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57,592
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|
39385
|
Discharge summary
|
report
|
Admission Date: [**2191-1-7**] Discharge Date: [**2191-1-13**]
Date of Birth: [**2123-10-24**] Sex: M
Service: MEDICINE
Allergies:
Cephalexin / Heparin Agents
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD [**2191-1-8**]
History of Present Illness:
67 year old male with alcoholic cirrhosis who was admitted in
[**2190-6-24**] to [**Hospital1 18**] for alcoholic hepatitis treated with
prednsione 40 mg po qdaily for five days.
.
He reports having progressive shortness of breath for past few
days with inability to even walk to block from unlimited
activity a week ago. He reports no abdominal pain, nausea,
vomiting, hematemesis, BRBPR, dark stools, dysuria, fever,
cough, chest pain, dizziness, palpatations or alcohol use (last
drink 3 weeks ago).
.
He presented to OSH today where he as noted to have dark bloody
stool and hematocrit of 15 along with elevated LFTs.
Unfortunately he refused NG lavage. He was transfused one unit
of PRBC and 2 units of FFP. He was given 750 mg levaquin
emperically and transferred to [**Hospital1 18**] ED with octreotide and
protonix started.
.
In the ED, his intial vitals were 99.0 94 118/76 18 98% RA. He
had guiaic positive but not grossly bloody stool in the vault in
the ED. He was continued on his octreotide and protonix gtt
while switched to ceftriaxone 1 gm q24. His labs were
significant for HCT of 15.4, INR of 2.1, T.Bili of 8.7, lactate
of 7.1, WBC of 17.2, Creatinine of 1.6 and sodium of 131. He was
transferred to [**Hospital1 18**] MICU for futher evaluation and management.
.
In the MICU, he reports feeling well except for right shoulder
pain which hurts with movement.
Past Medical History:
Alcoholic Cirrhosis
Social History:
Last alcoholic beverage was 3 weeks ago. He stopped smoking
twenty years ago. No illicit drug use. Lives alone at home.
Separated from his wife. Retired.
Family History:
No family history of liver disease
Physical Exam:
ADMISSION EXAM
Gen: Male in no acute distress
Vitals: 98.7 128/59 120 100%RA
HEENT: Normocephalic. Nontraumatic. Icteric.
Chest: Clear to auscultation bilaterally. No crackles or
wheezing noted
Heart: Regular rate and rhythm. Systolic murmur heard throughout
Abdomen: Soft and distended. Tenderness to deep palpation.
Shifting dullness to percussion noted.
External: 1+ pitting edema to the knee
Neuro: Alert and oriented to person, place and time. Mild
confusion with recall. Could not tell me who the current
president is. CN 2-12 intact. [**3-29**] muscles strength throughout
except R shoulder strength which was limited due to pain.
Skin: Jaundiced. B/l upper extremity bruises
DISCHARGE EXAM
Vitals: Tm/Tc 99.4/97.5, BP 150/85 (135-155)/(65-85), HR 85
(80-90), RR 20, SaO2 96-100%RA
In: 1560 PO, 100 IV ... Out: 2450, BM x0 (net fluid bal -800)
Gen: NAD
Chest: Clear to auscultation bilaterally. No crackles or
wheezing.
Heart: Regular rate and rhythm. Systolic murmur heard
throughout.
Abdomen: Soft and distended. Tenderness to deep palpation.
Shifting dullness to percussion noted.
Extrem: 2+ pitting edema to the knee bilaterally; RUE now
symmetrical to the LUE but with limited ROM [**1-26**] pain
Neuro: Alert and oriented to person, place and time. [**3-29**] muscle
strength throughout except R shoulder strength which was limited
due to pain.
Skin: Jaundiced. B/l upper extremity bruises.
Pertinent Results:
ADMISSION EXAM
[**2191-1-7**] 08:30PM BLOOD WBC-17.2* RBC-1.57*# Hgb-5.2*# Hct-15.4*#
MCV-98# MCH-33.2* MCHC-34.0 RDW-16.3* Plt Ct-124*
[**2191-1-7**] 08:30PM BLOOD Neuts-90.2* Lymphs-6.8* Monos-2.2 Eos-0.3
Baso-0.4
[**2191-1-7**] 08:30PM BLOOD PT-22.1* PTT-43.9* INR(PT)-2.1*
[**2191-1-7**] 11:35PM BLOOD Ret Aut-4.5*
[**2191-1-7**] 08:30PM BLOOD Glucose-160* UreaN-48* Creat-1.6* Na-131*
K-4.8 Cl-101 HCO3-18* AnGap-17
[**2191-1-7**] 08:30PM BLOOD ALT-17 AST-27 AlkPhos-77 TotBili-8.7*
[**2191-1-7**] 08:30PM BLOOD Lipase-22
[**2191-1-7**] 11:35PM BLOOD Albumin-2.0* Calcium-8.1* Phos-4.1#
Mg-1.6 Iron-123
[**2191-1-7**] 11:35PM BLOOD calTIBC-135* VitB12-GREATER TH
Folate-14.9 Hapto-30 Ferritn-250 TRF-104*
[**2191-1-7**] 08:30PM BLOOD Ammonia-43
[**2191-1-9**] 05:25AM BLOOD AFP-3.6
[**2191-1-7**] 11:46PM BLOOD Lactate-5.2*
[**2191-1-7**] 08:39PM BLOOD Lactate-7.1*
DISCHARGE LABS
[**2191-1-13**] 05:48AM BLOOD WBC-6.9 RBC-3.21* Hgb-10.0* Hct-29.6*
MCV-92 MCH-31.1 MCHC-33.7 RDW-17.0* Plt Ct-70*
[**2191-1-13**] 05:48AM BLOOD PT-23.3* PTT-45.2* INR(PT)-2.2*
[**2191-1-13**] 05:48AM BLOOD Glucose-100 UreaN-13 Creat-0.8 Na-133
K-3.7 Cl-101 HCO3-30 AnGap-6*
[**2191-1-13**] 05:48AM BLOOD ALT-20 AST-38 AlkPhos-117 TotBili-7.2*
[**2191-1-13**] 05:48AM BLOOD Albumin-1.9* Calcium-7.9* Phos-2.1*
Mg-1.8
EKG [**2191-1-7**]
Normal sinus rhythm with low limb lead voltage. Non-specific
ST-T wave
abnormalities. No previous tracing available for comparison.
CXR [**2191-1-8**]
No active disease.
SHOULDER X-RAY [**2191-1-8**]
Mild degenerative arthritic change.
RUE ULTRASOUND [**2191-1-10**]
No evidence of DVT in the right upper extremity.
RUQ ULTRASOUND [**2191-1-10**]
1. Fatty liver with no focal lesions seen. Additionally, there
is a reversal
of portal venous flow in the right and left system as seen on
prior.
2. There is mild intra-abdominal ascites around the liver as
well is in
bilateral lower quadrants, right greater than left.
3. Gallstone with no evidence of cholecystitis. The common bile
duct is
normal in caliber.
4. Splenomegaly.
CT HEAD W/O CONTRAST [**2191-1-12**]
1. No hemorrhage, edema, or evidence of other acute process.
2. Global atrophy, greater than expected for patient's age,
likely related to
history of ethanol abuse, and sequelae of chronic small vessel
ischemic
disease.
TTE [**2191-1-13**]
no vegetations seen
EGD [**2191-1-8**]
Impression: Ulcer in the first part of the duodenum (thermal
therapy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
Mr. [**Known lastname **] is a 67y/o gentleman with alcoholic cirrhosis who was
admitted with dark stools/anemia and was found to have duodenal
ulcer that was treated with gold probe, with stable Hct. His
course was complicated by Strep viridans bacteremia for which he
was treated with antibiotics and he was discharged home.
.
ACTIVE ISSUES
.
# GI bleed: Duodenal ulcer, Hct stable now.
EGD revealed duodenal ulcer which was treated with gold probe.
H. pylori negative. He was treated with PPI, Sucralfate, and
prophylactic Ceftriaxone. His Hct remained stable and he had no
more signs of active bleeding.
.
# Strep viridans bacteremia: unclear source.
He had 1 positive blood culture on [**1-7**], the day of admission.
He was initially started on Vanc but after speciation and
sensitivities returned, he was kept on Ceftriaxone (which he was
on for prophylaxis in the setting of GI bleed anyway). ID
consult was obtained; His access at the time was a right IJ
which was pulled (and cultured), and when blood cultures were
cleared, a PICC line was placed for outpatient antibiotics. TTE
was negative for vegetation and he remained afebrile without any
other psitive culture data. The plan is to treat with
Ceftriaxone for 2 weeks (last day is [**2191-1-21**]). He was
discharged home with VNA and he will follow up with his PCP and
Hepatologist.
.
# Alcohlic cirrhosis with ascites and total body volume
overload: MELD 27.
His diuretics had been held in the ICU and on arrival to the
floor he was total body volume overloaded. He was continued on
his home dose of diuretics: Lasix 40 daily, Aldactone 100 daily
with very good urine output. He will continue on this dose and
follow up with his Hepatologist.
.
# Hyponatremia: likely hypervolemic as well as hypovolemic.
While holding home lasix and aldactone, his hyponatremia
improved slightly, but it was still stable in the setting of
adding back diuretics. Sodium at the time of discharge was 133.
.
# Thrombocytopenia: Due to ESLD
His platelets were monitored and were 60-100 throughout
admission; level was 70 at the time of discharge.
.
# Acute kidney injury: Resolved.
Cr peaked at 1.6, likely was due to prerenal state from volume
depletion vs. ischemic ATN. His Cr was monitored and up to 1.6
but was 0.8 at the time of discharge.
.
# Right shoulder pain: Seems to be rotator cuff in nature but
unable to do an exam limited by pain. X-ray revealed just
arthritic changes. He was seen by PT and was cleared to go home
with PT. He may benefit from an outpatient MRI to assess for
rotator cuff injury.
Medications on Admission:
Lasix 40 mg po qdaily
Aldosterone 100 mg po qdaily
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO qAM.
2. spironolactone 100 mg Tablet Sig: One (1) Tablet PO qAM.
3. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
4. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) pack Intravenous Q24H (every 24 hours) for 2 weeks:
total 2 week course (last day is [**2191-1-21**]).
Disp:*14 pack* Refills:*0*
5. 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*
6. sucralfate 1 gram Tablet Sig: One (1) Tablet PO qPM: (please
take this separately from your other medications because it can
affect the absorption of other medications.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
GI bleed (duodenal ulcer)
alcohol cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to bloody stools, and you were found to
have an intestinal ulcer that was treated. We restarted your
diuretics (Lasix and Aldactone) and the extra fluid in your body
is being removed well.
.
During the admission, you had right shoulder pain, which you had
before admission as well. X-ray showed that you do not have a
fracture. Please follow up with your PCP to discuss this
(appointment listed below).
.
We made the following changes to your medications:
-start Sucralfate
-start Pantoprazole
-start Ceftriaxone (last day is [**2191-1-21**])
Followup Instructions:
PRIMARY CARE
Name: [**Last Name (LF) **],[**Known firstname **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 3947**].
Location: [**Hospital **] MEDICAL CENTER
Address: 1 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 72762**]
Phone: [**Telephone/Fax (1) 8572**]
Appt: [**1-20**] at 2pm
HEPATOLOGY
Department: LIVER CENTER
When: FRIDAY [**2191-1-28**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"456.8",
"041.09",
"303.91",
"572.2",
"532.40",
"782.3",
"287.5",
"263.9",
"276.1",
"537.89",
"571.2",
"790.92",
"790.7",
"584.9",
"790.01",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
9513, 9584
|
5975, 8549
|
298, 318
|
9672, 9672
|
3433, 5929
|
10415, 11095
|
1957, 1993
|
8650, 9490
|
9605, 9651
|
8575, 8627
|
9823, 10275
|
2008, 3414
|
10304, 10392
|
250, 260
|
346, 1727
|
9687, 9799
|
1749, 1770
|
1786, 1941
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,180
| 119,762
|
33698
|
Discharge summary
|
report
|
Admission Date: [**2115-8-30**] Discharge Date: [**2115-9-9**]
Date of Birth: [**2030-4-22**] Sex: M
Service: MEDICINE
Allergies:
Reglan / Haldol / Benzodiazepines
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
j-tube replacement
.
Reason for MICU transfer: Aspiration vs. Mucus plug w/ frequent
suctioning need
Major Surgical or Invasive Procedure:
none
History of Present Illness:
In brief, this is an 85M who presented to the ED on [**8-30**] from
nursing home for j-tube replacement (originally placed for
repeated aspirations) but admission labs showed Na 115, non-gap
acidosis, and ARF on CRF, and so was admitted to medicine for
abnormal labs.
His admission CXR also showed questionable LLL PNA, and so given
Vanc/Cefepime for presumed HCAP. Patient has significant
history of aspiration in the past and on while on floor on [**9-5**],
patient had episode of aspiration vs. mucus plugging with desats
to 70s on RA. Deep suctioning corrected to 98% on NRB. Patient
was transferred to MICU for continued need for frequent
suctioning.
During admission, patient had acute on chronic MS changes which
was thought to be [**1-30**] delerium vs. rapid correction on Na (now
145). Pt also has recent history of myoclonus. MRI was
negative in this patient with hx of CVA. Neurology is
following.
The cause of his hyponatremia and non-gap acidosis was presumed
to be from frequent free water flushes through his j-tube as
outpatient. Na has since corrected with sodium bicarb but
patient still has a metabolic nongap acidosis.
.
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:
Blown R pupil from childhood
DM
HTN
CVA
GIB/COLECTOMY WITH COLOSTOMY
-from diverticular bleed six years ago. Pt received six units of
blood and then had a colectomy. He subsequently had problems at
the anastamosis site, because septic and required a colostomy
that he still has.
Throat Ca
Empyema
Partial colectomy after GIB, appendectomy in childhood
Social History:
Lives in nursing home, distant tobacco, denies etoh/drugs.
Family History:
Heart disease and CVA
Physical Exam:
On transfer to MICU
GENERAL: Tired-appearing, pale, lethargic M in NAD
HEENT: MMM.
NECK: Supple, no JVD.
HEART: RRR, no MRG, nl S1-S2, but heart sounds distant.
LUNGS: Crackles over the LL lung field, good air movement, resp
unlabored.
ABDOMEN: NBS, SNTND, central area of scar tissue, 4x9cm, on L
abdomen around J-tube site which is covered by bandage,
colostomy bag at R.
EXTREMITIES: WWP, no edema.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-2**] throughout, sensation grossly intact throughout.
Abd: there is a central area of scar tissue about 4x9 cm, there
is a stoma in the RLQ with [**Last Name (un) **] green soft contents, there is
a small wound where the J tube was- no erythema or swelling.
Soft, non tender, non distended, no masses palpated, normal
bowel sounds.
Pertinent Results:
[**2115-9-9**] 03:57AM BLOOD WBC-9.5 RBC-2.63* Hgb-7.5* Hct-23.5*
MCV-89 MCH-28.5 MCHC-31.9 RDW-17.0* Plt Ct-426
[**2115-8-30**] 10:50AM BLOOD WBC-13.8*# RBC-2.91* Hgb-8.3* Hct-24.4*
MCV-84 MCH-28.7 MCHC-34.2 RDW-15.4 Plt Ct-323
[**2115-9-9**] 03:57AM BLOOD Glucose-104* UreaN-77* Creat-2.6* Na-146*
K-5.1 Cl-116* HCO3-21* AnGap-14
[**2115-8-30**] 10:50AM BLOOD Glucose-99 UreaN-72* Creat-3.5*# Na-115*
K-3.6 Cl-89* HCO3-12* AnGap-18
[**2115-9-9**] 03:57AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.3
[**2115-8-30**] 06:00PM BLOOD Calcium-7.4* Phos-4.0 Mg-1.4*
[**2115-9-2**] 05:45AM BLOOD calTIBC-160* Ferritn-756* TRF-123*
[**2115-8-30**] 06:00PM BLOOD Osmolal-269*
[**2115-9-7**] 03:46AM BLOOD TSH-2.3
[**2115-9-5**] 07:46PM BLOOD Vanco-17.1
[**2115-9-5**] 05:12PM BLOOD Type-ART pO2-75* pCO2-42 pH-7.21*
calTCO2-18* Base XS--10
[**2115-8-30**] 10:58AM BLOOD pH-7.21* Comment-GREEN TOP
[**2115-9-1**] 03:19PM BLOOD Lactate-0.9
[**2115-8-30**] 10:58AM BLOOD Lactate-0.7 Na-116* K-3.5 calHCO3-13*
Brief Hospital Course:
Primary Reason for Hospitalization: 85yo M with complex medical
hx who initially presented with hyponatremia, non-AG metabolic
acidosis and PNA. Transferred to MICU for aspiration pneumonitis
and mucus plugging requiring frequent suctioning and passed away
from hypoxic respiratory failure.
# Hypoxic Respiratory Failure: Throughout his course in the MICU
the patient had frequent hypoxic events. He was chronically
aspirating and mucous plugging with inability to clear
secretions. He would frequently desaturate to the 60s despite
supplemental oxygen which would improve with deep suctioning.
However eventually the deep suctioning became less effective and
the patient had longer and longer episodes of hypoxia. Plan of
care reviewed in detail with patient??????s family (including HCP) at
bedside. After discussion and review of the current situation,
they felt that the patient would not want a prolonged course of
suffering. They said he would want to focus all further efforts
on comfort. Given his inability to tolerate suctioning without
grimacing and struggling to breath, it was decided to defer any
further aggressive attempts to endo- or [**Last Name (un) **]-tracheally suction
him. He was transitioned to comfort measures only and passed
away shortly thereafter with family at the bedside.
.
#. Change in mental status: Change in mental status occurred
during admission with multiple intermittent hypoxic events as
well that were likely contributing to a hypoactive delirium.
.
# Hypernatremia: Initially hyponatremic on admission. Free
water flushes in tube feeds were titrated.
.
# HCAP: Completed course of Vanc and Cefepime (finished course
[**9-7**])
.
# Tachycardia/ECG changes: ECG showed TWIs in lateral leads,
lower voltage, positive troponin (however had renal failure).
TTE: Mild global biventricular systolic dysfunction (EF 40%).
Mild mitral regurgitation. Moderate tricuspid regurgitation.
Moderate pulmonary hypertension
.
#. Non AG metabolic acidosis: Felt to be due to GI losses from
colostomy bag and acute renal failure vs IVF hydration with NS.
.
# Acute on Chronic Renal Failure: Initially elevated to 3.5 on
admission, but returned to baseline with fluids.
.
# Anemia: Work up showed [**Doctor Last Name **] studies consistent with anemia
of chronic disease (Fe 23, TIBC 160, Ferritin 756, Transferrin
123). There were no active signs of bleeding.
Medications on Admission:
1. Acetaminophen 325 mg PO QHS
2. Aspirin 81 mg per J-tube daily, may crush
3. Ferrous sulfate oral elixer 220 (44 Fe) mg/5ml, 5mL PO BID
4. Multivitamin 1 tab PO daily
5. Omeprazole 40mg PO daily
6. Procrit Injection Solution 10000U/ml, 1ML SQ 9 AM every 2
weeks
7. Mirtazipine 7.5 mg PO QHS
8. SPS oral suspension 15GM/60ML. Give two bottles on MWF
9. Vit C 500mg PO daily
10. Acetaminophen Oral liquid 160mg/5ml 10ml PO every six hours
PRN for pain
11. Zinc oxide external ointment 20%, apply to coccyx daily
12. Dulcolax rectal suppository 10mg per rectum PRN constipation
13. Metamucil oral powerder 48.57% 1 tablespoon PO daily PRN
constipation
14. Water infusion J-tube 150ml/hr 8AM-8PM daily for dehydration
15. Water flush J-tube 100ml at 9AM and 5PM
16. Diet: House ground low potassium diet
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"486",
"276.8",
"E912",
"263.0",
"599.72",
"427.31",
"416.9",
"275.41",
"276.0",
"584.9",
"934.9",
"276.2",
"397.0",
"995.91",
"V10.21",
"507.0",
"599.0",
"285.21",
"585.4",
"V44.3",
"250.00",
"276.1",
"038.9",
"349.82",
"E849.7",
"333.2",
"518.81",
"787.91",
"569.62",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.03",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7696, 7705
|
4445, 5767
|
395, 401
|
7756, 7765
|
3432, 4422
|
7821, 7831
|
2518, 2541
|
7726, 7735
|
6867, 7673
|
7789, 7798
|
2556, 3413
|
1601, 2049
|
254, 357
|
429, 1582
|
5782, 6841
|
2071, 2425
|
2441, 2502
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,723
| 182,946
|
39031
|
Discharge summary
|
report
|
Admission Date: [**2111-4-19**] [**Month/Day/Year **] Date: [**2111-5-13**]
Date of Birth: [**2054-8-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Hit by tree limb on the back of neck, loss of conciousness, GCS
15 at presetation.
Major Surgical or Invasive Procedure:
1) [**2111-4-23**] fusion C2-3, C6-T3
2) [**2111-4-24**] Tracheostomy
3) [**2111-4-24**] Left hand debridement,left fourth digit open
reduction internal fixation of metacarpal fracture, Left
fifth digit open reduction internal fixation of metacarpal
fracture, Complex re-repair multiple hand lacerations including
debridement.
4) [**2111-4-27**] Debriedment of left hand and VAC placment
5) [**2111-4-30**] Exploratory laperotomy, repair of gastric wounds by
wedge resection of the greater curve, [**Last Name (un) 28222**] gastrostomy.
History of Present Illness:
This is a 56 year old male who was cutting down a 50 foot tree
at home when he was anchored in the tree and the top of the tree
fell down on the patient dropping the him 4 feet. He was pinned
between a lower tree limb and the top of the tree. He reports a
30 second loss of consciousness. This accident was not
witnessed. The patient's wife was not at home at the time of the
incident. The patient denies weakness, numbness or tingling
sensation, bowel or bladder incontinence, hearing or visual
deficit, vertigo.
Past Medical History:
IDDM
HTN
Left Shoulder Rotator Cuff Repair
Left Achilles
Kindey Stones
Lithotripsy
Social History:
Married, lives with wife.
Retired
Family History:
Noncontributory
Physical Exam:
On presentation:
ROS: Denies urinary or rectal incontinence
PHYSICAL EXAM:
Gen: comfortable, NAD.
HEENT: Pupils: [**3-31**] EOMs: intact
Neck: hard cervical collar in place
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light bilaterally.
Toes downgoing bilaterally
Rectal exam normal sphincter control
Pertinent Results:
[**2111-4-19**] 08:19PM GLUCOSE-263* LACTATE-2.1* NA+-141 K+-3.8
CL--101 TCO2-24
[**2111-4-19**] 08:19PM HGB-15.0 calcHCT-45 O2 SAT-75
[**2111-4-19**] 07:55PM WBC-23.1* RBC-4.82 HGB-14.7 HCT-41.6 MCV-86
MCH-30.4 MCHC-35.2* RDW-13.5
[**2111-4-19**] 07:55PM PLT COUNT-351
[**2111-4-19**] 07:55PM PT-12.6 PTT-21.1* INR(PT)-1.1
[**4-19**] Imaging:
CT head: No acute intracranial process
CT C-spine: fracture C2-T1 spinous process. Extension of
fracture in C2, C4 to canal. Prevertebral hematoma at C2.
Hematoma at C2 in canal ?cord compression
CT torso: min mediastinal fluid
CXR: poor inspiratory effort
XR LUE: 4th/5th metacarpal fracture
[**5-6**] Imaging (s/p fall):
CT head: no acute pathology
CT cervical spine: unchanged fractures, hardware in place
[**5-7**]
CT torso: no evidence of infection chest or abdomen
[**5-8**]
CT neck w/ contrast: fluid collection from occiput to T4
skin graft vs groin flap...area has poor collaterals so no free
flap
plastics also concerned with long case in patient with multiple
other issues.
Brief Hospital Course:
He was admitted to the Trauma service and was transferred to the
Trauma ICU. On [**4-20**] he was fiberoptically intubated secondary to
worsening narrowing of airway felt secondary to the C2 hematoma.
On [**4-21**] he was noted with increasing sputum production, CXR
concerning for retrocardiac opacity and ? early infiltrate of
the RLL, and episode of hypoxia. Started on Levaquin/Zosyn after
mini bronch.
Neurosurgery was consulted for the spine injuries and he was
taken to the operating room on [**4-23**] for fusion of his fractures.
On [**4-24**] he was taken to the operating room for a tracheostomy
and PEG by trauma and ORIF of left hand, with wound VAC applied
done by Plastics. Postoperatively he remained in the Trauma ICU.
Interventional Radiology was consulted for guided placement of
Dobbhoff tube for enteral access for which patient self removed.
A bedside nasogastric tube was placed and he was found to have
free air on CXR and was brought to OR emergently for exploratory
laparotomy; 2 perforations found in stomach.
His blood pressures were intermittently elevated initially
requiring Labetalol drip while in the ICU. He is currently on
oral Lopressor and Norvasc with adequate blood pressure control.
On [**5-1**] he was weaned from ventilator and was tolerating Trach
collar. Once hemodynamically stable he was transferred to the
regular nursing unit. He was quite delirious upon transfer from
the ICU and was started on an antipsychotic to manage the
intermittent agitation. Trazodone was also added to help
regulate his sleep-wake cycle. His mental status improved
dramatically and he is currently awake, alert and oriented.
On [**5-5**] he sustained a fall and was re-scanned. No new injuries
were identified. On the following day he was noted with elevated
WBC and fevers; his cervical spine incision on exam was noted to
be erythematous. A CT scan was done to assess for collection and
one was identified. It was felt by Neurosurgery that this was
CSF fluid and was to be expected with this type of surgery. It
was deemed that this collection did not warrant drainage; rather
continue to watch patient clinically for any other changes
suggestive of infectious process.
He was taken back to the operating room on [**5-12**] by Plastics for
radial forearm flap and left thigh skin graft. The drain was
pulled on POD 1 by Plastics. He will follow up as an outpatient
on [**2111-5-19**] in [**Hospital 3595**] clinic.
His tracheosotmy was removed on [**5-13**]; his respiratory stauts and
oxygen saturations have remained stable since removal.
An incidental finding upon admission on CT imaging noted a left
thyroid nodule that will require a non-urgent ultrasound. He
should follow up with his PCP for this.
He was evaluated by Physical therapy and continued to progress
throughout his stay. He is being recommended for rehab after his
acute hospitalization.
Medications on Admission:
Glipizide
"Insulin"
[**Month/Year (2) **] Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation .
12. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
13. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty
Four (24) units Subcutaneous once a day.
14. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) Units Subcutaneous @ Dinner.
15. Humalog 100 unit/mL Solution Sig: One (1) dose Subcutaneous
four times a day as needed for per sliding scale: See attached
sliding scale.
[**Month/Year (2) **] Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
[**Hospital1 **] Diagnosis:
s/p Blunt injury to head and back from tree cutting accident
C2-T1 fracture
C2 hematoma
Left hand degloving injury
4th & 5th left metacarpal fractures
Gastric perforation
[**Hospital1 **] Condition:
Level of Consciousness: Alert and interactive; oriented x3
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Hospital1 **] Instructions:
Left hand care:
* Please keep your left arm elevated.
* Do not remove dressings/wraps over left forearm/hand.
* Do not get left arm/hand wet
.
Left thigh skin graft donor site:
* Leave yellow xeroform dressing in place and leave open to air
to dry out.
* Do not get this area wet
Followup Instructions:
Follow up in 4 weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery; call
[**Telephone/Fax (1) 1669**] for an appointment.
Follow up in 4 weeks with Dr.[**Last Name (STitle) **], Trauma Surgery for follow
up of your gastric perforation; call [**Telephone/Fax (1) 6429**] for an
appointment.
Hand Clinic: ([**Telephone/Fax (1) 32269**]
[**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building, [**Location (un) **]
Please follow up in the Hand Clinic on Tuesday, [**2111-5-19**]. You
must call ([**Telephone/Fax (1) 32269**] to make an appointment so they know you
are coming. The clinic is open from 8-12pm most Tuesdays and
you may show up at any time between those hours, despite your
formal appointment time. The clinic is located on the [**Hospital Ward Name 5074**], [**Hospital Ward Name 23**] Building, [**Location (un) **].
