date of Birth: [**2124-9-13**] Sex: M
Service: Transplant Surgery
CHIEF COMPLAINT: Fever and chills, sepsis, history of
orthotopic liver transplant.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 19672**] is a 51-year-old male
with a history of hepatitis C and alcohol abuse with
cirrhosis, who underwent a liver transplant in [**2176-3-9**]. His transplant was complicated by a biliary leak and a
septic knee with orthopedic washout. Mr. [**Known lastname 19672**] had been
discharged just a few days prior to his presentation. He had
been discharged to a rehabilitation facility after an
extended stay after his liver transplant here.
In his previous stay, he had been treated with multiple ERCPs
as well as stents. He also had a drain placed and a washout
of his knee as noted above. He now presents with two days
after his discharge to rehabilitation with fevers and chills
to 101.9. He denies any abdominal pain. No nausea or
vomiting. No dysuria, no cough, and no diarrhea. He denies
no changes in his baseline left knee pain.
PAST MEDICAL HISTORY:
1. Hepatitis C and alcoholic cirrhosis, Childs Class C.
2. Status post orthotopic liver transplant in [**2176-3-9**].
3. Status post septic left knee joint washout.
4. Portal gastropathy.
5. Grade II varices.
6. Ascites.
7. Multiple episodes of spontaneous bacterial peritonitis.
8. Multiple episodes of encephalopathy.
9. Type 1 diabetes.
10. Gastroparesis.
11. Chronic renal insufficiency.
12. Osteoporosis.
13. Diverticulitis.
14. Status post hemicolectomy secondary to diverticulitis.
MEDICATIONS ON ADMISSION:
1. Neoral 150 mg po bid.
2. Insulin-sliding scale as well as 18 units of NPH am and 18
units NPH pm.
3. Lasix 40 mg po bid.
4. Prednisone 50 mg po q day.
5. CellCept 1,000 mg po bid.
6. Nystatin swish and swallow 5 mg po qid.
7. Vicodin prn.
8. Fluconazole 400 mg po q day.
9. Trazodone 7.5 mg po q hs.
10. Actigall 300 mg po tid.
11. Valcyte 450 mg po q day.
12. Protonix 40 mg po q day.
13. Bactrim one tablet one q day.
ALLERGIES: Ceftriaxone and questionable Heparin.
PHYSICAL EXAMINATION: In general, he is chronically ill
appearing, however, in no apparent distress. His vital
signs: Temperature is 99.7, rest of his vitals are stable.
His heart is regular, rate, and rhythm. His lungs are clear
to auscultation with decreased breath sounds at the bases.
His abdomen is soft, nontender, and mildly distended. His
extremities are warm. His left knee is mildly tender. The
rectal is guaiac negative.
[**Hospital 1749**] HOSPITAL COURSE: On [**3-22**], the patient was
admitted to the hospital for his fevers and chills. He was
placed on broad-spectrum antibiotics and pancultured. A CT
scan was also performed as well as a HIDA scan and
laboratories were checked. There was a worry of biliary
sepsis given his history. The HIDA and CT scan, however,
were negative, so the patient was scheduled for an ERCP and
was afebrile on his first presentation.
Of note, the Endocrine Service as well as Nutrition and
Infectious Disease followed this patient while he was in the
hospital.
The patient was placed on broad-spectrum antibiotics
including levofloxacin, linazolid, and meropenem. On [**3-25**], [**Numeric Identifier 105901**], the patient went for an ERCP and the ERCP, the
stent in the common bile duct was removed, and dark bile and
pus drained from the bile duct. He had a large anastomotic
biliary leak. A plastic and Teflon stent were then placed
across the biliary leak. Also of note, some of his cultures
at this point, grew out Klebsiella, and his antibiotics were
tailored to the bacteria.
On [**2176-5-27**], the patient underwent a percutaneous
transhepatic cholangiogram with a right percutaneous
transhepatic biliary drain placement. This PTC demonstrated
a biliary leak. After this percutaneous biliary drain was
placed, the patient was scheduled for an EGD and stent
removal which was scheduled and done.
After his EGD and stent removal, the patient was started to
spike temperatures to 101.3. This was most likely
cholangitis and he was cultured. These cultures would grow
out gram-positive cocci, and the patient was also put on
neutropenic precautions due to his white [**Year (4 digits) **] cell count
. These organisms would soon be noticed to be Vancomycin
resistant Enterococcus, and the patient was again started on
broad-spectrum antibiotics. The Infectious Disease team was
following closely.
On hospital day 14, the patient went for angiogram to assess
his hepatic artery. This angiogram showed hepatic artery
stenosis and in light of his laboratories, there was a
concern that Mr. [**Known lastname 19672**] had ischemic cholangitis with
irreparable bile duct injury. A repeat angio was then
performed to possibly open up this artery and treat his
hepatic artery thrombosis.
On hospital day 19, the patient underwent an
ultrasound-guided liver biopsy. This biopsy showed mild
rejection and the next day, the patient underwent a hepatic
arteriogram which appeared to have a patent hepatic artery.
On hospital day 25, the patient went for a cholangiogram.
The cholangiogram showed patent ducts. Postprocedure, the
patient had some chills and spiked a temperature after the
manipulation to his biliary tree. Cultures were again sent
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Name8 (MD) 1750**]
MEDQUIST36
D: [**2176-5-23**] 02:50
T: [**2176-5-27**] 07:29
JOB#: [**Job Number 105902**]
Name: [**Known lastname 5129**], [**Known firstname **] Unit No: [**Numeric Identifier 17252**]
Admission Date: [**2176-3-22**] Discharge Date: [**2176-5-19**]
Date of Birth: [**2124-9-13**] Sex: M
Service:
On hospital day 33, the patient went for a transjugular liver
biopsy which he tolerated well. Over the next few days it
was noticed that the patient continued to have positive
cultures of linazolid resistant Enterococcus despite attempts
to drain and treat with antibiotics. Over the next few days
the patient continued to spike temperatures and have chills
with ongoing sepsis.
Around hospital day 42, the patient was found to have
decreased blood pressure and decreased urine output. At that
time a CT scan was done. The patient was also transferred to
the Intensive Care Unit for closer monitoring. The CT scan
shows an increased hyperperfused areas in the liver most
likely increased sepsis, cholangitis and progressive liver
failure. The patient was then intubated at that time.
While in the unit, the patient became hypotensive and had a
decreased cardiac output. A right diagnostic thoracentesis
was performed, however, after this the patient had decreased
cardiac output and a chest x-ray showed a massive hemothorax
compressing. A Cardiothoracic consult was obtained, and the
patient was taken for emergent thoracotomy. The patient
underwent a right thoracotomy with control of an interstitial
vascular bundle. Two chest tubes were placed. The patient
then went back to the unit.
Over the next few days, the patient's urine output dropped,
and it was necessary to put the patient on constant
hemodialysis. Renal Medicine was consulted, and the patient
was started on hemodialysis.
Over the next few days, the patient remained in the Intensive
Care Unit necessitating pressors to keep his blood pressure
up as well as CVVH to take fluid off and keep his
electrolytes stable. While in the unit, the patient was
unable to wean off of pressors or the CVVH. The patient
necessitated large amounts and finally after lengthy
discussions with the family and after a GI bleed was noted to
occur around [**5-19**], it was decided to withdraw support.
Initially the CVV hemodialysis was turned off, and then the
ventilator was turned off, and patient soon expired.
CONDITION ON DISCHARGE: Patient is deceased.
DISCHARGE STATUS: Deceased.
DISCHARGE DIAGNOSES:
1. Hepatitis C, alcoholic cirrhosis.
2. Status post orthotopic liver transplantation.
3. Insulin dependent diabetes mellitus.
4. Chronic renal insufficiency.
5. Sepsis, cholangitis.
6. Status post ultrasound guided pleural effusion tap
complicated by hemothorax.
7. Status post thoracotomy and hemothorax evacuation.
8. Acute tubular necrosis, renal failure.
9. Shock liver.
10. Deaf secondary to respiratory failure.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4043**]
Dictated By:[**Numeric Identifier 17253**]
MEDQUIST36
D: [**2176-5-23**] 04:49
T: [**2176-5-27**] 07:22
JOB#: [**Job Number 17254**]
|
[
"995.92",
"518.81",
"785.59",
"584.5",
"998.11",
"038.8",
"511.8",
"570",
"996.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"50.19",
"88.47",
"50.11",
"97.05",
"51.87",
"51.43",
"51.98",
"38.93",
"45.13",
"87.51",
"34.09",
"39.50",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
8038, 8694
|
1669, 2144
|
2622, 7940
|
2167, 2604
|
165, 232
|
261, 1131
|
1153, 1643
|
7965, 8017
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,273
| 157,520
|
46450+58911+58912+58921
|
Discharge summary
|
report+addendum+addendum+addendum
|
Admission Date: [**2159-10-22**] Discharge Date: [**2159-11-3**]
Date of Birth: [**2096-10-2**] Sex: M
Service: SURGERY
Allergies:
Nickel
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Thoracic aortic aneurysm
Major Surgical or Invasive Procedure:
[**2159-10-22**]
Total percutaneous stent graft repair of thoracic
aortic aneurysm. Zenith TX2 proximal device 38/152, distal
device 40/198 (ZTEG)
History of Present Illness:
Mr [**Known lastname **] is a 63 year old gentleman with aneurysmal disease in
multiple locations. His thoracic aneurysm is greater than 6 cm.
He is asymptomatic.The decision was mae to repair the thoracic
aortic aneursym by endovascular approach due to the extreme
angulation above and below the aneurysm.
Past Medical History:
PCI in [**2152**], at [**Hospital1 112**], unknown anatomy.
HTN
Hyperlipidemia
Diabetes
Renal artery stenosis
CAD s/p PCI @ [**Hospital1 112**] [**2152**]
Claudication
Colon polyp
GERD
Social History:
Originally from [**Country 5976**], moved to the US when he was 16. Works as a
security officer at [**Location (un) 86**] Latin School. He has been married for
41 years, 3 biological children, 20 adopted children. Currently
smokes 3 cigarrettes/day, previously smoked 3 ppd x40 years.
drinks alcholol on rare social occasions. No illicits.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Cancer (unknown type) in both parents.
Physical Exam:
T: 100.8 HR: 98 BP: 170/100 RR: 20 spo2: 96%
Gen: NAD, alert and oriented x3
Neuro: CN II-XII RLE [**4-23**] LLE [**3-23**]
Cardiac: RRR
Lungs: CTA bilaterally
Abd: soft, NT, ND
Gu: Foley draining clear, yellow urine
Wound: Groins stable, no hematoma, no bleed.
Pulses: Fem DP PT
[**Name (NI) 2325**] palp palp palp
Right palp palp palp
Pertinent Results:
[**2159-10-30**] 07:35AM BLOOD WBC-11.1* RBC-3.95* Hgb-11.5* Hct-34.0*
MCV-86 MCH-29.0 MCHC-33.7 RDW-16.4* Plt Ct-218#
[**2159-10-28**] 04:30AM BLOOD WBC-8.8 RBC-3.77* Hgb-10.7* Hct-32.5*
MCV-86 MCH-28.5 MCHC-33.0 RDW-16.7* Plt Ct-137*
[**2159-10-27**] 07:20AM BLOOD WBC-8.9 RBC-3.70* Hgb-10.7* Hct-32.6*
MCV-88 MCH-28.9 MCHC-32.8 RDW-16.7* Plt Ct-118*
[**2159-10-30**] 07:35AM BLOOD Plt Ct-218#
[**2159-10-28**] 04:30AM BLOOD Plt Ct-137*
[**2159-10-30**] 07:35AM BLOOD Glucose-114* UreaN-26* Creat-1.4* Na-136
K-4.5 Cl-101 HCO3-29 AnGap-11
[**2159-10-29**] 07:55AM BLOOD Glucose-115* UreaN-22* Creat-1.2 Na-137
K-4.1 Cl-101 HCO3-30 AnGap-10
[**2159-10-27**] 09:45PM BLOOD CK(CPK)-37*
[**2159-10-23**] 01:45PM BLOOD CK(CPK)-117
[**2159-10-28**] 04:30AM BLOOD cTropnT-0.08*
[**2159-10-27**] 09:45PM BLOOD CK-MB-1 cTropnT-0.10*
[**2159-10-30**] 07:35AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0
[**2159-10-29**] 07:55AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.0
[**2159-10-28**] 04:30AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.3
[**2159-10-27**] 07:20AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.1
[**2159-10-22**] 10:22AM BLOOD Type-ART pO2-246* pCO2-38 pH-7.40
calTCO2-24 Base XS-0
[**2159-10-22**] 10:22AM BLOOD Glucose-108* Lactate-0.9 Na-140 K-3.7
Cl-108
[**2159-10-22**] 10:22AM BLOOD Hgb-9.9* calcHCT-30
[**2159-10-22**] 10:22AM BLOOD freeCa-1.08*
[**2159-10-27**] 01:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2159-10-27**] 01:15AM URINE Blood-NEG Nitrite-NEG Protein-75
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2159-10-24**] 04:42AM URINE Blood-LGE Nitrite-NEG Protein-75
Glucose-TR Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-10-24**] 04:42AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2159-10-24**] 04:42AM URINE CastGr-0-2
URINE CULTURE (Final [**2159-10-28**]): NO GROWTH.
Brief Hospital Course:
This is a 62 year old man with known descending thoracic aortic
aneurysm who underwent an endovascular repair on [**2159-10-22**]. Post
operatively the patient was able to move legs and arms
immediately after surgery. Had an episode of chest pain and was
started on Nitroglycerine and nitroprusside for BP goal 100-120.
POD #1 the patient had limited movement of his Right foot with a
SBP at 100. Antihypertensives DC'd and lower extremity exam
improved with SBP 160-180. Neurology consulted and believe lower
extremity weakness to be likely spinal cord ischemia. Lumbar
drain is in place.
In the CVICU the patient was stable and afebrile POD #2. On
[**2159-10-23**] one unit of PRBC was infused for anemia related to
surgical blood loss. Patient was able to move right left off bed
and wiggle toes, unable to move left foot. Post operative CTA
showed patent graft without a leak. On the evening of [**2159-10-23**]
the patient verbalized chest pain at the sternum with nausea and
vomiting. ECG obtained, morphine and Aspirin given. Nitro gtt
started and pain decreased. Lopressor IV given and esmolol
started. Chest pain resolved, troponin flat. Cardiology
consulted.
Neurology continuing to follow patient. PT/OT working with
patient and recommended Rehab. On [**2159-10-24**] patient was
transferred to VICU. Blood cultures and urine cultures obtained
for TMAX 102. All culture results negative. Social work
consulted for coping management. Patient continues to work with
PT/OT. The patient failed a voiding trial twice and a Foley was
replaced on [**2159-10-27**]. Able to get OOB and pivot on left foot.
Rehab screening
On [**2159-10-30**] The patient was transferred to Rehab. Goal SBP
should be > 150 for adequate spinal perfusion. The patient was
stable on DC. He will follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 914**]
in one month with a CTA.
Medications on Admission:
amlodipine 10, atenolol 50, hctz 25, lisinopril 40, metformin
850'', detrol sr 4, asa 81
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for sbp <140; please let HO know if holding med. thanks .
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q4H (every 4 hours) as needed for nausea.
12. Insulin Sliding Scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol 71-100 mg/dL 0
Units 0 Units 0 Units
101-150 mg/dL 3 Units 3 Units 3 Units
151-200 mg/dL 6 Units 6 Units 6 Units
201-250 mg/dL 9 Units 9 Units 9 Units
251-300 mg/dL 12 Units 12 Units 12 Units
301-350 mg/dL 15 Units 15 Units 15 Units
> 350 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Descending thoracic aortic aneurysm.
PMH:
Hypertension
Hyperlipidemia
Diabetes
Renal artery stenosis
Claudication
Colon polyp
GERD
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
Endovascular Thoracic Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? 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
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-21**]
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
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin 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 or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-24**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
It is very important that the Systolic Blood Pressure remain
higher than normal to ensure appropriate spinal perfusion,
maintain. The goal SBP for Mr. [**Known lastname **] is 150-170. He should not
receive antihypertensive meds if his SBP is <140
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2159-11-27**] 8:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2159-11-27**] 10:45
Completed by:[**2159-10-30**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 15763**]
Admission Date: [**2159-10-22**] Discharge Date: [**2159-11-3**]
Date of Birth: [**2096-10-2**] Sex: M
Service: SURGERY
Allergies:
Nickel
Attending:[**First Name3 (LF) 270**]
Addendum:
The patient's scheduled discharge was postponed secondary to bed
availability. Overnight on [**2159-10-31**] it was noted that the
patient had new petechia to the left foot and calf. The patient
had no sensory loss and was able to move his feet. This was
suspected to be related to small emboli in the distal vessels of
the left foot. A CTA was obtained which showed bilateral
occlusion of the the SFAs with 3 [**Last Name (un) 15764**] run off intact. There
was a delayed flow to bilateral DPs which suggested proximal
occlusion. He was started on a heparin gtt and bridged with
coumadin for a goal INR of [**2-21**]. Cardiology was also consulted
for better blood pressure management and medication assessment.
The patient was transferred to [**Hospital1 **] on a Heparin gtt. Last
INR was 1.3 after one dose of coumadin. Rehab should reintroduce
blood pressure medications as needed to mantain HR and BP
150-170 systolic for adequate spinal perfusion.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2159-11-2**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 15763**]
Admission Date: [**2159-10-22**] Discharge Date: [**2159-11-3**]
Date of Birth: [**2096-10-2**] Sex: M
Service: SURGERY
Allergies:
Nickel
Attending:[**First Name3 (LF) 270**]
Addendum:
Mr. [**Known lastname 15765**] admission was extended an additional day due to a
change in the rehab facility assignment. Additionally, his
heparin drip was discontinued, and he was started on lovenox to
bridge him until his coumadin becomes therapeutic. He was
discharged to [**Hospital3 **] on this lovenox/coumadin regimen
on [**2159-11-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2159-11-3**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 15763**]
Admission Date: [**2159-10-22**] Discharge Date: [**2159-11-3**]
Date of Birth: [**2096-10-2**] Sex: M
Service: SURGERY
Allergies:
Nickel
Attending:[**First Name3 (LF) 270**]
Addendum:
Updated discharge medications as follows:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q4H (every 4 hours) as needed for nausea.
10. Insulin Sliding Scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol 71-100 mg/dL 0
Units 0 Units 0 Units
101-150 mg/dL 3 Units 3 Units 3 Units
151-200 mg/dL 6 Units 6 Units 6 Units
201-250 mg/dL 9 Units 9 Units 9 Units
251-300 mg/dL 12 Units 12 Units 12 Units
301-350 mg/dL 15 Units 15 Units 15 Units
> 350 mg/dL Notify M.D.
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Medication on admission
amlodipine 10, atenolol 50, hctz 25, lisinopril 40, metformin
850'', detrol sr 4, asa 81
14. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours).
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q4H (every 4 hours) as needed for nausea.
10. Insulin Sliding Scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol 71-100 mg/dL 0
Units 0 Units 0 Units
101-150 mg/dL 3 Units 3 Units 3 Units
151-200 mg/dL 6 Units 6 Units 6 Units
201-250 mg/dL 9 Units 9 Units 9 Units
251-300 mg/dL 12 Units 12 Units 12 Units
301-350 mg/dL 15 Units 15 Units 15 Units
> 350 mg/dL Notify M.D.