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab for a finding on one of your CT scans, a thyroid nodule
was noted and ultrasound imaging on non urgent basis is being
recommended.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2111-5-13**]
|
[
"518.5",
"863.0",
"276.1",
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"790.01",
"806.00",
"V58.67",
"401.9",
"276.3",
"486",
"815.19",
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] |
icd9cm
|
[
[
[]
]
] |
[
"81.03",
"82.36",
"96.6",
"84.52",
"86.59",
"03.53",
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"43.42",
"03.59",
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"96.72",
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] |
icd9pcs
|
[
[
[]
]
] |
3448, 6343
|
408, 952
|
2382, 2737
|
8678, 9904
|
1672, 1689
|
6369, 7987
|
1781, 1918
|
286, 370
|
980, 1499
|
3070, 3425
|
1933, 2363
|
8015, 8343
|
1521, 1605
|
1621, 1656
|
8374, 8655
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,010
| 137,947
|
33645
|
Discharge summary
|
report
|
Admission Date: [**2186-1-7**] Discharge Date: [**2186-1-11**]
Date of Birth: [**2119-12-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Transfer for RV thrombus and bilateral PEs
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 66 yo female with h/o fibromyalgia, depression,
migraine who was transferred from [**Hospital6 33**] for
further management of RV thrombus and bilateral PEs. Patient
presented to [**Hospital6 **] with leg pain and SOB. LENI
revealed LLE DVT in the peroneal vein and CTA revelaed bilater
pulmonary emboli, largest in right lower lobe artery just below
the origin of the superior segment branch. Echocardiogram was
performed and revealed EF of 55-60 %, right ventricle with
mobile mass suggestive of thrombus or tumor, trace TR, trivial
pericardial effusion. Per patient she has had worsening SOB over
the couple of months and since the end of [**Month (only) **] until [**Month (only) 404**]
has had low grade fevers, chills and sweats. She also has had a
persistent cough throughout this time. She saw her PCP, [**Name10 (NameIs) **]
could articulate what the thoughts were about the etiology. Over
the past month her SOB has worsened and 10 days ago she began
having left LE pain. The pain in her leg and SOB worsened to the
point of her presenting to the ED at [**Hospital3 **]. This was also
associated with some pleuritic chest pain located in the mid
chest which has since significantly improved. Of note, she has
been much less active over the recent months, sleeping most of
the day and not very mobile due to her SOB and fibromyalgia
pain. Denies any recent surgeries or trauma to the leg. She was
given a dose of lovenox on [**1-5**] and was started on a heparin
drip and transferred to [**Hospital1 18**] for further management.
.
On arrival to [**Hospital1 18**] patient reports SOB feels about the same,
her CP is much improved. Denies palpitations, lightheadedness.
She does have some shoulder and abdominal pain that is
consistent with her fibromyalgia.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, hemoptysis, black stools or red stools. She has
myalgias from her fibromyalgia. She also notes a 50 pound weight
gain over the past 3 years. She also has had a superficial
phlebitis. She also notes that she had a period of [**1-24**] weeks
back in [**Month (only) 321**]-[**Month (only) **] when she had difficulty swallowing
with food getting "stuck in her throat."
.
Cardiac review of systems is notable for 3+ pillow orthopnea
which is stable. She reports snoring at night and possible
apneic episodes. Denies ankle edema, palpitations, syncope or
presyncope.
.
Past Medical History:
Fibromyalgia
Depression
Migraines
Anxiety
IBS
s/p CYY
s/p appendectomy
s/p parital oopherectomy
Righ LE superficial phelbitis
6 miscarriages
2 still births
She bellieves she is UTD on her mammogram, but never had a
colonoscopy and is not UTD on Pap
Social History:
Social history is significant for theabsence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. No family h/o of blood clots. Mother died at 92
of unknown cancer. father died in his 60s from neck cancer. no
sibling. 4 children all healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.5, BP 116/64 , HR 82 , RR 20, 92 O2 % on 5 L
Gen: Older female with audible wheezes, appearing midly ethargic
but awakens to voice and is conversant and appropriate Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Large neck, no JVP
CV: RR, normal S1, S2. No S4, no S3. no m/g/r
Chest: Resp were unlabored but has audible inspiratory wheezes
but no expirtatpry wheezes on exam. No crackles, rhonchi.
Abd: Obese, soft, NTND, multiple well-healed scar, no HSM or
tenderness. No abdominial bruits.
Ext: No edema, no calf tenderness.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: 2+ DP
Left: 2+ DP
Pertinent Results:
================
ADMISSION LABS
================
8.7 \______/ 204
/ 35.3 \
PT-13.2 PTT-88.9* INR(PT)-1.1
Glucose-105 UreaN-12 Creat-0.9 Na-133 K-4.4 Cl-95* HCO3-29
AnGap-13
Calcium-7.9* Phos-4.9* Mg-2.1
ART BLOOD GAS: pO2-92 pCO2-60* pH-7.34* calTCO2-34* Base XS-3
=================
DISCHARGE LABS
=================
6.5 \______/ 190
/ 38.5 \
PT-30.7* PTT-46.9* INR(PT)-3.1*
Glucose-82 UreaN-12 Creat-0.8 Na-136 K-4.8 Cl-98 HCO3-27
AnGap-16
Calcium-8.2* Phos-3.3 Mg-2.2
VitB12-820 Folate-9.2
================
RADIOLOGY
================
[**2186-1-7**] CTA CHEST
1. Multiple bilateral pulmonary emboli in the left lower lobe,
right middle lobe and right lower lobe.
2. Patchy left and right lower lobe and right middle lobe
atelectasis.
[**2186-1-7**] TRANS-THORACIC ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. There is no
mass/thrombus in the right ventricle. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
[**2186-1-8**] CHEST X-RAY
Cardiomediastinal contours are unchanged. Elevation of the right
hemidiaphragm is longstanding. Right basal atelectasis have
improved. There is no overt CHF, pneumothorax or pleural
effusions.
[**2186-1-10**] NON-CONTRAST HEAD CT:
There is no hemorrhage, hydrocephalus, shift of normally midline
structures, or evidence of major vascular territorial infarct.
The [**Doctor Last Name 352**]-white matter differentiation is preserved. The
visualized paranasal sinuses and mastoid air cells remain
normally aerated. The surrounding osseous and soft tissue
structures are within normal limits.
IMPRESSION: Normal unenhanced head CT.
Brief Hospital Course:
66 yo female with obesity, fibromyalgia, depression, IBS who
presented wit left LE pain and SOB found to have bilateral PEs
and RV thrombus
# Bilateral PE's and RV thrombus: Patient with history of
miscarriages and superficial thrombophlebitis, suggestive of
underlying hypercoagulable disorder. Per transfer records,
patient had been briefly evaluated by hematology-oncology but
no formal diagnosis has been reached. Upon arrival, patient was
anticoagulated and echocardiogram was repeated, which did not
reveal presence of previously reported RV thrombus. Due to
concerns of distal embolization, CTA of the chest was obtained,
revealing multiple pulmonary emboli. Patient remained stable and
did not have any signs of RV strain. She was transitioned to
injectable lovenox as she was bridged on coumadin.
Hypercoagulable workup would be very limited at this time as
patient is already anticoagulated, but this should be performed
as an outpatient in the near future. Will defer to PCP to
arrange for Hematology follow up.
Ms [**Known lastname 732**] should also complete routine cancer screening, as
hypercoagulable state may be a manifestation of underlying
malignancy. Defer mammogram, colonoscopy and GYN exams to PCP.
# Respiratory distress: Patient had mild oxygen requirement on
arrival as well as inspiratory wheezing on exam. Patient
received supplemental oxygen and nebulizer treatments, with good
improvement in symptoms. She reports having dyspnea and
"bronchitis" for months, and may have underlying pulmonary
disease, most likely reactive airway disease. Patient discharged
on inhalers, will defer further management to PCP.
Patient was also noted to have episodes of apnea while sleeping
and would benefit from formal sleep study as an outpatient.
# Altered mental status / Depression: Psychiatry was consulted
for management of chronic anxiety, depression and for new
altered mental status. Patient underwent extensive testing
including toxicology screening, serum hormone levels and head
CT. Workup was negative with the exception of TSH, for details
please see below. Per family, patient is currently at baseline
and has been experiencing somnolence and a flat affect for
months. Medications were adjusted per psychiatry
recommendations, will defer further management to outpatient
psychiatrist.
# Abnormal Thyroid function tests: Elevated TSH with low levels
of free T4. In the acute illness setting, this likely represents
sick euthyroid and does not warrant further workup at this time.
Patient should have repeat testing once stable in the outpatient
setting; will defer to PCP.
# Fibromyalgia: We continued outpatient regimen of topamax,
neurontin, pamelor, flexeril, lidoderm patch. Doses adjusted per
psychiatry recommendations, for details please see medications
section.
Medications on Admission:
Flexeril 10 mg PO TID
Protonix 40 mg Po Qday
Advair 100/50 1 puff [**Hospital1 **]
Neurontin 400 mg PO TID
Albuterol nebs PRN
Pamelor 40 mg Po QAM
Depakote 1000 mg PO BID
Paxil 40 mg PO qday
Lidoderm patch to affected area daily
Miralax 17 grams daily
Heparin gtt at 950 mg
Tylenol 650 mg Q6H PRN
Percocet 2 tablets Q4H PRN pain
Discharge Medications:
1. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) Powder in Packet PO DAILY (Daily).
9. Enoxaparin 100 mg/mL Syringe Sig: One (1) mL Subcutaneous
Q12H (every 12 hours) for 2 days.
Disp:*4 mL* Refills:*0*
10. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please check PT, PTT, INR. First draw on [**2186-1-12**]. Please fax
results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 77905**] [**Telephone/Fax (1) 77906**]. (phone
[**Telephone/Fax (1) 77907**])
12. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
Disp:*30 Capsule(s)* Refills:*0*
13. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
14. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Primary
1. Bilateral pulmonary embolisms
2. Left LE DVT
3. RV thrombus
4. Delerium
5. Fibriomyalgia
Secondary
1. Anxiety
2. Obesity
Discharge Condition:
Afebrile, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital because you had a blood clot
in your heart and blood clots in your lungs (pulmonary emboli).
You were treated with blood thinner with improvement in your
oxygen level.
The following changes have been made to your medications:
1. You are now on a medicine called lovenox. You will be
receiving these shots every 12 hours for the next 2 days.
2. You are also on coumadin, which is a blood thinner. The dose
of this medications will be adjusted depending on your INR
level. You will be on this medication indefinitely until you
discuss this further with a hematology specialist.
3. Your paroxetine dose has been decreased from 40 mg to 20 mg
daily
4. Your depakote dosing has been decreased from 1000 mg twice
daily to 750 mg twice daily
5. Your Nortriptyline has been decreased to 25 mg daily.
Please take all of your medications as directed.
Please keep all of your follow up appointments.
If you develop chest pain, shortness of breath, palpitations,
fevers, worsening cough, bleeding or any other concerning
symptoms, you should call your doctor or come to the emergency
room.
Followup Instructions:
You should follow up with your primary doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 77905**], [**Telephone/Fax (1) 77907**]. She will be contacting you to come see
you at home within the next week. If you do not hear from her,
please call her to schedule an appointment.
You will be having your INR checked. Dr. [**Last Name (STitle) 77905**] will be
adjusting your coumadin level based on your INR.
You should discuss being referred to a hematologist by your
primary doctor to be evaluated for a blood clotting problem. [**Name (NI) **]
should also discuss getting a mammogram, pap smear and
colonoscopy so that you are up to date on your screening tests.
You have been scheduled for a follow up appointment with your
pain management doctor, Dr. [**First Name (STitle) 21364**] [**Name (STitle) 77908**] [**Telephone/Fax (1) 77909**] on Thursday,
[**1-19**] at 9:45 am. At that time you should discuss
making an appointment with your therapist, Dr. [**First Name (STitle) 10712**].
You have been ordered for a sleep study to determine if you have
problems breathing when you sleep. You should call [**Telephone/Fax (1) 16716**]
to schedule the study.
You should also call [**Telephone/Fax (1) 612**] to schedule an appointment to
see Drs. [**Last Name (STitle) 77910**] and [**Name5 (PTitle) **] in pulmonary medicine. You
should see them after you do the sleep study because they will
interpret the results and discuss treatment options with you
based on that test.
|
[
"300.4",
"415.19",
"429.89",
"729.1",
"453.42",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11291, 11350
|
6376, 9184
|
356, 363
|
11526, 11561
|
4328, 5944
|
12728, 14238
|
3298, 3523
|
9564, 11268
|
11371, 11505
|
9210, 9541
|
11585, 12705
|
3563, 4309
|
274, 318
|
391, 2885
|
5953, 6353
|
2907, 3158
|
3174, 3282
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,095
| 167,836
|
8296
|
Discharge summary
|
report
|
Admission Date: [**2200-3-19**] Discharge Date: [**2200-3-26**]
Date of Birth: [**2123-7-21**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Desaturation and change in mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 76-year-old man with DM II, ESRD on HD via LUE AV
fistula, AAA, carotid disease, MSSA bacteremia of unclear
source, recently admitted for hypotension and complete heart
block treated with a permanent pacemaker. Patient now returns
to [**Hospital1 18**] with aletered mental status and hypoxemia. Was at his
usual HD session when O2 sat was noted to be 80% RA. Was
reportedly having labored breathing. Complained of an odd
feeling in his stomach. Patient was only 1.5KG over dry weight,
so only small amount of fluid removed. During hypoxemic
episode, patient initially required 5L NC. Became increasinly
confused and changed to 100% NRB. HD session was completed and
about 1L fluid was removed. By report from the family, patient
was recently hospitalized at [**Hospital3 7362**] and discharged day
before admission for hypotension with demand ischemia.
According to family, patient has been confused intermittently
for several months.
In the ED, initial vs were: T98.0 HR 98 BP 122/77 RR 24 O2 100
on NRB. Patient sleepy but appropriate. No JVD, but accessory
muscle use. Taking deep full breaths. No murmur/gallop. Belly
was soft but patient complained of abdominal pain. LLE erythema
w/o tenderness. EKG -> sinus tachycardia w/ atrial sensing and
V-pacing. Patient got aspirin 325 for troponin elevation, and
haldol 2.5mg IV x2 for agitation.
Past Medical History:
-Recent permanent pacemaker for CHB
-Ongoing MSSA bacteremia
-Diabetes mellitus 2 - last A1c 5.6%
-chronic kidney disease stage 4 on HD MWF
-Ulcerative colitis: no flares x 25 years
-Right adrenal adenoma
-Gout.
-History of prostate cancer, status post prostatectomy.
-Remote history of nephrolithiasis.
-Hypertension
-Peripheral vascular disease s/p left [**Doctor Last Name **]-dp bypass
-carotid stenosis
-infrarenal abdominal aortic aneurysm
-deep venous thrombosis in [**2195**]
-iron deficiency anemia
-recent episode of aphasia which resolved - ? TIA
-Prostate cancer s/p prostatectomy
-?Pulmonary hypertension -Uses home oxygen of 2L NC, normally
sats 84-86% as per family
Social History:
Quit smoking at age 73. Retired as a chemical mixer from a
leather tannery. No alcohol or illicit drug use. Lives at home
with his wife and family.
Family History:
Brother had liver cancer. Father and mother had CVAs. Paternal
grandfather had rectal cancer.
Physical Exam:
Vitals: T: 97.1 BP: 136/77 P: 83 R:24 O2: 100% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera slightly icteric, MMM, oropharynx clear
Neck: Supple; no JVP appreciated
Lungs: Clear bilaterally with decreased sounds at bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Distended, +BS, tympanic, no organomegally appreciate
(but difficult exam)
Ext: 1+ edema bilaterally; left second toe is bandaged (bandage
is clean, dry, and intact). Scar on left shin.
Skin: Warm and dry
Psych: Appropriate
Neuro: Alert to person and place; tired during interview
Pertinent Results:
Labs on admission:
[**2200-3-19**] 10:00AM PLT SMR-VERY LOW PLT COUNT-38*#
[**2200-3-19**] 10:00AM NEUTS-78.8* LYMPHS-11.1* MONOS-7.6 EOS-2.1
BASOS-0.3
[**2200-3-19**] 10:00AM WBC-7.4 RBC-3.10*# HGB-9.7*# HCT-31.7*
MCV-102*# MCH-31.1 MCHC-30.5* RDW-26.5*
[**2200-3-19**] 10:00AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2200-3-19**] 10:00AM HAPTOGLOB-55 FERRITIN-1089*
[**2200-3-19**] 10:00AM CK-MB-NotDone proBNP-GREATER TH
[**2200-3-19**] 10:00AM cTropnT-2.99*
[**2200-3-19**] 10:00AM LIPASE-53
[**2200-3-19**] 10:00AM ALT(SGPT)-3 AST(SGOT)-31 LD(LDH)-367*
CK(CPK)-29* ALK PHOS-102 TOT BILI-1.8*
[**2200-3-19**] 10:00AM estGFR-Using this
[**2200-3-19**] 10:00AM GLUCOSE-82 UREA N-17 CREAT-4.5*# SODIUM-146*
POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-39* ANION GAP-14
[**2200-3-19**] 10:32AM PT-14.4* PTT-33.1 INR(PT)-1.3*
[**2200-3-19**] 12:45PM LACTATE-1.5
[**2200-3-19**] 02:20PM PO2-77* PCO2-52* PH-7.48* TOTAL CO2-40* BASE
XS-12
[**2200-3-19**] 03:58PM URINE HYALINE-34*
[**2200-3-19**] 03:58PM URINE RBC-<1 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-0
[**2200-3-19**] 03:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-NEG
[**2200-3-19**] 03:58PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2200-3-19**] 03:58PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2200-3-19**] 03:58PM URINE HOURS-RANDOM CHLORIDE-47
[**2200-3-19**] 05:33PM ETHANOL-NEG
[**2200-3-19**] 05:33PM CK-MB-NotDone cTropnT-3.06*
[**2200-3-19**] 05:33PM CK(CPK)-26*
[**2200-3-19**] Non-contrast head CT:
NON-CONTRAST HEAD CT: Please note that evaluation is
significantly limited by head motion. Within that limitation,
there is no intracranial hemorrhage, mass effect, edema, shift
of normally midline structures, or major vascular territorial
infarction. The [**Doctor Last Name 352**]-white matter differentiation is preserved.
A 6-mm hyperdense lesion at the foramen of [**Last Name (un) 2044**] appears stable
as compared to prior exams, consistent with a colloid cyst. This
appeared relatively less conspicuous on certain prior exams.
Prominent ventricles are essentially stable, without evidence of
acute hydrocephalus. Sulci are prominent, compatible with
age-related involutional change. There is extensive subcortical
and periventricular white matter hypoattenuation, consistent
with small vessel ischemic disease, unchanged. A hypodense focus
is noted in the right lentiform nucleus, consistent with lacune
versus prominent perivascular space. Within significant
limitation by motion artifacts, paranasal sinuses and mastoid
air cells appear relatively aerated.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Stable 6 mm colloid cyst and stable appearance of prominent
ventricle without evidence of hydrocephalus.
3. Extensive small vessel ischemic disease and age-related
involutional change.
.
CT [**2200-3-19**]:
IMPRESSION:
1. No evidence of central pulmonary embolism. Limited evaluation
of the more peripheral pulmonary vasculature due to patient
respiratory motion.
2. Overall stable appearance of a fusiform AAA since [**Month (only) 404**]
[**2197**], continues to measure 5 cm in diameter. No evidence of
current rupture.
3. Extensive atherosclerotic vascular disease with two
penetrating thoracic aortic ulcers, one of which is increased in
size as compared to [**2197**].
4. Two 4-mm right middle lobe pulmonary nodular opacities are of
uncertain
chronicity without prior chest studies to compare. 12-month
followup is
recommended to document resolution or stability. Right lung base
linear
densities are unchanged since [**2198**], most consistent with chronic
fibrotic
changes.
5. Nonspecific mediastinal and axillary lymphadenopathy.
6. Perihepatic and perisplenic ascites. Nodular liver contour
suggests
cirrhosis. Gynecomastia.
7. Heterogeneous-appearing thyroid with a possible subcentimeter
nodule and punctate calcification on the left. Findings could be
further evaluated on nonemergent ultrasound.
8. Nonspecific mild stable pancreatic ductal dilatation. No
obstructive or
mass lesion identified.
9. Atrophic kidneys consistent with history of end-stage renal
disease.
Unchanged occlusion of the left renal artery, unchanged since
[**2197**].
.
ECHO [**2200-3-24**]:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is moderate global left ventricular hypokinesis
(LVEF = 35-40 %). The right ventricular cavity is moderately
dilated with mild global free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-14**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
RIGHT UPPER QUADRANT ULTRASOUND [**2200-3-25**]:
IMPRESSION:
1. Gallbladder wall edema, without gallbladder wall stones,
sludge or
[**Doctor Last Name 515**] sign. These findings are nonspecific and could be
related to third spacing versus renal failure. However, in the
appropriate clinical setting, acalculous cholecystitis is not
entirely excluded. Therefore, at this time, a HIDA scan is
recommended for further evaluation, if clinical suspicion
warrants.
2. Trace ascites.
3. Mild splenomegaly.
Brief Hospital Course:
This is a 76-year-old man w/ CAD, AAA, MSSA bacteremia, and
pulmonary hypertension who presents with confusion and
hypoxemia.
.
#. ALTERED MENTAL STATUS: Patient has a history of "dementia"
for several months, as per family members. Patient's mental
status waxed and waned throughout admission, especially during
dialysis sessions. Patient is alert and oriented, and
consistently answers correctly when asked about "person, place,
time, and events." However, his behavior is sometimes
inappropriate and he is not always sure of his surroundings (at
one point he thought he was in a bakery). Likely Mr. [**Known lastname **] has
some underlying dementia with superimposed delirium in the
setting of frequent hospitalizations and medicalizations. Also
possible that there are metabolic derrangements in the setting
of frequent dialysis. All offending medications were
discontinued, such as ranitidine. Efforts were made to orient
patient and discontinue unnecessary tethers. Patient will
follow-up with geriatrics as an outpatient for neuro-psychiatric
testing. He was given low-dose haldol (~0.5mg) as needed for
agitation. Of note, Mr. [**Known lastname **] was given 5mg of Haldol in the ICU
and was unarousable for hours.
.
# HYPOXIA/PULMONARY HYPERTENSION: Mr. [**Known lastname **] was initially
admitted because of hypoxia (O2 sats in the 80s) during a
dialysis session. However, during admission, Mr. [**Known lastname **] had no
problems with oxygenation. He was satting 95% on room air on
discharge.
.
#DYSSYNCHRONY ON ECHO: As per echocardiogram performed during
admission, there is dyssynchrony between native heart beat and
pacemaker. Electrophysiology was consulted who made some
changes to pacemaker setting with moderate effect. Mr. [**Known lastname **]
will follow-up with general cardiology in 2 weeks.
.
#. CAD/TROPONIN ELEVATION: Mr. [**Known lastname **] had a troponin elevation on
admission--however, troponin was lower than on admission [**Hospital1 **] the week before (at [**Hospital1 3597**], troponin was 8.9). Likely
patient had a missed MI or troponin leak in setting of
hypotension prior to arrival at [**Hospital3 7362**]. Patient was
continued on ASA, plavix, metoprolol, and statin. Throughout
admission, patient had no ECG changes to suggest ischemia, and
no new chest pain. Mr. [**Known lastname **] will follow-up with cardiology in 2
weeks.
.
#. THROMBOCYTOPENIA: Patient had a rapidly dropping platelet
count, ever since being started on cefazolin for MSSA bacteremia
in early [**Month (only) 958**]. Cefazolin was held and platelet count went up.
Mr. [**Known lastname **] was switched to nafcillin with good effect, but
antibiotic was finally changed to vancomycin as this can be
easily administered at dialysis. Patient will continue on
vancomycin (given at dialysis) through [**4-11**]. Patient had no
signs or symptoms of bleeding throughout admission. Patient's
platelet count should be re-checked in 3 days at rehab.
.
# MSSA BACTEREMIA: Patient with MSSA bacteremia found on recent
admission in [**2200-2-10**]. Source was never identified, but
thought to be from infected fistula. Extensive work-up
completed on previous admission. Mr. [**Known lastname **] did not have a fever
or elevated white count during hospitalziation. Patient will
continue on vancomycin through [**4-11**]. He will follow-up with ID
specialists.
.
# DIABETES: Patient's oral medications were held during
admission, and he was started on an insulin sliding scale. His
oral medications can be restarted upon discharge.
.
# ITCHING: Likely from uremia. Patient was continued on Sarna
cream as needed.
.
# HALLUCINATIONS: Family states that patient has been
complaining of bugs crawling on his skin and over his sheets.
Hallucinations have been increasing in frequency. Can consider
delerium vs. [**Last Name (un) 309**] Body Dementia diagnosis as an outpatient.
Patient was given low-dose haldol as needed for agitation (can
be changed to an anti-psychotic with fewer extrapyramidal side
effects if [**Last Name (un) 309**] Body is suspected) and will follow-up with
geriatrics as an outpatient.
.
# ESRD ON HD: Patient will continue on dialysis Monday,
Wednesdays, and Fridays. Patient will receive vancomycin at
dialysis through [**4-11**] or unless directed otherwise by infectious
disease.
Medications on Admission:
-Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
-Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
-Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
-Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
-Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID
-Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
-Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
-Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY
-Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical
DAILY (Daily) as needed for apply to foot wounds.
-Cefazolin 10 gram Recon Soln Sig: Two (2) grams IV Injection
HD PROTOCOL (HD Protochol).
-Glipizide 2.5 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*
-Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
-Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO daily
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Succinate 25 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*
10. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous HD PROTOCOL (HD Protochol).
11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
13. Silver Sulfadiazine 1 % Cream Sig: One (1) Topical once a
day.
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3145**] Rehab
Discharge Diagnosis:
Primary:
1. Hypoxia (resolved)
2. Thrombocytopenia
3. MSSA bacteremia
4. Delirium
.
Secondary:
1. ESRD on HD
2. HTN
3. Hyperlipidemia
4. Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you on this admission. You
came to the hospital because of low oxygen levels at dialysis.
You were initially admitted to the intensive care unit, but you
were transferred to the general medical wards when your levels
normalized.
.
You were found to have low platelets and your Cefazolin was
switched to Vancomycin. You will continue this antibiotic
through [**4-11**]. Your platelt count should be rechecked in 3 days
.
The electrophysiologists made some changes to your pacemaker.
You should follow-up with cardiology in 2 weeks.
.
The following changes were made to your medications:
1. STOP taking cefazolin
2. START taking vancomycin as directed by your dialysis center
3. START taking Toprol XL 25mg once a day
4. STOP taking metoprolol 100mg once a day
5. STOP taking Ranitidine (this may have been making your
platelets low).
.
Please take all of your medications as prescribed. Please keep
all of your follow-up [**Month/Year (2) 4314**].