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Medication on admission
amlodipine 10, atenolol 50, hctz 25, lisinopril 40, metformin
850'', detrol sr 4, asa 81
14. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**]
Completed by:[**2159-11-3**]
|
[
"593.9",
"336.1",
"440.1",
"997.01",
"530.81",
"441.2",
"272.4",
"401.9",
"788.20",
"305.1",
"443.9",
"780.62",
"344.1",
"285.1",
"250.00",
"414.01",
"V45.82",
"786.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.73",
"57.95"
] |
icd9pcs
|
[
[
[]
]
] |
17071, 17298
|
3842, 5730
|
292, 441
|
7635, 7635
|
1977, 3819
|
10618, 12199
|
1362, 1484
|
15416, 17048
|
7481, 7614
|
5756, 5847
|
7786, 9788
|
9814, 10595
|
1499, 1958
|
228, 254
|
469, 779
|
7650, 7762
|
801, 988
|
1004, 1346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,120
| 121,474
|
35269
|
Discharge summary
|
report
|
Admission Date: [**2175-10-10**] Discharge Date: [**2175-10-15**]
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
CC:[**CC Contact Info 80451**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 88F h/o HTN, s/p unwitnessed fall. Pt found down with large
amount vomitus, around 4hours ago. Taken to [**Hospital6 **]
and intubated. Found to have right 6mm fixed pupils and a large
right IPH. Transferred to [**Hospital1 18**] for further eval.
Past Medical History:
PMHx: Stomach Ca, HTN
Social History:
Social Hx: no tobacco, etoh or alcohol
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
O: T: BP: 189/75 HR:65 R:16 O2Sats:100% CMV 0.99 470x17 Peep 5
Gen: unresponsive. Intubated. GCS3
HEENT: Pupils:R-5 nonreactive L-3 nonreactive
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: unresponsive to noxious stimuli
Orientation: unable to obtain
Cranial Nerves:
I: Not tested
II+III: Pupils fixed bilaterally. Right is 5mm and left is 3mm.
CNIV-XII unable to examine.
Motor: No reaction to noxious stimuli
Sensation: No reaction to noxious stimuli.
Toes downgoing left. Upgoing toes right
Coordination: unable to assess
Train of four - twitch stimulator positive
Pertinent Results:
CT:
CT head: (prelim) large right sided multifocal intraparenchymal
hemorrhage involving the right frontal and temporal lobes with
surrounding edema. 1.4 cm leftward shift with subfalcine
herniation. subarachnoid hemorrhage in right sylvian fissure,
hemorrhage layering in the left lateral ventrical atrium. air
fluid levels in bilateral frontal, ethmoid, maxillary and
sphenoid sinus. no fracture seen.
Brief Hospital Course:
Pt's grave prognosis was discussed with the family. Surgical
intervention was discussed as medically futile. Family was in
agreement. Pt was admitted to ICU, made CMO and extubated. She
was on morphine drip which was transitioned to sublingual.
Family requested transfer to facility that was closer to home.
Case management and palliative care assisted in this effort.
Unfortunatley she expired prior to her placement on [**2175-10-15**].
Medications on Admission:
unknown
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
cerebral hemorrhage
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2175-10-17**]
|
[
"348.4",
"852.05",
"V10.04",
"401.9",
"E888.9",
"853.05",
"852.25"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2300, 2309
|
1770, 2212
|
279, 285
|
2373, 2382
|
1341, 1345
|
2435, 2472
|
686, 690
|
2271, 2277
|
2330, 2352
|
2238, 2248
|
2406, 2412
|
720, 920
|
210, 241
|
313, 568
|
1014, 1322
|
1354, 1747
|
935, 998
|
590, 613
|
629, 670
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,674
| 118,419
|
54966
|
Discharge summary
|
report
|
Admission Date: [**2183-7-10**] Discharge Date: [**2183-7-15**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
SDH and tSAH after a Fall on Coumadin
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 yo M w/ h/o dementia, Afib, s/p PPM, CHF (on Coumadin), CKD
(baseline Cr 1.5-2.2) p/w fall and found to have SDH and
traumatic SAH.
Pt fell (trip and witnessed, ? LOC, felt to be mechanical) on
his way to coumadin clinic, and went to OSH where his INR was
2.0, and CT head demonstrated small parafalcine SDH and bilat
SAH. He received vitamin K then transferred to [**Hospital1 18**]. He was
initially admitted to the NSG ICU then transfered to MICU for
[**Last Name (un) **] (at that time did not know baseline Cr), and increasing
bilateral pulmonary infiltrates. He was placed on keppra ppx.
He was placed on neuro checks and had an trauma survey revealed
minimally displaced, extraarticular distal right radius and ulna
fractures. On [**7-11**] he had repeat head CT that showed increased
bifrontal SAH and right SDH. Though CT worse, exam clinically
the same. Per NSG patient not surgical candidate, but wanted
f/u head CT on [**7-13**]. All anti-coag being held. Ortho was c/s
and his arm was splinted. On collaberation w/ family, patient
was thought to be close to his baseline (brief conversation,
walks w/ cane). Cards also c/s b/c trop leak 0.08, flat ck-mb,
cardiology felt to be in setting of ckd not. CXR showed
bilateral pleural effusions w/ ? focal consolidation. Felt to
be all volume related, got 80mg iv lasix x1 w/ good diuresis, on
room air, except for at night. He is -2L length of stay.
Currently, denies any shortness of breath or chest pain.
Review of systems: denies fevers, chills, nausea, vomiting,
headache, shortness of breath, or chest pain.
Past Medical History:
Afib
CAD status post CABG x3
MI 4 years ago
CHF with EF 25%, status post AICD
hyperlipidemia
hypertension,
rhabdomyolysis
Right hip fracture
CKD s/p hypothermic episode
Social History:
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
Sister w/ parkinsons, hypertension and CAD in family
Physical Exam:
At admission:
T: 97 HR: 90 BP: 136/68 RR: 18 Sat: 97% ra
Gen: cachectic, appears stated age, comfortable, NAD.
HEENT: right eyebrow laceration and hematoma. Small laceration
right posterior scalp
Neck: Supple. C-collar in place
Extrem: dorsum right hand with abrasions, abraisions right
shoulder.
Neuro:
Mental status: Awake and alert, cooperative with exam
Orientation: AOx2 (baseline) Oriented to person, place
"hospital"
but not date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2.5
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, but HOH on Right
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: decreased bulk throughout with normal tone bilaterally.
No
abnormal movements,tremors. Right UE weakness bis/tris [**5-1**],
right
grip full. Otherwise strength is symmetric with bilat Delt
weakness. Otherwise strength is full [**5-31**] throughout.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
At discharge:
Vitals: 98.0 98.0 143/87 110s-140s/70s-80s 72 70s-90s (70s in
AM) 95-100% RA
I/Os: 340 / 0 | 125 +large incont / 0 AM: 0/0| large incont / 0
General: awake, follows commands, responsive
HEENT: Sclera anicteric, oropharynx clear, EOMI, PERRL (3->2
bl). Eyelids pulsing with motion.
Neck: No appreciable LAD. JVP non-elevated.
CV: Irreg rhythm. 3/6SEM at base radiating b/l to neck and to
apex, normal S1 + S2, without rubs, gallops
Lungs: With quiet breathing, CTAB with ?crackles at bases. After
deep breaths, tachypneic with suprasternal retractions.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: White nails. Warm, well perfused, 2+ pulses, no clubbing or
edema.
Neuro: EOMI, PERRL, CNII-XII intact. Sensation grossly intact to
light touch in upper/lower ext. 4+ strength in all extremities
(testing of R arm limited by cast).
MS: A&Ox1 (no 'hospital').
Pertinent Results:
[**2183-7-10**] 07:20PM BLOOD WBC-7.0 RBC-3.88* Hgb-12.0* Hct-36.9*
MCV-95 MCH-31.0 MCHC-32.6 RDW-15.4 Plt Ct-157
[**2183-7-11**] 03:43AM BLOOD WBC-7.8 RBC-3.73* Hgb-11.5* Hct-35.5*
MCV-95 MCH-30.8 MCHC-32.4 RDW-15.5 Plt Ct-140*
[**2183-7-11**] 03:04PM BLOOD WBC-7.1 RBC-3.63* Hgb-10.9* Hct-34.6*
MCV-95 MCH-29.9 MCHC-31.4 RDW-15.5 Plt Ct-150
[**2183-7-12**] 02:13AM BLOOD WBC-6.0 RBC-3.54* Hgb-10.7* Hct-34.2*
MCV-96 MCH-30.1 MCHC-31.2 RDW-15.3 Plt Ct-129*
[**2183-7-13**] 06:15AM BLOOD WBC-5.4 RBC-3.86* Hgb-11.5* Hct-37.2*
MCV-97 MCH-29.8 MCHC-30.9* RDW-15.1 Plt Ct-142*
[**2183-7-14**] 05:53AM BLOOD WBC-5.3 RBC-3.95* Hgb-11.9* Hct-38.4*
MCV-97 MCH-30.1 MCHC-31.0 RDW-15.2 Plt Ct-163
[**2183-7-15**] 05:12AM BLOOD WBC-4.8 RBC-3.63* Hgb-11.3* Hct-34.7*
MCV-96 MCH-31.1 MCHC-32.6 RDW-15.6* Plt Ct-148*
[**2183-7-10**] 07:20PM BLOOD PT-21.6* PTT-32.5 INR(PT)-2.1*
[**2183-7-11**] 03:43AM BLOOD PT-16.6* PTT-31.5 INR(PT)-1.6*
[**2183-7-11**] 09:17AM BLOOD PT-15.0* PTT-31.2 INR(PT)-1.4*
[**2183-7-11**] 03:04PM BLOOD PT-13.5* PTT-32.4 INR(PT)-1.3*
[**2183-7-12**] 02:13AM BLOOD PT-14.1* PTT-29.7 INR(PT)-1.3*
[**2183-7-13**] 06:15AM BLOOD PT-12.8* INR(PT)-1.2*
[**2183-7-10**] 07:20PM BLOOD Glucose-134* UreaN-57* Creat-1.8* Na-140
K-4.5 Cl-101 HCO3-26 AnGap-18
[**2183-7-11**] 03:43AM BLOOD Glucose-154* UreaN-57* Creat-1.8* Na-140
K-5.1 Cl-101 HCO3-28 AnGap-16
[**2183-7-11**] 03:04PM BLOOD Glucose-108* UreaN-57* Creat-1.9* Na-141
K-4.5 Cl-102 HCO3-29 AnGap-15
[**2183-7-12**] 02:13AM BLOOD Glucose-93 UreaN-60* Creat-1.9* Na-142
K-4.6 Cl-103 HCO3-30 AnGap-14
[**2183-7-13**] 06:15AM BLOOD Glucose-63* UreaN-64* Creat-1.9* Na-146*
K-4.3 Cl-105 HCO3-26 AnGap-19
[**2183-7-14**] 05:53AM BLOOD Glucose-98 UreaN-65* Creat-1.9* Na-146*
K-4.0 Cl-104 HCO3-30 AnGap-16
[**2183-7-15**] 05:12AM BLOOD Glucose-92 UreaN-59* Creat-1.8* Na-147*
K-3.9 Cl-106 HCO3-30 AnGap-15
[**2183-7-10**] 07:20PM BLOOD CK(CPK)-61
[**2183-7-11**] 03:43AM BLOOD ALT-37 AST-45* CK(CPK)-99 AlkPhos-71
TotBili-1.4
[**2183-7-13**] 06:15AM BLOOD ALT-21 AST-21 AlkPhos-59 TotBili-1.9*
[**2183-7-14**] 05:53AM BLOOD ALT-20 AST-20 AlkPhos-62 TotBili-1.5
[**2183-7-10**] 07:20PM BLOOD CK-MB-3 cTropnT-0.08*
[**2183-7-11**] 03:43AM BLOOD CK-MB-3 cTropnT-0.08*
[**2183-7-10**] 07:20PM BLOOD Calcium-9.2 Phos-3.6 Mg-2.5
[**2183-7-11**] 03:43AM BLOOD Albumin-4.1 Calcium-9.7 Phos-3.7 Mg-2.5
[**2183-7-11**] 03:04PM BLOOD Calcium-9.5 Phos-3.8 Mg-2.4
[**2183-7-12**] 02:13AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.5
[**2183-7-13**] 06:15AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.4
[**2183-7-14**] 05:53AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.5
Brief Hospital Course:
The patient is an 88 year old gentleman with multiple medical
problems who was admitted initially to the Neurosurgery service
for SDH and SAH. He appeared at his neurological baseline (AOx
[**1-27**]). INR was reversed at admission.
.
#SDH and SAH
Neuro: Repeat HCT showed enlargement of right occipital SDH.
Given his multiple medical problems (dementia, CHF with EF 25%,
CRF), he is not a candidate for surgical intervention. No shift
caused by SDH. INR was reversed and he was monitored clinically.
Fall was likely mechanical in nature. On [**7-13**], a repeat head CT
was stable without extension or new hemorrhage. His neuro exam
remained stable throughout his stay. He was followed by
neurosurgery. He was continued on Keppra for seizure
prophylaxis. Per neurosurgery, it was confirmed that he could be
restarted on aspirin 81mg. He should continue to hold coumadin
until his outpatient appointment with neurosurgery.
#SOB/tachypnea/sCHF
Increasing bilateral pulmonary infiltrates on repeat cxr.
Cardiology c/s was placed in ED who recommended diuresis. The
patient was diuresed with IV lasix. A TTE on HD3 revealed
significant global systolic dysfunction and dilated left
ventricle consistent with multivessel coronary artery disease.
He was restarted on his metoprolol and the dose was titrated up
his home dose of 100mg daily. He was started lisinopril 2.5mg
after discussion with outpatient provider, [**Name10 (NameIs) **] was restarted on
home lasix 40 mg PO daily.
.
#Renal Insufficiency: Baseline creatinine 1.5-1.8, although as
been as high as 2.2 in [**2181**]. Mild [**Last Name (un) **] in setting of SDH and
traumatic SAH. I His creatinine continued to trend down and on
discharge was 1.8. His foley was out and he was voiding well,
but incontinent. He was started on lisinopril 2.5mg. Should
have repeat Chem 7 within 3 days of discharge.
.
#Fall: Likely mechanical. No recollection of events related to
fall or syncopal episode. No evidence by ICD of an arrhythmia
(ie. VT or VF). Troponins were borderline elevated, likely due
to renal insufficiency as his CK-MB was flat, and ECG was
consistent with strain pattern not ischemia. Cards saw the pt in
the ED. No infectious source. On telemetry, he had one run of 8
beats of NSVT. He had no evidence of infection or metabolic
disease to explain his fall. No report of seizure activity.
C-collar was cleared clinically and radiographically. PT
recommended rehab.
.
# Distal radial/ulnar fractures: He was followed by the Ortho
Trauma service. His right arm was initial spinted and later a
short arm cast was placed. He should keep it elevated and
non-weight bearing.
.
CAD: Pt with EF 25% s/p AICD placement and signficiant coronary
disease and h/o MI and CABG. Elevated troponins and flat CK-MB,
in setting of [**Last Name (un) **]. ECG c/w strain pattern. Prior troponins at [**Hospital6 **] 0.11. Likely exacerbated in setting of [**Last Name (un) **].
Cardiology reviewed imaging on admission and recommended
diuresis. A TTE was performed on HD3 and revealed significant
global systolic dysfunction and dilated left ventricle
consistent with multivessel coronary artery disease. He was
restarted on aspirin and started on lisinopril 2.5mg. He was
continued on pravastatin and metoprolol was titrated up to home
dose.
.
# Afib: He appeared to be in sinus rhythm with multiple PVCs
through his stay. His coumadin was held, in the setting of the
head bleed. After the CT and exam were stable, he was restarted
on aspirin. His beta-blocker was titrated up to his home dose.
He should continue to hold coumadin until he is reevaluated by
neurosurgery at his follow-up appointment.
# Hypernatremia: He developed a mild hypernatremia (Na 147 -
free water deficit 2L). It was thought to be due to limited PO
intake and he was thirsty and has been reliant on assistance for
all eating/drinking. He was given 500cc 1/2 NS. Should have
repeat Chem 7 within 3 days of discharge.
TRANSITIONAL ISSUES:
- Start tylenol PRN for pain
- Start calcium carbonate and vitamin D to help with low bone
density
- Start keppra for seizure prophylaxis and discuss with
Neurosurgery
- Start lisinopril 2.5 mg daily for heart failure, hold for SBP
< 100 and discuss at cardiology follow-up
- STOP coumadin. [**Month (only) 116**] restart if neurosurgery recommends at
follow-up appointment.
- Scheduled for a repeat X-ray and follow-up with Orthopedics
- Scheduled for a repeat head CT and follow-up with Neurosurgery
- Scheduled for follow-up with Cardiology
- DNR/I
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Pravastatin 10 mg PO DAILY
3. Warfarin 3.75 mg PO DAILY16
4. Aspirin 81 mg PO DAILY
5. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Pravastatin 10 mg PO DAILY
4. Calcium Carbonate 500 mg PO TID
5. Acetaminophen 650 mg PO TID
6. LeVETiracetam 500 mg PO BID
7. Lisinopril 2.5 mg PO DAILY
hold for sbp<100
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Green Nursing & Rehab Center - [**Hospital1 **]
Discharge Diagnosis:
Subdural hematoma
Subarachnoid hemorrhage
[**Last Name (un) **]
Right radial and ulnar distal fracture
Systolic heart failure with pulmonary edema
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 112243**],
It was a pleasure participating in your care at [**Hospital1 18**]. You came
into the hospital because you fell and had a head bleed. We
reversed your anticoagulation and stopped your coumadin. You
were in the ICU because of fluid in your lungs and kidney
failure. Your repeat head CT showed that the bleeding your brain
was stable and your mental thinking has appeared to stabilize.
We restarted your home heart medications.
goes up more than 3 lbs.
Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2183-7-29**] at 1:20 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2183-7-29**] at 1:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: MONDAY [**2183-8-4**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
*Nothing to eat or drink 3 hours prior to the Cat Scan.
Department: NEUROSURGERY
When: MONDAY [**2183-8-4**] at 12:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 43708**], MD [**Telephone/Fax (1) 2731**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2183-9-17**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2183-7-15**]
|
[
"852.01",
"428.0",
"813.44",
"294.20",
"414.00",
"V45.02",
"428.23",
"852.21",
"585.9",
"E888.9",
"873.49",
"V58.61",
"V45.81",
"584.9",
"403.90",
"427.31",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
12358, 12456
|
7186, 11141
|
290, 296
|
12647, 12647
|
4579, 7163
|
13336, 14877
|
2196, 2251
|
12031, 12335
|
12477, 12626
|
11741, 12008
|
12822, 13313
|
2266, 2572
|
3660, 4560
|
11162, 11715
|
1826, 1915
|
212, 252
|
324, 1807
|
2838, 3646
|
12662, 12798
|
1937, 2107
|
2123, 2180
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,825
| 156,835
|
48377
|
Discharge summary
|
report
|
Admission Date: [**2166-12-18**] Discharge Date: [**2166-12-25**]
Service: MEDICINE
Allergies:
Vasotec / Niacin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
fatigue, renal failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 1728**] is an 86M with cardiomyopathy (EF 15-20%), CAD s/p
PCI's x 3, mod-severe AS, prior MVR, and atrial flutter who
presents with acute on chronic renal failure on outpatient
follow up. He was recently admitted to hospital for increased
fatigue and diarrhea and discharged on [**2166-12-14**]. This
hospitalization was complicated by hypotension requiring fluid
resuscitation in the MICU. He was discharged home on torsemide
20 mg [**Hospital1 **] which was an increase from previous home regimen of
lasix 20mg [**Hospital1 **]. He presented to his cardiologist's office for
routine labs. His creatinine increased to 4.5 with increased
lower extremity edema.
.
In the ED, VS were stable. EKG showed RBBB with no acute
changes. His creatinine increased from 2.9 on [**2166-12-14**] to 4.9.
Patient denied dietary indiscretions. He was started on a new
medication, minocycline prior to having his labs drawn for a
pruritic rash on his torso. Other relatively new medications
include coumadin for his atrial flutter.