Followup Instructions:
Department: GERONTOLOGY
When: TUESDAY [**2200-4-8**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 13171**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2200-4-11**] 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
Department: ADVANCED VASC. CARE CNT
When: THURSDAY [**2200-4-17**] at 8:30 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
INFECTIOUS DISEASE: [**2200-4-22**] 10:00a [**Doctor Last Name **] [**Location (un) **]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
ID WEST (SB)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"518.82",
"441.4",
"287.5",
"250.00",
"440.20",
"433.10",
"227.0",
"556.9",
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"V10.46",
"790.7",
"790.99",
"V12.51",
"294.8",
"285.21",
"041.11",
"276.0",
"799.02",
"416.8",
"V45.01",
"403.91",
"440.4",
"585.6",
"293.0",
"272.4",
"426.0",
"707.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.45",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
16066, 16118
|
9079, 9218
|
311, 318
|
16315, 16315
|
3345, 3350
|
17512, 18738
|
2608, 2704
|
14720, 16043
|
16139, 16294
|
13461, 14697
|
16467, 17489
|
2719, 3326
|
230, 273
|
346, 1720
|
5020, 9056
|
3364, 4989
|
16330, 16443
|
1742, 2424
|
2440, 2592
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,116
| 157,106
|
53654
|
Discharge summary
|
report
|
Admission Date: [**2150-2-19**] Discharge Date: [**2150-3-11**]
Date of Birth: [**2109-3-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Upper GIB
Major Surgical or Invasive Procedure:
EGD, Paracentesis, CVL Placement, TIPS procedure
History of Present Illness:
Mr. [**Known lastname **] is a 40 y/o male with a history of alcohol abuse, GERD
and hyperension who presented on [**2150-2-14**] with 4 days of
hematemesis and melena. According to the discharge summary from
[**Hospital3 **] the patient had been vomiting blood and having
black stools for 4 days which he attributed to a virus. He
became progressively more fatigued and lightheaded. On the day
of admission he fell at his brother's home but had no loss of
consciousness. His brother called 911 and he was taken to [**Hospital 2586**] emergency room. At that time he was found to have a
Hct of 12, INR of 1.5 and platelet count of 44. GI was consulted
and he was started on an octreotide and pantoprazole drip.
.
During his course, he recieved a total of 11 units of PRBCs, 4
units of FFP and 2 units of platelets. He had 3 endoscopies with
the last one revealing a large clot in the fundus of the
stomach. He was transferred for a TIPS procedure.
Past Medical History:
Alcohol Abuse
Alcoholic Hepatitis
GERD
Hypertension
Left Hip Surgery s/p internal fixation (metal plate and pins)
Social History:
- Alcohol: drinking 1 L of vodka a day prior to admission.
No smoking, no recreational drugs per patient.
Was extremely depressed on/off antidepressants.
Family History:
NC
Physical Exam:
Admission Exam:
GENERAL: Well appearing in NAD. Jaundiced
HEENT: Sclera icteric. MMM.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness appreciated.
EXTREMITIES: 1+ edema b/l. Warm and well perfused, no clubbing
or cyanosis.
NEURO: Intubated, opens eyes to voice
On Discharge:
VS: 98.5 111/61 92 70 98%RA
GENERAL: Well appearing in NAD. improved jaundice, A+Ox3, more
alert
HEENT: Sclera icteric. MMM.
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness appreciated.
EXTREMITIES: 1+ edema b/l. Warm and well perfused, no clubbing
or cyanosis.
Pertinent Results:
Admission Labs:
[**2150-2-19**] 01:30AM BLOOD WBC-5.3 RBC-3.57* Hgb-10.8* Hct-30.6*
MCV-86 MCH-30.3 MCHC-35.3* RDW-17.8* Plt Ct-103*
[**2150-2-19**] 01:30AM BLOOD Neuts-68.7 Lymphs-18.3 Monos-7.1 Eos-5.1*
Baso-0.8
[**2150-2-19**] 01:30AM BLOOD PT-15.8* PTT-31.8 INR(PT)-1.5*
[**2150-2-19**] 01:30AM BLOOD Fibrino-301
[**2150-2-20**] 01:15PM BLOOD Ret Aut-6.5*
[**2150-2-19**] 01:30AM BLOOD Glucose-95 UreaN-7 Creat-0.5 Na-140 K-3.5
Cl-110* HCO3-24 AnGap-10
[**2150-2-19**] 01:30AM BLOOD ALT-16 AST-77* LD(LDH)-255* AlkPhos-145*
TotBili-2.7* DirBili-2.0* IndBili-0.7
[**2150-2-19**] 01:30AM BLOOD Albumin-2.5* Calcium-7.1* Phos-3.2 Mg-1.7
[**2150-2-19**] 10:35AM BLOOD Type-ART Rates-12/ Tidal V-500 PEEP-5
FiO2-40 pO2-127* pCO2-37 pH-7.42 calTCO2-25 Base XS-0
-ASSIST/CON Comment-CA ADDED P
[**2150-2-19**] 01:32AM BLOOD Lactate-1.1
[**2150-2-19**] 10:35AM BLOOD freeCa-1.11*
.
EGD ([**2150-2-19**]):
- No esophageal varices.
- A large adherent formed blood clot in the fundus. Despite
multiple attempts at suctioning with a single channel
therapeutic endoscope, the clot could not be removed. We saw the
edge of fundic varix but could not visualize completely due to
overlying adherent clot.
- Edge of fundic varix seen.
- Duodenitis
- Small superficial ulcer in the duodenal bulb
- Portal hypertensive gastropathy
- Otherwise normal EGD to third part of the duodenum
.
Hepatic Venogram ([**2150-2-20**]):
1. Unsuccessful uncomplicated attempt at TIPS placement.
2. Elevation of the portosystemic gradient consistent with
portal
hypertension.
3. Splenorenal shunt.
4. Paracentesis with aspiration of 1300 cc of ascites.
5. Replacement of right internal jugular trauma line with tip in
SVC.
.
EGD ([**2150-2-21**]):
- Blood in the esophagus
- Blood in the fundus with large gastric varix
- Abnormal mucosa in the stomach
- Blood in the antrum
- Otherwise normal EGD to third part of the duodenum
.
TIPS ([**2150-2-21**]):
1. Pre TIPS portosystemic gradient measured 21 mmHg.
2. Successful placement of a TIPS (Viatorr 8 mm x 8 cm x 2cm)
post-dilated to 8 mm; portosystemic gradient changed to 24 mmHg.
3. Given that post-TIPS venography demonstrated persistent
filling of two very large varices leading to splenorenal shunts
and lack of improvement in the portosystemic gradient following
TIPS placement, the two large
varices/splenorenal shunts were sclerosed with denaturated
alcohol and
embolized with Aplatzer plugs.
4. Post TIPS+ variceal/splenorenal shunt embolization
portosystemic gradient is 13mmHg.
.
CTA ([**2150-2-24**]):
1. Patent TIPS shunt.
2. Area of hepatic hypoperfusion involving the posterior right
hepatic lobe (segments VI and VII) are likely secondary to
reduced portal flow following TIPS placement. The main celiac
trunk and common hepatic arteries appear
widely patent.
3. New right adrenal hemorrhage.
4. Splenorenal shunt.
5. Simple-appearing ascites.
.
RUQ Ultrasound ([**2150-2-24**]):
[**Doctor Last Name **]-scale imaging of the liver reveals a diffuse increase in
echogenicity
with a heterogeneous pattern consistent with fatty liver plus
fibrosis. No
discrete liver lesions are identified. There is minimal
perihepatic ascites noted. The spleen is enlarged at 13.7 cm.
Color flow and pulse Doppler waveform analysis was performed.
The TIPS stent is seen extending from the posterior right portal
vein to the right hepatic vein and is fully patent with
wall-to-wall flow on color flow imaging. Velocities within the
TIPS range from 41 cm/sec proximally to 111 cm/sec mid TIPS and
137 cm/sec distally. Main portal vein velocity is 33 cm/sec.
There is reversal of flow in the left portal and anterior right
portal vein branches towards the stent. Scans through the flanks
and lower abdomen reveal a moderate amount of ascites in both
lower quadrants, right greater than left.
US [**2-28**]: 1. Cirrhotic liver without discrete focal lesion.
Evidence of portal hypertension including stable splenomegaly.
2. Patent TIPS stent with unchanged velocities compared to
recent prior
examination.
3. No intra- or extra-hepatic biliary ductal dilatation.
4. No focal lesion within the liver to suggest necrosis or
abscess.
IR guided Feeding Tube placement [**2150-3-2**]: Successful
fluoroscopic-guided post-pyloric positioning of a Dobbhoff
feeding tube with unsuccessful bridling.
CXR [**3-2**]: The Dobbhoff tube tip is in the proximal stomach.
Cardiomediastinal silhouette is unchanged. Widespread
parenchymal opacities are unchanged in the short-term interval.
Brief Hospital Course:
Primary Reason for Admission: Mr. [**Known lastname **] is a 40 y/o male with a
history of alcohol abuse, GERD and hyperension who presented on
[**2150-2-14**] with 4 days of hematemesis and melena requiring
transfusion and intubation for airway protection.
.
Active Problems:
.
# GI Bleed: Given hematemesis and EtOH abuse, concern was for
upper GIB, likely variceal. He was intubated for airway
protection and IV access was obtained with PIV x2 and a R IJ
trauma line. He was transfused 11 units pRBCs at OSH prior to
transfer and on admission HCT was 30. He underwent EGD which
showed a large clot adherent to the fundus of the stomach; no
intervention was undertaken. The pt was started on IV PPI and
had active T&S with 8 units crossmatched. His HCT was initially
stable and he was sent to IR for TIPS due to high suspicion for
variceal bleeding. Initial attempt at TIPS was unsuccessful due
to difficult anatomy, though porto-systemic gradient was noted
to be 10. Given his low gradient, he underwent repeat EGD on
[**2150-2-21**] to remove the clot and confirm the bleed was variceal in
origin. Prior to repeat EGD the pt was reintubated and given a
bolus of Propofol for sedation. Large amounts of clot were
removed with [**First Name8 (NamePattern2) **] [**Doctor First Name **] gastric lavage, followed by BRB. The pt's
BP then dropped to the 40s and he was started on Neosynephrine
gtt with immediate improvement in his BP to 140s. No chest
compressions or Epi were administered. Two units pRBCs were hung
due to concern for re-bleeding. However, no active bleeding was
noted on EGD, though a very large gastric varix was visualized
and not intervened upon. The night of [**2-21**] the pts HCT trended
down and his Neosynephrine was stopped after the Propofol was
disconintued. He was transfused another 6 units pRBCs and his
HCT remained stable in the 28-30 range. TIPS and embolization of
spleno-renal shunts were performed [**2-22**], at which time his
porto-systemic gradient was noted to be 21, with normalization
post-procedure. Thereafter, his HCT remained stable.
Patient recently initiated on Nadolol 20mg [**Hospital1 **] and remained
hemodynamically stable. Patient has mild baseline dizziness but
will need to be watched for any signs and symptoms of
hypotension or bradycardia, such as lightheadedness, syncope,
dizziness, SOB, etc. Please hold medication should SBP<95,
HR<60.
.
# AMS: Likely Hepatic Encephalopathy c/b delerium. Throughout
his MICU course pt was A/O to person only. Lactulose was started
once the pt was extubated and tolerating POs and Rifaximin was
started on [**2-25**] upon leaving the MICU. Upon arrival to the floor
he remained AOx1. This improved to normal mental status during
the last week of stay; lactulose and rifaximin were continued.
There was a question of whether or not patient had any short
term memory loss from alcohol abuse such as Wernike's
encephalopathy, but as his mental status returned to [**Location 213**], it
became clear that his short term memory was intact.
.
# Decompensated Cirrhosis: Patient presented with acute upper GI
bleed secondary to gastric varices and splenorenal shunting.
Patient underwent TIPS procedure as described above and was slow
to resolve encephalopathy. A feeding tube was placed for
nutrition in the mean time and patient will leave the hospital
with tube feeds. Patient's bilirubin and rest of liver function
panel gradually improved as did his mental status. Patient to
continue with spirinolactone and lasix to prevent volume
reaccumulation and overload.
.
# Benzodiazepine Withdrawl: Prior to transfer from OSH, pt
received a large amount of Benzodiazepines for EtOH withdrawl.
On arrival to [**Hospital1 18**], he was felt to be in Benzo withdrawl given
he was 7 days s/p last drink and was clinically withdrawing
(hypertensive, tachycardic, tremulous). He was started on CIWA
and IV Ativan. His Benzos were slowly tapered and upon leaving
the MICU was not requiring additional Ativan for withdrawl and
did not require any upon arrival to the floor either.
.
# Hepatic Infarct: On post TIPS day 1, pt developed an acute
progression of his transaminitis and hyperbiliburinemia. There
was initially concern for TIPS thrombosis or reversal of flow
[**1-8**] splenorenal shunt embolization and RUQ ultrasounnd was
performed. TIPS was patent and flow was normal; CTA was
performed, which showed infarction of the inferior portion of
the R lobe of liver. This was felt to be a complication of his
TIPS. His LFTs slowly improved and he was called out to the
floor. His bilirubin rose to a peak of 10.9 before downtrending.
.
# Fever: On [**2150-2-23**] pt spiked a fever to 101.1. Blood, urine and
sputum cultures were drawn and a diagnostic paracentesis was
performed. Para was negative for SBP. At the time of transfer to
the floor, all cultures were NGTD. His fever was felt to be [**1-8**]
hepatic infarct. Upon arrival to the floor his fever curve
downtrended. He was iniated on ciprofloxacin for SBP prophylaxis
given his low ascites albumin level.
.
# Coagulopathy: Likely [**1-8**] liver disease. FFP was given with
transfusions in the setting of acute blood loss.
.
#Depression: Patient has had long history of depression, came in
on prozac and buspirone but patient describes that it did not
help him very much. He was evaluated by psych and was initiated
on mirtazipine to treat anxiety, depression as well as insomnia.
He is discharged on 15mg qhs, which has been working well for
him.
.
# Back Pain: Patient had recent fall prior to hospitalization
and has been well controlled on tylenol prn and lidocaine patch.
Medications on Admission:
-BuSpar 10mg TID
-Prozac 20mg Daily
-Nadolol 20mg Daily
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12hours
on, 12 hours off.
6. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO every [**5-15**]
hours: titrate to [**2-8**] BM /day.
8. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain: no more than 2g per day
.
9. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-8**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for nasal irritation.
10. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): can adjust based on
phosphorous levels.
11. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): pls hold for BP<95, HR<60
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
alcoholic hepatitis
decompensated cirrhosis
malnutrition
.
GERD
Hypertension
Left Hip Surgery s/p internal fixation (metal plate and pins)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted for decompensated
cirrhosis secondary to alcohol abuse. Your course was
complicated and involved gastrointestinal bleeding and a
procedure was done to lower your portal pressures to decrease
the likelihood of this happening again. However, the best thing
you can do for your health is to abstain from alcohol from this
day forward, as you will be endangering your life each and every
time you drink.
You medication list is detailed below. This is your updated
list--please use this list when taking your medications.
STOP Buspirone
STOP Prozac
INCREASE Nadolol from 20mg daily to 20mg twice daily
START Lasix
START Spirinolactone
START Lactulose
START Rifaximin
START MVI
START Thiamine
START Folic Acid
START Tylenol as needed for pain
START nasal saline spray as needed for dry membranes
START Mirtazipine 15mg at bedtime
START Sevelemer three times a day with meals.
You have follow up appointments, detailed below.
Followup Instructions:
You have the following appointments
You will need to follow up with your PCP when you get discharged
from rehab[**Hospital 110185**] rehab will be contacting your [**Name (NI) 6435**] office and
getting you an appointment when you are ready to leave. Please
follow up with your PCP [**Name Initial (PRE) 176**] 1 week of discharge from rehab.
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 12411**] ; NP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Department: LIVER CENTER
When: FRIDAY [**2150-3-20**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"571.2",
"572.3",
"571.1",
"578.0",
"573.4",
"304.10",
"572.2",
"303.91",
"530.81",
"292.0",
"780.62",
"285.1",
"996.74",
"518.81",
"263.9",
"456.8",
"311",
"401.9",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.1",
"88.64",
"96.04",
"96.71",
"54.91",
"45.13",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14109, 14182
|
7160, 12789
|
315, 365
|
14365, 14365
|
2641, 2641
|
15577, 16424
|
1669, 1673
|
12895, 14086
|
14203, 14344
|
12815, 12872
|
14516, 15554
|
1688, 2145
|
2159, 2622
|
266, 277
|
393, 1343
|
2658, 7137
|
14380, 14492
|
1365, 1481
|
1497, 1653
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,430
| 154,596
|
10458
|
Discharge summary
|
report
|
Admission Date: [**2179-9-1**] Discharge Date: [**2179-9-4**]
Date of Birth: [**2127-9-18**] Sex: M
Service: CARD [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is a 51 year old
male with known severe mitral regurgitation. The patient has
been followed for mitral regurgitation for the past four
years since his hospitalization with endocarditis. His most
recent echocardiogram in [**2179-4-17**] showed four plus mitral
regurgitation, one plus aortic regurgitation and a left
ventricular ejection fraction of approximately 60%. In
addition, the patient had cardiac catheterization performed
on [**2179-8-23**], which showed no angiographic evidence of
coronary artery disease but severe mitral regurgitation and
normal ventricular function of approximately 58%.
The patient had relatively few symptoms. He does not report
any dyspnea unless he is exerting himself significantly. The
patient actually walks for about a half hour daily without
any symptoms per report. He climbs stairs without
difficulty. The patient denied any symptoms of chest pain,
claudication, orthopnea, edema, paroxysmal nocturnal dyspnea,
or lightheadedness.
The patient presented for further evaluation and a possible
surgical intervention.
PAST MEDICAL HISTORY:
1. Endocarditis approximately four years ago with possible
Staphylococcus.
2. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. Status post hernia repair bilaterally.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg p.o. q. day.
LABORATORY: On admission hematocrit 43.8, white blood cell
count 4.7, platelet count 198. Urinalysis negative. Glucose
79, potassium 4.4, BUN 16, creatinine 0.8. Sodium 141,
alkaline phosphatase 35, total bilirubin 0.4.
PHYSICAL EXAMINATION: Afebrile with stable blood pressure
and heart rate. The patient was alert and oriented times
three in no apparent distress. Neurologically he was grossly
intact. Cardiovascular examination: Regular rate and rhythm
with a loud IV/VI systolic ejection murmur. Pulses two plus
present bilaterally in the upper and lower extremities. Lung
examination is clear to auscultation bilaterally without any
wheezes or crackles. Abdomen soft, nontender, nondistended.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to
Cardiac Surgery Service. Although the patient did not have
severe symptoms, he did present with severe mitral
regurgitation. It was decided at the time that a surgical
intervention would benefit the patient.
On [**2179-9-1**], the patient underwent mitral valve repair,
annuloplasty, No. 30mm [**Doctor Last Name 405**], plus quadrangular resection
P2. The postoperative systolic ejection fraction was
measured at approximately 55%. The patient tolerated the
procedure well; there were no complications.
The patient was transferred to the Intensive Care Unit in
fair condition. The patient's heart rate remained in sinus
rhythm with occasional premature ventricular contractions.
The patient was extubated on postoperative day zero. He
showed good oxygen saturation. He was making adequate urine
output. The patient was transferred to the regular floor on
postoperative day one in stable condition.
At that time, he experienced atrial fibrillation with heart
rate in the 130s to 140s. He was treated with Lopressor and
amiodarone. The patient remained in atrial fibrillation
overnight but then converted to sinus rhythm. The patient
was placed on a standing dose of oral amiodarone. The
patient was also continued on oral Lopressor as well.
The patient remained in sinus rhythm during the rest of his
hospitalization. The patient was ambulating. Physical
Therapy was consulted and followed the patient throughout his
hospitalization. He was cleared to go home.
The pacing wire was removed prior to discharge. The incision
was clean, dry and intact. The patient was discharged to
home on [**2179-9-4**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
DISCHARGE DIAGNOSES:
1. Severe mitral regurgitation status post mitral valve
repair.
DISCHARGE MEDICATIONS:
1. Lopressor 25 mg p.o. twice a day.
2. Amiodarone 400 mg p.o. twice a day times seven days
followed by 400 mg p.o. q. day times seven days, then 200 mg
p.o. q. day until he sees his Cardiologist.
3. Aspirin 325 mg p.o. q. day.
4. Lasix 20 mg p.o. twice a day times seven days.
5. Potassium chloride 20 mEq p.o. twice a day times seven
days.
6. Percocet one to two tablets p.o. q. four to six hours
p.r.n. pain.
7. Colace 100 mg p.o. twice a day.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with his surgeon, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] in approximately four weeks.
2. The patient is to follow-up with his Cardiologist, Dr.
[**First Name (STitle) **], in approximately three weeks.
3. The patient is to follow-up with his primary care
physician in approximately one to two weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2179-9-4**] 16:15
T: [**2179-9-4**] 16:54
JOB#: [**Job Number 34201**]
|
[
"E878.8",
"424.0",
"997.1",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
4012, 4019
|
4040, 4106
|
4129, 4584
|
1524, 1781
|
4608, 5234
|
1415, 1498
|
2298, 3952
|
1805, 2269
|
189, 1267
|
1289, 1392
|
3978, 3987
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,843
| 110,029
|
34542
|
Discharge summary
|
report
|
Admission Date: [**2200-9-2**] Discharge Date: [**2200-9-11**]
Date of Birth: [**2159-4-2**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
hypoxia, hemodynamic instability
Major Surgical or Invasive Procedure:
1. Ultrasound-guided puncture of left common femoral
artery.
2. Ipsilateral second-order catheterization of left
external iliac artery.
3. Pelvic arteriogram.
4. Stent placement in common iliac artery.
5. Perclose closure of the left common femoral arteriotomy.
History of Present Illness:
41 yo M with h/o L4 burst fracture s/p L3-L5 fusion, complicated
by psoas abscess and formation of chronic sinus tract,
presenting with bleeding from sinus tract, fever, and hypoxia.
The patient had an L4 burst fracture in [**2195**], fused with cage in
[**State 108**]. He later developed a fluid collection in that area, and
has a drain put in [**2200-8-25**]. 1 month later, the drain was
pulled, and the patient developed a draining sinus tract. The
patient was taken to the OR for debridement in 12/[**2197**]. This was
complicated by ureter injury. Since then, the patient had
persistent yellow/green drainage from the sinus tract.
On Sunday, the patient developed profuse bleeding from sinus
tract, which resolved before he reached [**Hospital3 417**] Medical
Center. At [**Hospital3 417**], the patient had a abd/pelvis CT
showing post-surgical changes in the left psoas muscle extending
into the left lateral abdominal wall, with no discrete fluid
collection or hematoma. Labs were notable for WBC 14.9, 51%
bands. The [**Hospital 228**] hospital course was complicated by fever
to as high as 103, hypotension to 89/43 which was
fluid-responsive, and further bleeding from the sinus tract in
the setting of fever and vomiting. Surgery consulted at the [**Hospital 6451**] hospital, who packed the sinus tract but did not
pursue more aggressive debridement. Pt was directly transferred
to the internal medicine
team at the [**Hospital1 18**] for further management of sinus tract
infection.
Upon arrival to the floor, patient was noted to have active,
profuse bleeding of bright red blood from the sinus tract. He
was hypotensive to low 100's/60's, with HR in low 100's. He was
bolused 3L NS, and transfusion of 2 units of PRBCs and FFP was
begun. He was given Vanc + Zosyn for broad coverage, and
admitted
to the ICU. His hemodynamics stabilized with BP's 120s/60's, and
HR 80's. The pressure dressing was removed, and sinus tract
examined, which did not appear to be actively bleeding any
longer. A CTA of abdomen/pelvis demonstrated active
extravasation of blood from a lumbar artery to L psoas muscle.
Vascular surgery
was consulted for further management.
Review of systems:
-Constitutional: +fevers, chills. Lost 10 pounds in past year.
-Resp: No cough. No shortness of breath.
-CV: No chest pain. No dizziness or lightheadedness.
-GI: No abdominal pain. +non-bloody emesis on Sunday. Chronic
diarrhea/BRBPR. No melena. No bowel or bladder incontinence.
-GU: No difficulty urinating or pain with urination.
-Neuro: No focal weakness, tingling, or numbness.
Past Medical History:
ulcerative colitis
L4 burst fracture s/p L3-L5 fusion [**2196**]
chronic sinus tract, as above
IVC filter placed via right groin
previous ureteric stent, now removed
PAST SURGICAL HISTORY:
s/p L ankle ORIF with hardware placement
s/p lumbar fusion with hardware placement
s/p OR washout/debridement [**12/2198**]
Social History:
Works as [**Doctor Last Name 3456**]. Married. Lives with wife.
-Tob: [**1-26**] cig/month
-EtOH: none
-Drugs: none
Family History:
hyperlipidemia
Physical Exam:
ADMISSION
T 98.9, HR 93, BP 115/64, RR 19, O2 Sat 96%/6L NC (was on NRB on
transfer to MICU)
Gen: No acute distress.
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Normal respiratory effort. Mild basilar rales.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. NT/ND. No rebound or guarding.
Back: Sinus tract in left flank with wick in place and large
amount of blood on dressing but no active bleeding.
Ext: Warm and well-perfused. Radial and DP pulses 2+
bilaterally.
Neuro: A+Ox3. Face symmetric. Strength 5/5 throughout upper and
lower extremities.
DISHCARGE
T 99.7 HR 72 BP 132/78 RR 16 97%RA
Gen: No acute distress.
Neuro: A+Ox3.
Resp: Normal respiratory effort. No resp distress.
CV: RRR. Normal s1 and s2.
Abd: +BS. Soft. NT/ND.
Ext: Warm and well-perfused.
Pulses: Radial pulses palp bilaterally. DP/PT palp bilat
Pertinent Results:
CTA Abd/Pelvis
1. Psoas phlegmonous changes are again visualized with a chronic
sinus tract. However, the left psoas appears enlarged with
hyperdense foci consistent with intramuscular hemorrhage with
evidence of foci of active arterial extravasation. Evaluation of
the left psoas is somewhat obscured by streak artifact from
adjacent metallic structures. However, multiple dilated tortuous
structures are visualized and may represent mycotic aneurysms
involving the iliolumbar artery versus foci of hemorrhage.
2. Relatively stable appearance of mild left hydronephrosis
tapering to the level of the left psoas collection.
3. Mild wall thickening and hyperemia involving the descending
colon, sigmoid colon, and rectum. Although these findings may
represent proctocolitis, evaluation is somewhat limited due to
lack of distention of the bowel. Correlation with symptoms is
recommended.
4. New mild ascites as well as new bilateral small pleural
effusions with
adjacent airspace atelectasis.
5. Right fat-containing inguinal hernia descending into the
scrotal sac with a right hydrocele.
6. IVC filter in place.
7. L4 burst fracture with L3-L5 cage.
.
MRA Abd w and w/o Contrast
Pseudoaneurysm from the left common iliac artery arising
adjacent to lumbar orthopedic hardware within the left psoas
muscle. This arises roughly 2 cm from the origin of the left
common iliac artery and 1 cm proximal to the origin of the left
internal iliac artery. Large multilobulated pseudoaneurysm
occupying the left psoas muscle with large surrounding thrombus
and hemorrhage. Report was urgently communicated to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at 5:57 p.m. on [**2200-9-5**], and with the
interventional radiology fellow on call at pager [**Numeric Identifier 5603**] at the
time of scan.
Blood cultures negative.
[**2200-9-10**] 07:40PM BLOOD Hct-31.5*
[**2200-9-10**] 03:51AM BLOOD WBC-9.8 RBC-3.49* Hgb-9.9* Hct-28.3*
MCV-81* MCH-28.4 MCHC-35.0 RDW-16.0* Plt Ct-631*
Brief Hospital Course:
HOSPITAL COURSE
41 yo M with h/o L4 burst fracture s/p L3-L5 fusion complicated
chronic sinus tract, presenting with active bleeding from sinus
tract, fever, hypoxia and hemodynamic instability, found to have
pseudoaneurysm of left common iliac artery communicating w sinus
tract, now s/p endovascular stenting. Patient admitted to MICU.
Course in MICU [**Date range (1) 40895**]:
#Pseudoaneurysm of left common iliac artery: Patient initially
presented to [**Hospital1 18**] in setting of profuse bleeding from sinus
tract. Patient received 6 units pRBCs, 2 units FFP, 1 bag
platelets. CTA abd/pelvis demonstrated intramuscular hemorrhage
at area of ileopsoas with a mycotic psuedoaneurysm w evidence
active arterial extravasation. IR attempted embolization of the
psuedoaneurysm, but were unable to locate the artery feeding it.
Subsequent MRA demonstrated pseudoaneurysm from the left common
iliac artery with large surrounding thrombus and hemorrhage.
Patient was transferred to Vascular Service and underwent
endovascular stenting.
.
#Hypoxemia: Following transfer, patient w worsening oxygen
requirement, fluffy infilatrate on CXR. Initial concern was for
CHF vs ARDS [**2-26**] unknown infectious process. Timeline not
consistent w TRALI. TTE demonstrated low-normal systolic
ejection function w possible hypokinesis of basal inferoseptal
segment. Patient received 10mg IV lasix w good effect, although
patient remained w 2L O2 requirement at time of transfer.
#Fever: Patient initially w fever and bandemia at OSH w/o
localizing symptoms or culture data. Patient has a long history
of signs of infection w/o positive culture data. Patient
remained w intermittent fevers through the ICU stay. Likely
source of infection is known sinus tract. Patient treated w
vanco/zosyn. No culture data at time of transfer.
.
#Ulcerative colitis - No known flare. Held lialda given ongoing
other issues.
Patient was transferred to VICU on [**2200-9-6**]. He underwent angio
and endovascular stent placement x2 in the common iliac artery
on the left with perclosure of left common femoral artery on
[**9-6**]. Bleeding continued and patient was transfused 2 units of
blood and patient underwent repeat angio with another stent
placed on [**9-8**]. Crit was still low so additional 2 units of
blood were given. Patient did well postoperatively. Crits were
closely followed and stable. Pt was switch from vanco/zosyn to
bactrim. Patient was tolerating a regular diet, pain well
managed and ambulating on his own. Discussed operation to remove
hardware in a few weeks, patient seems amenable. Discussed
operation with Dr. [**Last Name (STitle) 1391**] and Dr. [**Last Name (STitle) 363**]. Patient will go home
on Bactrim. On discharge, pt was ambulating, tolerating regular
diet, pain controlled, hematocrit stable.
Medications on Admission:
Lialda 1.2 grams, 2 tabs daily
Discharge Medications:
1. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): Take until you come back to
hospital for reoperation.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left common iliac pseudoaneurysm.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 [**2-27**]
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 [**4-30**] weeks for
post procedure check and CTA
Followup Instructions:
If you have questions call Dr.[**Name (NI) 1392**] office [**Telephone/Fax (1) 1393**].
|
[
"799.02",
"998.59",
"997.2",
"038.9",
"V12.79",
"567.31",
"995.91",
"E878.1",
"998.6",
"442.2",
"729.92",
"284.1",
"686.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"88.42",
"88.47",
"00.46",
"39.90",
"00.40",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
9844, 9850
|
6608, 9433
|
300, 572
|
9928, 9928
|
4588, 6585
|
11991, 12082
|
3666, 3682
|
9515, 9821
|
9871, 9907
|
9459, 9492
|
10079, 11968
|
3390, 3516
|
3697, 4569
|
2794, 3178
|
227, 262
|
600, 2775
|
9943, 10055
|
3200, 3367
|
3532, 3650
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,739
| 172,168
|
1111+1112
|
Discharge summary
|
report+report
|
Admission Date: [**2110-2-17**] Discharge Date: [**2110-2-25**]
Date of Birth: [**2050-11-22**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 59 year old woman
with a past medical history of diabetes, peripheral vascular
disease, chronic renal insufficiency, stent in [**2104**] to the
left anterior descending, a rota of the obtuse marginal in
8/99, a percutaneous transluminal coronary angioplasty of the
left posterior descending artery [**9-/2106**], a percutaneous
transluminal coronary angioplasty of the obtuse marginal 1,
status post unsuccessful percutaneous transluminal coronary
angioplasty of proximal obtuse marginal, and cypher to the
circumflex [**10-24**], who awoke from sleep today with 8 out of 10
anginal equivalent pain, non-radiating, positive shortness of
breath, and sweats with diaphoresis. The pain was
non-pleuritic. Although this pain normally resolves with
Nitroglycerin, after taking three sublingual Nitroglycerins,
the pain remained. The patient called the Emergency Medical
Services and was brought to an outside hospital. At the
outside hospital, the patient was found to be in congestive
heart failure with positive troponin and CK as well as
changes on her electrocardiogram.
PAST MEDICAL HISTORY:
1. Gout.
2. Osteoporosis.
3. Chronic renal insufficiency.
4. Peripheral vascular disease.
5. Diabetes mellitus.
6. Appendicitis.
7. Carpal tunnel surgery.
8. Status post femoral popliteal bypass [**2100**].
9. Hematemesis.
10. Anemia.
11. Thyroid disease.
12. Peripheral neuropathy.
ALLERGIES: Morphine, sodium pentothal, Tylenol #3.
MEDICATIONS:
1. Lopressor 100.
2. Lasix 80.
3. Lantus 25 in the evening.
4. Prilosec 20.
5. Prinivil 10.
6. Plavix 75.
7. Humalog.
8. Neurontin 300.
9. Aspirin 325.
10. Keflex 500.
11. Colchicine 0.6 mg.
12. Imdur 60 mg.
13. Pravachol 40.
14. Diovan 160.
15. Allopurinol 100.
16. Ecotrin 325.
17. Norvasc 20.
18. Lopressor 50.
LABS AT THE OUTSIDE HOSPITAL: White blood count 7.7;
hematocrit 29.7; platelets 310; sodium 138; INR 1.0; BUN 86;
creatinine 2.5; potassium 4.5; glucose 237; CK 116; MB 5.3;
troponin 4.1. Chest x-ray at the time was consistent with
failure.
PERTINENT PREVIOUS STUDIES: [**2104**] the patient had a stent to
the left anterior descending; [**6-/2105**] had a rota of the obtuse
marginal; [**9-/2106**] percutaneous transluminal coronary
angioplasty of the left posterior descending artery;
percutaneous transluminal coronary angioplasty of the obtuse
marginal 1; status post unsuccessful percutaneous
transluminal coronary angioplasty of the proximal obtuse
marginal 1; [**10-24**] cypher to the circumflex artery.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Blood
pressure 140/60, heart rate 74; respiratory rate 20, oxygen
saturation rate 99% on 3 liters. General: She was an
elderly female lying in bed in no apparent distress with
face mask on and able to speak in full sentences. Neck: No
jugular venous distention. Cardiovascular: Regular rate and
rhythm, no murmurs, rubs, or gallops. Lungs: Bilateral
crackles three quarters of the way up. Extremities: 1+
bilateral lower extremity edema. Neurological: Awake, alert
and oriented times three. Her groin site had no hematoma or
oozing and no pain.
HOSPITAL COURSE: The patient was initially encountered in
the holding area status post catheterization. After arriving
at the hospital, the patient was brought in for cardiac
catheterization. The results of the catheterization were as
follows: Three vessel disease, patent left circumflex stent,
cardiac output 6.60, ............ index 3.28, pulmonary
capillary wedge pressure 34, right atrium pressure 7, and
pulmonary artery pressure 46. The left main coronary artery
showed no obstruction. The left anterior descending showed
mild disease. The left circumflex showed subtotal obtuse
marginal severely diseased before stent. Right coronary
artery showed small, non-dominant 60% mid occlusion in a 1 mm
vessel. The recommendations include medical management.
In the holding area, the patient was on 3 liters and
saturating at 97%. She was able to speak in full sentences
and it was decided the patient would tolerate being on the
floor and that patient would not need to go to the Cardiac
Care Unit for closer monitoring. Prior to arriving to the
floor, the patient had an episode of desaturation, with
saturation levels getting into the high 80s. The patient
also had severe nausea and occasional vomiting the first
night on the floor. The following day, it was noted that the
patient's creatinine level had increased sharply and her
urine output had decreased as well. At this point, the renal
consult team was notified, saw the patient, and felt that the
best course of action was to transfer the patient to the
Cardiac Care Unit for emergent dialysis.
After initial preparation, the patient was brought to the
Cardiac Care Unit, was given a femoral arterial hemodialysis
line catheter and dialysis was begun. On the initial day of
hemodialysis, 4.7 liters of fluid were taken from the
patient. Two days later, an additional 2 liters were taken
from the patient. During this time, the patient's creatinine
worsened slightly, reaching a peak of 4.9. After the second
round of dialysis, the patient was then able to produce urine
and the patient's respiratory status continued to improve.
After two days in the unit, the patient was transferred to
the floor once again where it was determined by the floor
team, as well as by the renal consult service, that the
patient probably would not need additional hemodialysis. The
patient continued to put out better urine. She was given
Lasix to augment the diuresis. Over the next two days, the
creatinine subsequently decreased to a level very near her
baseline of 3.
1. Non-ST elevation myocardial infarction: The patient,
with chest pain and electrocardiogram changes, presented to
an outside hospital. The patient had multiple elevations in
troponin CK while in the hospital. She received her
catheterization without any intervention. An echocardiogram
was done which showed an ejection fraction of 35 to 40%.
During her stay, her CK continued to drop and her troponin
remained elevated for a time, possibly secondary to her renal
failure. The patient had one very short episode of chest
pain while in the Cardiac Care Unit, but other than that, had
no cardiac symptoms while in the hospital.
2. Congestive heart failure: The patient's initial x-ray at
the outside hospital was consistent with congestive heart
failure. On initial examination, the patient had rales
bilaterally and severe shortness of breath. After
transferring to the Cardiac Care Unit and subsequent
dialysis, the patient's respiratory status improved
dramatically, resulting in a decreased need for oxygen. Two
days after being transferred back from the Cardiac Care Unit
to the floor, the patient was on room air and saturating 95%.
The patient was given Lasix to help with diuresis which was
effective in making her negative, every day of her hospital
stay, status post hemodialysis. The patient will be sent
home on her normal regimen of 80 mg Lasix once daily. The
patient will also be restarted on an ACE inhibitor for
afterload reduction once her creatinine falls to below 3.
The patient's on her Labetalol for her beta-blockade.
3. Hypoxia: The patient demonstrated hypoxia, starting
initially in the holding area, most likely secondary to
pulmonary edema and congestive heart failure. Once those
issues were resolved on hemodialysis and adequate diuresis,
the patient's respiratory status improved and she was no
longer hypoxic.
4. Chronic renal insufficiency: The patient arrived with a
baseline creatinine level around 3. After her subsequent
stay in the Cardiac Care Unit and adequate rehydration and
diuresis, the patient's creatinine was near baseline.
5. Hypertension: The patient was controlled relatively well
on her normal antihypertensives that she had been taking as
an outpatient. No significant changes were made while
in-house. The patient will be discharged home with a similar
regimen of antihypertensive medications.
DISPOSITION: Patient will likely be discharged home with
plans for follow-up with her cardiolgoist and primary care
physician.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Myocardial infarction.
2. Status post cardiac catheterization.
3. Chronic renal insufficiency.
4. Acute renal failure.
5. Hypertension.
6. Diabetes mellitus.
7. Congestive heart failure.
DISCHARGE MEDICATIONS:
1. Aspirin 25 mg by mouth once daily.
2. Clopidogrel 75 mg by mouth once daily.
3. Gabapentin 800 mg by mouth three times a day.
4. Levothyroxine sodium 112 micrograms by mouth once daily.
5. Acetaminophen 325 mg as needed.
6. Isosorbide mononitrate 60 mg by mouth once daily.
7. Carvedilol 25 mg by mouth twice a day.
8. Atorvastatin 80 mg by mouth once daily.
9. Furosemide 80 mg by mouth once daily.
FOLLOW-UP PLANS: Patient will follow-up with her
cardiologist and primary care physician within the next 7 to
10 days.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 7170**]
MEDQUIST36
D: [**2110-2-24**] 10:47
T: [**2110-2-26**] 20:31
JOB#: [**Job Number 7171**]
Admission Date: [**2110-2-17**] Discharge Date: [**2110-2-26**]
Date of Birth: [**2050-11-22**] Sex: F
Service: [**Hospital Unit Name 196**]
CHIEF COMPLAINT: Congestive heart failure and acute non ST
elevation myocardial infarction status post catheterization.
HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old
female with a past medical history of diabetes, peripheral
vascular disease, chronic renal insufficiency, [**2104**] stent to
the left anterior descending coronary artery, in 8/99 rota of
the obtuse marginal, and [**9-/2106**] percutaneous transluminal
coronary angioplasty of the LPDA, percutaneous transluminal
coronary angioplasty of the obtuse marginal one, status post
unsuccessful percutaneous transluminal coronary angioplasty
of the proximal obtuse marginal one, [**10-24**] cipher to the
circumflex who awoke from sleep today with 8 to 10 anginal
equivalent pain, nonradiating and positive shortness of
breath, positive diaphoresis with the pain that was
nonpleuritic. The pain, which normally resolve with one
nitroglycerin did not resolve with three nitroglycerin. The
patient called EMS and was brought to an outside hospital.
There was found to be in failure with positive enzymes and
electrocardiogram changes. The patient was transferred here
for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Gout.
2. Osteoporosis.
3. Chronic renal insufficiency.
4. Peripheral vascular disease.
5. Diabetes mellitus.
6. Status post appendectomy.
7. Carpal tunnel surgery.
8. Status post femoral popliteal bypass in [**2100**].
9. Hematemesis.
10. Anemia.
11. Hypothyroidism.
12. Peripheral neuropathy.
ALLERGIES: Morphine, sodium penathol and Tylenol #3.
MEDICATIONS ON ARRIVAL:
1. Lopresor 100.
2. Lasix 80.
3. Lantus 10 in the evening.
4. Prilosec 20.
5. Prinivil 10.
6. Plavix 75.
7. Humalog 100.
8. Neurontin 300.
9. Aspirin 325.
10. Keflex 500.
11. Colchicine .6.
12. Imdur 60.
13. Pravachol 40.
14. Diovan 160.
15. Allopurinol 100.
16. Ecotrin 325.
17. Norvasc 20.
18. Lopressor 50.
OUTSIDE HOSPITAL LABORATORIES: White blood cell count 7.7,
hematocrit 29.7, platelets 310, sodium 138, INR 1.0, BUN 86,
creatinine 2.5, potassium 4.5, glucose 237. Her CK was 116
with an MB fraction of 5.3 and her troponin was 4.1. Chest
x-ray was consistent with failure.
PERTINENT PREVIOUS STUDIES: In [**2104**] stent to the left
anterior descending coronary artery, [**2104**] rota of the obtuse
marginal and [**9-/2106**] percutaneous transluminal coronary
angioplasty of the LPDA and a percutaneous transluminal
coronary angioplasty of the obtuse marginal one. Status post
unsuccessful percutaneous transluminal coronary angioplasty
of the proximal obtuse marginal one and [**10-24**] cipher to
circumflex.
CURRENT STUDIES IN HOUSE: Catheterization report, which
showed three vessel disease, patent left circumflex stent,
cardiac output of 6.60, cardiac index of 3.28, capillary
wedge pressure of 34, right atrial pressure of 7 and
pulmonary artery pressure 46. Her left main coronary artery
showed no obstruction. Her left anterior descending coronary
artery showed mild disease, left circumflex showed subtotal
obtuse marginal severely diseased before stenting and with
current collateralization. Her right coronary artery showed
small nondominant 50% occlusion in the middle vessel and the
recommendations status post catheterization were medical
management.
PHYSICAL EXAMINATION: Vital signs when seeing the patient
were blood pressure 140/60. Heart rate 74. Respiratory rate
20. Satting 99% on 3 liters. She was an elderly female
lying in bed in no acute distress. Face mask on. Able to
speak in full sentences. No JVD. Regular rate and rhythm.
No murmurs, rubs or gallops. Bilateral crackles [**1-23**] of the
way up. 1+ bilateral lower extremity edema. Alert and
oriented times three. Groin site with no hematoma or oozing.
HOSPITAL COURSE: The patient was initially evaluated in the
holding room after catheterization. At this point she was
satting 97 to 99% on 3 liters and looked relatively
comfortable. Upon arrival to the floor the patient had a
moment of desaturation. She went down to the high 80s, which
was resolved after positioning the patient in a better
position. The patient also suffered from nausea during the
first evening on the floor, which resolved with the
application of Zofran and Ativan. The next day after arrival
to the floor it was noted that the patient's urine output had
decreased and the patient's creatinine had bumped from her
baseline around 2 to over 3. The Renal Service was consulted
and they felt that the patient would require emergent
hemodialysis to combat the acute renal failure. The patient
was transferred to the CCU where she underwent hemodialysis
on two of the three days that she stayed in the unit. The
first day 4.7 liters of fluid were removed from the patient
and on the third day an additional 2 liters were removed from
the patient. During her time in the unit the patient had one
bout of chest pain 4 out of 10, which lasted approximately 20
minutes, which resolved with sublingual nitroglycerin. After
significant clinical improvement the patient was transferred
to the floor for further care.
After return to the floor the patient's creatinine came back
down from a high of 4.9 down to approximately 3. At this
point the patient had no other complaints of chest pain,
shortness of breath, nausea, vomiting, fevers or chills and
began to put out better urine output. Over the next few days
her creatinine slowly increased from 3 to 3.3 to 3.5 and
finally on the day of discharge 3.4. Renal continued to
follow the patient and felt that dialysis was not needed at
this point, however, they would continue to monitor her urine
output as well as creatinine. Their thought was that her
acute on chronic renal failure was probably secondary to
contrast nephropathy, which resulted from the contrast dye
given during catheterization.
1. Non ST elevation myocardial infarction: The patient
arrived without chest pain, but had a history of chest pain,
electrocardiogram changes and positive enzymes. She also had
multiple risk factors as well. The patient underwent cardiac
catheterization (see report above), but no intervention
occurred during the catheterization. An echocardiogram while
in house showed an ejection fraction of 35 to 40%, which was
worse from an echocardiogram done two years ago, which showed
an ejection fraction of 40 to 45%. On [**2-23**] three days before
discharge her CK and troponin had a significant increase
after trending down for the rest of her hospital stay. The
following two days the CK and troponin both went back down
with no further chest pain, shortness of breath, nausea or
vomiting.
2. Congestive heart failure: The patient's initial chest
x-ray was consistent with congestive heart failure. Prior to
the CCU admission the patient was given Lasix and was
responsive, however, the day that she was transferred to the
CCU her urine output dropped off despite the application of
120 mg of Lasix. Now that the patient is no longer being
dialyzed and is back in the CCU her urine output is once
again responsive to Lasix. Her clinical examination has
drastically improved from admission with only very small
crackles at the bases remaining. She is satting well on room
air currently.
3. Hypoxia: The patient was on 3 liters of nasal cannula.
This most likely was secondary to congestive heart failure
and pulmonary edema. After the significant diuresis by
dialysis as well as the good urine output over the last few
days of her hospital stay the patient continues to sat well
on room air with no other respiratory issues.
4. Chronic renal insufficiency: The patient's creatinine is
slightly up from baseline, however, she continues to have
good urine output and his Lasix responding. Her creatinine
appears to be stable and slightly decreasing now at a level
near 3.5. It will be sometime to determine whether she will
return back to her baseline or whether she will develop a new
baseline slightly higher then prior.
5. Diabetes mellitus: The patient had no issues during her
hospital stay. Her control was adequate during her hospital
stay with no need for any acute intervention.
6. High blood pressure: The patient was put on her normal
blood pressure medications and her blood pressure was
controlled adequately throughout her hospital stay.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehab for cardiopulmonary rehab as well
as physical therapy. The patient is significantly
deconditioned after spending this much time in the hospital.
DISCHARGE DIAGNOSES:
1. Non ST elevation myocardial infarction.
2. Chronic renal insufficiency.
3. Acute renal failure.
4. Congestive heart failure.
5. Hypoxia.
6. Diabetes mellitus.
7. Hypertension.
DISCHARGE MEDICATIONS:
1. Aspirin 325 po q day.
2. Plavix 75 mg po q day.
3. Gabapentin 400 mg po t.i.d.
4. Levothyroxine 112 micrograms one po q day.
5. Isosorbide mononitrate 60 mg sustained release one q.d.
6. Carvedilol 12.5 tablets two po b.i.d.
7. Atorvastatin 40 mg one po q.d.
8. Furosemide 80 mg one po q.d.
FOLLOW UP PLANS: The patient will initially go to rehab for
an unknown amount of time. The patient will then follow up
with her cardiolgoist in three to five days. The patient
will also follow up with her primary care physician at this
point.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 7170**]
MEDQUIST36
D: [**2110-2-26**] 09:35
T: [**2110-2-26**] 09:41
JOB#: [**Job Number 7172**]
|
[
"584.9",
"416.8",
"414.01",
"443.9",
"593.9",
"410.71",
"250.00",
"356.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"88.53",
"88.55",
"37.22",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
8343, 8379
|
18168, 18355
|
18378, 19235
|
8400, 8598
|
13401, 17940
|
12922, 13383
|
9052, 9608
|
9626, 9730
|
9759, 10779
|
2704, 3277
|
10801, 12899
|
17965, 18147
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,953
| 160,372
|
35719
|
Discharge summary
|
report
|
Admission Date: [**2173-6-28**] Discharge Date: [**2173-7-1**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Abdominal pain and Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Chief Complaint: Abdominal Pain
Reason for MICU transfer: Hypoxia requiring BiPAP
History of Present Illness: [**Age over 90 **]F with h/o metastatic renal CA,
CHF, pacemaker, presented to ED yesterday ([**6-28**]) c/o of
epigastric abdominal pain and weakness, was admitted to medicine
for hypoxia, and was transferred to MICU this morning for
inability to maintain O2 sat on NRB.
.
She initially presented with abdominal pain, which is chronic in
nature and has gone on intermittently for several years. She
states that it is associated with certain foods such as
"cucumbers and tomatoes." Her Alum-Mag hydroxide-simethicone
typically helps somewhat. The pain does not radiate anywhere and
is associated with some nausea. Patient lives alone but has been
feeling weak for the past 3 days. Has no appetite and has not
been eating much. Denies fevers/chills, cough, chest pain, SOB,
pain anywhere else, dysuria, vomiting. Went to OSH and had
abdominal CT 3 days ago showing worsening right renal mass and
invasion to right renal vein and IVC. Not currently undergoing
treatment for CA.
.
Patient initially came here with complaints of abdominal pain
again, but was noted to be hypoxic in the ED. She denies
orthopnea, PND, but does complain of difficulty climbing a
flight of stairs. The family is unable to detail if these
symptoms have changed recently, but they said she has been
hypoxic before when she was seen at [**Hospital1 3494**] 3 days ago. She
was given "some liquid" which resulted in her being able to come
off o2. Other than that, her only prior O2 requirement was when
she required pacer placement in [**2169**] at the time of her RCC
diagnosis.
.
In the ED, initial vitals: 97.6 104 149/75 18 86%. Labs notable
for Na 125, K 5.4, BNP [**Numeric Identifier 81257**], WBC 12.9, diff N:93.9 L:5.1 M:0.7
E:0.1 Bas:0.1. The pt underwent a CXR PA and Lat which showed a
L sided consolidation concerning for PNA vs atelectasis, She
received nothing in the ED. Vitals prior to transfer to floor:
98.2, 149/78, 25, 94, 99%4L.
.
Initially on the floor, patient's vitals were 98.5, 146/83, 99,
20, 94%, 3L. Were treating and working up hypoxia as PE vs. MI
vs. malignancy vs. CHF. Also treating hyponatremia. Became
hypoxic on floor early this morning to O2 sat 61, put on NRB,
came up to mid 80s. ABG showed 7.28/64/63/31. Given nebs,
started on vanc and cefepime. Patient is DNR/DNI, but was
transferred to the floor for BiPAP.
On arrival to the MICU, patient was satting poorly on NRB. She
seemed confused and disoriented and was switched to non-invasive
pressure support.
Review of systems:
(+) Per HPI
(-) Not able to complete full ROS due to AMS.
Past Medical History:
hypertension,
congestive heart failure, presumably diastolic
pacer dependent heart block
diverticulosis.
Colectomy in [**2161**] at [**Hospital3 **]
left hip pinning in the 40s.
Social History:
Ms. [**Known lastname **] lives alone in [**Hospital1 3494**] in an apartment on the 5th
floor. Her brother and sister-in-law live nearby. She has never
been married. She has no children. No tobacco use. Occassional
EtOH use.
Family History:
father had kidney cancer in his 60s
mother had melanoma
Physical Exam:
Admit Exam:
GENERAL ?????? increased work of breathing
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, distended neck veins, no carotid bruits
LUNGS - lungs with crackles, poor airation
HEART - RRR, 3/6 systolic murmer, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no edema, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO ?????? disoriented, pulling at lines/mask
Pertinent Results:
[**2173-6-28**] 08:47AM BLOOD WBC-12.9* RBC-4.10* Hgb-12.0 Hct-36.3
MCV-89 MCH-29.2 MCHC-33.0 RDW-13.9 Plt Ct-256
[**2173-6-29**] 01:54AM BLOOD WBC-13.7* RBC-3.96* Hgb-12.4 Hct-35.0*
MCV-88 MCH-31.3 MCHC-35.4* RDW-14.0 Plt Ct-250
[**2173-6-29**] 05:22AM BLOOD WBC-18.6* RBC-4.48 Hgb-13.3 Hct-40.3
MCV-90 MCH-29.7 MCHC-33.1 RDW-13.9 Plt Ct-305
[**2173-6-30**] 02:43AM BLOOD WBC-19.9* RBC-4.05* Hgb-12.0 Hct-36.7
MCV-91 MCH-29.7 MCHC-32.8 RDW-14.1 Plt Ct-264
[**2173-7-1**] 04:46AM BLOOD WBC-15.4* RBC-4.17* Hgb-12.2 Hct-38.8
MCV-93 MCH-29.3 MCHC-31.5 RDW-13.9 Plt Ct-276
[**2173-6-28**] 08:47AM BLOOD Glucose-218* UreaN-25* Creat-1.1 Na-125*
K-5.4* Cl-89* HCO3-24 AnGap-17
[**2173-6-28**] 09:15PM BLOOD Na-128* K-5.6* Cl-89*
[**2173-6-29**] 01:54AM BLOOD Glucose-168* UreaN-23* Creat-0.9 Na-125*
K-5.7* Cl-88* HCO3-28 AnGap-15
[**2173-6-29**] 05:22AM BLOOD Glucose-222* UreaN-24* Creat-1.0 Na-126*
K-5.2* Cl-87* HCO3-25 AnGap-19
[**2173-6-30**] 02:43AM BLOOD Glucose-142* UreaN-33* Creat-1.3* Na-129*
K-5.1 Cl-89* HCO3-31 AnGap-14
[**2173-7-1**] 04:46AM BLOOD Glucose-110* UreaN-47* Creat-1.7* Na-134
K-5.5* Cl-95* HCO3-29 AnGap-16
[**2173-6-28**] 08:47AM BLOOD proBNP-[**Numeric Identifier 81257**]*
[**2173-6-28**] 08:47AM BLOOD cTropnT-0.07*
[**2173-6-28**] 09:15PM BLOOD CK-MB-6 cTropnT-0.08*
[**2173-6-29**] 01:54AM BLOOD CK-MB-6 cTropnT-0.09*
[**2173-6-28**] 05:24PM BLOOD Type-ART pO2-54* pCO2-46* pH-7.43
calTCO2-32* Base XS-4 Intubat-NOT INTUBA
[**2173-6-29**] 04:09AM BLOOD Type-ART pO2-63* pCO2-64* pH-7.28*
calTCO2-31* Base XS-0 Comment-NON-REBREA
[**2173-6-29**] 05:36AM BLOOD Type-[**Last Name (un) **] pO2-65* pCO2-102* pH-7.13*
calTCO2-36* Base XS-0
[**2173-6-29**] 05:38AM BLOOD Type-ART Temp-36.7 FiO2-100 pO2-76*
pCO2-98* pH-7.14* calTCO2-35* Base XS-0 AADO2-545 REQ O2-90
Intubat-NOT INTUBA
[**2173-6-29**] 07:30AM BLOOD Type-ART pO2-65* pCO2-78* pH-7.22*
calTCO2-34* Base XS-0 Intubat-NOT INTUBA Comment-NON-REBREA
[**2173-6-29**] 06:38PM BLOOD Type-[**Last Name (un) **] Temp-36.4 pO2-182* pCO2-68*
pH-7.27* calTCO2-33* Base XS-2 Intubat-NOT INTUBA
[**2173-6-30**] 02:58AM BLOOD Type-[**Last Name (un) **] Temp-36.5 pO2-47* pCO2-79*
pH-7.24* calTCO2-36* Base XS-2 Intubat-NOT INTUBA
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] yo female with a hx of CHF, RCC, and HTN
presenting with abdominal pain, now resolved, but noted to be
hypoxic on admission to 86%. Given vacomycin and cefepime.