.
He was admitted to the [**Hospital1 1516**] service where his ACE was held given
renal failure. He was started on hydral for afterload reduction
and lasix gtt for diuresis. He is followed by Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] who
recommended milrinone + lasix gtt for treatment of his
decompensated end stage CHF. He was transferred to the CCU for
further management.
.
On review of systems, he denies any prior history of stroke,
TIA, 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. Cardiac review of systems is
notable for absence of chest pain, dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope. He admits to significant chronic lower extremity
edema.
Past Medical History:
1 CAD: s/p PCI to LAD, LMCA and LCX in [**2163**]; chronically
occluded RCA with L->R collaterals
2 History of Colon cancer - last scope [**2162**] with polyp
3 Atrial fibrillation/flutter - on coumadin
4 History of Basal cell carcinoma
5 Mitral valve replacement [**1-/2164**] - (#29 Perimount Thermafix
pericardial valve).
6 Hypertension
7 Gout
8 Peripheral vascular disease (PVD)
9 Mild aortic stenosis
10 History of deep venous thrombosis - IVF filter placed [**2163**]
11 Hypercholesterolemia
12 Spinal stenosis
13 Familial hand tremor
14 Hernia repair, R-side inguinal
15 Cataract repair, last [**2165-8-14**]
16 Nephrolithiasis
17 Chronic kidney disease ( baseline Cr 2-2.7 per recent labs)
Social History:
- Former orthodontist.
- Smoked until early 40s at 1-1.5 packs/day since age 22. Denies
smoking since. Denies drinking.
- Lives with wife in [**Location (un) 55**].
Family History:
- Father had heart attack at age 60.
- Denies history of CA, diabetes in family.
Physical Exam:
VS: HR 71 BP 101/56 98% RA
Gen: WDWN elderly 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. Hearing aid in
place
Neck: Supple, no LAD, with JVP at mandible
CV: PMI located in 5th intercostal space, anterior axilla.
Irregular irregular, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
Chest: 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: warm, dry, pitting edema up to mid thigh
Skin: pale, macular, pruritic rash around lower abdomen and
back, with scattered lesions on chest
Pertinent Results:
[**2166-12-18**] 02:00PM BLOOD WBC-7.1 RBC-4.19* Hgb-10.1* Hct-32.8*
MCV-78* MCH-24.1* MCHC-30.8* RDW-17.5* Plt Ct-300
[**2166-12-18**] 02:00PM BLOOD PT-14.3* PTT-27.9 INR(PT)-1.2*
[**2166-12-18**] 02:00PM BLOOD Glucose-83 UreaN-96* Creat-4.9*# Na-135
K-4.8 Cl-96 HCO3-28 AnGap-16
[**2166-12-18**] 02:00PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 45271**]*
[**2166-12-18**] 02:00PM BLOOD cTropnT-0.18*
[**2166-12-19**] 06:15AM BLOOD CK-MB-NotDone cTropnT-0.16*
[**2166-12-18**] 02:00PM BLOOD Calcium-8.6 Phos-5.6* Mg-2.9*
[**2166-12-18**] 02:00PM BLOOD Digoxin-1.3
.
[**2166-12-19**]: Atrial flutter, rate 71, nl axis, wide QRS, RBBB, ST
depression in I, avL
.
TTE [**2166-12-9**]
The left atrium is markedly dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. There is severe global left ventricular
hypokinesis (LVEF = 15-20% %). The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are moderately thickened. There is moderate to
severe aortic valve stenosis (area 0.8-1.0cm2). Mild to moderate
([**1-22**]+) aortic regurgitation is seen. A bioprosthetic mitral
valve prosthesis is present. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. Moderate to
severe tricuspid regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. The pulmonic valve leaflets
are thickened. There is no pericardial effusion.
.
[**2166-12-18**] CXR: Mild pulmonary edema, with no focal consolidation.
.
TTE [**2166-12-20**]
There appears to be a mass in the body of the left atrium. It
appears to be attached to the posterior wall. This may be a
tumour, thrombus or an artifact from the prosthetic mitral
valve. It has been present, with a similar size on
echocardiograms on [**4-22**]/8 and 11/18/8. It was also seen on a
cardiac MRIon [**2165-10-15**]. A TEE could be done to further clarify,
if indicated. Moderately dilated left ventricle with severe
global hypokinesis. Moderate to severe aortic stenosis and mild
to moderate aortic regurgitation. Normally functioning mitral
prosthesis. Mild pulmonary artery systolic hypertension.
Brief Hospital Course:
1. ACUTE ON CHRONIC SYSTOLIC CHF
This is due to ischemic cardiomyopathy with an EF of 15-20%.
BNP was elevated on admission. He was initially put on a Lasix
drip on the floor but was minimally responsive. He was then
sent to the CCU on [**2166-12-19**] and was started on Milrinone. He
was given a 25 mcg/kg Milrinone bolus and then put on 0.25
mcg/kg/min Milrinone drip on [**2166-12-19**]. This was increased to
0.375 on [**2166-12-20**] and to 0.5 mcg/kg/min on [**2166-12-21**]. He was
kept on a Lasix drip at 12mg/min. Due to low blood pressure he
was started on phenylephrine which ranged from 0.5-1.0
mcg/kg/min to maintain his BP with MAPs in the 50s. He diuresed
well and was negative 9.5L for his length of stay, averaging
between 2-3L per day. His metoprolol was titrated up to improve
diastolic filling time. His echo on [**2166-11-19**] showed improvement
of his stroke volume and cardiac output. His renal function
improved with creatinine of 4.9 on admission and 2.3 on
discharge. The milrinone and lasix were weaned off on [**2166-12-23**].
He required phenylephrine for BP support until [**2166-12-24**], when
this was weaned off. He was kept on a low sodium diet and was
fluid restricted. On [**2166-12-23**] he was started on Bumex 3mg PO
BID. He continued to diurese with this regimen. His Lisinopril
was stopped on admission and remained off due to acute renal
failure. He improved clinically and was discharged on [**2166-12-25**]
with outpatient follow-up with Dr. [**First Name (STitle) 437**].
.
2. CORONARY ARTERY DISASE
The patient had a history of coronary disease and had ST
depressions in leads I and AVL on admission. He had no
complaints of chest pain or SOB and these depressions were
unchanged on follow-up ECGs. His CKs were flat and troponins
trending down from last admission. He was kept on aspirin,
simvastatin and Metoprolol. He did not experience any chest
pain or ischemia during this admission.
.
3. ACUTE ON CHRONIC RENAL FAILURE
Mr. [**Known lastname **] creatinine was 4.9 on admission, likely from poor
perfusion in the setting of congestive heart failure. This
improved during admission with Milrinone therapy as his stroke
volume and cardiac output improved. His creatinine on discharge
was 2.3. His [**Known lastname **] output was excellent during this admission.
.
4. ATRIAL FLUTTER
The patient was recently started on Coumadin at 0.5mg during his
last hospitalization. His INR was subtherapeutic at 1.3 on
admission. He was started on Coumadin 2mg PO qday and this was
increased to 4mg PO qday on [**2166-12-23**] when his INR was still
sub-therapeutic at 1.3. His heart rate was controlled on
Metoprolol which was increased to 50mg PO TID as tolerated by
blood pressure. He was discharged with instructions to have his
labs rechecked in 3 days and have his INR results faxed to his
PCP.
.
5. RASH
The patient was recently evaluated by his dermatologist who
started Minocycline for his abdominal rash which was biopsied on
[**2166-12-16**]. This was continued during his admission. The biopsy
results returned as bullous pemphigoid. The patient will have
outpatient follow-up with his dermatologist on [**2167-1-1**]. He was
given sarna lotion and hydroxyzine for symptoms of itching.
.
6. SACRAL ULCER
The patient was found to have a grade II sacral ulcer on his
coccyx on [**2166-12-21**]. Wound care was consulted and appropriate
recommendations were followed for care of this ulcer.
.
DISCHARGE:
The patient was discharged with instructions to follow-up with
his PCP, [**Name10 (NameIs) 2085**] and dermatologist. He was instructed to
have his labs drawn to check his INR in 3 days. He was
evaluated by PT prior to discharged who cleared him to go home
with home PT.
Medications on Admission:
Warfarin 0.5mg daily
Digoxin 0.0675 mg PO daily
Torsemide 20mg PO BID
Lisinopril 2.5mg PO daily
Simvastatin 20mg PO daily
Metoprolol 12.5mg PO BID
ASA 81mg daily
Omeprazole 20mg daily
Docusate Sodium 100 mg [**Hospital1 **]
Monocycline 100 mg [**Hospital1 **] (started on wednesday)
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. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Digoxin 125 mcg Tablet Sig: [**1-22**] Tablet PO DAILY (Daily).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*2 tubes* Refills:*0*
6. Minocycline 50 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*0*
8. Bumetanide 2 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
9. Hydroxyzine HCl 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for itchiness.
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Outpatient Lab Work
please have INR checked and faxed to Dr. [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 58**]. His
phone number is [**Telephone/Fax (1) 3329**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Primary Diagnosis:
1. Acute Systolic CHF
2. Coronary Artery Disease
3. Atrial Fibrillation
Secondary Diagnoses:
4. Hypertension
5. Chronic Kidney Disease
Discharge Condition:
afebrile, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital with heart failure. You were
treated with diuretics and responsed. The fluid in your lungs
decreased. You were admitted to the ICU for close monitoring.
The echocardiogram of your heart showed improvement after
diuresing.
You should follow-up with your cardiologist, Dr. [**First Name (STitle) 437**] on
[**2167-1-12**] as indicated below. You should see your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 58**] in the next 1 week to have your INR level checked and
to see your PCP. [**Name10 (NameIs) 357**] call [**Telephone/Fax (1) 3329**] to schedule this
appointment. It is important to have your INR checked in the
next 3-4 days while on coumadin. You should see your
dermatologist as indicated below for your skin rash.
The following changes were made to your medications. Your
Coumadin was increased to 4mg by mouth once a day. Your
Metoprolol was increased to 75mg by mouth three times a day.
Your Torsemide was stopped and you were started on Bumex 3mg by
mouth twice a day. You were started on Sarna lotion and
Hydroxyzine 25mg by mouth every 6 hours as needed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 ml
You should call your doctor or seek medical attension for any
fevers > 100.4, chills, night sweats, chest pain, shortness of
breath, leg swelling, abdominal pain, bleeding from your bowels,
vomiting, worsening of your rash or any other symptoms that
concern you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2308**], MD Phone:[**Telephone/Fax (1) 2309**]
Date/Time:[**2167-1-1**] 1:15
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2167-1-12**]
10:00
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58**] for an appointment in the
next week. You should have your INR checked in the next [**3-25**]
days and have your coumadin dose adjusted if necessary.
|
[
"V42.2",
"414.00",
"424.1",
"V45.81",
"427.31",
"707.22",
"585.9",
"414.8",
"403.90",
"V10.83",
"V10.05",
"428.23",
"428.0",
"427.32",
"584.9",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11730, 11816
|
6402, 10159
|
257, 264
|
12015, 12050
|
4006, 6379
|
13623, 14176
|
3169, 3251
|
10492, 11707
|
11837, 11837
|
10185, 10469
|
12074, 13600
|
3266, 3987
|
11950, 11994
|
195, 219
|
292, 2239
|
11856, 11929
|
2261, 2970
|
2986, 3153
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,495
| 102,726
|
48261+48262
|
Discharge summary
|
report+report
|
Admission Date: [**2121-8-13**] Discharge Date: [**2121-8-27**]
Date of Birth: [**2053-10-25**] Sex: F
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
woman with a known history of three vessel coronary artery
disease dating back to [**2117**], a remote history of a silent
myocardial infarction and a known history of renal artery
disease. She originally underwent cardiac catheterization in
[**2117**] at which time no intervention was performed.
More recently, the patient underwent an EGG/Thallium stress
test. She had no anginal symptoms during exercise. Nuclear
imaging revealed distal anterior and apical ischemia with
ejection fraction of approximately 42% with akinesis of the
apex.
The patient's main complaint has been low extremity edema
which has been controlled with Lasix. Prior to admission,
she denied any chest pain or shortness of breath, although
according to patient's relatives she does become short of
breath after ambulating one and a half blocks. The patient
was consequently referred for a cardiac catheterization on
[**2121-8-14**]. Cardiac catheterization revealed a severe three
vessel coronary artery disease. Please see the full report
for detail.
The patient presented to [**Hospital6 256**]
for a possible surgical intervention for her coronary artery
disease.
PAST MEDICAL HISTORY:
1. Coronary artery disease x3
2. History of a silent myocardial infarction
3. Right renal artery stenosis, status post stenting in [**2117**]
4. Hypertension
5. Low extremity edema
SOCIAL HISTORY: History of smoking x40 years
PAST SURGICAL HISTORY: Cesarean section in [**2089**]
ALLERGIES: PENICILLIN
ADMISSION MEDICATIONS:
1. Aspirin 325 mg po q day
2. Atenolol 50 mg q day
3. Lasix 20 mg q day
4. Zestril 50 mg q day
5. Plavix 75 mg q day
6. Vioxx 25 mg q day
7. Isordil 10 mg tid
8. Serax 10 mg q day
ADMISSION LABORATORIES: Hematocrit 41, white blood cell
count 10, platelets 281. Sodium 140, potassium 4.5, BUN 27,
creatinine 1.6, INR 1.2, glucose 90.
PHYSICAL EXAMINATION:
GENERAL: Alert and oriented, afebrile.
VITAL SIGNS: Heart rate 60.
HEAD, EARS, EYES, NOSE AND THROAT: Within normal limits.
NECK: No bruits and no jugular venous distention.
CHEST: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm, no murmurs.
ABDOMEN: Soft, obese with a scar from previous cesarean
section.
EXTREMITIES: Trace ankle edema with normal pulses.
SUMMARY OF HOSPITAL COURSE: Given results of the cardiac
catheterization and patient's symptoms, it was decided that a
surgical approach would be the best option for her coronary
artery disease. On [**2121-8-15**], the patient underwent coronary
artery bypass grafting x3 with left internal mammary artery
to the ramus intermedius, coronary artery and reverse
saphenous vein graft from the aorta to the left anterior
descending coronary artery; reverse saphenous vein graft from
the aorta to the third obtuse marginal coronary artery. The
patient tolerated the procedure well. Pacing leads were
placed. There were no complications. The patient was
transferred to the Intensive Care Unit in stable condition.
The patient continued to do well in the Intensive Care Unit.
She was extubated on postoperative day 1. Postoperative
ejection fraction was 42%. The patient was without any
pressors postoperative day 1. She was started on Lasix,
Lopressor and aspirin. The patient exhibited 90% oxygen
saturation on 4 liters. She had a temperature of 100.7??????
which was thought to be due atelectasis. Physical therapy
was consulted which was following the patient throughout her
hospitalization. The patient was transferred to the floor on
postoperative day 2. Her pacing wires were removed. Her
chest tube was removed as well. Hematocrit remained stable.
The patient remained in sinus rhythm during her stay on the
floor. There was some difficulty in the beginning to wean
the patient off of supplemental oxygen. The chest x-ray
showed persistent left lower lobe atelectasis and left
pleural effusion.
On postoperative day 7, an attempt was made to tap pleural
fluid on the left side. That side tap was unsuccessful. The
patient was sent to radiology for ultrasound guided tap
effusion. However, that effort was unsuccessful as well
since there was little fluid to drain. At the same time, a
decubitus left lateral chest x-ray showed loculated fluid
question of a small pocket of consolidation. The patient was
diuresed aggressively. She continued to require less
supplemental oxygen. The patient was discharged on
postoperative day 7.
DISCHARGE CONDITION: Stable
DISPOSITION: Rehabilitation facility
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft x3
2. History of silent myocardial infarction
3. Renal artery stenosis status post stenting
4. Hypertension
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg po bid
2. Plavix 75 mg po q day
3. Lasix 40 mg po bid x14 days, followed by outpatient dose
of 20 mg po q day
4. Potassium chloride 20 milliequivalents po bid x14 days
5. Ranitidine 150 mg [**Hospital1 **]
6. Percocet 1 to 2 tablets po q 4 to 6 hours prn pain
7. Milk of Magnesia 30 ml po hs prn constipation
8. Tylenol 650 mg po q4h prn
9. Colace 100 mg po bid prn
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with her surgeon, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**], in approximately six weeks.
2. The patient is to follow up with her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in approximately one to two
weeks.
3. The patient is to follow up with cardiologist in
approximately three to four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2121-8-26**] 09:34
T: [**2121-8-26**] 09:43
JOB#: [**Job Number **]
Admission Date: [**2121-8-13**] Discharge Date: [**2121-9-3**]
Date of Birth: [**2053-10-25**] Sex: F
Service: CARDIAC SURGERY
This is an addendum to the previously-dictated discharge
summary. The patient was actually discharged on [**2121-9-3**].
The reason was that the patient developed a sternotomy wound
infection. The incision was opened, and yellowish pus was
drained by bedside. A VAC dressing was placed. The patient
did well. The wound improved without any additional
drainage. The patient was placed on levofloxacin and
vancomycin.
Plastic Surgery was consulted. The VAC dressing was removed
a few days later, and wet-to-dry dressings were applied and
changed two to three times a day. The wound culture grew E.
coli, sensitive to levofloxacin. Consequently, vancomycin
was discontinued.
The patient was discharged to [**Hospital **] Rehabilitation
facility on [**2121-9-3**] in stable condition.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting x 3
2. Sternal wound infection
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg by mouth twice a day
2. Plavix 75 mg by mouth once daily
3. Lasix 40 mg by mouth twice a day for 14 days
4. Potassium chloride 20 mEq by mouth twice a day for 14
days
5. Percocet one to two tablets every four to six hours as
needed for pain
6. Colace 100 mg by mouth twice a day as needed
7. Aspirin 325 mg by mouth once daily
8. Heparin subcutaneously every eight hours
9. Levofloxacin 250 mg by mouth once daily
10. Vioxx 12.5 mg by mouth once daily
DISCHARGE INSTRUCTIONS: The patient is to be brought to [**Hospital1 1444**] on Monday, [**9-8**], to the
Far Building on the [**Hospital Ward Name 517**], [**Location (un) 1773**]. The purpose
is a wound check and possible readmission for further
management of the wound. Cardiac Surgery should be paged at
that time.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358
Dictated By:[**Last Name (NamePattern1) 10097**]
MEDQUIST36
D: [**2121-9-3**] 20:43
T: [**2121-9-4**] 00:00
JOB#: [**Job Number **]
|
[
"998.59",
"412",
"440.1",
"997.3",
"599.0",
"518.0",
"E878.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"88.53",
"36.15",
"37.22",
"39.61",
"36.13",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
4652, 4699
|
4720, 4902
|
7174, 7655
|
7046, 7151
|
7680, 8201
|
1720, 2065
|
1641, 1697
|
2501, 4630
|
2087, 2472
|
178, 1361
|
1383, 1570
|
1587, 1617
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,582
| 148,874
|
34444
|
Discharge summary
|
report
|
Admission Date: [**2148-8-11**] Discharge Date: [**2148-8-19**]
Date of Birth: [**2098-1-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2148-8-13**] - AVR (23mm St. [**Male First Name (un) 923**] Mechanical Valve), Ascending Aorta
Replacement, Closure of PFO.
History of Present Illness:
50 year old gentleman with syncopal episode 1 month ago. A TTE
was obtained which showed a bicuspid aortic valve and a dilated
aorta. He underwent a cardiac catheterization which showed
normal coronaries. Given the severity of his aortic disease, he
is now admitted for surgical management.
Past Medical History:
AS/AI/Bicuspid AV/Dilated ascending aorta - s/p AVR/Replacement
of ascending aorta, PFO closure.
Hyperlipidemia
HTN
Anxiety
Hemorrhoids
AF
Social History:
Works in construction. Last dental exam 2 years ago. Never
smoked and does not drink alcohol. Lives with his wife.
Family History:
Father died of MI at age 62
Physical Exam:
VS - T 99.2; BP 130/74; HR 68; RR 20; 98% on RA
Gen: 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.
CV: RR, normal S1, S2. No thrills, lifts. Loud systolic murmur
radiating to bilateral carotids. Decreases with valsalva.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2148-8-17**] 05:35AM BLOOD WBC-8.2 RBC-2.60* Hgb-8.2* Hct-23.1*
MCV-89 MCH-31.4 MCHC-35.4* RDW-14.8 Plt Ct-176
[**2148-8-11**] 05:07PM BLOOD WBC-4.2 RBC-4.71 Hgb-14.2 Hct-41.3 MCV-88
MCH-30.1 MCHC-34.2 RDW-13.1 Plt Ct-212
[**2148-8-19**] 06:05AM BLOOD PT-32.7* PTT-61.7* INR(PT)-3.4*
[**2148-8-11**] 05:07PM BLOOD PT-12.3 PTT-30.5 INR(PT)-1.0
[**2148-8-18**] 06:30AM BLOOD Glucose-100 UreaN-19 Creat-1.1 Na-134
K-4.0 Cl-98 HCO3-26 AnGap-14
[**Known lastname **],[**Known firstname **] [**Medical Record Number 79173**] M 50 [**2098-1-30**]
Radiology Report CHEST (PA & LAT) Study Date of [**2148-8-19**] 9:03 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2148-8-19**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 79174**]
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with
REASON FOR THIS EXAMINATION:
r/o inf, eff
Provisional Findings Impression: AJy MON [**2148-8-19**] 11:27 AM
PFI: Stable cardiomegaly with cephalization of the pulmonary
vasculature but
no evidence for cardiac decompensation. Small bilateral
effusions are
improving. There is evidence for pneumonia. Lung volumes are
improved with
decreased bibasilar atelectasis.
Preliminary Report !! PFI !!
PFI: Stable cardiomegaly with cephalization of the pulmonary
vasculature but
no evidence for cardiac decompensation. Small bilateral
effusions are
improving. There is evidence for pneumonia. Lung volumes are
improved with
decreased bibasilar atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
PFI entered: MON [**2148-8-19**] 11:27 AM
Imaging Lab
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2148-8-11**] for preoperative
workup in preparation for his aorta and aortic valve surgery.
Panorex dental films were obtained which ruled out any evidence
of infection. A CTA was obtained for evaluation of his aorta
whcih showed a heavily calcified aortic valve with dilatation
of the aorta at the level of the sinus of Valsalva. On [**2148-8-13**],
Mr. [**Known lastname **] was taken to the operating room where he underwent an
aortic valve replacement with a mechanical prosthesis, an
ascending aorta replacement and a PFO closure. Please see
operative note for details. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. Within 24
hours, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated.
He developed atrial fibrillation which was treated with
amiodarone. He was transfused with packed red blood cells for
postoperative anemia. There was a question of a transfusion
reaction however further testing was negative. On postoperataive
day 2, Mr. [**Known lastname **] was transferred to the step down unit for
further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility.
Mr. [**Known lastname **] continued to make steady progress and was discharged
home on postoperative day #6. He will follow-up with Dr. [**Last Name (STitle) **]
in 1 month following discharge. He has been instructed to follow
up with his cardiologist, Dr.[**Last Name (STitle) 410**] on [**2148-8-20**] for his
INR/Coumadin dosing.He has also been instructed to follow up
with his primary care physician as an outpatient.
Medications on Admission:
Paxil 10'', Xanax PRN, ASA 81, Lipitor 10', Torprol XL 25',
Wellbutrin 75'', MVI
Discharge Medications:
1. Outpatient Lab Work
INR check on Tuesday [**2148-8-20**] with the office of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 410**] ([**Telephone/Fax (1) 79175**]. INR goal for a mechanical AVR is 2-2.5.
Plan confirmed with [**Doctor First Name **] from Dr.[**Name (NI) 3588**] office.
2. Paroxetine HCl 10 mg [**Name (NI) 8426**] Sig: One (1) [**Name (NI) 8426**] PO BID (2
times a day).
[**Name (NI) **]:*60 [**Name (NI) 8426**](s)* Refills:*0*
3. Bupropion 75 mg [**Name (NI) 8426**] Sig: One (1) [**Name (NI) 8426**] PO DAILY (Daily).
[**Name (NI) **]:*30 [**Name (NI) 8426**](s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Name (NI) **]:*60 Capsule(s)* Refills:*0*
5. Aspirin 81 mg [**Name (NI) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Name (NI) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
[**Name (NI) **]:*30 [**Name (NI) 8426**], Delayed Release (E.C.)(s)* Refills:*0*
6. Atorvastatin 10 mg [**Name (NI) 8426**] Sig: One (1) [**Name (NI) 8426**] PO DAILY
(Daily).
[**Name (NI) **]:*30 [**Name (NI) 8426**](s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg [**Name (NI) 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
[**Name (NI) **]:*45 [**Name (NI) 8426**](s)* Refills:*0*
8. Lorazepam 0.5 mg [**Name (NI) 8426**] Sig: One (1) [**Name (NI) 8426**] PO Q8H (every 8
hours) as needed.
[**Name (NI) **]:*45 [**Name (NI) 8426**](s)* Refills:*0*
9. Amiodarone 200 mg [**Name (NI) 8426**] Sig: One (1) [**Name (NI) 8426**] PO BID (2 times
a day) for 7 days.
[**Name (NI) **]:*14 [**Name (NI) 8426**](s)* Refills:*0*
10. Amiodarone 200 mg [**Name (NI) 8426**] Sig: One (1) [**Name (NI) 8426**] PO once a day:
as directed by MD.
[**Last Name (Titles) **]:*30 [**Last Name (Titles) 8426**](s)* Refills:*0*
11. Amiodarone 200 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO twice a day
for 3 days: Amio 400mg once daily x 3 days, then decrease to
200mg twice daily x7days, then decrease to 200mg once daily.
[**Last Name (Titles) **]:*12 [**Last Name (Titles) 8426**](s)* Refills:*0*
12. Metoprolol Tartrate 25 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO TID
(3 times a day).
[**Last Name (Titles) **]:*90 [**Last Name (Titles) 8426**](s)* Refills:*0*
13. Warfarin 2.5 mg [**Last Name (Titles) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day.
[**Last Name (Titles) **]:*90 [**Last Name (Titles) 8426**](s)* Refills:*0*
14. Lasix 40 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO once a day for 5
days.
[**Last Name (Titles) **]:*5 [**Last Name (Titles) 8426**](s)* Refills:*0*
15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 5 days.
[**Last Name (Titles) **]:*10 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
new [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
AS/AI/Bicuspid AV/Dilated ascending aorta - s/p AVR/Replacement
of ascending aorta, PFO closure.
Hyperlipidemia
HTN
Anxiety
Hemorrhoids
AF
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. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] ([**Telephone/Fax (1) 79175**] **[**2148-8-20**] for
Coumadin dosing/INR. Lab hours 8:15-5p.
Follow-up with Dr. [**Last Name (STitle) 79176**] in [**2-26**] weeks.
Follow-up with Dr. [**Last Name (STitle) 914**] on Tues. [**2148-8-27**] at 2:30pm:
[**Telephone/Fax (1) **]
Call all providers for appointments.
INR check on Tuesday [**2148-8-20**] at the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**]
([**Telephone/Fax (1) 79175**]. INR goal for a mechanical AVR is 2-2.5. Plan
confirmed with Traycan from Dr.[**Name (NI) 3588**] office. Updated plan
for Coumadin dosing to start with Dr.[**Last Name (STitle) 410**] on [**2148-8-20**] d/w
[**Doctor First Name **] [**2148-8-19**].
Completed by:[**2148-8-19**]
|
[
"285.9",
"427.31",
"272.4",
"401.9",
"441.2",
"424.1",
"300.00",
"745.5",
"746.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.71",
"38.45",
"39.63",
"88.72",
"39.61",
"35.22",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8280, 8380
|
3422, 5193
|
329, 458
|
8563, 8572
|
1727, 2520
|
9314, 10240
|
1088, 1117
|
5324, 8257
|
2560, 2581
|
8401, 8542
|
5219, 5301
|
8596, 9291
|
1132, 1708
|
282, 291
|
2613, 3399
|
486, 778
|
800, 940
|
956, 1072
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,958
| 113,742
|
33505
|
Discharge summary
|
report
|
Admission Date: [**2108-2-28**] Discharge Date: [**2108-3-15**]
Date of Birth: [**2037-10-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
increased SOB, lower extremity edema
Major Surgical or Invasive Procedure:
AVR (25mm [**First Name8 (NamePattern2) **] [**Male First Name (un) **] tissue), CABGx3(SVG>PDA, SVG>LAD, SVG>Diag)/
Lt CEA [**3-8**]
tooth extraction [**3-3**]
History of Present Illness:
70 yo M who has not received medical care for most of his life
presented to ED on [**2-23**] with SOB, edema. Received lasix gtt with
some relief, cath at OSH with 2 VD, ech with AS and EF 10%.
Past Medical History:
DM, ischemic cardiomyopathy-new dx, etoh abuse, s/p cyst removal
from tailbone as child
Social History:
worked in plumbing and heating
quit tobacco [**2060**]
quit etoh 25 years ago
Family History:
NC
Physical Exam:
NAD HR 86, R 14 BP 87/56
HEENT teeth in poor repair
Lungs decreased t/o
Heart RRR 2/6 SEM
Abdomen benign
Extrem with 1+ edema to knees
No varicose veins, 1+ dp/pt pulses
Left carotid with loud bruit
Pertinent Results:
[**2108-3-15**] 06:55AM BLOOD WBC-9.7 RBC-3.44* Hgb-9.7* Hct-30.0*
MCV-87 MCH-28.0 MCHC-32.2 RDW-17.1* Plt Ct-319
[**2108-3-15**] 06:55AM BLOOD Plt Ct-319
[**2108-3-13**] 07:15AM BLOOD PT-14.9* INR(PT)-1.3*
[**2108-3-15**] 06:55AM BLOOD Glucose-128* UreaN-26* Creat-1.5* Na-140
K-4.2 Cl-101 HCO3-29 AnGap-14
[**2108-3-13**] 07:15AM BLOOD Glucose-137* UreaN-36* Creat-2.0* Na-134
K-4.2 Cl-99 HCO3-26 AnGap-13
[**2108-3-12**] 01:15PM BLOOD UreaN-33* Creat-1.9* K-4.9
CHEST (PA & LAT) [**2108-3-14**] 2:35 PM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
70 year old man s/p AVR CABG
REASON FOR THIS EXAMINATION:
eval for pleural effusions
PROCEDURE: Chest PA and lateral on [**2108-3-14**].
COMPARISON: [**2108-3-12**].
HISTORY: 70-year-old man status post AVR and CABG, evaluate for
pleural effusions.
FINDINGS: In the interim, there is a gradual decrease in the
bilateral pleural effusions with gradual decrease in the
bibasilar lower lobe atelectasis. Persistent stable
cardiomegaly. There is no evidence of pulmonary edema.
IMPRESSION:
1. Gradual decrease in the bilateral bibasilar pleural effusions
which are small to moderate on today's examination along with
gradual decrease of the bilateral bibasilar lower lobe
atelectasis.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 77685**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77686**] (Complete)
Done [**2108-3-8**] at 9:22:59 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2037-10-7**]
Age (years): 70 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: CABG/AVR
ICD-9 Codes: 428.0, 402.90, 435.9, 786.05, 786.51, 799.02,
440.0, 424.1, 424.0
Test Information
Date/Time: [**2108-3-8**] at 09:22 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW-1: Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 10% to 15% >= 55%
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *2.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *30 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 23 mm Hg
Aortic Valve - LVOT pk vel: 0.50 m/sec
Aortic Valve - LVOT diam: 2.2 cm
Aortic Valve - Valve Area: *0.7 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Severely depressed LVEF.
RIGHT VENTRICLE: Severe global RV free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate (2+) 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
severely depressed (LVEF= 10 - 15%). RV also with severe global
free wall hypokinesis. There are simple atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. Moderate (2+) mitral
regurgitation is seen. There is no pericardial effusion.
Post- CPB: The patient is in SR, with infusions of milrinone and
epinephrine.
A well-seated and functioning aortic valve prosthesis is seen,
with no AI, and no perivalvular leak. Mean gradient is 15.
Aorta intact.
MR is 1+.
Biventricular systolic fxn is still moderately depressed.
Brief Hospital Course:
He was admitted to cardiac surgery. Carotid duplex showed Left
CCA stenosis of 80-99%, he was seen by vascular surgery. CT scan
showed very calcified aortic arch and carotid arteries and CEA
was recommended. He was seen by dentistry and tooth extraction
was recommended. He underwent 1 tooth extraction on [**3-4**]. On
[**3-8**] he was taken to the operating room where he underwent an
AVR, CABG x 3 and Left CEA. He was transferred to the ICU in
critical but stable condition on epinephrine, nitroglycerine,
and milrinone. He was extubated on POD #1. He was weaned from
his milrinone over several days and transferred to the floor on
POD #3. He required extensive diuresis. he was seen by [**Last Name (un) **]
for preoperative HbA1c of 9 and uncontrolled diabetes postop. He
was started on lantus and humalog sliding scale. He was seen by
PT and cleared for home over several days. He was ready for
discharge on POD #7.
Medications on Admission:
aspirin
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*qs 1 month* Refills:*0*
9. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
Disp:*qs 1 month* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days: then 40 mg daily.
Disp:*60 Tablet(s)* Refills:*0*
11. Diabetic Supplies
one touch ultra glucometer,
Test strips for one touch ultra, Insulin syringes,
Lancets
QS 1 month
Refills per PCP
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6011**] Care
Discharge Diagnosis:
AS/CAD now s/p AVR/CABG
uncontrolled diabtes
acute on chronic systolic heart failure
L carotid stenosis now s/p CEA
DM, ischemic cardiomyopathy-new dx, etoh abuse, s/p cyst removal
from tailbone as child
Discharge Condition:
Stable
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks, no driving until
follow up with surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 1 week
Dr. [**Last Name (STitle) 914**] 2 weeks
Dr. [**Last Name (STitle) 39975**]/[**Last Name (un) 55499**] 4 weeks
Dr. [**Last Name (STitle) 77687**] 6 weeks
Completed by:[**2108-3-15**]
|
[
"424.1",
"428.0",
"520.6",
"250.92",
"425.4",
"401.9",
"428.23",
"433.10",
"E879.9",
"458.29",
"782.3",
"414.01",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"88.72",
"39.61",
"35.21",
"99.04",
"36.13",
"38.12",
"23.19"
] |
icd9pcs
|
[
[
[]
]
] |
8389, 8445
|
6021, 6945
|
357, 520
|
8693, 8702
|
1204, 1767
|
9016, 9238
|
966, 970
|
7003, 8366
|
1804, 1833
|
8466, 8672
|
6971, 6980
|
8726, 8993
|
985, 1185
|
281, 319
|
1862, 5998
|
548, 744
|
766, 855
|
871, 950
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,182
| 115,802
|
30343
|
Discharge summary
|
report
|
Admission Date: [**2148-3-30**] Discharge Date: [**2148-4-19**]
Date of Birth: [**2098-10-23**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
49 yo F with h/o heavy ETOH use now with hematemesis. States her
father's funeral was Thursday [**3-28**] and she drank her normal 3
glasses of wine that evening. The whole day she had only eaten a
[**Location (un) 6002**] platter. At 3 a.m. on Friday [**3-29**] she started having
intense abd cramps and started vomiting blood. At the same time
she started having copious black diarrhea. States throughout the
day she vomited and had diarrhea approx 20 times. States she
briefly felt better around 2 p.m. and had a rum and coke but
then had more vomiting. Had more rum and coke at 11 p.m. and
hematemesis continued and her sister convinced her to go to the
[**Name (NI) **] ED. States she has had light-headedness but has not
passed out. Pt states before this she has never had hematemesis
or black stools. Denies knowledge of liver disease.
.
At [**Hospital1 **] Hct was 28.2, plt 23, blood ETOH 103. Pt was given
1L NS, Zofran 4mg IV, Protonix 40mg IV, one unit pRBC's, vitamin
K 10mg IM and was transfered to [**Hospital1 18**] where she vomited once in
the ED with dark brown emesis. At [**Hospital1 18**] Hct was 30.6, INR was
1.6. She was given anzemet 25mg IV, octreotide 50mcg IV, and
phenergan 12.5mg IV.
.
Past Medical History:
HTN
hypothyroidism
torticolis "spasms" diagnosed by neurologist several years ago
Social History:
Lives with her husband in [**Name (NI) 1110**], MA. Her eldest son died last
year. She has 2 other grown children. Used to work as a cook but
is now retired. States she and her husband drink approx [**2-25**]
glasses of wine each evening and have occasional hard alcohol on
the weekends (x 30 years). States that when she doesn't drink
she gets more shakey and doesn't feel well but has never had
seizures. She smokes [**2-25**] - 1 ppd. Denies any cocaine, marijuana,
heroin, or other substances.
Family History:
denies knowledge of liver disease.
Physical Exam:
101.2, 118, 130/67, 18, 98% on RA
GEN: appears slightly anxious, in NAD
HEENT: OP clear, dry. No petechiae or evidence of bleeding.
Skin: no palmar erythema or spider angiomata.
CV: tachy, regular, no m/r/g
Abd: s/nt/slightly distended but no obvious fluid wave. +bs.
Lungs: CTAB
Ext: no c/c/e.
Rectal: guaiac positive black stool.
Neuro: A&Ox3, no focal abnormalities.
Pertinent Results:
CHEST SINGLE VIEW ON [**3-31**]
HISTORY: Oxygen requirement, question pneumonia or fluid
overload. There are no old films available for comparison.
There is an area of increased opacity in the left lower lobe
consistent with left lower lobe pneumonia. There is a small
left pleural effusion. The heart is upper limits normal in
size. The bony thorax is normal. IMPRESSION: Left lower lobe
pneumonia.
.
Brief Hospital Course:
1. GI bleed: at admission, the patient underwent banding of
grade 2 varices. Her hematocrit remained stable and she was
transferred to the floor. She had a repeat endoscopy during the
admission with repeat banding of the varices. She was on
sucralfate and PPI. She will have subsequent endoscopies and
banding as an outpatient.
.
2. Alcoholic liver disease: the patient had a new diagnosis of
alcoholic liver disease and likely cirrhosis. She did not
undergo liver biopsy during this admission. She has marked
hepatomegaly and splenomegaly, ascites and esophageal varices.
Her course was complicated by alcoholic hepatitis. Her
discriminate function was 36, however, she was not a candidate
for steroids given the recent GI bleed and infection (see
below). She had prolonged abdominal distention and pain (see
below) despite improvement in her LFTs. She underwent three
paracenteses and was started on diuretics to control her fluid
accumulation. There was no evidence of SBP. Her relatively low
blood pressure limited the dose of diuretics. She will have
liver center follow up as an outpatient. The patient was
actively drinking prior to admission. HBsAb neg, HAV neg, anti
smooth muscle antibody neg, IgG 1406. IgA 540 (elevated).
Ceruloplasmin negative.
.
3. Pain: the patient suffered from chronic abdominal pain which
was difficult to control. Her pain was severe despite resolution
of her alcoholic hepatitis. CT scan did not have evidence of
liver bleed or abscess or other anatomic reason for her pain.