Hypoxemia progressed despite ABX and patient developed [**Last Name (un) **].
Worsening hypoxemia and [**Last Name (un) **] in the setting of metastatic RCC and
DNR/DNI prompted decision to transition to CMO. Ms. [**Known lastname **]
passed while in the MICU on [**2173-7-1**].
Medications on Admission:
- Amlodipine 5 mg PO/NG DAILY
- Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO/NG QID:PRN
dyspepsia
- CefePIME 2 g IV Q24H
- Furosemide 40 mg IV x 3
- Heparin 5000 UNIT SC TID
- Metoprolol Succinate XL 25 mg PO DAILY
- Omeprazole 40 mg PO DAILY
- Vancomycin 1000 mg IV Q48H
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
|
[
"198.89",
"189.0",
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"428.32",
"482.9",
"276.2",
"V45.01",
"V49.86",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7080, 7089
|
6260, 6754
|
276, 282
|
7140, 7150
|
4030, 6237
|
3447, 3505
|
7110, 7119
|
6780, 7057
|
3520, 4011
|
2923, 2983
|
327, 394
|
423, 2904
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3005, 3185
|
3201, 3431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,014
| 172,701
|
43570
|
Discharge summary
|
report
|
Admission Date: [**2165-8-14**] Discharge Date: [**2165-8-15**]
Date of Birth: [**2098-2-18**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hypoxia, rapid a-fib, hypotensive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
: 67 yr old male with multiple medical problems including recent
intracranial hemorrhage s/p coil and stent with prolonged wean
from vent requiring trach and peg, severe CAD, PE, CHF and UGIB
returns from [**Hospital3 **] with decreased 02 sats, Afib with
RVR, borderline hypotension and lethargy. At [**Name (NI) **], pt noted
to be tachy in 140-150 and O2 sat of 80% on 30% via trach. Inc
CPAP and inc O2 improved oxygen sat but O2 sat repeatedly
dropped. Pt noted to have thick sputum production and suctioning
helped his sats. Pt transferred to ED and given dilt but became
hypotensive. On last admission, pt was in rapid a-fib with good
response to metoprolol. Pt was discharged with metoprolol 50 mg
tid and was in NSR. In the rehab, pt was on metoprolol 50 tid
but a-fib got more tachy as he started to have thick secretion
and became hypoxic in the 80's. He was also started on Ritalin
recently. In the ED, given lopressor 5mg IV x2 and 50 mg po x1
with little effect, digoxin started per cardiology rec.
Levo/flagyl given at ED. CTA negative for PE.
To [**Hospital Unit Name 153**]: IV metoprolol 10 mg with brief [**Month (only) **] in HR. Tried PO
metoprolol 12.5 mg with good response: HR 80's, SBP in 110's.
Gave Lasix IV 20 mg with good UOP with good BP.
Past Medical History:
-CAD, s/p MI, CABG x 2 in '[**50**] and '[**62**], multiple stents
-htn
-s/p MV annuloplasty in '[**62**]
-s/p AICD
-s/p intracranial bleed [**5-28**], per HPI
-mult L sided PEs ([**6-28**])
-h/o hyponatremia
-VRE pos
-CHF - [**6-28**] echo with EF 30%, moderate regional LV systolic
dysfunction with near AK of inferior and inferolateral walls,
sever HK of anterolat. wall.
Physical Exam:
VS: 97.3 121/78 118 a-fib, RR 18 100% on 10L trach
GEN: Ill appearling, wiggles toes on right to comand but
otherwise unresponsive but in NAD.
HEENT: PERRL, anicteric, unable to get mouth open
Neck: supple, +trach
CV: Irreg, irreg, no m/r/g
Lungs: [**Month (only) **] BS bilateral bases with coarse BS bilateral upper
lung fields L>R, no wheezes
Abd: Soft NTND, no NSM, no masses, normal BS, G tube site c/d/i
Ext: no c/c/e
Skin: Sacral + perirectal ulcers/ breakdown otherwise no rashes.
ICD site C/D/I, well healed stenotomy scar
Neuro: Localizes pain bilaterally, no nystagmus, increased tone
with marginal cog-wheele rigidity of bilateral UE. LE tone
normal. Resting tremors vs choreathosis movement of both hands,
+grasp reflex bilaterally. Reflexes: biceps 3+/3+, patellar [**1-24**],
Babinski upgoing bilateral
Pertinent Results:
[**2165-8-14**] 10:46PM CK(CPK)-31*
[**2165-8-14**] 10:46PM CK-MB-3 cTropnT-0.02*
[**2165-8-14**] 10:46PM ALBUMIN-3.0*
[**2165-8-14**] 08:58PM TYPE-ART PO2-65* PCO2-41 PH-7.43 TOTAL CO2-28
BASE XS-2
[**2165-8-14**] 08:58PM LACTATE-1.5
[**2165-8-14**] 11:07AM LACTATE-1.7
[**2165-8-14**] 10:50AM GLUCOSE-100 UREA N-21* CREAT-0.5 SODIUM-138
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13
[**2165-8-14**] 10:50AM CK(CPK)-27*
[**2165-8-14**] 10:50AM cTropnT-0.02*
[**2165-8-14**] 10:50AM CK-MB-NotDone
[**2165-8-14**] 10:50AM WBC-11.8* RBC-3.82* HGB-11.1* HCT-34.5*
MCV-90 MCH-29.2 MCHC-32.3 RDW-14.9
[**2165-8-14**] 12:17AM LACTATE-2.3* K+-4.4
[**2165-8-13**] 10:55PM WBC-12.0* RBC-3.88* HGB-11.4* HCT-34.3*
MCV-88 MCH-29.4 MCHC-33.3 RDW-15.0
[**2165-8-13**] 10:55PM HYPOCHROM-3+ POIKILOCY-1+
[**2165-8-13**] 10:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-5.0 LEUK-NEG
[**2165-8-13**] 10:55PM URINE RBC-[**12-14**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-[**7-4**]
Brief Hospital Course:
To [**Hospital Unit Name 153**]: IV metoprolol 10 mg with brief [**Month (only) **] in HR. Tried PO
metoprolol 12.5 mg with good response: Gave Lasix IV 20 mg with
good UOP with good BP.
1)A-fib: Pt presented with a-fib w/ RVR minimally responsive to
lopressor IV. Dilt lowers rate but pt became hypotensive. On
last admission, pt's a-fib controlled with metoprolol 50 mg tid.
Pt was taking that amount at rehab but had worsening of
tachycardia which improved with suctioning of sputum. Cause of
worsening a-fib: hypoxia, CHF exacerbation, PE, MI,
hyperthyroid, electrolytes inbalance, recent start of Ritalin.
Nl TSH, CTA showing neg PE, bilateral pleural effusion with
possible CHF exacerbation. It was strongly believed that recent
initiation of Ritalin worsened his atrial fibrillation. In
addition, worsening pleural effusion indication worsening CHF
may have also contributed his rapid a-fib. On admission, IV
metoprolol 10 mg gave brief [**Month (only) **] in HR. Po metoprolol 12.5 mg
[**Hospital1 **] gave good response: HR 80's, SBP in 110's. On day #2
metoprolol was increased to 25 mg [**Hospital1 **]. Pt will be discharged
with Toprol XL 25 mg per G-tube qd. Pt's PCP can titrate this
dose further if his BP tolerates. Digoxin was also loaded at ED
and received the loading dose of digoxin 0.25 mg x 4. He will
be continued on digoxin 0.125 mg q6 and need to have his digoxin
level checked on [**8-16**]. He will also need to have his potassium
level checked as well. He will resume the anticoagulation with
lovenox.
2)EKG changes: New ST changes in V4-V6 with decreased amplitude
after beta blocker in HR 70's. Most likely rate-related ischemic
changes. Cardiac enzymes negative.
3)Hypotension: Pt became hypotensive after diltiazem, otherwise
in normal BP. Pt is either euvolemic or slightly fluid
overloaded. Patient should not be on diltiazem for rate control
since it causes hypotension. Patient needs to be diuresised
with lasix since he has large amount of pleural effusion to
diuresis.
4)Resp: Pt became hypoxic at the Rehab with productive sputm.
Suctioning seem to help oxygenate. ABG with large A-a gradient
(133). Although pO2 65 and 100% O2 sat does not correlate. Most
likely CHF exacerbation given bilateral pleural effusion vs.
pneumonia vs. mucous plugging from bronchitis vs [**Last Name (un) 6055**] stoke.
Unlikely pneumonia since CT with no consolidation, pt afebrile
but sputum with G+C and G+R. Levaquin and flagyl initially
given at the ED but was held since pneumonia was thought
unlikely. Pt noted to have [**Last Name (un) 6055**] stoke respiration most likely
from CNS etiology given recent insult to vertebrobasilar
distribution but CHF still a possibility. Pt may benefit from
sleep study to evaluate for his [**Last Name (un) 6055**] stoke respiration. Pt
may also benefit from CO2 titration ventilation. Pt needs
frequent suction. Pt was oxygenating 98-100% on 12 L FM, FiO2
0.50.
5)CHF: CT with worsened bilateral pleural effusion worrisome for
fluid overload. Pt does not appear hypovolemic. CHF exacerbation
could be the cause of rapid a-fib. Pt was diuresised with lasix
while maintiaing good BP. Pt should be diuresised further with
Lasix 20-40 mg po qd, but this medication was not added to the
discharge meds since it will be up to the PCP to monitor his
fluid status. We strongly encourace him to have his PCP start
him on Lasix to remove further fluid.
6)CAD: Pt with severe CAD hx with hx of MI, multiple stents and
CABG. EKG with ST depression on lateral leads most likely rate
related. Goal was to rate control for HR<100 with B-blocker,
continue [**Last Name (un) **] & Plavix, atorvastatin 10 mg qd was initiated and
pt needs to have his LFT's checked by his PCP. [**Name10 (NameIs) **] should also be
on ACE-inhibitor for his CHF and CAD. Lisinopril 5 mg qd was
started.
7)Lactic acidosis: Lactate 2.3 most likely from hypoxic event.
Unlikely sepsis since pt afebrile and normotensive unless
diltiazem given. Resolving now 2.3-> 1.5
8)MS change: Per wife, pt's MS improved since initiation of
Ritalin and amantadine. She says he was at his baseline today at
ED where he could follow commands with hands and able to
whisper. Rehab and ED thought he was unresponsive. Pt with
recent hx of vertebrobasilar bleed s/p stent. Since Ritalin was
thought to induced the a-fibrillation RVR, amantadine and
ritalin were held. Spoke with the neurosurgery team who is
aware the the patient of Dr. [**Last Name (STitle) 1132**] was admitted. Pt will be
discharged with the same meds [**Last Name (STitle) **] and Plavix for post-stent
prophylaxis.
Medications on Admission:
Fragmin 255 u SQ QD, Ritalin 7.5 mg [**Hospital1 **], Sucralfate 1 gram QID,
Metoprolol 50 mg TID, Amandtadine 100 mg [**Hospital1 **], Pantoprazole 40 mg
NG [**Hospital1 **], Clopigdogrel 75 mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 325 mg QD
Discharge Medications:
Toprol XL 25 mg per G-tube qd
Lisinopril 5 mg per G-tube qd
Clopigdrogrel 75 per G-tube qd
[**First Name3 (LF) **] 325 mg per G-tube qd
Digoxin 0.125 mg per G-tube qd
Atorvastatin 10 mg per G-tube qd
Protonix 40 mg per G-tube [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular rate
Hypoxia
Hypotension
Discharge Condition:
Fair, stable, heart rate controlled under 100 bpm.
Discharge Instructions:
Patient should have his digoxin level checked on [**8-15**] as well as
his potassium level. Patient's PCP should be notified for the
new medications we have started: Toprolol XL 25 mg qd, Digoxin
.125 mg q6, lisionpril 5 mg qd, atorvastatin 10 mg qd, Protonix
40 mg per G-tube [**Hospital1 **]
Followup Instructions:
Pt needs a follow up with his PCP [**Name Initial (PRE) 176**] 1 week.
Pt needs to have his digoxin level and potassium checked on [**8-16**]
|
[
"458.29",
"V44.0",
"428.0",
"E942.4",
"414.00",
"V45.02",
"530.21",
"V45.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9174, 9244
|
3971, 8601
|
342, 348
|
9355, 9407
|
2900, 3948
|
9750, 9894
|
8906, 9151
|
9265, 9334
|
8627, 8883
|
9431, 9727
|
2060, 2881
|
269, 304
|
377, 1647
|
1669, 2045
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,101
| 129,188
|
15988
|
Discharge summary
|
report
|
Admission Date: [**2199-10-8**] Discharge Date: [**2199-10-13**]
Date of Birth: [**2122-10-15**] Sex: M
Service: CCU MED
ADMITTING DIAGNOSIS: Ventricular tachycardia.
HISTORY OF PRESENT ILLNESS: The patient is a 76 year old
male with a history of coronary artery disease, status post
CABG in [**2178**] and [**2194**], AS status post DCC four weeks ago,
history of nonsustained VT, multiple myeloma, prostate cancer
and bladder cancer who developed new onset chest pain,
shortness of breath and diaphoresis last night. Called 911
and was found in VT status post DCC. In the E.R. chest pain
resolved with nitroglycerin drip. EKG with left bundle
branch block unchanged from previous. The patient was
transferred here for cardiac catheterization.
PAST MEDICAL HISTORY: Prolonged PR interval, left bundle
branch block, nonsustained VT, a-flutter. Multiple myeloma
being treated with thalidomide, stopped secondary to
dizziness, trial of methylprednisolone. Cholecystectomy.
Coronary artery disease status post CABG in [**2178**] and [**2196**].
Prostate cancer status post radiation therapy. Bladder
cancer.
SOCIAL HISTORY: The patient lives with his wife. His son
works at [**Hospital1 18**]. Denies alcohol, smoking. Former business
executive.
ALLERGIES: Penicillin causes knee swelling.
PHYSICAL EXAMINATION: Vital signs heart rate 80 to 90, blood
pressure 127/75, respiratory rate low 20s, SPO2 100 percent
on 2 liters. HEENT normocephalic, atraumatic, moist mucous
membranes. Neck supple, no lymphadenopathy, JVD not
elevated. Pulmonary decreased breath sounds over the left
base, no crackles, wheezing. Cardiac S1, S2 normal, no
murmurs, gallops or rubs. Abdomen soft, nondistended,
nontender. Extremities no edema of lower extremities. Neuro
awake, alert and oriented times three. Cranial nerves II-XII
intact.
LABORATORY DATA: On admission EKG left bundle branch block,
regular rhythm. LFTs within normal limits.
HOSPITAL COURSE:
1. Ventricular tachycardia. The patient ruled out for MI
with peak CK being 377 on this admission. Ruled out for MI
with three negative cardiac enzymes. The patient was
continued on aspirin, metoprolol, Lipitor. Plavix was
started. Cardiac catheterization at this time showed no
culprit lesion, although a thrombus may have formed in the
old SVG and embolized distally. The patient's MCA was found
with 40 percent disease and LAD with 80 percent mid-disease
with SVG to LAD, SVG to PDA with diffuse disease, SVG to RA
to OM patent and LIMA to diagonal to LAD patent. EP was
consulted for the patient's ventricular tachycardia.
Secondary to VT with left bundle branch block and LAD, the
patient had an ICD placed. Biventricular pacemaker was
unable to be put in. The patient was monitored for 24 hours
and had no episodes of ICD being fired. The patient's
ejection fraction was 20 to 25 percent. EP recommended to
start amiodarone on the patient. Amiodarone was started and
will need to be titrated as an outpatient.
2. Hematology/oncology. The patient has multiple myeloma.
His primary oncologist was notified of this admission. The
patient started to become pansytopenic during this admission.
However, his primary oncologist was aware and outpatient
follow-up with his oncologist was made. Otherwise the patient
had no active issues during this admission.
CONDITION ON DISCHARGE: The patient was stable and
discharged to home in room air.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSES:
1. Sustained ventricular tachycardia.
2. Atrial flutter.
3. Multiple myeloma.
4. Coronary artery disease.
5. Prostate cancer.
6. Bladder cancer.
DISCHARGE MEDICATIONS:
1. Atorvastatin 40 mg p.o. q.day.
2. Multivitamin one capsule p.o. q.day.
3. Metoprolol 50 mg p.o. b.i.d.
4. Amiodarone 400 mg p.o. q.day which is to be titrated
downward.
5. Coumadin 5 mg p.o. q.h.s.
6. Aspirin 81 mg p.o. q.day.
7. Metformin 500 mg p.o. b.i.d.
8. Tricor 160 mg p.o. q.h.s.
9. Vasotec 2.5 mg p.o. q.day.
10. Hydrochlorothiazide 25 mg p.o. q.day.
11. Glipizide 10 mg p.o. q.day.
FOLLOWUP: The patient is to have followup in device clinic
on [**2199-10-18**]. The patient is to call Dr. [**Last Name (STitle) **] for oncology
followup. The patient is to follow up with his PCP [**Last Name (NamePattern4) **] [**10-14**]
and then follow up in [**Hospital 197**] clinic as appropriate.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**MD Number(1) 25755**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2199-11-7**] 08:41
T: [**2199-11-7**] 08:58
JOB#: [**Job Number 45783**]
|
[
"412",
"427.1",
"V10.46",
"414.02",
"203.00",
"593.9",
"401.9",
"414.01",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"88.56",
"37.23",
"37.26",
"37.34",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
3528, 3680
|
3703, 4668
|
1989, 3366
|
1351, 1972
|
219, 774
|
164, 190
|
797, 1139
|
1156, 1328
|
3391, 3507
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,849
| 114,623
|
26604
|
Discharge summary
|
report
|
Admission Date: [**2171-5-26**] Discharge Date: [**2171-6-6**]
Date of Birth: [**2112-11-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
neutropenic fever
Major Surgical or Invasive Procedure:
Intubation
Lumpar puncture
History of Present Illness:
58M w/ IgA predominant multiple myeloma s/p recent high dose
Cytoxan [**2171-5-18**] in preparation for stem cell mobilization
admitted to [**Hospital Unit Name 153**] for febrile neutropenia.
Recently d/c'd from BMT service on [**5-18**] after treatment with
high dose Cytoxan in preparation for stem cell mobilization. Per
pt and wife, he has experienced increased anorexia and some
nausea with one episode of vomitting over the last week. No
fevers or chills. No abdominal pain. Notes thrush but no
dysphagia. Notes onset of cough with white sputum over the last
day. No chest pain. No urinary or bowel changes, no diarrhea. No
rashes. He does have skin breakdown near sacrum which doesn't
appear to have changed significantly. No pain at dialysis
catheter site. No sick contacts. Reports compliance w/ abx and
neupogen. Mild HA but no vision changes. ?mild increased
confusion in terms of getting days of week mixed up. No
neck/back pain.
On evening of admission, he developed nausea and vomitting and
then was noted to have temperature to 101. In ED, noted febrile
to 101.2, tachy to 100, hypotensive to systolic 60's. Labs
notable for neutropenia w/ trilineage decrease. Lactate 1.3. UA
notable for tr ketone and prbc/wbc. CXR w/ increased left sided
pleural effusion. Blood cultures drawn and pt received
Vancomycin and Cefepime and several liters of IVF. SBP improved
to 100's.
Onc. History:
USOH until [**6-/2170**], when he developed a rotator cuff
injury of his right shoulder. He was initially treated with
supportive therapy. However, he developed progressive pain in
his right clavicle, associated with increasing fatigue. On
further evaluation he was anemic and had a high total protein.
He was hypercalcemic and had a component of renal insufficiency.
He was seen by Dr. [**Last Name (STitle) 65635**] on [**2170-7-17**]. Bone marrow
aspirate revealed a hypercellular marrow with 50% plasma cells.
His hemoglobin was 12.4, BUN 39, creatinine was 2.4, and LDH was
normal. On physical examination, he had a 3 cm expandable mass
in his right mid clavicle. He was diagnosed with a stage IIB
IgA kappa multiple myeloma.
.
- Started on high-dose Decadron, thalidomide and Zometa. He
received 100 mg of thalidomide q.h.s. Intially IgA decreased on
this treatment, but he developed progressive renal
insufficiency. Despite a trial of the plasmapheresis, his renal
function continued to deteriorate and he was started on
hemodialysis on [**2170-8-2**].
.
- Prior to his progressive renal insufficiency, he did have an
upper respiratory tract infection characterized by low- grade
fevers and nonproductive cough. All cultures were negative.
Skeletal survey revealed multiple lytic lesions throughout his
thorax. There were lesions in his sternum, posterior ribs, and
vertebral bodies. He continued on Decadron, thalidomide, and
hemodialysis.
.
- In [**10/2170**], he noticed the onset of progressive right hip
pain. This interfered with his ability to walk. Apparently, an
MRI of the area did not reveal a lytic lesion. The question was
raised of avascular necrosis considering his recent use of
steroids. He was noted to have a lytic lesion in his C-spine
and received local radiation therapy, and is advised to wear a
cervical collar.
.
- In the [**12/2170**], he was switched from dexamethasone and low
dose of thalidomide to Velcade + decadron. He has tolerated
the Velcade well. He was seen at the [**Hospital 4601**] Cancer Center
by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**], who recommended that he continue on the
Velcade. He continued to have ongoing renal insufficiency and
was on 3-times- a-week hemodialysis.
.
- He was hospitalized in NH on [**2171-3-25**] with hypotension and
fever.
He was suspected to have adrenal insufficiency, considering his
use of steroids. Blood cultures were positive for coag-negative
staph, and he was started on a course of vancomycin. Dialysis
catheter was changed. A new dialysis catheter was inserted on
[**2171-4-1**]. He continued on HD TIW. [**4-11**]: Noted progressive pain
in his right hip. He is using the wheelchair. He cannot walk
more
than [**Age over 90 **] yards because of pain in his right hip. Repeat MRIs
did not reveal lytic lesions.
Past Medical History:
1. IgA predominant multiple myeloma dx'd [**7-10**] progessive despite
initial therapy w/ Decadron/Thalidomide/Zometa later changed to
Velcade/Decadron now s/p recent high dose Cytoxan [**2171-5-18**] and
awaiting stem cell mobilization
2. ESRD on HD presumed secondary to myeloma
3. recent coag negative staph bacteremia at osh [**3-11**]
4. s/p left av fistula w/ ligation during hospitalization [**5-11**]
5. ?adrenal insuffiency at osh
6. htn
7. hyperlipidemia
8. cervical lytic lesion
9. ?restrictive lung pattern by pft (fev1/fvc 117% predicted w/
fev1 of 68% predicted, and decreased TLC)
Social History:
married with wife and works as designer
Family History:
He has 3 siblings; one of them has prostatic
cancer. He has 2 adult children.
Physical Exam:
GEN: Thin male lying in bed with NC on dyspnea with short
sentences.
HEENT: mmm, OP clear, PERRL
CVR: RRR, nl s1, s2 no r/m/g
Chest: Bilateral crackles. [**Date range (1) 5082**] way up bilaterally.
ABD: NABS, soft, nontender
EXT: 2+ lower extremity edema bilaterally
NEuro: A&O X 3.
Sacrum: stage 1 decub.
Pertinent Results:
137 | 105 | 20 AGap=14
-------------<87
4.0 | 22 | 3.8
Ca: 9.2 Mg: 2.3 P: 3.4
Vanco: 21.6
1.2>---<8.7
....25.9
Gran-Ct: 780
PT: 15.2 PTT: 37.1 INR: 1.4
CK: 14 MB: 3 Trop-*T*: 0.41
Brief Hospital Course:
A/P: 55 yom with IGa Mutiple myeloma, complicated by renal
failure and multiple osteolytic lesions s/p recent cytoxan
therapy awaiting auto transplant admitted with febrile
neutorpenia.
.
# Febrile neutropenia: Patient with nausea, vomiting and caugh
prior to admission. Sources include lungs, ?secondary to decub
(only stage 1), or line related (has tunnled line catheter). He
was admitted to the ICU initially and received IVF for
hypotension. He defervasced and once hemodynamically stable was
transferred to the floor. After transfer he was continued on
Cefepime, Vancomycin (by level) and levofloxacin. He was noted
to have a pleural effusion which was tapped and revealed a
transudate with no organisms on gram stain and cultures. During
his hospitalization he was converted to hospice care, and
patient was sent home off Abx.
.
# Pleural effusion: noted to have pleural effusion on
echocardiogram so had a Chest CT which revevealed a large
leftsided effusion. This was tapped and revealed a transudate.
Patient's sob and dyspnea improved significantly after
thoracentesis. 2 days later sob worsened and on CXR was noted
to have recurrance of pleural effusion. Effusion was thought
likely secondary to inflammatory reaction to the plasmacytomas
seen on CT. Rad/Onc was consulted for possible radiation to the
plasmacytoma, however they did not believe that radiation would
change management as pt had several lesions. Interventional
pulmonary was consulted for possible pleuradisis vs pigtail
catheter placement given quick reaccumulation of the effusion.
They did not believe that pleuradisis would be useful as the
effusion was a transudate. Repeat thoracentesis was perfored on
[**6-1**]. Pt was successfully extubated on [**6-4**], and continued to
oxygenate well on supplemental o2.
.
# Mutliple myeloma - Once afebrile pt underwent pharesis for
stem cell collection. He had 3 cycles however the yield was low
and for now the plan is to hold off on further stem cell
collection. Further work up and management per Dr. [**First Name (STitle) 1557**].
Supportive meastures for pain control with fentynyl patch and
oxycodone, cervical collar and levaquin and bactrim prophylaxis
were continued. Pt was discharged home with hospice care.
.
#. Hypotension: on admission thought secondary to sepsis vs post
dialysis hypotension. It resolved with fluids. Midodrine was
added per renal.
.
#. ESRD - Dialysed per Renal team's recs on T/R/S. Pt was sent
home to initiate hospice care with to decide on further dialysis
as per patient's wishes.
# Diet: renal, neutropenic
# Prophylaxis: PPI, bowel regimen
# Access: dialysis port.
# Code: full
Medications on Admission:
Meds on admission:
Percocet PRN
ASA 81 qd
Bactrim DS qod
Pyrodoxine 100 qd
Vitamin E 400qd
Sevalamer 800 tid
Fentanyl patch 50 q72
Colace
Senna
Ambien prn
Levaquin 250 q24
Discharge Disposition:
Home With Service
Facility:
North Country Home Health and Hospice
Discharge Diagnosis:
Primary Diagnoses:
Respiratory Failure
Febrile Neutropenia
Altered Mental Status
.
Secondary Diagnoses:
Refractory Multiple Myeloma
ESRD on HD
Discharge Condition:
Stable to be discharged home with hospice care
Discharge Instructions:
.
Please take medications as below.
.
If you develop any complaints, please call your doctor or
primary oncologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**]. If emergent please go to the
nearest emergency department
Followup Instructions:
Please call Dr. [**Last Name (STitle) 65636**] to schedule a follow up appointment as
needed; call [**0-0-**] to schedule that appointment.
|
[
"458.9",
"V15.3",
"V16.42",
"272.4",
"292.81",
"203.00",
"707.03",
"112.0",
"515",
"486",
"518.81",
"403.91",
"284.8",
"511.9",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"03.31",
"99.07",
"99.04",
"99.71",
"96.71",
"96.04",
"96.6",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8859, 8927
|
5971, 8637
|
332, 361
|
9114, 9163
|
5754, 5948
|
9459, 9602
|
5324, 5404
|
8948, 9031
|
8663, 8668
|
9187, 9436
|
5419, 5735
|
9052, 9093
|
275, 294
|
389, 4632
|
8682, 8836
|
4654, 5251
|
5267, 5308
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,723
| 161,935
|
3126
|
Discharge summary
|
report
|
Admission Date: [**2101-4-23**] Discharge Date: [**2101-5-12**]
Date of Birth: [**2022-6-28**] Sex: M
Service: MEDICINE
Allergies:
Phenytoin / Tegretol
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
BRBPR, hypotension
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
The patient is a 78 year old male with a history of stroke
(residual partial aphasia), CAD, hypertension, diastolic CHF
with recent switch to Torsemide, and AFib with recent initiation
Dabigatran who presents with BRBPR. He had a visit with his PCP
[**Last Name (NamePattern4) **] [**2101-4-20**], at which he was feeling well with recent improvement
in his LE edema and breathing after switching to Torsemide on
[**2101-3-30**]. Immediately after the visit and over the next 3 days,
he felt intermittently lightheaded, but otherwise close to his
baseline.
.
Earlier today, he noted BRB after a bowel movement, which was
new for him. Given his recent initiation of Dabigatran in
[**Month (only) 404**], he was concerned by the bleeding and contact[**Name (NI) **] his PCP,
[**Name10 (NameIs) 1023**] recommended [**Name (NI) **] evaluation. He denies any bruising or easy
bleeding other than the above-mentioned blood in his diaper.
Over the past couple of hours that is daughter has been with
him, he has not had any stools, and he reported that for the
most part his stools have been brown.
.
In the ED, initial VS were T 98.2, HR 90, BP 92/49, RR 16, and
SpO2 100% on RA. Physical exam showed irregular tachycardia,
clear lungs, slight LE edema, and benign abdomen. Rectal exam
was notable for bright red blood and streaks of brown stool.
Notable labs included Hct 33.7 down from 37.5 on [**2101-3-25**],
creatinine 2.6 up from baseline 1.6 with creatine 0.6 on [**2101-4-20**]
most likely spurious. CXR showed no acute process with clear
lung fields and mild-moderate cardiomegaly. ECG showed atrial
fibrillation at 86-101 bpm with RBBB, unchanged from prior on
[**2101-3-30**]. GI was consulted and recommended observation with
consideration of CTA if developing rapid bleeding.
.
Access was obtained with three 18g PIVs. He was given normal
saline 1500 ml with continued mild tachycardia and blood
pressure 90s-100s, which seems to be slightly below his baseline
of around 120/80 seen at recent clinic visits. He was also
given about 400 ml of sodium bicarbonate 150 mEq in D5W in
anticipation of possible need for CTA.
.
He was admitted to the MICU for continued monitoring. VS prior
to transfer were T 97.5, HR 80, BP 104/53, RR 20, and SpO2 99%
on RA. On arrival to the MICU, he reported feeling close to his
baseline without any specific complaints.
Past Medical History:
HTN
BPH
History of CVA [**2090**] post meningioma resection
History of seizure disorder post meningioma resection
History of L inguinal hernia repair
Depression
History of CAD s/p 3 vessel CABG
Hyperlipidemia.
Social History:
Denies tobacco, alcohol or illicits. Retired from work at the
Post-office. His wife is currently in a [**Name (NI) **], and the patient
lives alone.
Family History:
non contributory
Physical Exam:
Admission Exam:
VS: BP 99/49, HR 82, RR 18, SpO2 98% on RA
Gen: Elderly male in NAD. Oriented x3. Mild aphasia. Pleasant
and appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva without
pallor or injection. MMM, OP clear.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
CV: Irregularly irregular with normal rate. Somewhat distant
heart soudns. Normal S1, S2. No M/R/G appreciated,
Chest: Respiration unlabored, no accessory muscle use. CTAB with
no crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly.
Abdominal aorta not enlarged by palpation. No abdominal bruits.
Ext: WWP. LE edema 1+ bilaterally. Distal pulses intact 2+
radial, DP, and PT.
Skin: Chronic venous stasis changes on LEs. No major
ecchymoses, hematomas, or petechiae.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities.
Discharge Exam:
VS: 98.3, 112/57 (92-122/48-64), 68 (65-82), 18, 96/RA
weight: 89.5 kg
Gen: Elderly male in NAD. Oriented x3. Mild aphasia. Gets
aggitated when discussing prolonged hospitalization but
redirectable.
HEENT: NCAT. Scleara anicteric. Dry MM.
Neck: Supple. JVP to mandible
CV: Irregularly irregular and tachycardic. No M/R/G
appreciated,
Chest: Respiration unlabored, no accessory muscle use. CTAB with
no crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND.
Ext: WWP. Improved [**Location (un) **]. No ankle TTP. TTP left plantar facia.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities.
Pertinent Results:
Admission Labs:
[**2101-4-22**] 10:13PM BLOOD WBC-6.3 RBC-3.82* Hgb-11.6* Hct-33.7*
MCV-88 MCH-30.3 MCHC-34.4 RDW-12.4 Plt Ct-117*
[**2101-4-22**] 10:13PM BLOOD PT-25.7* PTT-87.3* INR(PT)-2.5*
[**2101-4-22**] 10:13PM BLOOD Glucose-118* UreaN-67* Creat-2.6*# Na-139
K-4.1 Cl-100 HCO3-27 AnGap-16
[**2101-4-23**] 02:32AM BLOOD Calcium-8.5 Phos-4.6* Mg-2.6
[**2101-4-22**] 10:57PM BLOOD Lactate-1.5
Pertinent Labs:
[**2101-4-26**] 05:55AM BLOOD CK(CPK)-[**2026**]*
[**2101-4-26**] 03:30PM BLOOD ALT-22 AST-91* CK(CPK)-2244*
[**2101-4-27**] 02:59AM BLOOD CK(CPK)-1708*
[**2101-4-28**] 07:39AM BLOOD ALT-29 AST-60* CK(CPK)-606*
[**2101-4-29**] 08:00AM BLOOD CK(CPK)-329*
[**2101-5-5**] 07:55AM BLOOD CK(CPK)-83
[**2101-4-26**] 05:55AM BLOOD CK-MB-15* MB Indx-0.8 cTropnT-0.02*
[**2101-4-26**] 03:30PM BLOOD CK-MB-18* MB Indx-0.8 cTropnT-0.02*
[**2101-4-27**] 02:59AM BLOOD CK-MB-12* MB Indx-0.7 cTropnT-0.02*
Dishcarge Labs:
Imaging:
CXR ([**2101-4-22**]):
The patient is status post sternotomy. The heart is
mild-to-moderately enlarged. The aortic arch is partly
calcified. The
cardiac, mediastinal and hilar contours appear unchanged. The
lungs appear
clear. There are no pleural effusions or pneumothorax.
Mild-to-moderate
osteophytes are noted along the visualized thoracolumbar spine.
Final Report
INDICATION: Swelling.
COMPARISON: None available.
LE ultrasound:
FINDINGS: Waveforms in the common femoral veins are symmetric
bilaterally
with appropriate response to Valsalva maneuvers. In both lower
extremities, the common femoral, proximal greater saphenous,
superficial femoral and popliteal veins are normal with
appropriate compressibility, wall-to-wall flow on color Doppler
analysis and response to waveform augmentation. Wall-to-wall
flow is also present in the posterior tibial and peroneal veins
on the left as well as in the posterior tibial veins on the
right. The peroneal vein in the
right calf was not visualized. Just anterior to the right common
femoral
vasculature, proximal to the insertion of the greater saphenous
vein is a
large ovoid hypoechoic collection measuring 5.2 x 1.4 cm,
without internal
vascularity.
IMPRESSION:
1. No deep venous thrombosis in either lower extremity. The
peroneal veins
in the right calf were not visualized.
2. Ovoid hypoechoic collection measuring 5.2 cm in the right
groin, possibly a seroma, chronic hematoma or lymphocele.
Results discussed via telephone by Dr. [**Last Name (STitle) 14804**] with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] via
telephone at 14:45 on [**0-0-0**]
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2101-5-5**] 8:01 PM
CXR
Final Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Fever, right pneumonia.
Comparison is made to the prior study, [**4-28**].
Mild-to-moderate cardiomegaly is stable. Vascular congestion has
resolved. The left lobe is clear. There is no pneumothorax. If
any, there is a small right pleural effusion. Multifocal right
lung opacities have improved, consistent with improving
pneumonia.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: [**Doctor First Name **] [**2101-5-5**] 4:31 PM
Video-swallow
Final Report
HISTORY: 78 year-old-man, with history of CVA. Query for silent
aspiration.
FINDINGS: Swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple
consistencies of barium were
administered. Intermittent trace-to-mild laryngeal penetration
was noted with thin liquid. There was no gross aspiration.
IMPRESSION: Trace-to-mild penetration with thin liquid. No gross
aspiration.
For full details, please see detailed speech and swallow
therapist's note in OMR.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: SAT [**2101-4-30**] 8:07 PM
Microbiology: all negative
[**2101-5-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2101-5-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2101-5-5**] URINE URINE CULTURE-FINAL INPATIENT
[**2101-5-5**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2101-5-5**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2101-4-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2101-4-27**] URINE URINE CULTURE-FINAL INPATIENT
[**2101-4-27**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2101-4-26**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2101-4-23**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
DISCHARGE LABS:
[**2101-5-12**] 06:43AM BLOOD WBC-6.6 RBC-3.52* Hgb-10.1* Hct-32.0*
MCV-91 MCH-28.7 MCHC-31.6 RDW-13.6 Plt Ct-341
[**2101-5-12**] 06:43AM BLOOD PT-15.7* PTT-38.3* INR(PT)-1.5*
[**2101-5-12**] 06:43AM BLOOD Glucose-102* UreaN-33* Creat-1.9* Na-142
K-3.9 Cl-101 HCO3-31 AnGap-14
[**2101-5-12**] 06:43AM BLOOD Mg-2.2
Brief Hospital Course:
Primary Reason for Admission: The patient is a 78 year old male
with a history of stroke (residual partial aphasia), CAD,
hypertension, diastolic CHF with recent switch to Torsemide, and
AFib with recent initiation Dabigatran who initially presented
with bright red blood per rectum in the setting of acute kidney
injury.
# BRBPR/Hypotension: He presented with one day of moderate
BRBPR in the setting of elevated coags and supratherapeutic
Dabigatran, most likely related to [**Last Name (un) **]. His Hct was 33.7 on
admission from baseline 37.5 on [**2101-3-25**], and subsequently
dropped to 31.2 after IV fluids in the ED. He never required
transfusion. His last colonoscopy was in [**2098**], showed only
polyps and grade 1 internal hemorrhoids. He was seen by GI, and
admitted to the MICU, where his HCTs were trended and were
stable for >24h, did not require transfusion. ASA, Pradaxa
Lisinopril, Terazosin, and Torsemide were all initially held and
after discussion with outpatient PCP (Trifletti) and cardiology
([**Doctor Last Name 437**]) dabigatran was restarted at 75mg [**Hospital1 **] to reduce risk of
bleeding given fluctuating creatinine clearance. Colonoscopy
inconclusive. Capsule endoscopy without any sites of
recent/acitve bleeding. Endoscopy [**5-2**] with gastritis with
recent bleeding and esophagitis. The bleeding was thought most
likely due to his hemorrhoids. While patient frquent had blood
pressures with systolics in the 90s on the floor, he was always
mentating at baseline and asymptomatic. These blood pressures
were thought not to be due from infection or bleeding, but from
increases in his required nodal agents for atrial fibrillation.
# [**Last Name (un) **] on CKD: His creatinine was 2.6 on admission from a
baseline around 1.6 on [**2101-3-25**]. He was recently switched from
Furosemide to Torsemide on [**2101-3-30**] with marked decrease in his
LE edema. He saw his PCP [**Last Name (NamePattern4) **] [**2101-4-20**], where his creatinine was
reported as 0.6 but with BUN 61. Most likely, this creatinine
value was spurious. His UA on admission was completely bland.
He does have a history of BPH, but denied any recent change in
urinary habits. He was given gently IVF recussitation with
improvement in his Cr to baseline. FeUrea 22.6, was consistent
with pre-renal process. Creatinine had improved to baseline by
time of discharge. We recommend follow-up of his electrolytes in
1 week after discharge.
# Chronic Diastolic CHF: His last TTE was on [**2101-3-25**] with LVEF
60-65%. He is followed by Dr [**Known firstname 449**] [**Last Name (NamePattern1) 437**] in Cardiology and was
recently switched from Furosemide to Torsemide [**2101-3-30**] with
marked improvement in his LE edema and overall volume status
over the last few weeks. Given his current [**Last Name (un) **], at admission he
was thought to be over diuresed on this new regimen. He
received about [**2089**] ml IV fluids in the ED with continued
respiratory stability and improvement in his Cr. He remained off
his torsemide due to continued tachycardia and fevers with HCAP
and insensible losses. Approximately [**5-3**], patient began
developing increased LE edema, ankle pain and weight. Torsmide
was restarted and then patient was aggresively diuresed with
lasix. Cardiology was consulted and followed and he was
discharged on home furosemide at a weight of 89.5kg. His weight
should be checked daily and if increase in more than 2 pounds,
he should be given toresmide 40mg for two days and the
cardiology doctor should be called.
# Atrial Fibrillation: He was recently started on Dabigatran in
[**2101-2-13**] for new persistent AFib/Flutter and CHADS2 score 5
with a prior CVA. He was on Metoprolol succinate 150 mg PO
daily for rate control at home. His Metoprolol was held in the
MICU in the setting of recent GIB. While on the medical floor,
patient developed afib with RVR with rates up to the 140s-160s
without hemodynamic changes and without mental status changes.
This was thought likely due to volume overload status and left
atrial dilation though did not develop signs of pulmonary edema
on exam. It was also thought that fever could suggest infectious
etiology for rapid rates. Less likely PE as no calf tenderness,
no pulmonary/cardiac sxs and LENIS negative on [**2101-5-5**]. He was
uptitrated to maximum doses of metoprolol and diltiazem.
Cardiology was consulted and planned for TEE with cardioversion
if rates did not improve with diuresis however TEE was aborted
due to trauma observed in the posterior oralpharynx. Dabigatran
was restarted at 75mg [**Hospital1 **] after GI evaluation was completed.
Plan is for outpatient cardiolgy evaluation in 2 wees and
consideration of cardioversion vs TEE/cardioversion in
approximately 1 month on dabigatran to reduce risk of blood
clots embolizing. Patients heart rates at discharge were 110s,
thought adequate by cardiology. Diltiazem can be increased if
needed to 480mg daily.
# Seizure History: He has a seizure history s/p meningioma
resection and CVA in [**2090**]. He has not had any recent seizures.
Besides his baseline aphasia and difficulty following
instructions, he did not have any changes in his neurologic
exam. His Keppra was renally dosed to 500mg PO BID (home 1000
mg PO BID).
# HCAP: Completed 7 days of Vanc/Zosyn on [**4-4**]. Continues to
saturate well on room air.
# fever: After treatment for HCAP, patient with high grade fever
overnight to 102. Differential includes infectious (stopped
Vanc/Zosyn 3 days ago). CXR with resolving pneumonia, blood
cultures pending and UA/Uctx shows hematuria with low number of
WBCs to RBCs. Reviewed LE u/s with radiology and right groin 5cm
fluid collection thought to be chronic, and not an abscess,
possibly related to past cardiac catheterizations. Cdiff
negative earlier during hospitalization on [**4-28**]. He had low
grade temperatures approx 99 during the remainder of his
hospital course which were not thought to be indications of
fever.
# ? tracheal ulcer: per GI, on capsule, tracheal ulcer seen
while patient coughing, though capsule never actually below
glottis. Pictures obtained from GI today and were sent to ENT
and IP. Given patient has nonspecific sxs, IP consulted. They
recommend outpatient management which they have arranged f/u
for.
# Rhabdomylysis: During afib with RVR on [**4-26**], patient noted to
have new EK changes and a CK was checked which was >[**2089**]. This
downtrended with IVF and stopping his statin to the normal
range. Possibly due to viral illness (later developed fever),
statin use. Statin restarted at lower dose of 10mg due to
diltiazem on [**5-5**] and CKS remained stable. They should be
checked again with lipids in approximately 5 weeks.
# oralpharyngeal bleeding: On [**5-10**] in setting of possible TEE
trauma. They did not pass probe past oral space. No active
bleeding or lacerations found by ENT. He should continue inhaled
saline mist nebulizers and presedex at discharge. Will need
outpatient ENT f/u at [**Telephone/Fax (1) 14805**].
# New ECG changes: H/o CAD s/p 3 vessel CABG. Asymptomatic but
new ST segment depression in I, aVL earlier in admission. Ruled
out for MI [**Date range (1) 14806**] and asymptomatic.
# Hyperlipidemia:Decreased dose of simvastatin to 10mg given
addition of diltiazem.
# Depression: Continued home sertraline.
# BPH: Given hypotension, alpha-blocker was held.
Transitional issues:
- check electrolytes in 1 week
- monitoring of lipids, CKs given rhabdomylysis in 5 weeks
- His weight should be checked daily and if increase in more
than 2 pounds, he should be given toresmide 40mg for two days
and the cardiology doctor should be called.
- For atrial fibrillation, plan is for outpatient cardiolgy
evaluation in 2 weeks and consideration of cardioversion vs
TEE/cardioversion in approximately 1 month on dabigatran to
reduce risk of blood clots embolizing.
- If blood pressure consistently above 100 systolic, would
restart alpha-blocker (Terazosin) and then lisinopril.
Medications on Admission:
Dabigatran 150 mg PO BID
Aspirin 81 mg PO daily
Atorvastatin 20 mg PO daily
Lisinopril 10 mg PO daily
Metoprolol succinate 150 mg PO daily
Torsemide 20 mg PO daily
Levetiracetam 1000 mg PO BID
Terazosin 10 mg PO daily
Oxybutynin ER 10 mg PO daily
Sertraline 50 mg PO daily
Discharge Medications:
1. sertraline 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig: One
(1) Tablet Extended Rel 24 hr PO once a day.
3. dabigatran etexilate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO Q12H (every 12
hours).
7. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. diltiazem HCl 120 mg Capsule, Extended Release Sig: Three
(3) Capsule, Extended Release PO DAILY (Daily).
12. chlorhexidine gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day) for 1 weeks.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Elmhurst - [**Location (un) **]
Discharge Diagnosis:
Primary:
gastritis/esophagitis
health care associated/aspiration pneumonia
atrial fibrillation with RVR
acute on chronic diastolic CHF
Discharge Condition:
Mental Status: Confused - always. More than confused, has
aphasia with wrong word choice.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of bleeding from your gastrointestinal tract. We think
this was because of worsening kidney disease while you were on
Pradaxa, a medication which is processed by the kidney. While
you were here, your bleeding resolved and you did not require
any blood transfusions.
You had an endoscopy, colonoscopy and capsule endoscopy which
found inflammation in the lining of your esophagus (swallowing
tube) and stomach and hemorrhoides which may have been the cause
of the bleeding.
While you were here, you also had a pneumonia which resolved
with one week of antibiotics.
You had uncontrolled heart rates from your atrial fibrillation
and your CHF worsened as your torsemide was initially stopped
because of worsening kidney function. You were given lasix to
improve this.
Cardiology followed you for the afib and CHF. Your water pill
(torsemide) was restarted once your kidneys improved. You are
now on new medications for your heart rate and the cardiology
team wants to continue to see you as an outpatient for
consideration of cardioversion to put your heart into a normal
rhythm.
While you were here, you also had trauma to the back of your
mouth from one of the camera probes. You were seen by an ear,
nose and throat doctor who did not find any ongoing bleeding or
injury which needed intervention. You were found to maybe have
an ulcer in your trachea (swallowing tube). For these reasons,
you will see and ear nose and throat doctor and an
interventional pulmonologist.
While you were here, some of your medications were changed. You
should:
DECREASE Pradaxa from 150mg twice a day and INSTEAD START 75mg
twice a day
DECREASE Simvastatin from 20mg once a day and INSTEAD START 10mg
once a day
DECREASE Keppra from 1000mg twice a day and INSTEAD START 500mg
twice a day
INCREASE Toprol from 150mg daily to 200mg twice a day
START Diltiazem 360mg daily
START omeprazole twice a day
START chlorhexidine rinses for your mouth
START docusate for constipation and senna if needed
Continue to take all other medications as prescribed by your
doctors.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY (for tracheal ulcer)
When: Thursday, [**5-19**] 11am
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6543**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2101-6-29**] at 9:00 AM
With: [**Known firstname **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: WEDNESDAY [**2101-8-10**] at 11:30 AM
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: WEDNESDAY [**2101-5-25**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: OTOLARYNGOLOGY (ENT)
When: WEDNESDAY [**2101-6-8**] at 9:45 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], M.D. [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Unit Name **] [**Location (un) 895**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
|
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icd9cm
|
[
[
[]
]
] |
[
"29.11",
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] |
icd9pcs
|
[
[
[]
]
] |
19689, 19778
|
10006, 17447
|
301, 314
|
19957, 19957
|
4699, 4699
|
22410, 24002
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|
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|
19799, 19936
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18085, 18360
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4058, 4680
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4716, 5097
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19972, 20171
|
5113, 9651
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2739, 2951
|
2967, 3118
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,950
| 146,102
|
42847
|
Discharge summary
|
report
|
Admission Date: [**2189-11-4**] [**Month/Day/Year **] Date: [**2189-11-5**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography - [**2189-11-4**]
History of Present Illness:
87 y/o M with PMHx of CAD, [**Month/Day/Year 19874**] (EF=40-45%), HTN, HL, COPD
presented to OSH on [**11-3**] after feeling faint and pressing his
LifeLine button. Per OSH records, he has been more tired for
several days, had transient chest pain, RUQ pain prior to
syncoplal episode on morning of presentation. Initially on
presentation, was somnolent, SBP in the 80s, responded to
fluids, fever to 100.1. Initial labs showing AST 400, ALT 300,
TB 1.0. Repeat labs AST 550, ALT 5000, ALP 230, lipase 1800,
amylase 1300). RUQ ultrasound showed cholelithiasis with wall
thickening, but no wall edema and no CBD dilitation, negative
[**Doctor Last Name **] sign. CXR with small pleural effusion. U/A normal.
Surgery consulted on the patient and he was not a surgical
candidate. Started on Unasyn. GI consulted and thought patient
requires ERCP for concern of cholangitis. Of note his blood
pressures were persistently low, he required 2 250 cc boluses at
least to keep his SBPs < 90 in addition to maintenance fluids.
.
On arrival to the ICU, patient awake, alert but confused. VS
99.1; 85; 94/67; 20; 95%3LNC. Complains of epigastric and RUQ
pain.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Dementia
CAD
[**Last Name (LF) 19874**], [**First Name3 (LF) **] 40-45%
HTN
HL
COPD
Social History:
- Tobacco: heavy smoking history, but quit many years ago
- Alcohol: Denies
- Illicits: Denies
Family History:
Unable to obtain due to dementia
Physical Exam:
Admission exam:
Vitals: T: 99.1 BP: 94/67 P: 84 R: 18 O2: 95%3LNC
General: Alert, only oriented to self, no acute distress
HEENT: Sclera anicteric, MMM, poor dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
murmur, no rubs or gallops
Abdomen: Soft, + BS, tenderness to palpation in epigastric and
RUQ, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
[**First Name3 (LF) **] exam:
Vitals: T 98.2 HR 90 BP 116/62 RR 23 O2Sat 91% on 5L NC
General: Alert, oriented only to self
Abdomen: soft, distended, +BS, no tenderness to palpation, no
rebound/guarding
Exam otherwise stable
Pertinent Results:
[**2189-11-4**] 01:37AM BLOOD WBC-8.8 RBC-3.69* Hgb-10.7* Hct-31.2*
MCV-85 MCH-29.1 MCHC-34.4 RDW-15.1 Plt Ct-168
[**2189-11-4**] 01:37AM BLOOD Neuts-86.2* Lymphs-6.2* Monos-4.5 Eos-2.8
Baso-0.2
[**2189-11-4**] 01:37AM BLOOD PT-13.0* PTT-28.5 INR(PT)-1.2*
[**2189-11-4**] 01:37AM BLOOD Glucose-106* UreaN-32* Creat-1.4* Na-142
K-5.0 Cl-105 HCO3-28 AnGap-14
[**2189-11-4**] 01:37AM BLOOD ALT-598* AST-448* LD(LDH)-377* CK(CPK)-93
AlkPhos-227* Amylase-966* TotBili-3.0*
[**2189-11-4**] 01:37AM BLOOD Lipase-1116*
[**2189-11-4**] 01:37AM BLOOD CK-MB-2 cTropnT-<0.01
[**2189-11-4**] 01:37AM BLOOD Albumin-3.7 Calcium-8.5 Phos-3.5 Mg-2.3
[**2189-11-4**] 01:37AM BLOOD Ethanol-NEG Acetmnp-NEG
[**2189-11-4**] 03:41AM BLOOD Lactate-1.0
.
MICROBIOLOGY:
Blood culture x 2 ([**2189-11-4**])- no growth to date, pending final
Urine culture ([**2189-11-4**])- no growth
.
(OSH)
CXR: [**2189-11-3**] Small right sided pleural effusion versus
pleural thickening. Probable left sided atelectasis/scarring
.
RUQ ultrasound: [**2189-11-3**]: Evaluation is limited due to
patients body habitus. The liver is heterogenoeous in
echotexture with no focal lesions identified. There is no
evidence of intra-or extrahepatic ductal dilation. The common
hepatic duct measures 2mm and within normal limits. The
gallbladder is visualized and appears to contain a 1 cm stone.
There is mild gallbladder wall mildly thickened to 5mm however
no evidence of gallbladder wall edema, pericholecystic fluid. A
negative [**Doctor Last Name **] sign was elicited. There is no free fluiid.
The pancreas is not visualized due to overlying bowel gas. The
right kidney is unremarkable.
.
[**Hospital1 18**]
CXR [**2189-11-4**]:
There is mild cardiomegaly. There are low lung volumes.
Small-to-moderate right pleural effusion is associated with
adjacent opacities, likely atelectases. Ill-defined rounded
nodular opacities in the left upper lobe have a broad
differential diagnosis as etiology including infectious process.
The pulmonary arteries are enlarged. Ill-defined faint opacity
in the left lower lobe obscures partially the lung vessels.
.
CT is recommended for further evaluation of the chest to exclude
pulmonary embolism, pulmonary artery hypertension, and further
assessment of probable infectious process in the left lung.
.
ERCP Report ([**2189-11-4**]):
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was initially
unsuccessful. Thus, a careful pre-cut sphincterotomy was
performed to gain access. Cannulation was subsequently
successful and deep with a sphincterotome after a guidewire was
placed. Contrast medium was injected resulting in complete
opacification.
.
Biliary Tree Fluoroscopic Interpretation: A mild diffuse
dilation was seen at the biliary tree with the CBD measuring 9
mm. There were no filling defects seen. An occlusion
cholangiogram was not done given concern for cholangitis. Given
cholangitis and gallstone pancreatitis, decision was made to
extend the pre-cut sphincterotomy. An extension sphincterotomy
was performed in the 12 o'clock position using a sphincterotome
over an existing guidewire. Balloon sweep x 2 was performed with
successful extraction of sludge.
Pancreas Fluoroscopic Interpretation: A limited pancreatogram
was normal.
.
Impression: Cannulation of the biliary duct was initially
unsuccessful.
A careful pre-cut sphincterotomy was performed to gain access to
the biliary tree.
Cannulation was subsequently successful and deep with a
sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
A mild diffuse dilation was seen at the biliary tree with the
CBD measuring 9 mm.
There were no filling defects seen.
An occlusion cholangiogram was not done given concern for
cholangitis.
Given cholangitis and gallstone pancreatitis, decision was made
to extend the pre-cut sphincterotomy.
An extension sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Balloon sweep x 2 was performed with successful extraction of
sludge.
.