She required high doses of narcotics for pain control, and
denied (repeatedly) ever using narcotics before. It was
suspected that her pain was from capsular stretch from
hepatomegaly. Ultimately, pain service was involved and she was
put on 30 mg Oxycontin twice daily with oxycodone for
breakthrough and Neurontin. This regimen provided improved pain
control. The patient has an addiction (alcohol) history and
attempts to wean her narcotics were unsuccessful. At discharge,
the patient was given Oxycontin 40 mg [**Hospital1 **] and prn oxycodone for
breakthrough and Neurontin. She was given 2 weeks of narcotics
and was told she needs to see her PCP for chronic narcotic
management.
.
4. Community acquired pneumonia: the patient was diagnosed with
pneumonia at admission. She completed 10 days of Levoquin and 7
days of Flagyl. The patient continued to spike fevers during her
prolonged hospitalization. Repeat xray showed no infiltrate.
.
5. UTI: group A strep urinary infection treated with four days
of Augmentin with subsequent clean culture. The patient
continued to spike fevers and Ceftriaxone was added to her
regimen to complete at 10 day course for the UTI in this patient
with liver disease. The patient was transferred to Cefpodoxime
at discharge.
.
6. Alcohol abuse/addiction: the patient was actively drinking
prior to admission. She has a long history of alcohol use with
[**2-25**] drinks of wine daily. She was seen by addiction services
and social work during this hospitalization and was given
material regarding alcoholics annonymous and other abstinence
programs. There was also a strong suspicion of outpatient
Vicodin abuse given overheard conversations between the patient
and her husband, however, this was denied repeatedly on direct
questioning. The patient displayed drug-seeking behaviors while
inpatient. She was repeatedly informed that she can no longer
drink alcohol and verbalized understanding.
.
7. Hypertension: the patient had a history of hypertension prior
to admission, but her blood pressure tended to run low during
this hospitalization. It is likely that this is related to lack
of alcohol while hospitalized and pain medication. The patient
also was started on Nadolol for her varices, but was unable to
tolerate this in addition to the doses of Lasix and Aldactone
needed to control her abdominal distention.
.
8. Hypothyroidism: continued outpatient levoxyl.
.
9. Disposition: the patient was discharged home to complete a
10 day course of Cefpodoxime. She was given a prescription for 2
weeks of narcotics and will follow up with her PCP. [**Name10 (NameIs) **] has
close liver center follow up. She had been cleared by PT for
going home. She requires daily magnesium repletion. She was
full code.
Medications on Admission:
Lisinopril 5mg daily
Levoxyl 5 mg daily
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO twice a day.
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*1*
10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
11. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Alcoholic liver disease
Variceal bleed
Alcoholic hepatitis
Ascites
Secondary
Esophageal varices
Thrombocytopenia
Hypothyroidism
Hypertension
Abdominal pain
Discharge Condition:
Stable. Tolerating a regular diet. Pain improved. Able to walk
with walker.
Discharge Instructions:
You were admitted with bleeding from your GI tract and then
treated for alcoholic hepatitis. Please call your doctor or
come to the ED if you develop vomiting blood, blood per rectum,
dark tarry stools, nausea, vomiting, uncontrollable pain,
inability to take your medications, increase size of your
abdomen, worsening lower extremity swelling, chest pain or
shortness of breath.
.
There are several new medications for you to take daily:
1. Lasix (diuretic) 80 mg daily
2. Spironolactone (diuretic) 150 mg daily
3. Oxycontin 40 mg twice a day
4. Oxycodone 5 mg every 4-6 hours as needed for pain
5. Protonix (acid blocker) 40 mg twice a day
6. Folate (Vitamin) 1 mg daily
7. Thiamine (Vitamin) 100 mg daily
8. Neurontin (pain medication) 300 mg three times daily
9. Magnesium oxide (electrolyte replacement) 400 mg daily
10. Cefpodoxime 200 mg twice daily for 6 days (antibiotic, start
[**2148-4-20**]).
Followup Instructions:
Repeat endoscopy:
Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Date/Time:[**2148-4-24**] 8:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2148-4-24**] 8:30
Liver Center follow up:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2148-5-22**] 8:30
.
Primary Care
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 72189**] Call to schedule
appointment
|
[
"244.9",
"486",
"599.0",
"789.5",
"291.81",
"571.2",
"284.1",
"571.1",
"401.9",
"305.01",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
8718, 8724
|
3094, 7383
|
329, 334
|
8934, 9012
|
2661, 3071
|
9966, 10224
|
2219, 2255
|
7474, 8695
|
8745, 8913
|
7409, 7451
|
9036, 9943
|
2270, 2642
|
10235, 10522
|
278, 291
|
362, 1581
|
1603, 1687
|
1703, 2203
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,654
| 136,941
|
25027
|
Discharge summary
|
report
|
Admission Date: [**2172-9-7**] Discharge Date: [**2172-9-9**]
Date of Birth: [**2119-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest pain while at rest
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
52 year old male with pmhx of CAD (3 vessel disease s/p PTCA
[**12-15**]), MI, HTN, ETOH abuse, and afib presenting with chest pain
while at rest, lasting 45 minutes. Transferred from OSH to
[**Hospital1 18**]. Cardiac enzymes were negative, ECG was negative. At OSH
ED, ETOH level was 240 and INR was 8.0.
CP characterized as similar to previous MI with 8/10 stabbing
pain, increased with respiration, no radiation, no
nausea/vomiting, no diaphoresis, palpitations, or exacerbating
or alleviating factors.
At [**Hospital1 18**], pain decreased to [**4-18**] on nitro drip, morphine, banana
bag. He denied orthopnea, DOE, weight gain. On ROS: he has
slight HA, no n/v/f/c, diarrhea/brbpr, melena, no wieght gain,
loss. Cardiac review of systems is notable for absence dyspnea
on exertion, paroxysmal noctural dyspnea, orthopnea, ankle
edema, syncope, or presyncope.
His Cardiac Risk Factors include: Hypertension
Past Medical History:
CAD - [**10-14**] : MI w/ PTCA (LAD stented w/ 3.0 Cypher DES and
major diagonal with a 2.5 Cypher DES)
[**12-15**] Coronary Angiography revealed three vessel disease, mildly
elevated right sided filling pressures, low cardiac output,
elevated LVEDP (24 mmHg).
[**12-15**] Echo showed extensive anteroseptal and apical infarction.
Ejection fraction 20-30%. Mild 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) 62843**]
Regurg. No pericardial effusions.
1)Atrial fibrillation
2)CAD, s/p cardiac catheterization w/ coronary angioplasty to
LAD [**10/2170**]
3)Angina
4)ETOH abuse
5)Tobacco (2-3ppd * >35yr)
6)h/o chest pain with negative ETT (>10 years ago)
7)documented h/o cocaine use
8)undocumented h/o "back problems"
Social History:
ETOH use: [**3-14**] 6pack/week, DUI hx, AA
Tobacco use: (2-3ppd * >35yr)
Denies IVDA
works in landscaping/painting
lives alone
Family History:
Father: MI at 40 y.o, died of CVA at 75 yo
Mother died of CA at age 80 y.o.
Sister alive and in good health
Physical Exam:
VS ([**2172-9-9**]): T: 98.3, BP 102/54, HR 67(afib), RR=13-20,
O2Sat:94-96 on RA
fluid balance(last 24 hrs): 800 cc in / 3200 cc out
General: No actute distress
HEENT: Sclera anicteric, PERRL, EOMI, Conjuctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10 cm
CV: PMI located at 5th intercostal space, midclavicular line,
irregularly irregular rhythm. Normal S1/S2. No murmurs. No
carotid bruits
Chest: CTAB. Good air movement, no crackles, no wheezing. No
accessory muscle use.
Abdomen: Soft, non-distended, bowel sounds heard in four
quadrants
Extremities: No clubbing, 1+ DP/PT bilaterally, no pedal edema
Nerological Examination: AAOx3, mildly agitated, no asterixis
Pertinent Results:
[**2172-9-9**] 06:36AM BLOOD WBC-6.6 RBC-3.71* Hgb-11.1* Hct-33.7*
MCV-91 MCH-29.9 MCHC-32.8 RDW-16.9* Plt Ct-336
[**2172-9-9**] 06:36AM BLOOD PT-17.7* PTT-25.2 INR(PT)-1.7*
[**2172-9-9**] 06:36AM BLOOD Plt Ct-336
[**2172-9-9**] 06:36AM BLOOD Neuts-72.4* Lymphs-18.6 Monos-4.7 Eos-3.7
Baso-0.6
[**2172-9-9**] 06:36AM BLOOD Glucose-95 UreaN-15 Creat-0.9 Na-141
K-4.6 Cl-107 HCO3-25 AnGap-14
[**2172-9-7**] 07:05AM BLOOD ALT-24 AST-24 CK(CPK)-147 AlkPhos-56
Amylase-48 TotBili-0.3
[**2172-9-7**] 07:05AM BLOOD Lipase-32
[**2172-9-7**] 03:14PM BLOOD CK-MB-3 cTropnT-<0.01
[**2172-9-8**] 05:19AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2172-9-9**] 06:36AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.4
[**2172-9-8**] 05:19AM BLOOD calTIBC-359 Ferritn-48 TRF-276
[**2172-9-7**] 07:05AM BLOOD Triglyc-73 HDL-65 CHOL/HD-2.2 LDLcalc-60
[**2172-9-7**] 07:05AM BLOOD Digoxin-0.4*
[**2172-9-7**] 07:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
RESTING DATA
EKG: ATRIAL FIB, Q-WAVES ANTERIORALLY, NSSTTW
HEART RATE: 60S BLOOD PRESSURE: 110/86
PROTOCOL [**Known firstname 569**] - TREADMILL /
STAGE TIME SPEED ELEVATION HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
1 0-3 1.7 10 100 112/80 [**Numeric Identifier **]
2 [**4-14**] 2.5 12 110S 120/60 [**Numeric Identifier 23114**]
3 6-6.5 3.4 14 120S 140/60 [**Numeric Identifier 62844**]
TOTAL EXERCISE TIME: 6.5 % MAX HRT RATE ACHIEVED: 71
SYMPTOMS: NONE
INTERPRETATION: 52 yo man (h/o atrial fibrillation, 3-vessel CAD
with multiple PCIs, ischemic cardiomyopathy) was referred to
evaluate an
atypical chest discomfort and shortness of breath. The patient
completed
6.5 minutes of [**Initials (NamePattern4) **] [**Known firstname **] protocol representing a limited to fair
functional exercise tolerance for his age; ~ 7 METS. The
exercise test
was stopped at the patient's request secondary to marked
fatigue. No
chest, back, neck or arm discomforts were reported. In the
presence of
the course atrial fib and digoxin therapy, no obvious ECG
changes were
noted from baseline. The rhythm was atrial fibrillation with no
vea
noted during the procedure. The blood pressure increased with
exercise.
IMPRESSION: Fair functional exercise tolerance. No anginal
symptoms or
obvious ECG changes from baseline. Nuclear report sent
separately.
EXERCISE MIBI [**2172-9-9**]
EXERCISE MIBI
Reason: CHEST PAIN ? ISCHEMIA
RADIOPHARMECEUTICAL DATA:
10.9 mCi Tc-[**Age over 90 **]m Sestamibi Rest ([**2172-9-9**]);
28.8 mCi Tc-99m Sestamibi Stress ([**2172-9-9**]);
HISTORY: 52 yo male with known history of CAD referred for chest
pain
evaluation.
SUMMARY OF DATA FROM THE EXERCISE LAB:
Exercise protocol: [**Known firstname **]
Resting heart rate: 60's
Resting blood pressure: 112/80
Exercise Duration: 6.5 mins
Peak heart rate: 120's
Percent maximum predicted heart rate obtained: 71 %
Peak blood pressure: 140/60
Symptoms during exercise: None
Reason exercise terminated: Fatigue
ECG findings: AFib
METHOD:
Resting perfusion images were obtained with Tc-[**Age over 90 **]m sestamibi.
Tracer was
injected approximately one hour prior to obtaining the resting
images.
At peak exercise, approximately three times the resting dose of
Tc-[**Age over 90 **]m sestamibi
was administered IV. Stress images were obtained approximately
one hour
following tracer injection.
Imaging Protocol: Gated SPECT
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is good.
Left ventricular cavity size is severly dilated.
Resting and stress perfusion images show a large, severe, fixed
perfusion defect
invloving the apex, distal lateral, distal inferior and distal
anterior wall.
There is also a small, mild, fixed perfusion defect involving
the septum.
Gated images reveal global hypokinesis. The apex, distal
lateral, distal
inferior and distal anterior wall cannot be evaluated due to
absent counts.
The calculated left ventricular ejection fraction is 23 %.
IMPRESSION:
1. Abnormal study.
2. Large, severe, fixed perfusion defect invloving the apex,
distal lateral,
distal inferior and distal anterior wall.
3. Small, mild, fixed perfusion defect involving the septum.
4. Severly dilated LV.
5. Global hypokinesis; LVEF 23%.
Findings were discussed with Dr. [**First Name (STitle) 1833**] [**2172-9-9**] at 1355.
Brief Hospital Course:
52 year old man with history of CAD/PTCA, MI, Afib, alcohol
abuse presenting with chest pains on transfer from OSH.
At [**Hospital1 18**], his INR was improved after Vitamin K/FFP from OSH. His
chest pains were subsided on morphine, banana bag, and nitro
drip.
Problems:
Cardiac:
--CAD:
Chest pains on admission: serial cardiac enzymes were negative.
ECG with no significant changes from prior ECG, showing previous
QS morphology on V1, V2 suggestive of anteroseptal infarct, and
non-specific T-wave abnormalities. Chest pain was relieved with
morphine, nitro drip with good effect. Maintained on
atrovastatin, clopidogrel, metoprolol, lisinopril for afterload
reduction. On hospital day two, he had an echo which
demonstrated previously noted anteroseptal infract, global
hypokinesis, EF of 20-30%, and depressed RV function. A stress
ECHO on day of discharge demonstrated unchanged findings from
prior studies. He is to follow up with his outpatient
cardiologist.
--Pump:
In the afternoon of day of admission, he had flash pulmonary
edema with crackles heard bilaterally and fever of 101F. His
blood pressure was elevated to 170s/80s. He was diuresed with
lasix with good effect, and blood pressure was controlled with
captopril. Blood cultures x 2 were sent (negative as of
[**2172-9-9**]). Chest x-ray was notable mild congestion and
cardiomegaly.
--Rhythm:
Continued to have afib with rates in the 70s. Maintained on
amiodarone, warfarin, lopressor with good control
EtoH Abuse:
--Through out hospital stay, he was mildly agitated showing mild
withdrawl symptoms. He was placed on CIWA scale monitoring to
prevent DT. Treatement for EtOH withdrawl included lorazepam
PRN, and thiamine folate. On day of discharge, he was improved
and denied any new symptoms of chest pain or dyspnea. He was
counseled on refraining from drinking alcohol and its negative
impact on his health.
Anemia:
--Hematocrit of 33% was stable and thought due to
iron-deficiency. His stools were Guaic positive. A colonscopy as
an outpatient in indicated to follow-up anemia.
Medications on Admission:
Amiodarone 200mg daily
Digitek 0.25 mg Daily
Lisinopril 2.5 mg [**Hospital1 **]
MVI Daily
Plavix 75 mg Daily
Toprol 12.5 mg [**Hospital1 **]
Coumadin 7/7.5 alternating days
Fish Oil
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK
(MO,WE,FR).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
-Coronary Artery Disease
Secondary Diagnoses:
-Atrial fibrillation
-Hypertension
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for chest pain. A number of tests were
completed, including monitoring on telemetry, ECGs, blood tests,
and a stress test, which revealed you did not have a new heart
attack.
You should follow up with Dr. [**Last Name (STitle) 17642**] on [**9-14**] at
10am. You should take all medications as prescribed. Please note
that you should take 5mg of lisinopril once a day, and 25 mg of
metoprolol twice a day. You should also take atorvastatin 80mg
daily and 325mg aspirin daily.
Please contact your primary care doctor, Dr. [**Last Name (STitle) 12982**], or go to
the Emergency Room, if you experience chest pain, shortness of
breath, dizziness or lightheadedness, abdominal pain, headache,
or other concerning symptoms.
Followup Instructions:
You should follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **], on [**9-14**] at 10am. His phone number is [**Telephone/Fax (1) 62845**], and he is located
at [**Hospital3 **].
Please continue to follow up with Dr. [**Last Name (STitle) 12982**] to monitor your
dosing of Coumadin.
You should also arrange to have a colonscopy, if this has not
been completed, through Dr. [**Last Name (STitle) 12982**] sometime in the near future
as well.
You should also abstain from drinking alcohol.
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,296
| 180,549
|
33188+57838+57839
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2192-9-7**] Discharge Date: [**2192-9-22**]
Date of Birth: [**2112-7-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
80M, NH resident with prior abdominal surgeries presents with
almost 24hr of nausea and inability to tolerate pos. Started
last evening. Denies any fever/chills/ab pain/CP/SOB. Denies any
vomitting or burping. States is passing gas, but no
BMs(chronically constipated). These particular symptoms have
never
happened before, but has had obstructions per daughter but with
much more severe symptoms.
Past Medical History:
major recurrent depression, prostate cancer with mets to the
spine, lacunar infarct, gastric volvulus s/p gastropexy, hiatal
hernia and ventral hernia repair, chronic constipation
Social History:
Widowed, NH resident ([**Hospital3 537**]). Grew up in [**Location (un) 17004**], NY and
worked as teacher, SW, guidance counselor. Was married and had
2 children; wife passed away in [**2158**]. Daughter is a
psychiatrist in [**Location (un) 86**] area.
Family History:
Son died of a brain tumor at age 19 in [**2160**].
Physical Exam:
On admission:
PE: 96.8 88 145/69 18 97%RA
NAD AOx3
CTAB
RRR
soft NT ND 2 large ventral hernias, left of midline easily
reducible, midline more difficult ? reduced, +bs
no c/c/e
guiac neg, lots impacted stool in vault
Pertinent Results:
[**2192-9-8**] 06:25AM BLOOD WBC-10.8 RBC-3.73* Hgb-11.4* Hct-34.2*
MCV-92 MCH-30.6 MCHC-33.4 RDW-14.2 Plt Ct-199
[**2192-9-8**] 06:25AM BLOOD Glucose-133* UreaN-21* Creat-0.8 Na-144
K-4.3 Cl-107 HCO3-27 AnGap-14
[**2192-9-7**] 10:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2192-9-7**] 10:30 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2192-9-9**]**
URINE CULTURE (Final [**2192-9-9**]): <10,000 organisms/ml.
[**2192-9-7**] CT ABDOMEN W/CONTRAST
1. Moderate grade small-bowel obstruction with transition point
noted within a fat and bowel containing umbilical hernia.
Multiple distal loops of jejunum and ileum are noted to be
decompressed. The large bowel displays a moderate fecal load and
is largely aerated. No finding to suggest underlying ischemia.
2. Heterogeneous but bulk fat-containing exophytic right renal
lesion is
consistent with an angiomyolipoma.
3. Diffusely metastatic prostate cancer with lesions within the
pelvis,
femurs, spine, and ribs.
4. A polypoid, partially calcified 1.4 x 1.7 cm lesion is noted
to extend off the anterior wall of the gastric fundus. Likely
partially calcified polypoid lesion projecting off the anterior
fundal wall. Correlation with endoscopy is recommended. A
polypoid, partially calcified 1.4 x 1.7 cm lesion is noted to
extend off the anterior wall of the gastric fundus (2:9).
Surgical clips are also noted adjacent to the lower esophageal
sphincter.
5. Hypoattenuating splenic and left renal lesions, likely benign
cysts.
Brief Hospital Course:
In the ED, CT exam identified a moderate grade small-bowel
obstruction with transition point noted within a fat and bowel
containing umbilical hernia but no finding to suggest underlying
ischemia. He was admitted to the surgery service for further
treatment and evaluation. Conservative management was begun.