Brief Hospital Course:
87 y/o M with PMHx of CAD, [**Month/Day/Year 19874**] (EF=40-45%), HTN, HL, COPD
presented to OSH on [**11-3**] with RUQ, fever, and rapidly
developing transaminitis and pancreatic enzymes, transferred to
[**Hospital1 18**] for ERCP with concern for cholangitis.
.
# Gallstone pancreatitis - Bisap score= 4 on admission. RUQ
ultrasound at OSH showed evidence of gallstone with common bile
duct dilation. Amylase and lipase were grossly elevated,
consistent with pancreatitis. ERCP performed on HD1 with
sphincterotomy performed (see attached report). Amylase/lipase
were downtrending following ERCP. Patient was pain free
following procedure and vital signs were stable. On HD2 patient
was started on clear liquid diet and advanced to a regular diet
which he tolerated without issue.
.
# Suspected cholangitis - Evidence of biliary dilation on ERCP
and with known gallstone, concern for cholangitis. Patient
started on cipro/Flagyl to cover biliary bacteria. Thus far,
cultures are negative. AST/ALT downtrending following ERCP. Plan
to continue oral cipro and flagyl for 10 day course (day
1=[**2189-11-4**], ending [**2189-11-10**]).
.
# Hypotension - Patient was hypotensive at [**Hospital **] Hospital
but responsive to fluid boluses. Patient treated for septic
shock with IV antibiotics for biliary bacteria and fluid
boluses. Following ERCP, patient's blood pressure normalized
and he did not require fluid boluses or pressure support. His
home anti-hypertensives were held at the time of transfer.
.
# Altered mental status - Patient has baseline dementia.
Unclear baseline function, but does have report of increasing
solmnolence at OSH, likely d/t initial hypotension. Currently
AAOx1, but awake, alert and conversant. Per HCP, this is
patient??????s baseline.
.
# CAD- Patient reported chest pain prior to syncopal event. EKG
showed RBBB, unchanged from [**3-/2189**], and cardiac enzymes were
negative x2. Chest pain likely from abdominal process.
.
# [**Year (4 digits) 19874**]- No signs of acute heart failure. Did not appear volume
overloaded. Continued aspirin 81 mg daily and held carvedilol,
lasix and lisinopril in the setting of hypotension. These
medications were restarted on HD...
.
# Hypertension- Blood pressure medications were initially held
in the setting of hypotension and were not restarted at the time
of transfer.
.
# COPD- No evidence of exacerbation. Continued on home advair,
spiriva and 3LNC.
.
# Transitional issues-
- HCP [**Name (NI) **] [**Name (NI) 41275**] H [**Telephone/Fax (1) 92536**] C [**Telephone/Fax (1) 92537**]
- Patient will need physical therapy evaluation; consider short
term rehab vs visiting nurse services. Patient lives at home
alone and has significant dementia. It is unlikely that he will
be able to administer antibiotics without assistance. HCP very
concerned about mental status/ability to be alone.
Medications on Admission:
ASA 81mg daily
Carvedilol 3.125mg daily
Fish oil 1200mg daily
Temazepam 7.5mg daily
MVT daily
Klorcon 10meq daily
Lasix 20mg daily
Lisinopril 2.5mg daily
Citalopram 20mg daily
Advair 250/50 [**Hospital1 **]
Spiriva 18mcg 1 cap daily
Continuous home O2 3LNC
[**Hospital1 **] Medications:
TRANSFER MEDICATIONS:
Ciprofloxacin 500mg po q12h (day 1=[**2189-11-4**], ending [**2189-11-13**])
Metronidazole 500mg po q8h (day 1=[**2189-11-4**], ending [**2189-11-13**])
Aspirin 81mg po daily
Fluticasone-salmeterol 250/50 INH [**Hospital1 **]
Tiotropium 1 cap INH daily
Ipratropium bromide Neb INH q6h prn shortness of breath/wheezing
Docusate 100mg po BID prn constipation
Senna 1 tab po BID prn constipation
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital1 **] - [**Location (un) 47**]
[**Location (un) **] Diagnosis:
Primary diagnosis:
1. Gallstone pancreatitis
2. Cholangitis
.
Secondary diagnosis:
1. Chronic obstructive pulmonary disease
2. Congestive heart failure
[**Location (un) **] Condition:
Stable
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
Dear Mr [**Known lastname 26438**],
It was a pleasure taking care of you during your recent stay at
[**Hospital1 18**]. You were transferred here because a there was a stone in
your biliary system causing your pancreas to be inflammed and an
infection to form. You underwent a procedure to remove the
stone and relieve the obstruction. You were started on IV
antibiotics. You tolerated this procedure very well and your
pain and fever improved. You were able to start eating regular
food without any issue. You will be transferred back to
[**Hospital1 **] for further management.
You will need evaluation from physical therapy to determine how
safe you are to return home.
Followup Instructions:
- Physical therapy: please evaluate for home safety
- Please schedule an appointment with the patient's primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **].
|
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[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,696
| 124,335
|
33699
|
Discharge summary
|
report
|
Admission Date: [**2185-10-15**] Discharge Date: [**2185-10-24**]
Date of Birth: [**2127-6-29**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Tetracycline
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD ([**2185-10-17**])
Sigmoidoscopy ([**2185-10-17**])
Colonoscopy ([**2185-10-19**])
Meckel's Scan ([**2185-10-21**])
Triple lumen central venous line.
History of Present Illness:
58 [**Last Name (un) 9232**] with history of recent MI in [**Month (only) **] and placement of
stent (unclear what type) on ASA and plavix presenting to OSH
with BRBPR. Patient reports that at 4pm began to have large
volume blood from rectum. Went to OSH where Crit had fallen to
mid 20's from baseline in the 40's. Patient received 4u PRBCs,
FFP and DDAVP. She continued to have BRBPR and and got up to go
to bathroom and had syncopal episode. Was transferred here for
Gi evaluations.
.
In the ED, initial VS were: 98 70 100/60 20 100%
.
She was not activly bleeding and a stat HCT was 35. Rectal exam
was notable for BRB no stool. NG lavage was negative.
.
On arrival to the MICU, she is pain free and mildly anxious.
.
Review of systems:
Per HPI
Past Medical History:
- Multifocal bilateral papillary thyroid carcinoma s/p total
- thyroidectomy followed by RAI treatment in [**2181**].
- Hypercalcemia.
- Insulin-requiring type 2 diabetes followed by Dr. [**Last Name (STitle) 978**] at
[**Last Name (un) 387**]
- hyperlipidemia
- fatty liver
- diverticulosis/recurrent diverticulitis
- nephrolithiasis s/p surgery in [**2169**]
- right renal cancer s/p partial nephrectomy XRT in [**2173**]
- fibroid surgery in [**2178**]
- anxiety/depression
- fibromyalgia
- migraine headaches
- menopause in [**2181**]
Social History:
- Tobacco: No
- Alcohol: Denies
- Illicits: Denies
.
Family History:
Non contributory
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: Gorssly intact.
DISCHARGE PHYSICAL EXAM:
VS - 96.9, 115/63, 67, 20, 97%RA Fs 224
GENERAL - elderly woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no cervical LAD; CVL place
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/ND, mild tenderness over left abdomen, no
masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-28**] throughout, sensation grossly intact throughout, +SLR on L.
Pertinent Results:
ADMISSION LABS
[**2185-10-15**] 12:00AM BLOOD WBC-6.5 RBC-4.24 Hgb-13.2 Hct-35.9*
MCV-85 MCH-31.3 MCHC-36.9* RDW-12.8 Plt Ct-184
[**2185-10-15**] 12:00AM BLOOD Neuts-70.0 Lymphs-24.9 Monos-3.7 Eos-0.7
Baso-0.8
[**2185-10-15**] 12:00AM BLOOD PT-12.0 PTT-22.2 INR(PT)-1.0
[**2185-10-15**] 12:00AM BLOOD Glucose-230* UreaN-20 Creat-0.5 Na-139
K-4.2 Cl-105 HCO3-25 AnGap-13
[**2185-10-15**] 05:40AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.4*
[**2185-10-15**] 12:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2185-10-15**] 12:00AM BLOOD CK(CPK)-49
[**2185-10-15**] 12:09AM BLOOD Lactate-1.4
.
EGD ([**2185-10-17**])
-Normal mucosa in the esophagus
-Erythema in the Antrum compatible with Gastritis
-Erythema in the Duodenal bulb compatible with duodenitis
-Otherwise normal EGD to third part of the duodenum
.
Sigmoidoscopy ([**2185-10-17**])
-Diverticulosis of the Sigmoid and descending colon
-Clotted blood consistent with recent GI bleed was noted
throughout the colon up to the splenic flexure
-External hemorrhoids
-Otherwise normal sigmoidoscopy to splenic flexure
.
Colonoscopy ([**2185-10-19**])
-Diverticulosis of the whole colon. No blood was seen in the
colon.
-Some diverticula had blood in them that could be washed away;
no active bleeding was seen.
-Despite multiple attempts the terminal ileum could not be
intubated.
-Otherwise normal colonoscopy to cecum
.
Meckel's Scan ([**2185-10-21**])
-Normal study, no evidence of ectopic gastric mucosa to suggest
a gastric mucosa containing Meckel's diverticulum as a source of
GI bleeding.
.
CXR ([**2185-10-21**])
-No acute cardiopulmonary findings. No displaced rib fracture.
IJ catheter tip in the upper right atrium.
Brief Hospital Course:
58 yo woman with history of MI on ASA and Plavix presenting with
acute painless GI bleed of likely lower GI source.
ACTIVE ISSUES
# GI bleed, [**1-26**] diverticular bleed:
Pt was initially directly admitted to MICU where she had a
negative NG lavage and was initially hemodynamically stable with
an appropriate response to transfusions. Pt had a known history
of diverticulosis and her presentation was though to be likely
secondary to a diverticular bleed. She was transferred to the
general medical floor and GI was consulted. A colonoscopy was
planned, however the patient started to have more episodes BRBPR
with the colonoscopy prep. Her blood pressure also dropped to
systolic of 78 and the patient was transferred back to the MICU.
Over the course of her second MICU stay, she underwent CTA which
did not identify a bleeding source. Interventional radiology
performed an angiography to continue to look for source of
bleeding given her persistent BRBPR and borderline hypotension
that transiently required pressors. They unfortunately were
also unable to find a source of her bleeding.
GI performed EGD and sigmoidoscopy on [**10-17**] which showed
gastritis and clots in the sigmoid colon with multiple
diverticulae, however again no source of her bleeding was
identified. Subsequently, she underwent a colonoscopy on
[**2185-10-19**] after 1 day of stable hematocrit. She was noted to
have diverticulae throughout her entire colon all the way to the
cecum and no active bleeding was seen. At the end of MICU, she
received a total of 7 units of pRBC, 2 units of plt, 2 units of
FFP on [**2185-10-17**]. Her Hct remained stable between 27-29 for 1
day prior to transfer to the floor.
On the medical floor, the patient remained hemodynamically
stable and her hematocrit ranged from 26-30. She had one
additional episode of BRBPR without significant hematocrit drop
or HD compromise. Her additional BM were significant for brown
stools that remained guaiac positive. She then under went a
Meckel's scan which did not reveal a Meckel's diverticulum.
# History of CAD:
Due to recent placement of DES in [**7-/2185**], it was felt that the
patient should continue to receive her aspirin and plavix when
ever possible. They were both held transiently in the setting
of her active bleed and hypotension. They were restarted when
the patient remained more stable. Her home metoprolol was also
held transiently due to her active bleeding.
CHRONIC ISSUES
# DM: ISS
# Hypothyroidism: Continued home thyroid meds
# Depression/Anxiety; Continued cymbalta and adderal. It was
held on the day of her acute bleeding on [**10-17**], and she was
given ativan for anxiety. She was transitioned back to her home
meds prior to transfer to the floor on [**10-19**].
Medications on Admission:
AMPHETAMINE-DEXTROAMPHETAMINE [ADDERALL XR] - (Prescribed by
Other Provider) - 20 mg Capsule, Ext Release 24 hr - 1 (One)
Capsule(s) by mouth twice a day
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider; 75 mg) -
Dosage uncertain
DULOXETINE [CYMBALTA] - (Prescribed by Other Provider) - 60 mg
Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth at
bedtime
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - (Prescribed by Other
Provider) - 145 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
INSULIN 75/25 - (Prescribed by Other Provider) - - 24 units
SQ
before breakfast and before dinner.
LAMOTRIGINE [LAMICTAL] - (Prescribed by Other Provider) - 150
mg
Tablet - 1 (One) Tablet(s) by mouth once a day
LEVOTHYROXINE [SYNTHROID] - 175 mcg Tablet - 1 (One) Tablet(s)
by
mouth daily for 6 days weekly and [**12-26**] tablet daily for one day
weekly. Fasting with water only - No Substitution
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet
Extended Release 24 hr - one Tablet(s) by mouth twice a day.
METOPROLOL SUCCINATE [TOPROL XL] - (Prescribed by Other
Provider; 50 mg) - Dosage uncertain
OMEGA-3 ACID ETHYL ESTERS [LOVAZA] - (Prescribed by Other
Provider) - Dosage uncertain
Discharge Medications:
1. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a
day).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO at bedtime.
4. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daIly ().
5. Synthroid 175 mcg Tablet Sig: One (1) Tablet PO once a day:
Please take 1 tablet for 6 days weekly, and [**12-26**] tablet daily for
one day weekly. No substitutions.
6. insulin lispro protam & lispro 100 unit/mL (75-25) Suspension
Sig: Twenty Four (24) unit Subcutaneous twice a day: before
breakfast and dinner.
7. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO twice a day.
8. lamotrigine 150 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lovaza 1 gram Capsule Sig: One (1) Capsule PO once a day.
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. Outpatient Lab Work
please check a hematocrit on Thursday [**2185-10-27**] and fax results to
Dr. [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 3100**]
Office Phone:([**Telephone/Fax (1) 2306**]
Office Fax:([**Telephone/Fax (1) 23366**]
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: diverticulosis
secondary diagnosis: coronary artery disease, hypertension,
anxiety, depression, type II diabetes mellitus
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 taking part in your care. We hope you
continue to feel better. You were admitted for GI bleeding
which required multiple blood transfusions. You underwent an
endoscopy, sigmoidoscopy, and colonscopy which revealed many
divertiuli but no active bleeding.
No changes were made to your medications. Please continue taking
all of your medications as prescribed.
It is very important that you have your blood checked when you
see Dr. [**Last Name (STitle) 3100**] on Thursday [**2185-10-27**]. A prescription has been
provided. Please call your doctors if [**Name5 (PTitle) **] develop any bloody
stool, and call 911 if it is a large volume or if you feel
weak/dizzy.
Please be sure to follow up with your physicians.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: THURSDAY [**2185-10-27**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], 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) **],[**First Name3 (LF) **] R.
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Street Address(2) 65734**], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 65735**]
Appt: [**10-31**] at 1:30pm
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
|
[
"571.8",
"346.90",
"729.1",
"V10.87",
"250.00",
"244.0",
"300.00",
"458.9",
"V58.67",
"562.12",
"272.4",
"V58.61",
"285.1",
"V45.82",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"45.13",
"45.23",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
10108, 10114
|
4797, 7575
|
294, 449
|
10300, 10300
|
3113, 4774
|
11246, 11971
|
1878, 1897
|
8830, 10085
|
10135, 10135
|
7601, 8807
|
10451, 11223
|
1912, 2394
|
1218, 1228
|
246, 256
|
477, 1199
|
10191, 10279
|
10154, 10170
|
10315, 10427
|
1250, 1791
|
1807, 1862
|
2419, 3094
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,856
| 150,934
|
42037
|
Discharge summary
|
report
|
Admission Date: [**2183-7-5**] Discharge Date: [**2183-7-27**]
Date of Birth: [**2121-9-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2183-7-18**] Diagnostic laparoscopy converted to laparotomy
with small-bowel resection and primary anastomosis, sigmoid
and descending colon colectomy with transverse ostomy and
omentectomy.
History of Present Illness:
61F with recent admission for CVA on [**2183-6-30**]. Discharged on
Plavix. She was home for one day, and developed chest pain.
She
presented to an OSH and found to be bradycardic with melanotic
stool.Echo showed question of aortic flap. She was was
transferred to [**Hospital1 18**] for further evaluation of possible type A
dissection. Pt arrived intubated on Nipride drip for blood
pressure control.
Past Medical History:
Diabetes Mellitus,
Chronic Renal Insufficiency ( ? baseline 2.8)
Hypertension
CVA
Hyperlipidemia
Hypothyroidism
Coronary Artery Disease s/p CABG [**2180**]
Anxiety
Depression
Social History:
Lives with: husband, independent in ADLs
Contact: Phone #
Occupation:
Cigarettes: Smoked no [] yes [x] last cigarette _many years ago_
Hx:
Other Tobacco use:
ETOH: < 1 drink/week [x] [**12-30**] drinks/week [] >8 drinks/week []
Illicit drug use
Family History:
no premature CAD
Physical Exam:
** arrived intubated and sedated
Pulse: 62 junctional Resp: 12 O2 sat: 90%
B/P Right: Left: 134/62
Height: Weight:
Five Meter Walk Test #1_______ #2 _________ #3_________
General: Intubated, sedated
Skin: Dry [x] intact [x]
well healed median sternotomy
well healed [**Doctor Last Name **] incision on abdomen
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] distant heart sounds Murmur []
grade
______
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds
+
[] **bowel sounds not appreciated
Extremities: Warm [x], well-perfused [] Edema [x] trace pedal_
Varicosities: None [x]
Neuro: Grossly intact [] sedated
Pulses:
Femoral Right: 2+ Left:2+
DP Right: Left: doppler
PT [**Name (NI) 167**]: Left: doppler
Radial Right: 1+ Left: a-line
Carotid Bruit Right: 2+ Left: 2+
no bruits appreciated
Pertinent Results:
IMPRESSION:
1. Type A dissection extending down to the coronary arteries.
2. 6.7 x 4.3 cm contrast-containing collection between the aorta
and the main
pulmonary arteries concerning for a contained
rupture/pseudoaneurysm. This
causes mass effect on the pulmonary artery trunk and the left
upper pulmonary
vein.
3. The inferior extent of the dissection is down to just
proximal to the
bifurcation of the abdominal aorta. The dissection extends into
the proximal
aspects of the superior mesenteric and celiac arteries, although
the more
distal aspects of these vessels arise from the true lumen.
4. Both kidneys are hypoperfused although arising from the true
lumen, aside
from an accessory right renal artery which supplies the inferior
pole of the
right kidney arising from the false lumen.
5. Inferior mesenteric artery arises from the false lumen.
6. Fibroid uterus.
7. Consolidations in the left upper lobe concerning for
pneumonia. Bibasilar
atelectasis with possible superimposed infection in the right
lower lobe.
8. Small bilateral simple effusions.
These findings were communicated to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, via
telephone at 9
p.m. on [**2183-7-5**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 28398**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
[**2183-7-27**] 02:47AM BLOOD WBC-30.5* RBC-3.81* Hgb-11.7* Hct-34.4*
MCV-90 MCH-30.7 MCHC-34.0 RDW-14.6 Plt Ct-294
[**2183-7-5**] 04:11PM BLOOD WBC-18.0* RBC-2.92* Hgb-9.4* Hct-27.4*
MCV-94 MCH-32.1* MCHC-34.3 RDW-14.9 Plt Ct-177
[**2183-7-26**] 02:03AM BLOOD PT-14.0* PTT-26.2 INR(PT)-1.2*
[**2183-7-5**] 04:11PM BLOOD PT-13.4 PTT-26.4 INR(PT)-1.1
[**2183-7-27**] 02:47AM BLOOD Glucose-113* UreaN-35* Creat-1.5* Na-136
K-4.2 Cl-103 HCO3-22 AnGap-15
[**2183-7-5**] 04:11PM BLOOD Glucose-175* UreaN-65* Creat-3.4* Na-141
K-4.8 Cl-114* HCO3-15* AnGap-17
[**2183-7-27**] 02:47AM BLOOD ALT-44* AST-92* LD(LDH)-394* AlkPhos-119*
Amylase-535* TotBili-0.3
[**2183-7-5**] 04:11PM BLOOD ALT-15 AST-33 LD(LDH)-249 CK(CPK)-203*
AlkPhos-57 Amylase-131* TotBili-0.2
[**2183-7-27**] 11:13AM BLOOD Type-ART pO2-86 pCO2-34* pH-7.39
calTCO2-21 Base XS--3
[**2183-7-5**] 04:31PM BLOOD Type-ART pO2-64* pCO2-42 pH-7.16*
calTCO2-16* Base XS--13 Comment-VERIFIED
Brief Hospital Course:
Mrs.[**Known lastname 91263**] had a previous admission to OSH for a CVA for which
she was discharged on [**6-30**] on plavix. Twenty-four hours after her
discharge she returned to the OSH complaining of chest pain and
was found to be bradycardic and having melenotic stool. TTE at
the OSH revealed a possible aortic flap. She was placed on
Nipride drip for blood pressure management. Her status
deteriorated requiring intubation. Mrs.[**Known lastname 91263**] was transferred
to [**Hospital1 18**] on [**7-5**] intubated and sedated. She was admitted to the
CVICU and IV Blood Pressure management continued. CTA done given
recent CVA with GI bleed. CTA demonstrated a Type A aortic
dissection extending from coronaries to the abdominal
bifurcation involving the major vessels including the renals,
celiac, SMA and [**Female First Name (un) 899**]. Echo done the following morning confirmed
moderate to severe AI, moderate MR [**First Name (Titles) **] [**Last Name (Titles) **], normal EF and a
dissection flap from aortic root into descending aorta. Hospital
day one she became anuric and acidotic and CRRT was started
after consultation with renal service. Mrs.[**Known lastname 91263**] had a severe
metabolic acidosis and was treated with a sodium bicarbonate
drip as well as CVVH. Cardiac surgery for her type A dissection
was was delayed initially due to the patients severe acidosis,
hemodynamic instability, and extreme risk of mortality. EP was
consulted for evaluation of bradycardia. Per EP no indication
for transvenous pacing as symptomatic episodes associated with
bradycardia were with known metabolic abnormalities. EP
continued to follow the patient due to her ongoing rhythm
issues. Per EP the patient very possibly has tachy-brady
syndrome leading to aberrantly-conducted atrial tachycardia,
followed by conversion pauses to sinus bradycardia. On [**7-11**] the
Vascular surgery team consulted and discussed with patient's
family their wishes regarding the need for a major operation
following the needed type A dissection repair (open
thoracoabdominal aortic aneurysm repair). Of note, Mrs.[**Known lastname 91263**]
was requiring multiple pressors for hemodynamic support at this
time. On [**7-15**] General surgery was consulted secondary to
concern for mesenteric ischemia from the type A dissection
involving major vessels to intestine with acutely increasing
WBC, lactate and stool output. Gen [**Doctor First Name **] felt that chances of
surviving laparotomy at that point were low. It was felt at that
time in discussion with family, general surgery and csurg team,
consensus was to pursue conservative management with treatment
for cdiff colitis and assessing progress prior to further
decisions. On [**7-18**] as the patients condition was not improving,
General surgery took Mrs.[**Known lastname 91263**] to the operating room where she
underwent diagnostic laparoscopy converted to laparotomy with
small-bowel resection and primary anastomosis, sigmoid and
descending colon colectomy with transverse ostomy and
omentectomy due to ischemic bowel. Initially her condition did
show improvement after removal of ischemic bowel. She was weaned
to extubation on [**7-21**]. The following day she required
reintubation for respiratory failure, hemodynamic instability
requiring pressor support and CVVH. Again she showed improvement
and was extubated on [**7-25**].
Initially Mrs.[**Known lastname 91263**] was appropriate even while intubated and
she was last extubated on [**7-25**], was interactive and with
appropriate mental status. On [**7-26**] afternoon, she developed flash
pulmonary edema and required reintubation. She continued to be
responsive until approximately 23:30-0:00, when she was noted to
have a left fixed and dilated pupil. Neurology was consulted.
These findings began to resolve on repeat exams and CT did not
demonstrate any acute processes to explain this change.
Neurology continued to follow.
There was a family meeting on [**7-27**] and they decided to withdraw
care. The pt. was extubated at 13:15 and expired at 16:45. The
family declined an autopsy.
Medications on Admission:
Coreg 25mg [**Hospital1 **], Vitamin B12 1000mcg daily, Prozac 20mg daily,
Lantus 20 units hs, Novolog Sliding Scale, Levothyroxine 5mcg
daily, Crestor 40mg daily, Norvasc 10mg daily, Plavix 75mg
daily,
Lasix
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Type A aortic dissection
Diabetes Mellitus,
acute renal failure
Chronic Renal Insufficiency, Hypertension, h/o
CVA, Hyperlipidemia, Hypothyroidism, Coronary Artery Disease s/p
CABG [**2180**], Anxiety, Depression
Past Surgical History
Coronary Artery Bypass [**2180**]
?open cholecystectomy
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2183-7-27**]
|
[
"414.00",
"518.81",
"584.9",
"518.4",
"008.45",
"585.9",
"V66.7",
"276.3",
"427.89",
"441.01",
"276.2",
"V64.41",
"272.4",
"244.9",
"V49.86",
"557.9",
"403.90",
"427.5",
"V12.54",
"300.00",
"311",
"443.23",
"V45.81",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.6",
"96.72",
"99.15",
"33.29",
"96.71",
"45.62",
"38.91",
"46.11",
"54.4",
"39.95",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9271, 9280
|
4858, 8982
|
320, 516
|
9615, 9624
|
2440, 4835
|
9677, 9804
|
1450, 1468
|
9242, 9248
|
9301, 9594
|
9008, 9219
|
9648, 9654
|
1483, 2421
|
269, 282
|
544, 950
|
972, 1149
|
1165, 1434
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,682
| 164,570
|
45235
|
Discharge summary
|
report
|
Admission Date: [**2148-9-5**] Discharge Date: [**2148-9-12**]
Date of Birth: [**2065-4-28**] Sex: F
Service: SURGERY
Allergies:
Aspirin / Milk
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
1. [**Doctor Last Name 1132**] embolization
2. splenectomy
History of Present Illness:
83F known to the Trauma surgery service presents with LLQ
pain, right chest pain and hypotension with some amount of
diaphoresis. She presnets after three days of symptoms and in
the absence of recent trauma. She is appropriately
anticoagulated for a St. Jude's valve. Does have a history of
prior L-sided fall seven months ago.
Past Medical History:
PMH
1. Atrial fibrillation
2. Hypercholesterolemia
3. GERD
4. Depression
5. Osteoporosis
6. Retroperitoneal bleed [**4-16**]
7. Diastolic heart failure
PSH
1. S/P MVR with mechanical valve [**2145**]
2. S/P L4-5 laminectomy [**12-16**]
Social History:
Patient lives with a 24 hour aide and is able to do ADLs with
help from aide. She is a Holocaust survivor. Her son, [**Name (NI) **], is
very involved in her medical care and is her HCP.
[**Name (NI) 1139**]: Non-smoker
EtOH: none
Illicits: none
Family History:
Non-contributory
Physical Exam:
O:96.6 88 108/50 32 100
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5 min reactive EOMs full
Chest CTAB Cor RRR
Abd s/nd/ LUQ tenderness most prominent with diffuse tenderness
region
Ext moves all extremities
Pertinent Results:
[**2148-9-4**] 09:40PM WBC-16.1*# RBC-3.22* HGB-10.1* HCT-30.6*
MCV-95 MCH-31.3 MCHC-33.1 RDW-14.1
[**2148-9-4**] 09:40PM NEUTS-82.7* LYMPHS-13.8* MONOS-2.9 EOS-0.4
BASOS-0.1
[**2148-9-4**] 09:40PM PLT COUNT-335
[**2148-9-4**] 09:40PM ALT(SGPT)-26 AST(SGOT)-32 ALK PHOS-174* TOT
BILI-0.2
[**2148-9-4**] 09:40PM GLUCOSE-174* UREA N-26* CREAT-0.8 SODIUM-143
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-27 ANION GAP-14
[**2148-9-5**] 12:20AM HGB-8.2* HCT-25.0* MCHC-32.8
[**2148-9-5**] 03:51AM WBC-9.3 RBC-3.46* HGB-10.5* HCT-31.8* MCV-92
MCH-30.4 MCHC-33.0 RDW-14.9
[**2148-9-4**] CT Abd/pelvis : 1. Large splenic hematoma (grade 3) with
evidence of extravasation into the
hematoma. There is associated small volume of free fluid in the
abdomen.