Hydration was maintained with IV fluids. A foley was placed.
Serial abdominal exams were performed. A nasogastric tube was
placed for decompression and was removed on hospital day 3. Diet
was advanced first to clear liquids and then to a regular diet.
All psychiatric medications were restarted on hospital day 3.
Foley was removed on HD 3. The patient experienced flatus on
hospital day 3 and bowel movements on hospital day 4.
Per the request of the family, a psychiatric consultation was
obtained as the patient was fixating on his clothing.
Recommendations are as follows:
1) given his recent sbo I am reluctant to increase his zyprexa
given anticholinergic side effects until some time has passed
from the sbo, so would keep all medications as they are now. Can
consider increasing his zyprexa to 10mg qhs once his intestinal
issues are resolved 2)he will follow up with his outpatient
treater, and now is more willing to discuss ECT which may be a
good treatment option. He also may need an increase in effexor
over time as well 3)check TSH if not recently checked.
Physical therapy deemed the patient appropriate for return to
his home facility but recommended physical therapy services.
Otherwise, the patient was completely compliant with medical
care, was not disruptive, and was deemed appropriate with for
discharge to his facility. At the time of discharge, the patient
was afebrile, and was tolerating food by mouth.
Medications on Admission:
[**Last Name (un) 1724**]:
CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider) - 0.25
mg
Tablet, Rapid Dissolve - 1 (One) Tablet(s) by mouth twice a day
LEUPROLIDE [LUPRON DEPOT] - (Prescribed by Other Provider) -
Dosage uncertain
MIRTAZAPINE [REMERON] - (Prescribed by Other Provider) - 45 mg
Tablet - 1 (One) Tablet(s) by mouth at bedtime
OLANZAPINE [ZYPREXA] - (Prescribed by Other Provider) - 7.5 mg
Tablet - 1 (One) Tablet(s) by mouth at bedtime
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Prescribed by Other
Provider) - Dosage uncertain
TAMSULOSIN [FLOMAX] - 0.4 mg Capsule, Sust. Release 24 hr - 1
(One) Capsule(s) by mouth once a day
VENLAFAXINE [EFFEXOR XR] - (Prescribed by Other Provider) - 150
mg Capsule, Sust. Release 24 hr - 1.5 (One and a half)
Capsule(s)
by mouth once a day
Medications - OTC
ASPIRIN [ASPIRIN [**Hospital1 **]] - (OTC) - 81 mg Tablet, Chewable -
1
(One) Tablet(s) by mouth once a day
CALCIUM - (Prescribed by Other Provider) - Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3] - 400 unit Tablet - 1
(One) Tablet(s) by mouth once a day
CYANOCOBALAMIN [VITAMIN B-12] - (Prescribed by Other Provider)
-
Dosage uncertain
GARLIC - (Prescribed by Other Provider) - Dosage uncertain
OMEGA-3 FATTY ACIDS - (Prescribed by Other Provider) - 1,000 mg
Capsule - Capsule(s) by mouth
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid
Dissolves PO QHS (once a day (at bedtime)).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. medications
Please continue all home medications
10. Lupron Subcutaneous
11. Polyethylene Glycol 3350 Oral
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
13. Calcium Oral
14. Cyanocobalamin Oral
15. Garlic Oral
16. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
good
Followup Instructions:
A polypoid lesion on the anterior wall of the gastric fundus was
noted on your CT scan. Please follow-up with your primary care
phyiscian for a possible EGD.
You have a follow-up appointment with Dr. [**Last Name (STitle) **] on [**9-28**]
at 1PM. [**Hospital Ward Name 23**] Building, [**Location (un) **]. [**Hospital1 **].
Please call with questions. [**Telephone/Fax (1) 2723**]
Please follow-up with your psychiatrist Dr. [**Last Name (STitle) 77126**] following
discharge.
Completed by:[**2192-9-11**] Name: [**Known lastname 3936**],[**Known firstname 1523**] Unit No: [**Numeric Identifier 12525**]
Admission Date: [**2192-9-7**] Discharge Date: [**2192-9-22**]
Date of Birth: [**2112-7-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 559**]
Addendum:
[**2192-9-11**] Patient was stable and preparing for discharge when he
was noted to be coughing during ingestion of fluids. Subsequent
oxygen saturations were low necessitating an increased need for
further oxygen support. A chest x-ray was obtained showing
density in RLL consistent for aspiration pneumonia. He was
transferred to ICU for further monitoring and management.
[**2192-9-13**] A repeat CT scan showed continued small bowel
obstruction, with a transition point in am umbilical hernia,
compatible with an incarcerated hernia. Patient was taken to the
operating room and repair of ventral hernia was performed on
[**2192-9-14**].
On [**2192-9-17**] patient was extubated and transferred to the regular
floor. He was agitated at times pulling at his iv's and
nasogastric tube. He was given haldol and soft upper extremity
restraints were applied as needed to keep him safe.
[**2192-9-18**] KUB done showing dilated sigmoid but no small bowel
obstruction. Dulcolox suppository was given. Nasogastric tube
was self discontinued.
[**2192-9-19**] Patient was started on clear liquids and all narcotics
and haldol was discontinued. Psychiatry reconsulted to help us
manage his delirium and confusion.
[**2192-9-20**] Patient advanced to regular diet. Taking small amounts
and tolerating well. Soap suds enema given with resulting
passing of stool.
[**2192-9-21**] HCT 22 - 2 units of packed cells given. Placed on
regular diet with encouragement and assistance with eating.
Calorie counts ordered. Geriatric consulted regarding medication
and co-morbidities.
[**2192-9-22**] HCT stable after transfusion (27), TPN continuing. Pt
transfered to [**Hospital **] Rehab MACU at the recommendation of Dr.
[**Last Name (STitle) **] and the Geriatrics team and with our approval.
Chief Complaint:
Admitted with small bowel obstruction
Major Surgical or Invasive Procedure:
Ventral Incisional Hernia Repair
History of Present Illness:
80M, NH resident with prior abdominal surgeries presents with
almost 24hr of nausea and inability to tolerate pos. Started
last evening. Denies any fever/chills/ab pain/CP/SOB. Denies any
vomitting or burping. States is passing gas, but no
BMs(chronically constipated). These particular symptoms have
never
happened before, but has had obstructions per daughter but with
much more severe symptoms.
Past Medical History:
major recurrent depression, prostate cancer with mets to the
spine, lacunar infarct, gastric volvulus s/p gastropexy, hiatal
hernia and ventral hernia repair, chronic constipation
Social History:
Widowed, NH resident ([**Hospital3 474**]). Grew up in [**Location (un) 12526**], NY and
worked as teacher, SW, guidance counselor. Was married and had
2 children; wife passed away in [**2158**]. Daughter is a
psychiatrist in [**Location (un) 42**] area.
Family History:
Son died of a brain tumor at age 19 in [**2160**].
Physical Exam:
PE: 96.8 88 145/69 18 97%RA
NAD AOx3
CTAB
RRR
soft NT ND 2 large ventral hernias, left of midline easily
reducible, midline more difficult ? reduced, +bs
no c/c/e
guiac neg, lots impacted stool in vault
Pertinent Results:
[**2192-9-12**] 02:30AM BLOOD WBC-13.1*# RBC-3.84* Hgb-12.0* Hct-34.0*
MCV-89 MCH-31.2 MCHC-35.3* RDW-14.4 Plt Ct-235
[**2192-9-14**] 02:14AM BLOOD WBC-11.4* RBC-3.15* Hgb-9.6* Hct-28.8*
MCV-91 MCH-30.7 MCHC-33.6 RDW-14.2 Plt Ct-187
[**2192-9-18**] 05:40AM BLOOD WBC-8.1 RBC-2.74* Hgb-8.5* Hct-25.1*
MCV-92 MCH-31.0 MCHC-33.8 RDW-15.0 Plt Ct-260
[**2192-9-12**] 12:33PM BLOOD PTT-59.9*
[**2192-9-15**] 01:50AM BLOOD PT-13.0 PTT-31.0 INR(PT)-1.1
[**2192-9-18**] 05:40AM BLOOD Plt Ct-260
[**2192-9-12**] 02:30AM BLOOD Glucose-161* UreaN-49* Creat-2.3* Na-139
K-3.9 Cl-106 HCO3-20* AnGap-17
[**2192-9-14**] 04:20PM BLOOD Glucose-129* UreaN-32* Creat-1.1 Na-141
K-2.9* Cl-111* HCO3-21* AnGap-12
[**2192-9-19**] 05:40AM BLOOD Glucose-132* UreaN-11 Creat-0.9 Na-144
K-3.9 Cl-112* HCO3-24 AnGap-12
[**2192-9-7**] 04:40PM BLOOD TotProt-7.4 Albumin-4.4 Globuln-3.0
Calcium-9.9 Phos-3.9 Mg-2.2
[**2192-9-12**] 02:30AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.0
[**2192-9-19**] 05:40AM BLOOD Calcium-7.3* Phos-3.4 Mg-2.0
[**2192-9-11**] 11:18PM BLOOD Type-ART pO2-69* pCO2-28* pH-7.49*
calTCO2-22 Base XS-0
[**2192-9-12**] 12:53PM BLOOD Type-ART pO2-60* pCO2-27* pH-7.48*
calTCO2-21 Base XS--1
[**2192-9-15**] 02:00AM BLOOD Type-ART pO2-117* pCO2-36 pH-7.41
calTCO2-24 Base XS-0
CT Scan [**2192-9-13**]
1. Continued small bowel obstruction, with a transition point in
an umbilical
hernia, with associated skin thickening overlying the umbilical
hernia. These
findings are compatible with an incarcerated hernia. No findings
to suggest
associated ischemia.
2. Heterogeneous exophytic right renal lesion, likely reflecting
an
angiomyolipoma.
3. Diffuse metastatic prostate osseous lesions.
4. Previously noted polypoid lesion arising from the fundal wall
of the
stomach is not well evaluated due to obscuration by contrast.
[**2192-9-18**] KUB
THREE VIEWS OF THE ABDOMEN demonstrate residual contrast in the
ascending and
transverse colon. Air is seen through the bowel to the rectum.
There is
dilation of the sigmoid colon to approximately 6 cm. No
air-fluid levels or
free air is identified. Interval placement of multiple surgical
clips in the
upper abdomen and subcutaneous staples over the right upper and
lower abdomen
are noted. Sclerotic foci about both sacroiliac joints are again
noted and
unchanged. If there is any concern for osseous metastatic
lesions,
correlation with a bone scan is recommended.
Brief Hospital Course:
See addendum
Medications on Admission:
vit D3 400U daily, remeron 45 qhs, zyprexa 7.5 qhs, flomax 0.4',
ASA 81', omega-3 FA 1000mg cap, klonopin 0.25mg [**Hospital1 **], calcium
250, vit B12 1000mcg, effexor XR 150 (1.5 tabs daily), garlic
1mg, lupron depot 3.75mg IM kit, miralax 17g powder packet
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lupron Subcutaneous
5. Polyethylene Glycol 3350 Oral
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
7. Calcium Oral
8. Cyanocobalamin Oral
9. Garlic Oral
10. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
11. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for agitation.
12. Haloperidol 1 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime).
13. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
14. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One
(1) Tablet PO BID (2 times a day) for 1 days: This is a taper of
his home dose with Psychiatry recommendation to discontinue. .
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
19. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
21. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
22. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
24. Insulin Regimen
Insulin SC Sliding Scale
Fingerstick q6hrs--Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-50 mg/dL 4 oz. Juice
51-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
351-400 mg/dL 10 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
Discharge Diagnosis:
1. Small bowel obstruction
2. Ventral Hernia
3. Urinary Tract Infection
4. Aspiration Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have 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.
* 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.
Activity:
No heavy lifting of items [**9-19**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
A polypoid lesion on the anterior wall of the gastric fundus was
noted on your CT scan. Please follow-up with your primary care
phyiscian for a possible EGD.
You have a follow-up appointment with Dr. [**Last Name (STitle) **] on [**9-28**]
at 1PM. [**Hospital Ward Name **] Building, [**Location (un) 1826**]. [**Hospital1 **].
Please call with questions. [**Telephone/Fax (1) 1969**]
Please follow-up with your psychiatrist Dr. [**Last Name (STitle) 12527**] following
discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 560**] MD [**MD Number(1) 561**]
Completed by:[**2192-9-22**] Name: [**Known lastname 3936**],[**Known firstname 1523**] Unit No: [**Numeric Identifier 12525**]
Admission Date: [**2192-9-7**] Discharge Date: [**2192-9-22**]
Date of Birth: [**2112-7-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 559**]
Addendum:
Please see updated D/C meds
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lupron Subcutaneous
5. Polyethylene Glycol 3350 Oral
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
7. Calcium Oral
8. Cyanocobalamin Oral
9. Garlic Oral
10. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
once a day.
11. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for agitation.
12. Haloperidol 1 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime).
13. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
14. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One
(1) Tablet PO BID (2 times a day) for 1 days: This is a taper of
his home dose with Psychiatry recommendation to discontinue. .
15. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
19. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
21. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
22. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
24. Insulin Regimen
Insulin SC Sliding Scale
Fingerstick q6hrs--Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-50 mg/dL 4 oz. Juice
51-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
351-400 mg/dL 10 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 560**] MD [**MD Number(1) 561**]
Completed by:[**2192-9-22**]
|
[
"584.5",
"041.4",
"507.0",
"599.0",
"V10.46",
"293.9",
"401.9",
"296.30",
"552.21",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.51",
"45.02",
"96.71",
"99.15",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
21226, 21447
|
13959, 13973
|
10288, 10323
|
16653, 16660
|
11539, 13936
|
17983, 19041
|
11248, 11300
|
19064, 21203
|
16534, 16632
|
13999, 14260
|
16684, 17614
|
11315, 11520
|
10211, 10250
|
17626, 17960
|
10351, 10752
|
1332, 1537
|
10774, 10956
|
10972, 11232
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,063
| 193,685
|
40973
|
Discharge summary
|
report
|
Admission Date: [**2188-8-13**] Discharge Date: [**2188-8-28**]
Date of Birth: [**2103-10-5**] Sex: F
Service: MEDICINE
Allergies:
hay fever / grass pollen-[**Doctor Last Name **], std
Attending:[**First Name3 (LF) 4057**]
Chief Complaint:
Hematochezia, AF with RVR
Major Surgical or Invasive Procedure:
Colonic stent placement
History of Present Illness:
The patient is an 84F with atrial fibrillation on coumadin,
recently diagnosed rectal/sigmoid mass, transferred to MICU for
atrial fibrillation with RVR. She endorses intermittent
hematochezia since [**Month (only) 958**]. She underwent flexible sigmoidoscopy
on [**2188-8-13**] and was found to have a near obstructing lesion at
10-15cm (distal sigmoid/rectum). A cold forceps biopsy was
obtained. After the procedure she had worsening abdominal pain
and was admitted to colorectal surgery service for further
management. She has been strictly NPO and her atrial
fibrillation has been managed with lopressor 12.5mg IV Q4 and
diltiazem 10mg boluses. However, her heart rate has remained
difficult to control - mostly in 110s-120s with intermittent
runs to 150s.
Past Medical History:
-atrial fibrillation
-asthma
-hypertension
-hyperlipidemia
-osteoporosis
-no prior surgeries
Social History:
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
NC
Physical Exam:
ON ADMISSION:
Vitals: 97.4 153/102 132 24 97%1LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP not elevated
Lungs: decreased bs at bases, wheezes right
CV: S1, S2 irregular rhythm, increased rate, no murmurs
Abdomen: soft, + BS, distended, mild diffuse TTP
GU: no foley
Ext: trace edema bilaterally, pulses 2+ peripherally
.
On Discharge:
Vitals: 95.3, 110/60, 91, 16, 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP not elevated
Lungs: CTAB
CV: RRR, normal S1S2, no MRG
Abdomen: soft, + BS, distended
GU: no foley
Ext: trace edema bilaterally, pulses 2+ peripherally
Pertinent Results:
Labs on Admission:
[**2188-8-13**] 06:20PM BLOOD WBC-7.6 RBC-4.85 Hgb-14.9 Hct-44.3 MCV-91
MCH-30.7 MCHC-33.7 RDW-14.0 Plt Ct-286
[**2188-8-13**] 06:20PM BLOOD Neuts-71.0* Lymphs-20.8 Monos-6.3 Eos-1.1
Baso-0.9
[**2188-8-13**] 06:20PM BLOOD PT-14.3* INR(PT)-1.2*
[**2188-8-13**] 06:20PM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-137
K-2.8* Cl-98 HCO3-26 AnGap-16
[**2188-8-17**] 11:35AM BLOOD ALT-14 AST-24 LD(LDH)-258* AlkPhos-50
TotBili-0.9
[**2188-8-17**] 04:26PM BLOOD Lipase-14
[**2188-8-13**] 06:20PM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1
[**2188-8-19**] 04:09AM BLOOD CK-MB-4 cTropnT-<0.01
[**2188-8-19**] 04:55PM BLOOD CK-MB-4 cTropnT-<0.01
[**2188-8-19**] 04:09AM BLOOD Triglyc-69
[**2188-8-17**] 04:26PM BLOOD Osmolal-280
[**2188-8-15**] 06:30AM BLOOD CEA-5.6*
[**2188-8-17**] 07:29PM URINE Osmolal-585
[**2188-8-17**] 07:29PM URINE Hours-RANDOM Creat-70 Na-85 K-57 Cl-186
[**2188-8-19**] 05:19AM URINE CastHy-43*
[**2188-8-19**] 05:19AM URINE RBC->182* WBC-22* Bacteri-FEW Yeast-NONE
Epi-0
[**2188-8-19**] 05:19AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2188-8-19**] 05:19AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2188-8-17**] 7:29 pm URINE Source: Catheter.
Pertinet results during admission:
URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE, PRESUMPTIVELY NOT S.
SAPROPHYTICUS. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
[**8-14**] CT Torso:
1. Heterogeneously enhancing, likely malignant mass in the low
sigmoid, with upstream fecal loading, suggesting a degree of
obstruction. A 16-mm enhancing right external iliac lymph node
and an 11-mm left lower lobe pulmonary nodule are concerning for
metastatic disease.
2. Multiple small hepatic hypodensities, nonspecific, though
warranting
attention on followup studies.
3. No convincing evidence of perforation related to recent
sigmoidoscopy.
Fluid density structures with peripheral enhancement measuring
up to 2.5 cm at the left aspect of the sigmoid mass may reflect
necrosis within the mass.
4. Ectasia of the ascending aorta, measuring up to 4.2 cm.
5. Small bilateral pleural effusions, with associated
atelectasis.
[**8-16**] MRI Pelvis:
1. Locally invasive rectal mass located 10 cm from anal verge
with
longitudinal dimension of 3.5 cm. Findings are suggestive of
tumor
involvement of the uterus suggesting T4 disease.
2. Extensive mesorectal lymphadenopathy with posterior
perirectal nodes
touching the CRM and right external iliac node consistent with
metastasis.
3. Possible conglomerate of centrally necrotic nodes,
superolateral and to
the left of the mass measuring 2 x 2.6 cm. This could also
represent a
contained collection from localized tumor perforation or
necrotic extension of
the primary mass.
[**8-21**] CXR: Lung volumes are low. Right PICC follows a normal
course terminating in the upper SVC. Diffuse parenchymal opacity
has slightly
increased on the right. There are small bilateral pleural
effusions, slightly
decreased on the right and trace on the left. Associated
compressive
atelectasis at the right base is noted. Cardiomegaly is
unchanged.
Atherosclerotic calcification of the aortic arch is present,
with tortuosity
of the thoracic aorta.
.
Colonoscopy [**2188-8-20**]
A near completely obstructing mass was seen at 10 cm from the
anal verge consistent with newly diagnosed cancer.
A 0.035in Jagwire was placed through the stricture. Contrast was
injected via an extraction balloon catheter. A 3 cm long severe
malignant stricture was seen. Under fluoroscopy and direct
endoscopic view, a 6cm by 25mm WallFlex uncovered metal colonic
stent was placed successfully across the stricture. The position
was confirmed with the fluoroscopy and endoscopy. Massive liquid
stool came out.
.
Sigmoidoscopy [**2188-8-13**]
Mass in the rectum at a distance between 10 cm and 15 cm
(biopsy)
Internal & external hemorrhoids
Otherwise normal sigmoidoscopy to splenic flexure
.
Dicharge labs:
.
[**2188-8-28**] 07:03AM BLOOD WBC-10.2 RBC-3.85* Hgb-11.9* Hct-35.9*
MCV-93 MCH-31.0 MCHC-33.3 RDW-14.2 Plt Ct-387
[**2188-8-22**] 06:11AM BLOOD Neuts-83.9* Lymphs-9.1* Monos-5.1 Eos-1.5
Baso-0.3
[**2188-8-28**] 07:03AM BLOOD Glucose-98 UreaN-14 Creat-0.7 Na-140
K-3.4 Cl-104 HCO3-29 AnGap-10
[**2188-8-28**] 07:03AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
Brief Hospital Course:
This is the brief hospital course for an 84 year-old female with
atrial fibrillation on coumadin, recently diagnosed with a
rectal/sigmoid mass who was transferred to the MICU for atrial
fibrillation with RVR and then brought out to the floor for
planning and management of her newly diagnosed malignancy.
.
# AF with RVR: Pt. was transferred to MICU given continued RVR
and managed with a diltiazem gtt. She was transitioned to PO
metoprolol and diltiazem with improvement - discharged on
Metoprolol 50mg PO daily and Diltiazem 360mg PO daily with heart
rates in the 90s. She was also started on lasix to decrease
atrial stretch, which was effective. Anticoagulation was held at
admission for surgery and not restarted.
.
# Rectal Mass: The pt. was found to have a rectal mass on
sigmoidoscopy. Biopsy showed adenocarcinoma. MRI pelvis also
revealed involvement of lymph nodes and uterus, indicating
likely stage IV disease. Heme/Onc was consulted and recommended
relief of obstruction and likely chemo as outpatient. Surgery
continued to follow and ERCP placed colonic stent. She was
started on a diet post procedure and tolerated and her symptoms
improved and she had bowel movements.
.
# UTI: The patient was started on Vancomycin/Cefepime at
admission for UTI. Urine culture grew enterococcus sensitive to
ampicillin. Antibiotics were changed to Ampicillin on [**8-22**] for
planned 7 day course. UTI symptoms resolved. A repeat urine
culture is pending at the time of discharge.
#. CODE: DNR/DNI
TRANSITIONAL ISSUES:
- f/u Urine culture
- f/u appointment with Oncology to determine treatment options
for rectal cancer Monday [**2188-9-1**]
Medications on Admission:
-atenolol 100mg daily
-losartan 100mg daily
-HCTZ 25mg daily
-coumadin 1.25mg mg 5x week, 2.5mg twice week
-colase
-PEG QOD
-tylenol PRN
-KCL 10mg daily
Discharge Medications:
1. 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*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
Disp:*60 Capsule, Extended Release(s)* Refills:*2*
7. Tylenol 325 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
8. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day.
9. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Rectal adenocarcinoma
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 724**], you presented with abdominal pain, nausea, and
intermittent bloody stools. An obstructing lesion was found in
your rectum. During your stay, we also found that you had high
heart rate and that your heart medications needed to be altered.
For your rectal mass, a stent was placed in your colon in order
to alleviate the blockage, and your pain and bloody stools
resolved.
The following changes have been made to your medications:
#. STOP Atenolol
#. START Metoprolol daily
#. START Diltiazem daily
#. STOP Coumadin
#. STOP Hydrochlorothiazide
#. STOP Losartan
#. START Lasix.
#. START Multivitamin
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2188-9-1**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2188-9-1**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 24186**] [**Last Name (NamePattern1) 24187**]
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2188-9-1**] 10:00
Completed by:[**2188-8-28**]
|
[
"V58.61",
"196.6",
"455.3",
"198.82",
"428.0",
"428.31",
"401.9",
"560.89",
"733.00",
"272.4",
"280.0",
"154.1",
"493.90",
"263.9",
"455.0",
"427.31",
"599.0",
"275.3",
"276.8",
"041.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.86",
"38.97",
"48.24",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9927, 9997
|
6850, 8354
|
340, 365
|
10134, 10134
|
2099, 2104
|
10967, 11656
|
1366, 1370
|
8703, 9904
|
10018, 10018
|
8525, 8680
|
10314, 10944
|
1385, 1385
|
1786, 2080
|
8375, 8499
|
275, 302
|
3434, 6827
|
393, 1157
|
10037, 10113
|
2118, 3399
|
10149, 10290
|
1179, 1274
|
1290, 1350
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,114
| 183,312
|
21544
|
Discharge summary
|
report
|
Admission Date: [**2140-11-20**] Discharge Date: [**2140-12-13**]
Date of Birth: [**2063-5-18**] Sex: F
Service: MEDICINE
Allergies:
Zomig
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Unresponsive.
Major Surgical or Invasive Procedure:
Intubation.
History of Present Illness:
77 yo F with hx asthma, CHF, PAF, and OSA, found unresponsive at
psychiatyric facility with hypercarbic resp failure. She was
found with sat of 87% and while asleep 62%. She was recently
transfered from [**Hospital3 **] to [**Hospital1 **] HRI [**11-18**]. Pt has had
previous desats prior to yesterday. She was then given 40mg po
lasix, 1 mg ativan, and alb nebs. When arrived in ED, she was
given narcan and started on BIPAP. ABG 7.24/94/140/42.
Pt improved on BIPAP in ED and repeat ABG 7.28/85/129/42.
Past Medical History:
Dementia
A-fib
HTN
OA
hypothyroidism
Asthma
Social History:
She has been a resident of [**Location **] nursing homes. She was most
recently at Life center, [**Hospital3 2005**] then [**Hospital1 **] HRI, but had
previously been at [**Hospital3 **]. Her daughter [**Name (NI) **] [**First Name8 (NamePattern2) **]
[**Name (NI) 56783**] [**Telephone/Fax (1) 56784**] and her son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 56785**]
beeper are very involved in her care. She is mostly Portuguese
speaking but she does understand some English.
Physical Exam:
in ED
T 99.4 P 80 BP 112/palp Sat 98% on BIPAP
Gen - unresponsive except moans
HEENT - Pupils 2mm ERRL
Chest - CTA B anteriorly with occ upper airway sounds.
Cor - RRR nl s1/s2 no murmurs
Abd - soft obese, pos BS
Ext - trace edema
Neuro - minimally responsive to touch/pain
More recent exam:
[**2140-12-1**].
Vitals: Tm = 99.6, Tc = 98.1 BP = 120-152/68-78, P = 69-85, RR =
18-20, BS = 102-183, 93-94% on RA.
Gen: Obese female laying in bed. No acute distress. Cervical
collar not in place.
-Chest: CTA B anteriorly and posteriorly with good inspiratory
effort.
-Cor: RRR nl s1/s2
-Abd: soft obese, pos BS
-Ext: 2+ DPP appreciated bilaterally.
Right arm: 2-4 cm friction blister with skin breakdown and
serosang ooze covered by duoderm patch.
Pertinent Results:
[**2140-11-20**] 03:44AM TYPE-ART PO2-129* PCO2-85* PH-7.28* TOTAL
CO2-42* BASE XS-9
[**2140-11-20**] 02:47AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2140-11-20**] 02:47AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
[**2140-11-20**] 02:47AM URINE RBC-1 WBC-1 BACTERIA-RARE YEAST-NONE
EPI-1
[**2140-11-20**] 02:47AM URINE HYALINE-1*
[**2140-11-20**] 02:20AM GLUCOSE-103 UREA N-20 CREAT-0.8 SODIUM-148*
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-36* ANION GAP-11
[**2140-11-20**] 02:20AM CK(CPK)-35
[**2140-11-20**] 02:20AM cTropnT-<0.01
[**2140-11-20**] 02:20AM CK-MB-2
[**2140-11-20**] 02:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-11-20**] 02:20AM WBC-5.9 RBC-3.93* HGB-11.9* HCT-36.7 MCV-93
MCH-30.3 MCHC-32.4 RDW-13.0
[**2140-11-20**] 02:20AM NEUTS-51.6 LYMPHS-36.8 MONOS-7.5 EOS-3.2
BASOS-0.9
[**2140-11-20**] 02:20AM PLT COUNT-121*
[**2140-11-20**] 02:16AM TYPE-ART PO2-140* PCO2-94* PH-7.24* TOTAL
CO2-42* BASE XS-9
[**2140-11-20**] 02:16AM HGB-12.5 calcHCT-38
[**2140-11-20**] 06:59AM TYPE-ART RATES-/14 PEEP-8 O2-40 PO2-128*
PCO2-105* PH-7.19* TOTAL CO2-42* BASE XS-8 INTUBATED-NOT INTUBA
VENT-SPONTANEOU COMMENTS-CPAP
Admission Chest AP:
Allowing for technique, cardiac and mediastinal contours are
likely normal. Patchy opacity is seen in the left lower
lobe/lingular area. The right lung appears clear. There is
slight biapical pleural thickening. Pulmonary vasculature is
normal. Several calcified nodes are seen in the left hilum. In
addition, there appears to be a calcified granuloma in the right
upper lobe. There may be a small left pleural effusion. The
osseous structures are unremarkable.
IMPRESSION:
1. Left lower lobe/lingular patchy consolidation.
2. Calcified nodes/granuloma suggestive of past granulomatous
infection.
EKG NSR 78bpm, nl axis, no ST or T wave changes
[**2140-12-2**]: Chest AP
The heart is enlarged but stable. The aorta is tortuous. There
are calcified lymph nodes in the AP window and left hilum and
there are calcified granulomas in the left mid and right upper
lung zones. These findings, as well as an area of right apical
thickening are stable. The lungs demonstrate no focal areas of
consolidation. No definite pleural effusions are identified on
the single projection.
As compared to the recent study, there is improved visualization
of the left retrocardiac area.
Brief Hospital Course:
77 yo F with dementia, CHF? who presentedunresponsive at psych
facility with hypercarbic respiratory failure.
*
1) Respiratory Failure- We thought that her respiratory failure
was multifactorial in etiology. The patient is perhaps
hypercarbic at baseline. Pt likely hyper carbic at base line.
We thought that pnemonia exacerbated her possible COPD/OSA/
obesity hypoventilation to the point where she decompensated.
We also found that a pannus in the upper cervical spine which
might have contributed to the patient's apnea. (see neuro
below). The patient was transferred to the MICU where she was
intubated then weaned to pressure support and then successfully
extubated on [**11-23**]. She was then weaned off oxygen onto room
air.
*
2)Pneumonia exaceCeftriaxone/azith were started on admission
which was eventually changed to levofloxacin such that she
completed a 10 day course.
*
3)Obstructive sleep apnea: She continued to desaturate
periodically at night for which she was started on bipap with
good effect but the patient refused to wear the bipap mask. She
also underwent an inpatient sleep study but this was terminated
early secondary to her refusal to wear the bipap mask. (An
interpreter was present.)
*
4)Psych - Pt was originally started on her home psych meds (see
meds on admission). However zyprexa and depakote were stopped
due to possible respiratory depression. Psychiatry was
consulted and they thought that the patient had dementia and
resolving delerium. Her standing haldol was discontinued and
she was started on zyprexa prn agitation.
*
5) Neuro - CT of the head demonstrated basal ganlia lesion and a
pannus in the upper cervical spine. MRI done to further
evaluate which demonstrated: a Posterior vertebral pannus
formation C1-C2, with compression/stenosis of the spinal cord as
it exits the foramen magnum. There was no evidence of
intracranial hemorrhage, or minor or major vascular territorial
infarction. Chronic lacunar infarcts were also observed
Neurosurg consulted. The spoke to the pts home neurosurgeon at
[**Hospital 189**] Hospital and found that this was a problem that had
already been worked up. Because of her poor baseline functional
status the pt was felt to be a poor surgical candidate. She was
placed in a cervical collar which she refused to wear.
*
6)In light of the continued improvement in her mental status we
(the medical team and the patient's family) thought that it
would be best if the patient were transferred to a rehab/long
term care center where she could prepare for the upcoming
surgery should her family decide to procede. At this time the
family deferred surgery in light of her condition.
Medications on Admission:
KCl 10mg qday
Lasix 40mg qday
Prozac 20mg qday
Celebrex 20mg qday
Colace 100 mg [**Hospital1 **]
Ecotrin 81 mg qday
Protonix 40mg qday
Depakotote 250mg qam/ 500mg qpm
Zyprexa 10mg [**Hospital1 **]
Abilify 10mg qam
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15290**] [**Hospital **] Care Center
Discharge Diagnosis:
Primary:
1. Hypercarbic Respiratory Failure.
2. Pannus posterior to Odontoid at C2 with compression of the
cervicomedullary junction.
3. Degenerative disc disease from C3 through C6 with spinal cord
compression.
4. Dementia/Agitation.
Secondary:
1. Atrial Fibrillation (not corroborated).
2. Obstructive Sleep Apnea.
3. Hypothyroidism.
4. Hypertension.
Discharge Condition:
Good. Able to eat, interactive, at her baseline.
Discharge Instructions:
Please return to the emergency room if you experience shortness
of breath, difficulty breathing, chest pain, fevers or chills.
Please take all of your medications as prescribed.
Followup Instructions:
Please call Dr. [**First Name (STitle) 742**] [**Name (STitle) **] MD at [**Telephone/Fax (1) 1669**] to
follow up with regard to potential neck surgery.
|
[
"518.81",
"478.29",
"401.9",
"564.00",
"285.29",
"491.21",
"278.1",
"293.0",
"486",
"780.57",
"244.9",
"V15.81",
"294.8",
"722.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"93.90",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7633, 7709
|
4698, 7369
|
281, 295
|
8106, 8156
|
2197, 4675
|
8384, 8541
|
7730, 8085
|
7395, 7610
|
8180, 8361
|
1431, 2178
|
228, 243
|
323, 838
|
860, 906
|
922, 1416
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,786
| 150,050
|
42955
|
Discharge summary
|
report
|
Admission Date: [**2153-2-11**] Discharge Date: [**2153-2-27**]
Date of Birth: [**2096-12-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Compazine / Lipitor / Percocet
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Unstable angina
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x 5
(LIMA-LAD,SV-Dg1,SV-Dg2,SV-OM,SV-RCA) [**2153-2-16**]
Left heart catheterization, coronary angiogram
right closed thoracostomy
History of Present Illness:
This 56 year old male with hyperlipidemia has a 3 year history
of stable, exertional angina. He has deferred catheterizationa
dnposiible interventions. Over the past few months his
episodes have increased in frequency and with less exertion,
being precipitated with the cold weather. There was a
reversible inferior wall defect on a nuclear stress test a year
ago.
He awoke with angina the night of admission lasting 10 minutes,
followed by nausea and vomiting. He had recurrent pain in the ED
where he was given ASA and lovenox.
Catheterization revealed triple vessel disease with a left main
component. He was referred for revascularization.
Past Medical History:
recently diagnosed Bell's palsy
hypertension
hyperlipidemia
Migraines
depression
benign prostatic hypertrophy
Social History:
Never smoked.
Drinks wine occasionally.
Family History:
Father had angina starting in 50s and died in 70s of CHF vs
Emphysema
Physical Exam:
Discharge:
VS T99.2 BP 100/57 HR 75-SR RR 20 O2sat 94%-RA
General: Pale appearing male w/ right facial drop from Bells
Palsey in NAD.
HEENT: right facial droop. Right eye w/ blurred vision -
corrected w/ eyeglasses. Remainer of HEENT of exam unremarkable.
COR: RRR S1,S2
Chest: Lungs CTA bilat. Sternal incision C/D/I w/ stable
sternum. There is a click noted over the left sternal border at
the articulation of the first rib.
ABD: Large round, softly distended w/ positive bowel sounds.
Passing stool and flatus.
Extrem: trace pedal edema bilat.
Neuro; facial droop as previously stated otherwise intact.
Pertinent Results:
[**2153-2-11**] 10:00PM CK-MB-3 cTropnT-<0.01
[**2153-2-19**] 06:10AM BLOOD WBC-11.8* RBC-2.99* Hgb-9.8* Hct-25.7*
MCV-86 MCH-32.8* MCHC-38.0* RDW-14.8 Plt Ct-268#
[**2153-2-18**] 02:53AM BLOOD Glucose-111* UreaN-17 Creat-1.2 Na-130*
K-3.9 Cl-99 HCO3-29 AnGap-6*
[**2153-2-27**] 05:35AM BLOOD WBC-10.6 RBC-3.29* Hgb-9.9* Hct-28.1*
MCV-86 MCH-30.1 MCHC-35.2* RDW-15.4 Plt Ct-427
[**2153-2-27**] 05:35AM BLOOD Plt Ct-427
[**2153-2-23**] 04:58AM BLOOD PT-13.4 PTT-34.2 INR(PT)-1.1
[**2153-2-27**] 05:35AM BLOOD Glucose-100 UreaN-12 Creat-1.1 Na-137
K-3.5 Cl-102 HCO3-28 AnGap-11
[**2153-2-23**] 04:58AM BLOOD ALT-23 AST-24 LD(LDH)-281* AlkPhos-58
Amylase-53 TotBili-0.7
[**2153-2-12**] 11:30AM BLOOD %HbA1c-5.4
[**2153-2-12**] 11:30AM BLOOD Triglyc-93 HDL-38 CHOL/HD-3.8 LDLcalc-86
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 92708**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 92709**] (Complete)
Done [**2153-2-16**] at 9:51:47 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2096-12-4**]
Age (years): 56 M Hgt (in): 65
BP (mm Hg): 145/78 Wgt (lb): 192
HR (bpm): 67 BSA (m2): 1.95 m2
Indication: Intraoperative TEE for CABG procedure. Coronary
artery disease. Hypertension. Left ventricular function.
Preoperative assessment. Shortness of breath. Valvular heart
disease.
ICD-9 Codes: 786.05, 786.51, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2153-2-16**] at 09:51 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Limited Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2009AW1-: Machine: [**Doctor Last Name 11422**] 3D
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 2.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 4 mm Hg < 20 mm Hg
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.14
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2. Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7. Dr. [**Last Name (STitle) 914**] was notified in person of the results on
[**2153-2-16**] at 830am.
8. Very poor transgastric views.
Post Bypass
1. Patient is in sinus rhythm and receiving an infusion of
phenylephrine.
2. Biventricular systolic function is preserved.
3. Aorta intact post decannulation.
4. Mitral regurgitation is trivial.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2153-2-16**] 15:01
=
=
=
=
=
=
=
=
=
================================================================
SUPINE AND ERECT ABDOMINAL RADIOGRAPHS
INDICATION: Postoperative ileus, evaluate for interval change.
COMPARISON: [**2153-2-20**].
FINDINGS: The patient has had recent CABG with persistent
dilated loops of
air and fluid filled large bowel consistent with postoperative
ileus. There is no pneumatosis however cecal loops measure up to
12cm, There are surgical clips in the left upper quadrant. There
is no free air. There is a degenerative change in the lumbar
spine. There is persistent retrocardiac atelectasis.
IMPRESSION: Severe colonic ileus without pneumatosis. Consider
rectal tube
for decompression.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**First Name8 (NamePattern2) **] [**2153-2-22**] 11:58 PM
=
=
=
=
=
=
=
================================================================
SUPINE AND ERECT ABDOMINAL RADIOGRAPHS
INDICATION: Postoperative ileus, evaluate for interval change.
COMPARISON: [**2153-2-20**].
FINDINGS: The patient has had recent CABG with persistent
dilated loops of
air and fluid filled large bowel consistent with postoperative
ileus. There is no pneumatosis however cecal loops measure up to
12cm, There are surgical clips in the left upper quadrant. There
is no free air. There is a degenerative change in the lumbar
spine. There is persistent retrocardiac atelectasis.
IMPRESSION: Severe colonic ileus without pneumatosis. Consider
rectal tube
for decompression.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**First Name8 (NamePattern2) **] [**2153-2-22**] 11:58 PM
=
=
=
=
=
=
=
=
================================================================
[**Known lastname 92708**],[**Known firstname **] [**Medical Record Number 92710**] M 56 [**2096-12-4**]
Radiology Report CHEST (PA & LAT) Study Date of [**2153-2-26**] 2:38 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2153-2-26**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 92711**]
Reason: eval sternal integrity
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with "chest pain" probable muscular
REASON FOR THIS EXAMINATION:
eval sternal integrity
COMPARISON: [**2153-2-24**].
PA AND LATERAL CHEST RADIOGRAPHS: There is no evidence of
sternal dehiscence. Lung volumes are again low with bibasilar
atelectasis that is overall unchanged. There are small bilateral
pleural effusions. There is no pneumothorax.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: [**First Name8 (NamePattern2) **] [**2153-2-27**] 10:02 AM
=
=
=
=
=
=
=
=
=
================================================================
[**Known lastname 92708**],[**Known firstname **] [**Medical Record Number 92710**] M 56 [**2096-12-4**]
Cardiology Report C.CATH Study Date of [**2153-2-12**]
BRIEF HISTORY:
Mr. [**Known lastname **] is a 56 year old man with a history of chronic
stable
angina, hypertension, and hypercholesterolemia who presented
with
unstable angina and negative cardiac markers. He had a stress
echo one
year ago that showed reversible inferior wall and distal septal
hypokinesis at peak exercise. He is now referred for cardiac
catheterization for evaluation of his coronary arteries.
INDICATIONS FOR CATHETERIZATION:
Unstable angina
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French left [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Supravalvular Aortography: was performed in the 30 degrees [**Doctor Last Name **]
projection, using 40 ml of contrast injected at 20 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: m2
HEMOGLOBIN: gms %
FICK REST
**PRESSURES
AORTA {s/d/m} 131/75/83
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 60
2) MID RCA DIFFUSELY DISEASED
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DISCRETE 50
6) PROXIMAL LAD DISCRETE 60
6A) SEPTAL-1 NORMAL
7) MID-LAD DISCRETE 90
8) DISTAL LAD NORMAL
9) DIAGONAL-1 DISCRETE 50
10) DIAGONAL-2 DISCRETE 60
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 DISCRETE 50
15) OBTUSE MARGINAL-2 NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour31 minutes.
Arterial time = 0 hour25 minutes.
Fluoro time = 7.2 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 85 ml
Premedications:
Fentanyl 25 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Versed 1 mg iv
Zofran 4 mg iv
Nitroglycerin 20 mcg/min iv gtt
Cardiac Cath Supplies Used:
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
5FR [**Company **], MULTIPACK
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
three vessel coronary artery disease. The LMCA had a 50% distal
stenosis. The LAD had a proximal 60% stenosis followed by an
aneurysmal
segment. The mid LAD had a 90% stenosis and the distal LAD had a
70%
stenosis. The D1 had a 50% lesion at the origin and the D2 had a
60%
stenosis at the origin. The Lcx was small and the OM1 had a
proximal 50%
stenosis. The RCA had an ostial 60% lesion with mild luminal
irregularities. There was visible villing with contrast of the
RA.
2. Limited resting hemodynamics revealed normal central pressure
of
131/75 mmHg.
3. Supravalvular aortography showed minimal aortic
regurgitation, no
dissection and late filling of what is presumably the RA.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Referred for CT surgery
3. Minimal aortic regurgitation.
ATTENDING PHYSICIAN: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Doctor Last Name 28713**],[**Doctor First Name 28714**]
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Brief Hospital Course:
Patient admitted with unstable angina. Following admission he
remained stable on IV NTG. Enzymes were negative for infarction
and cardiac surgical consultation was obtained after
catheterization revealed sever three vessel disease.
On [**2153-2-16**] he went to the Operating Room where quintuple bypass
grafting was performed as noted. He weaned from bypass easily
on low dose neosynephrine.
He remained stable, was extubated and weaned from pressors. He
was transferred to the floor on POD 1. On POD 2 he was found to
have a large right pneumothorax and a CT was placed with re
expansion of the lung. Mediastinal and left CTs were left due
to serous drainage. Left and mediastinal tube were removed,
along with pacing wires on the third postoperative day. There
was no air leak from the right tube, however, it was left in
place. He was diuresed toward his preoperative weight and
mobilization was begun. Pain was controlled with narcotics and
non steroidals. Mr.[**Known lastname **] was placed on a liquid diet due to his
abdominal discomfort- softly distended,with dilated loops of
bowel seen on x-ray, despite his passing flatus and moving his
bowels. Liver function tests were followed, and narcotics
minimized.
He developed progressive colonic dilatation despite feeling
fairly well, passing flatus and having multiple bowel movements.
He was transferred to the ICU due to this. He received
neostigmine twice, without significant change. He felt well,
was mobilized and continued to pass flatus. A rectal tube was
placed, without any change in status. A repeat KUB on [**2-24**] was
significantly improved,the rectal tube was removed and he
transferred back to the floor. He was kept NPO except for
medications.
On POD#6 the right CT was able to be removed. He continued to
progress and he was ready for discharge to home with services on
POD #11. All follow up appointments were advised.
Medications on Admission:
Citalopram [Celexa] 20 mg Tablet QD
Metoprolol Succinate [Toprol XL]50 mg QD
Nitroglycerin [NitroQuick] 0.4 mg Tablet
Simvastatin 80 mg Tablet QD
Sumatriptan [Imitrex] 25 mg Tablet PRN
Aspirin 81 mg Tablet
Multivitamin
Prednisone 60mg qd - day 1 of 6d
Valcyclovir 1000mg - day 1 of 1 week
Discharge Medications:
1. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
5. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: [**2-16**]
Appls Ophthalmic QID (4 times a day) as needed.
Disp:*1 * Refills:*0*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p coronary artery bypass grafts x 5
Unstable Angina
Hyperlipidemia
Bell's Palsy
depression
benign prostatic hypertrophy
migraine headaches
Discharge Condition:
good
Discharge Instructions:
no lifting greater than 10 pounds for 10 weeks
no driving for 4 weeks and off all narcotics
shower daily. no baths or swimming 6 weeks
no lotions, creams or powders to incisions
report any fever greater than 100.5
report any redness of, or drainage from incisions
report any weight gain gretaer than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital 409**] clinic in 2 weeks
Dr. [**First Name8 (NamePattern2) 4559**] [**Last Name (NamePattern1) 58**] in [**2-16**] weeks ([**Telephone/Fax (1) 3329**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] in 2 weeks
please call for appointments
Completed by:[**2153-2-27**]
|
[
"411.1",
"351.0",
"272.4",
"346.90",
"311",
"512.1",
"910.0",
"997.4",
"565.0",
"560.89",
"560.1",
"E928.9",
"414.01",
"600.00",
"E878.2",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.15",
"88.72",
"88.42",
"99.04",
"88.53",
"39.61",
"36.14",
"34.04",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
16874, 16932
|
13851, 15766
|
312, 475
|
17117, 17124
|
2077, 9135
|
17539, 17921
|
1362, 1433
|
16106, 16851
|
9175, 9227
|
16953, 17096
|
15792, 16083
|
13369, 13828
|
17148, 17516
|
1448, 2058
|
12013, 13352
|
10561, 11994
|
257, 274
|
9259, 10528
|
503, 1156
|
1178, 1289
|
1305, 1346
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,375
| 118,708
|
52695
|
Discharge summary
|
report
|
Admission Date: [**2162-2-8**] Discharge Date: [**2162-2-18**]
Date of Birth: [**2104-11-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Massive recurrent ventral hernia
Major Surgical or Invasive Procedure:
1. Component separation muscle flap.
2. Reconstruction of abdominal wall with mesh placement.
History of Present Illness:
HISTORY/INDICATIONS: The patient had a colectomy in the past
with severe abdominal wall infection, treated with an open
abdomen. She presented with a large ventral hernia which she
wished to have repaired. She was seen by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] who
agreed that component separation would be a good approach.
Past Medical History:
Past medical history is diabetes type 2 diabetes on Humulin
insulin 50 units in the morning and 40 units in the evening. She
also has hypertension on cardiogram. H/o colon cancer, Left
hemicolectomy c/b MRSA infection, obesity.
Brief Hospital Course:
The patient was admitted on the day of surgery ([**2162-2-8**]). The
procedure itself was sucessful, and uncomplicated, and there was
minimal blood loss. Please refer to OMR reports for operative
details. The patient tolerated the procedure well, however due
to the replacement of the abdominal contents back into the
abdominal cavity, the anesthesiologist was not able to extubate
at the end of the procedure safely and the patient was therefore
taken intubated but in otherwise stable condition to the ICU.
POD1 she was febrile to 102.4, her urine output decreased and
she became hypotensive. She responded to fluid boluses and
levophed. EKG did not demonstrate any acute changes. Fever
work-up did not point to a clear source however she was started
on vancomycin, levofloxacin and flagyl. Her respiratory status
continued to necessitate the ventilator, and she began to
demonstrate mild CHF as well. Bladder pressure was checked due
to concern for possible abdominal compartment syndrome, however
it was normal and the respiratory failure was felt to be
primarily to the return of abdominal contents into the andominal
cavity in the OR. CT chest/abdomen was obtained on POD2 and was
negative for bowel herniation or other intra-abdominal process
as well as PE. Antibiotics were continued given fever and
elevated wbc (17.5 from 15ish post-surgery) and she remained
stable on pressors and vent. POD3 she was still intermittently
febrile, however she had begun to mobilize fluids and her urine
output picked up. We were also able to begin weaning pressors
and peep and it appeared she might be turning the corner,
however she had been enrolled in the esophageal balloon study
early in the course of her care and study prevented weaning her
vent settings as much or as fast as we otherwise would have. She
received a unit of PRBCs on POD4 for hct of 22.8, pressors were
weaned off, and she also extubated successfully once she was no
longer in the study and her vent settings could be weaned. Her
wbc decreased to normal, she remained afebrile and her cultures
returned negative and on POD5 her abx were discontinued. She
continued to progress clinically, was started on clears and
slowly her diet was advanced. She was transferred to the floor
on POD6 and was started on a full diet the following day. She
was working well with physical therapy and continued to steadily
become stronger over the next several days. Her JP drain
remained in place per plastics given the output was greater than
30cc/day. She is being discharged home on POD10 afebrile,
ambulating well, tolerating a full diet, wound healing nicely.
She is encouraged to wear her abdominal binder as often as
possible and record the daily output of the JP drain. She has
close follow-up as outlined below with both plastics and general
surgery.
Discharge Medications:
1. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Massive recurrent ventral hernia.
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.4 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
Please resume any of your home, pre-hospital medications.
You may resume your regular diet as tolerated.
Please wear abdominal binder as often as possible. Please keep
the area the JP drain clean and dry and record output twice
daily. Please bring the recording to your follow-up plastic
surgery appointment.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Followup Instructions:
Please follow-up within a week with Dr. [**Last Name (STitle) **] of Plastic
Surgery. Please call ASAP to make an appointment. ([**Telephone/Fax (1) 10419**]
Please also call to make an appointment with Dr. [**Last Name (STitle) **] in [**2-19**]
weeks. ([**Telephone/Fax (1) 6449**]
Completed by:[**2162-2-18**]
|
[
"518.81",
"V10.05",
"428.0",
"401.9",
"250.00",
"553.20",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"53.69",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4143, 4149
|
1091, 3903
|
304, 400
|
4227, 4234
|
5316, 5631
|
3926, 4120
|
4170, 4206
|
4258, 5293
|
232, 266
|
428, 817
|
839, 1068
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,447
| 116,609
|
4670
|
Discharge summary
|
report
|
Admission Date: [**2201-6-18**] Discharge Date: [**2201-6-24**]
Date of Birth: [**2158-11-18**] Sex: F
Service: Neurology/MICU/Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 43 year old
woman with a longstanding history of type I diabetes mellitus
end stage renal disease on peritoenal dialysis, atrial
fibrillation with prior right atrial thrombus, hypothyroidism and
chronic hypotension who presented on [**2201-6-18**] with
complaints of headache, and right sided weakness. Family members
noted that she was not acting her usual herself.
She was initially evaluated by Neurology service. MRI confirmed
an ischemic stroke in the left inferior division of the Lt MCA
artery. She was admitted to neurology but was then soon
transferred to the Medical Intensive Care Unit secondary to
the acute development of hypoxia.
PAST MEDICAL HISTORY:
Type I diabetes mellitus, complicated by triopathy.
End stage renal disease, on peritoneal dialysis q. night and
hemodialysis q. two weeks complicated by hypotension.
Atrial fibrillation, with history of right atrial thrombus on
coumadin.
Barrett's esophagus.
Chronic hypotension.
Hypothyroidism.
Osteoporosis.
ALLERGIES: The patient has allergies to Tetracycline,
Erythromycin, Morphine, Dilaudid and Ace inhibitors.
HOME MEDICATIONS:
Midodrine.
Reglan.
Levoxyl.
Nephro-caps.
Renogel.
Phos-Lo.
Amiodarone.
Neurontin.
Protonic.
Vitamin D.
Coumadin, currently 4 mg p.o. q. day.
Epogen.
Humilog insulin sliding scale, Lantis insulin.
Compazine.
Senokot.
Colace.
Lactulose.
Lomotil.
PHYSICAL EXAMINATION: Physical examination at the time of
admission to [**Hospital1 69**] revealed
the following: Vital signs revealed temperature of 97.2;
blood pressure 142/80; heart rate 676 and regular;
respirations 18; and oxygen saturation 98% on two liters of
oxygen. General: The patient was awake and alert, coherent
with fluent speech. HEAD, EYES, EARS, NOSE AND THROAT:
Anicteric. No oral lesions. Moist mucosa. Heart: Regular
rate and rhythm, normal S1 and S2, no murmurs, rubs or
gallops. Lungs: clear to auscultation bilaterally.
Abdomen: Soft, distended with diastole, nontender. Normal
bowel sounds. Extremities: No clubbing or cyanosis, trace
ankle edema. Neurologic: Mental status awake, alert,
oriented, coherent, fluent speech. Cranial nerves: Right
facial droop. Motor: 3/5 strength throughout on the right,
compared to [**5-4**] on the left.
LABORATORY DATA: CBC revealed a white blood cell count of
8.9; hemoglobin of 10.2; hematocrit of 33.4. PT 15.1, INR of
1.6; PTT 26.6. Sodium of 141; potassium of 4.8; chloride of
99; bicarbonate 22; BUN 63; creatinine 8.7; glucose 204.
Initial blood gas was 7.32, 46, 135. Lactate was 1.7.
CT of the head showed no acute intracranial hemorrhage;
probable subacute to chronic left temporal lobe infarct.
MR of the head showed an acute left frontoparietal infarct.
Electrocardiogram showed normal sinus rhythm with a left
axis.
HOSPITAL COURSE:
1.) Acute Stroke presenting with Rt facial droop and mild Rt
hemiparesis. Initial magnetic resonance scan showed an acute
stroke in the medial temporal lobe, left
insula and left posterior parietal lobe. The likely source of
the stroke was embolus from atrial fibrillation and sub-
therapeutic INR.
A cardiac echo was done showing a right atrial thrombus.
Carotid ultrasound did not show significant carotid disease. A
bubble
study was not able to be performed, secondary to a lack of venous
access. Heparin was started and coumadin was loaded. When the
INR came above
two, the heparin was discontinued while the Coumadin was
continued, closely following the INR. Goal INR [**2-2**].
In terms of the patient's right hemiparesis, the patient
slowly regained some strength on her right side throughout
her hospital course. At the time of discharge, she had 5/5
strength in her right lower extremity and 4/5 strength on her
right upper extremity, the patient having most difficulty
with hand grip on the right side. Also during her course,
the patient had episodes of incoherent speech and dysarthriawhich
improved
by the time of discharge. Speech and swallow evaluation showed
aspiratino of thin liquids and she was maintained on puree diet
and thickened liquids. By discharge she was switched to ground
foods and liquids at nectar consistency (thickened).
The patient was loaded with Dilantin for seizure prophylaxis to
be maintained for 4-6 weeks duration . She also is receiving
physical therapy daily with much improvement and she will be
discharged to a rehabilitation center.
2.) Hypoxia: The patient was initially admitted to the
Intensive
Care Unit because of hypoxia. This resolved without specific
intervention. X- ray did show a possible new right lower lobe
infiltrate but, given
the lack of fever and no increased white count, it was most
likely not an infectious process and no antibiotics were
started. It was presumed that this was from aspiration and
represented a chemical pneumonitis.
3.) End stage renal disease: The renal team was following the
patient throughout her visit and she was getting her
peritoneal dialysis five times a day. She was dialyzed less
aggressively than at home to avoid hypotension and to keep
systolic blood pressure at goal of 140 due to the acute stroke.
Patient has a history of too aggressively dialyzing herself at
home with peritoneal dialysis to the point of frequent
hypotension. She was also maintained on midodrine for blood
pressure support.
4.) Atrial fibrillation: The patient was in sinus rhythm
throughout most of her hospital stay. Amiodarone and Coumadin
were continued. Goal INR [**2-2**].
5.) Mental status: The patient's mental status waxed and waned
during her stay in the unit and the first couple of days.
Once transferred to the floor, it was noted that she was
receiving many doses of Haldol. When that was discontinued,
along with her Zyprexa, her mental status improved. She did
exhibit much reversal in sleep cycle and it was emphasized to the
family that she needed to be kept active and awake during the day
so she could sleep at night.
6.) Hypothyroidism: During her hospital stay,
her TSH was noted to be 14. However, her dose of
Levothyroxine was only recently increased and it was decided
to keep her at her current dose and have TSH rechecked in another
months time.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES:
Left frontal parietal stroke.
Subtherapeutic INR.
MEDICATIONS AT DISCHARGE:
Phenytoin 150 mg p.o. three times a day.
Metoclopromide 5 mg p.o. q.i.d.
Calcitriol 0.25 mcg p.o. q. day.
Warfarin 3 mg p.o. q h.s. - INR to be monitored - Goal [**2-2**].
Levothyroxine 88 mcg p.o. q. day.
Aluminum hydroxide 30 mls p.o. three times a day with meals.
Midodrine 5 mg p.o. three times a day.
Atorvastatin 10 mg p.o. q. day.
Epoetin 1,200 units subcutaneous two times per week on
Tuesdays and Fridays.
Docusate sodium 100 mg p.o. twice a day.
Pantoprazole 40 mg p.o. q. day.
Gabapentin 100 mg p.o. three times a day.
Amiodarone 200 mg p.o. q. day.
Nephro-caps, one capsule p.o. q. day.
Lantus Insulin QD
SSI - Regular
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AEH
Dictated By:[**Last Name (NamePattern4) 19744**]
MEDQUIST36
D: [**2201-6-24**] 06:16
T: [**2201-6-24**] 05:31
JOB#: [**Job Number 19745**]
cc:[**2201**]
|
[
"250.61",
"357.2",
"434.11",
"585",
"250.41",
"250.51",
"362.01",
"427.31",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98"
] |
icd9pcs
|
[
[
[]
]
] |
6427, 6490
|
2994, 5677
|
1313, 1558
|
1581, 2322
|
6504, 7386
|
187, 852
|
2339, 2976
|
5693, 6384
|
874, 1295
|
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