2. Dense atherosclerotic disease.
3. Diverticulosis.
4. Stable spinal compression deformities.
5. Unchanged pulmonary nodules.
Brief Hospital Course:
The patient was admitted to the ACS service on [**9-5**], and
underwent IR embolization of spontaneous splenic laceration with
gelfoam, then was taken to the OR for splenectomy. She
tolerated the surgery and was transferred to the SICU for
further care.
Cardiovascular: hx of a fib, MVR, diastolic HF, hypertrophic
cardiomyopathy. Heart rate was well controlled throughout her
stay with metoprolol. Cardiac enzymes negative x3.
Pulm: Pt was extubated on [**9-6**] and weaned from supplemental O2
by time of discharge; had no further pulmonary issues.
GI/GU: NGT was dc'd on [**9-8**]. Pt has been tolerating a small diet
and PO meds. Foley inserted [**9-4**], dc'd on [**9-9**]. Pt has had good
urine output although remains incontinent.
Hematology: Received 2 units PRBC for Hct 26 on [**9-6**].
Anti-coagulation was reversed for surgery. Heparin gtt
restarted post-op, with goal PTT 60-80. [**Month/Year (2) 197**] restarted on
[**9-8**], and the patient was therapeutic with an INR of 2.3 on [**9-11**].
Hep GTT was dc'd at that time. Her INR on [**9-12**] was 2.8 which
reflects a steady dose on 3 mg daily.
Infectious disease: UA showed positive leuk esterase, neg
nitrites. Chest CT showed no active infiltrate. Antibiotics held
for fever curve and WBC trend, which remained unimpressive.
Endocrine: On chronic prednisone for rheumatoid arthritis. Home
dose prednisone converted to methylprednisolone while in the
unit as patient unable to take PO meds. On [**9-10**], solumedrol IV
dc'd. Prednisone 5 mg daily may start [**2148-9-13**].
Rehab : Mrs. [**Known lastname **] was very deconditioned after surgery and
requires assistance getting out of bed and basically has been to
weak to walk. The hope is that she will regain strength and
increase her mobility so that she may return home again with her
caregiver.
Medications on Admission:
[**Known lastname **] 3', simvastatin 40'omeprazole 20', mirtazapine 15',
lopressor 25'', mtx 12.5 weekly prednisone 5 mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. [**Known lastname 197**] 3 mg Tablet Sig: One (1) Tablet PO once a day: to
keep INR 2.5-3.0.
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Splenic rupture
acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were hospitalized because you had a laceration of your
spleen which required an operation.
Please call your doctor if
* 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 [**11-22**] 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 staples will be removed at rehab
Followup Instructions:
Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment
in [**3-13**] weeks.
Call Dr. [**Last Name (STitle) 2204**] for a follow up appointment after you get home
from rehab
Completed by:[**2148-9-12**]
|
[
"311",
"428.32",
"425.4",
"V58.61",
"714.0",
"780.61",
"458.9",
"428.0",
"530.81",
"V58.65",
"733.00",
"427.31",
"568.81",
"788.30",
"285.1",
"V45.81",
"V43.3",
"289.59",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"41.5",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
5185, 5270
|
2420, 4258
|
289, 350
|
5354, 5354
|
1516, 2397
|
6699, 6944
|
1250, 1268
|
4436, 5162
|
5291, 5333
|
4284, 4413
|
5537, 6503
|
1283, 1497
|
234, 251
|
6515, 6676
|
378, 710
|
5369, 5513
|
732, 970
|
986, 1234
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,036
| 166,937
|
6754
|
Discharge summary
|
report
|
Admission Date: [**2149-1-29**] Discharge Date: [**2149-2-5**]
Date of Birth: [**2082-8-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Streptococcal sepsis s/p distal panc/splenectomy for IPMN ([**Hospital1 2025**])
Major Surgical or Invasive Procedure:
None
History of Present Illness:
66 year old with a past medical history IPMN in the tail of
the pancreas status-post distal pancreatectomy/splenectomy 4-5
months ago at [**Hospital1 2025**] who presents after a transfer from [**Hospital **]
Hospital after evaluation of diarrhea and vomiting for 2 days,
syncope X2 today and changes in mentals status. The patient was
in his usual state of health until two days ago when he began to
experience diarrhea, and a single episode of rigors. Today, he
spiked to 102, fainted and was sent by EMS to [**Hospital **] hospital.
In route, he went into asystole for 10 seconds at which time the
patient became unconscious. He spontaneously recovered.
At [**Location (un) **], ST segment elevations were noted in the anterior
leads, and the patient was sent to the cath lab. Global
ventricular dysfunction was noted but the coronary arteries were
clean. Of note, the patient has a known LAD stent placed 3 years
ago. Per report, myocarditis was suspected.
Since admission to [**Location (un) **], the patient has become increasing
confused, transiently responding to commands. He also has been
reverting to his native language of [**Hospital1 100**], despite being fully
fluent in English.
At the outside hospital, white count was 26.7, hematocrit was
39.0, and platelets were [**Numeric Identifier 14900**]. INR was 2.4. INR was 2.4, PTT
40.7, fibrinogen 447. D-dimer pending. Troponin 2.13, CK-MB 7.0.
AST 114, ALT 51, Bilirubin 2.8,
The patient presented on transfer on a nitroglycerine drip for
unclear reasons.
Past Medical History:
Hypercholesterolemia, NIDDM, HTN, IPMN s/p distal
pancreatectomy, splenectomy.
Social History:
Former smoker. Lives with wife. Daughter physician.
Family History:
Noncontributory.
Physical Exam:
Vitals signs stable, afebrile
Patient alert, awake and oriented x3 and is following commands.
Lungs clear to auscultation, RRR, S1/S2.
Abdomen soft, non-tender, active bowel sounds, midline scar
Neurologically intact with exception of hearing loss.
Extremities warm, well perfused and pulses palpable.
Pertinent Results:
[**2149-1-31**] 09:00AM BLOOD WBC-14.8* RBC-3.85* Hgb-11.7* Hct-32.4*
MCV-84 MCH-30.4 MCHC-36.1* RDW-16.5* Plt Ct-61*
[**2149-1-29**] 01:48PM BLOOD PT-14.8* PTT-29.2 INR(PT)-1.3*
[**2149-1-31**] 09:00AM BLOOD Glucose-154* UreaN-21* Creat-1.1 Na-136
K-3.4 Cl-101 HCO3-27 AnGap-11
Brief Hospital Course:
66 year old with a past medical history of intrapapillary
mucinous carcinoma in the tail of the pancreas status-post
distal pancreatectomy/splenectomy 4 months ago at [**Hospital1 2025**] presents
with pneumococcal sepsis. [**10-3**] pt. had distal
pancreatectomy/splenectomy at [**Hospital1 2025**], he received appropriate
vaccinations prior to this. He was feeling well until 10 days
prior to admission when he began having runny nose. Then 4 days
PTA he began having rigors at night. 3 days PTA began having N/V
then diarrhea. He fainted at home and his wife called 911. In
the ambulance he had a 10 period of asystole and spontaneously
regained sinus rhythm.
At [**Hospital **] hospital he was febrile to 103F, hypotensive, EKG
showed diffuse STE and troponins were positive. He had cardiac
catheterization which showed clean coronaries, previous stent,
global hypokinesis w/ EF 25%. After catheterization he was noted
to have altered mental status. He was thought to have viral
myocarditis, but was started on ceftriaxone and vancomycin and
was transferred to [**Hospital1 18**] for further management.
Since arrival at [**Hospital1 18**] he has had Echo which showed EF 50%,
aortic valve/mitral valve abnormalities. He was switched to
vancomycin, cipro and metronidazole. He defervesced and has
cleared mentally. SICU team recieved culture data from [**Hospital **]
hospital today w/ one set of blood cultures growing S.
pneumoniae. He was transferred out of the ICU.
On [**2-1**], the patient complained of acute hearing loss. The
patient had awoken at 10 AM and suddenly felt unable to hear low
pitch tones b/l accompanied by muffled higher pitched tones,
along with a overall decrease in amplitude of sound and an
increase in background "hissing" sound heard b/l. The hearing
abnormalities gradually lessened throughout the day but
persisted. He felt that the hearing loss was worse on the left.
He denied otalgia, recent ear aches, any past history of similar
episode, any past history of hearing loss or ear problems, fever
or chills in the past two days. He denied any vertigo at the
time. The patient received vancomycin at the OSH; since
admission here he had received eptifibatide, vancomycin,
ciprofloxacin, famotidine, and now is on ceftriaxone, which was
started yesterday morning. He also reports a history of vertigo
prior to his admission at the OSH: one week PTA he felt
extremely weak accompanied by fever and diarrhea, and had two
episodes during which the room was spinning and he subsequently
lost consciousness; following these the patient was brought to
the OSH. Otolaryngology was consulted and recommended a
prednisone taper after an audiogram confirmed hearing loss of
acute onset.
After complaining of possible diplopia on [**2149-2-3**], a neurology
consult was called and the patient received a CT scan of the
head. The results were unremarkable and neurology said their
exam was not indicative of any primary neurological process,
though may have a multifactorial etiology. They recommended
outpatient follow up with [**Hospital 878**] Clinic. Information for
follow up was provided.
Infectious disease followup and a course of 2 weeks of IV
ceftriaxone had been arranged for the patient along with access
to Otolaryngology followup. The patient is stable, ambulatory,
voiding and stooling, tolerating po intake and shows no signs of
serious issues requiring further hospitalization.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day) for 15 doses: Please see attached schedule of doses.
After course of 30 mg completed begin taper (20 mg x 4 doses
[**Hospital1 **]; 10 mg x 5 doses [**Hospital1 **]; 10 mg x 2 doses qday). .
Disp:*60 Tablet(s)* Refills:*0*
5. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours).
Disp:*14 doses* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for headache. Tablet(s)
7. Glimepiride 1 mg Tablet Sig: 0.5 Tablet PO q AM ().
8. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO q PM ().
9. Medication
Continue taking all your other medications as directed by your
primary care provider including your antidiabetic pain
medicines.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Streptococcal sepsis s/p distal panc/splenectomy for IPMN ([**Hospital1 2025**])
Hearing Loss
Discharge Condition:
Stable
Discharge Instructions:
Streptococcal sepsis s/p distal panc/splenectomy for IPMN ([**Hospital1 2025**])
Followup Instructions:
Please follow up with ENT (Dr. [**Last Name (STitle) 3878**] using the information
given to you by the ENT team.
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2149-3-6**] 10:30
|
[
"272.0",
"250.00",
"995.91",
"584.9",
"414.01",
"287.5",
"401.9",
"389.10",
"038.2",
"286.9",
"V10.09",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7270, 7333
|
2804, 6235
|
394, 401
|
7470, 7479
|
2501, 2781
|
7608, 7878
|
2146, 2164
|
6258, 7247
|
7354, 7449
|
7503, 7585
|
2179, 2482
|
273, 356
|
429, 1957
|
1979, 2060
|
2076, 2130
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,804
| 146,876
|
36554
|
Discharge summary
|
report
|
Admission Date: [**2118-4-18**] Discharge Date: [**2118-4-22**]
Date of Birth: [**2088-12-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
transfer for renal failure and severe hypertension
Major Surgical or Invasive Procedure:
tunnelled HD line placement
History of Present Illness:
29 y/o M no PMH p/w HTN and renal failure. He had been in USOH
until 1 month prior to admission when he began feeling increased
fatigue. Then, 1 week prior to admission he began feeling
worsening malaise and decreased PO intake. He denied any fever,
chills, HA, chest pain. Then, on morning of admission, he
developed acute onset severe upper abd pain which radiated to
his back and lasted for 5 hours. he then went to [**Hospital **] Hosp ED.
At [**Hospital1 **], 97.4, 77, 229/137, 100%RA. Hct 22 and creatinine
found to be 23. CXR and KUB negative by report. He was started
on labatalol gtt with decrease in BP to 170's and received
dilaudid and zofran. He was sent to [**Hospital1 18**] for further care.
.
In the emergency department, initial vitals: 98.5, 151/90, 55,
18, 100%RA. He was continued on labetalol gtt. CTA abd/pelvis
was negative for dissection. He had guaiac positive brown stool
in ED. he was seen by renal in ED.
.
Upon arrival to ICU, he currently reports only fatigue. He
denies any pain, N/V, abd discomfort. He denies any chest pain,
palpitations, headache, vision changes. He had been taking [**1-18**]
advil every other day X 1 month, but stopped last week.
Past Medical History:
None
Social History:
Smoking: none
EtOH: none
IVDU: denies
Family History:
Denies renal dz, HTN, DM
Physical Exam:
VS: T 97.2 BP 147/75 (147-187/76-100) HR 67-79 RR 14 O2 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
temp HD line in R neck
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
Pertinent Results:
[**2118-4-18**] 04:35AM WBC-9.7 RBC-2.73* HGB-7.7* HCT-22.4* MCV-83
MCH-28.4 MCHC-34.2 RDW-14.6
[**2118-4-18**] 04:35AM HCV Ab-NEGATIVE
[**2118-4-18**] 04:35AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2118-4-18**] 04:35AM CRP-5.4*
[**2118-4-18**] 04:35AM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE
[**2118-4-18**] 04:35AM TRIGLYCER-288* HDL CHOL-25 CHOL/HDL-8.6
LDL(CALC)-132*
[**2118-4-18**] 04:35AM CK-MB-3
[**2118-4-18**] 04:35AM LIPASE-65*
[**2118-4-18**] 04:35AM ALT(SGPT)-6 AST(SGOT)-9 LD(LDH)-470*
CK(CPK)-681* ALK PHOS-54 TOT BILI-0.3
[**2118-4-18**] 04:45AM URINE EOS-NEGATIVE
[**2118-4-18**] 04:45AM URINE AMORPH-RARE
[**2118-4-18**] 04:45AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2118-4-18**] 05:04AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**Doctor First Name **] negative, HIV negative, C3 c4 normal
Brief Hospital Course:
Mr [**Known lastname 82740**] is a 29 yo M, with acute on chronic renal failure on
HD and HTN controled on PO meds.
.
# Acute on chronic renal failure, initiation of HD - His renal
failure appears to be of chronic etiology. His symptoms,
including had leg swelling, mental status, and abdominal
pain/nausea have worsened over months to two years. The urine
sediment anaylsis had very large waxy brown muddy casts,
consistent with a chronic renal failure picture in addition to
possible ATN that could have been induced in the setting of
NSAID use. Despite nephrotic range proteinuria, the patient does
not have clinically overt nephrotic stigma of diffuse edema.
.
Definitive diagnosis is to be made upon results of kindey biopsy
that was done the day prior to discharge. Prilimiary
differential is most likely for focal segmental glomulonephritis
given age, ethinithy, and severity of disease. However, all
hepatic and HIV serologies were negative. Second most likely
given the severity of the hypertension is hypertensive
glomulerosclerosis. ANCA, [**Doctor First Name **], HIV, hepatitis serologies
negative. Normal c3 c4 complement levels and normal SPEP. Urine
tox screen was negative.
.
Patient was receiving daily [**Doctor First Name 2286**] through a tunnelled HD line
at the time of discharge and was clinically stable. Patient did
not have any symptoms consistent with uremia - no more vague
abdominal symptoms, pericarditis, or altered mental status.
Patient was seen by nutrition regarding having a renal diet. At
the time of discharge, patient was making urine, around 100-200
cc/hr. Patient is to have [**Doctor First Name 2286**] here and to be followed by
Dr. [**Last Name (STitle) **] until outpatient [**Last Name (STitle) 2286**] is arranged. Hep B vaccine
was administered.
.
PPD placed LEFT volar forearm on [**909-4-21**], will be read in
[**Month Year 2286**] on [**4-23**].
.
# HTN - The chronological relationship to renal failure unknown,
but clearly made worse by declining renal function. At the time
of discharge, the patient was normotensive with pressures of
121/65 on labetalol and amlodipine. Upon presentation to OSH
pressures were 230/130 suggesting a chronic hypertensive
picture. Patient says that he had seen a physician as an
outpatient within the past year, and was found to be
hypertensive and was started on presumably HCTZ, which the
patient was non-compliant. Once the results of the renal biopsy
are obtained, will consider starting ACEI.
.
# Hypertriglyergiemia - Could be elevated in the setting of
nephrotic disease. LDL was 130 and trigs 288. Patient was
started on simvastatin 10mg PO daily.
.
# Secondary Hyperparathyoidism in the setting of renal failure -
PTH elevated 561 suggesting a chronic renal failure picture. The
corrected calicium was 7 and the phos 5.8, suggesting that the
patient was severely nutritionally deficient. Patient was
started on Phos-Lo calcium acetate with meals.
.
#Abdominal pain - although CTA showed jejunal changes, benign
abdominal exam. The [**Doctor First Name 9189**] mesentery appears to be non-specific
edema in the setting of small ascities in a malnurished,
hypoalbuminemic, uremic patient. Uremia leads to inflammation
and can worsen the edema. The symptoms have resolved with the
initiation of [**Doctor First Name 2286**] and the patient at the time of discharge
did not have any nausea or vomitting. Phorphria was negative.
.
#Anemia - labs consistent with anemia of chronic disease, most
likely secondary to chronic renal failure. EPO being
administered with [**Doctor First Name 2286**] and patient being started on folate.
Normal ferritin levels. Red cell morphology normal, normal bili.
No evidence of hemolysis but elevated LDH.
.
# Elevated CK - appears idiopathic, and is in the 300-600 range
and not correlated clinically to a rhabdomylsis picture.
.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Multi-Day Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
acute on chronic renal failure requiring HD of unknown etiology
severe hypertension, well-controlled
Secondary:
hypertriglyeridemia
Discharge Condition:
stable, pressure stable, not dizzy or orthostatic at the time of
discharge.
Discharge Instructions:
You were admitted for acute on chronic renal failure and severe
hypertension. You were started on [**Doctor First Name 2286**] for your renal
failure and are to continue [**Doctor First Name 2286**] here until your outpatient
[**Doctor First Name 2286**] is arranged. You hypertension was controlled intially
with IV medications and you were stable at the time of discharge
on oral medications. You were instructed on the importance of a
renal diet and to take Phos-Lo calcium acetate with meals. You
are to have your PPD read tomorrow at [**Doctor First Name 2286**] by Dr. [**Last Name (STitle) **].
Please keep the area of your kidney biopsy site clean and dry.
Replace the bandaid daily for the next four days.
Please take all medications as prescribed.
Please contact your PCP or return to the [**Name (NI) **] if you develop
altered mental status, significant swelling, or develop an
infection or pain around the kidney biopsy site.
Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2118-4-23**]
7:30
Completed by:[**2118-4-23**]
|
[
"584.5",
"E935.9",
"403.01",
"272.1",
"585.6",
"285.21",
"588.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"55.23"
] |
icd9pcs
|
[
[
[]
]
] |
8061, 8067
|
3269, 7129
|
366, 396
|
8253, 8331
|
2311, 3246
|
9320, 9442
|
1712, 1738
|
7184, 8038
|
8088, 8232
|
7155, 7161
|
8355, 9297
|
1753, 2292
|
276, 328
|
424, 1612
|
1634, 1640
|
1656, 1696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,468
| 163,948
|
22995
|
Discharge summary
|
report
|
Admission Date: [**2109-1-17**] Discharge Date: [**2109-2-3**]
Date of Birth: [**2032-10-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
craniotomy s/p Subdural Hematoma evacuation ([**2109-1-17**])
general anesthesia
PEG placement (date [**1-29**])
History of Present Illness:
76 y/o female with ? underlying dementia had recent fall 2wk pta
with mild head trauma then had another fall day of presentation
to OSH ED. CT head demonstrated acute on chronic SDH 1.3cm with
4mm right to left shift. Transferred to [**Hospital1 18**] for neurosurg
consultation. Repeat CT demonstrated stable SDH but pt
symptomatic for left pronator drift. Taken to OR for craniotomy
and evacuation of SDH [**2109-1-17**]. Hospital course complicated by
CHF likely due to diastolic dysfunction and high afterload with
prerenal azotemia. CHF resolved with mild diruesis and BP
control. ARF also resolved (baseline creat 1.5) with free water
bolus. Also had mild hypernatremia which resolved with free
water boluses through NGT. She was asymptomatic for her
electrolyte disturbance before and after correction.
Presently has had difficult to manage hypertension. Was on
single-medication, Zestril, as outpatient, though BP control is
unknown. Post op was on nipride gtt for tight control, then
tapered off, now on betablocker, nitrate, and hydralazine. ACEI
and HCTZ not initiated given recent ARF that has now resolved
though patient continues to have elevated BUN:Cr ratio. BP has
improved slowly from 180??????s now to 150??????s over later course of the
day. She is asymptomatic without headache, chest pain, or SOB.
Past Medical History:
hypercholesterolemia
chronic renal insuficiency (baseline Cr 1.5-1.8)
"cognitive decline" per husband starting early [**2107**]
Social History:
Married and lives with daughter, has daughter. Smokes [**12-30**] pack
per day, drinks up to 5 martinis daily.
Family History:
noncontrib
Physical Exam:
VS: 98.7, 154/53 (131-184), p75 (60-78), r22 (14-22), 97% RA
gen: comfortable lying in bed with craniotomy incision c/d/i
HEENT: right frontal craniotomy incision with staples no
infection. pupils reactive 3mm to 2mm, very slight anisocoria,
op clear, eomi, no lad
LUngs: mild inspiratory crackles left base, no wheeze, good
aeration
Cor: s1/s2, no m/r/g
Abd: obese, soft, nabs, nttp, no hsm, ngt in place TF @70cc/hr
continuous.
Ext: no edema, mild erythema of left big toe but no
purulence/fluctuance. DP not palpable. (+) warmth, good
sensation.
Neuro: dlerious, no hallucinations, alert to person, time only.
place = [**Location (un) **]. MAE, withdrawls to noxious stimuli.
Pertinent Results:
LABS ON DISCHARGE:
RADIOLOGY:
CT, HEAD W/O CONTRAST, [**2109-1-16**]:
There is an acute subdural hematoma along the right frontal-
temporal- parietal cerebral convexity surface, of maximum width
1.6 cm. No evidence is intra-axial hemorrhage is seen, and no
blood products are present in the ventricles.
Associated with the right subdural hematoma is a moderate mass
effect on the right lateral ventricle, as well as moderate
leftward shift of the normally midline structures. The
ventricles remain patent, and there is no hydrocephalus. The
left cerebral hemispheric sulci are prominent, likely
representing age- related involutional change. The right sided
sulci are effaced by the hemorrhage.
The [**Doctor Last Name 352**]-white matter differentiation is preserved with no
evidence of acute major vascular territorial infarction. There
is, however, hypoattenuation of the periventricular white matter
of the cerebral hemispheres bilaterally, especially on the left,
most likely representing chronic small vessel ischemic disease.
A small chronic lacunar infarct is likely present in the left
caudate nuclues, and a smaller one possibly on the right as
well. There is a small cortical hypodensity in the left lateral
frontal lobe, possibly representing a chronic infarct.
There is slight soft tissue swelling on the right calvarium
overlying the region of the subdural hematoma, but no evidence
of fracture. The paranasal sinuses are clear.
IMPRESSION:
1. Acute subdural hematoma along the right cerebral convexity
surface. 2. Moderate shift of the normally midline structures on
the left.
3. Evidence of chronic small vessel ischemic disease.
4. Prominent sulci suggesting mild age-related involutional
changes.
CT, HEAD, [**2109-1-17**]:
Comparison with the prior study of [**1-16**] shows little
alteration in the extent of the large right cerebral convexity,
acute subdural hemorrhage causing effacement of the contiguous
cerebral sulci. There are multiple chronic lacunar infarcts seen
within the caudate nuclei bilaterally. The degree of
contralateral shift of normally midline structures and
ventricular compression is unaltered in extent. The surrounding
osseous and soft tissue structures display no new abnormalities.
The slight right-sided calvarial soft tissue swelling has not
changed in extent.
CT, HEAD, [**2109-1-18**]
1) Status post craniotomy, drainage catheter placement and
evacuation of subdural hemorrhage.
2) Interval development of small amounts of subarachnoid and
intraventricular blood.
3) Interval increase in size of ventricles which may be
secondary to resolution of mass effect.
Findings communicated to the ordering physician at the time this
report was issued.
CT HEAD W/O CONTRAST [**2109-1-19**]:
1. Interval increase in interventricular blood, and slight
interval increase in subarachnoid blood layering adjacent to the
right temporal, parietal, and frontal lobes, and adjacent to the
left parietal and temporal lobes.
2. No interval change in mass effect.
3. Status-post right frontal craniotomy with drainage catheter
is place.
CT HEAD, [**2109-1-21**]:
Stable appearance of small extraaxial hematoma adjacent to the
right frontal craniotomy site. Stable appearance of subarachnoid
hemorrhage and decrease in intraventricular blood.
CXR, [**2109-1-21**]:
Stable mild congestive heart failure allowing for differences in
lung volumes
CT, SPINE: 1) No evidence of fracture.
2) Degenerative changes of the mid-cervical spine as described.
TRAUMA #2 (AP CXR & PELVIS PORT) [**2109-1-16**]:
1. Limited chest x-ray due to technique. No definite acute
cardiopulmonary abnormality is visualized.
2. No fracture of the pelvis.
VIDEO OROPHARYNGEAL SWALLOW [**2109-1-24**]:
Penetration and aspiration with every consistency as above.
Please refer to the speech and swallow consultation notes for
specific recommendations.
CARDIAC:
TTE:
LA normal
LV normal diameter, no wall motion abnormality, LVEF >55%
RV: nml diamter, no strain
Brief Hospital Course:
76 y/o woman with acute on chronic subdural bleed admitted for
neurosurgical intervention. Hospital course outlined by
problem:
##Subdural hematoma: secondary to fall 2 weeks PTA and then new
fall without LOC. She underwent repeat CT which demonstrated
mild interval change but confirmed right to left midline shift.
She was symptomatic on neurologic exam with left sided pronator
drift. She underwent craniotomy for evacuation of the hematoma.
She required nipride gtt with IV BB and hydralazine for
optimal blood pressure control which was weaned. Repeat CT
post-op demonstrated much increased intraventricular blood which
slowly resolved over time. She had no evidence of any
rebleeding with mass effects. She continued to be delerious
however this also improved over time. This was felt to be
secondary to recent neurosurgical procedure, ICU stay in the
setting of baseline mild dementia. Delirium work up was
negative. In her delirious state, patient had another fall in
the hospital, but repeat head CT was stable and neuro exam was
normal. She will need to be seen by her neurosurgeon within 2
weeks of her hospital discharge for removal of her staples. She
will need to undergo repeat CT of her head prior to this visit.
She will need seizure prophlaxis with the Dilantin until [**2-17**]
(one month after SDH evacuation).
##Hypertension: her hopsital course was complicated by severe
hypertension with blood pressures in the low 200s. She was
asymptomatic for SOB and was thought to have mild heart failure
due to high afterload. This resolved with better control of her
blood pressures and she was able to be weaned onto a PO regimen.
In discussion with her PCP, [**Name10 (NameIs) **] had no prior documentation of
hypertension. She was discharged on an ACEI, high doses of
lopressor, and norvasc with BP's in the 150s.
##Delerium - She continued to remain delerious during her
hospital stay, however with significant improvement prior to DC.
This was attributed to her recent neurosurgical procedure, ICU
stay in the setting of baseline mild dementia. Delirium work up
was negative. Her PCP reported no history of dementia, however
her husband stated that over the last year she has been
increasingly forgetful and cognitively impaired. She does
consume moderate amounts of alcohol daily, however with the
exception of her severe hypertension, she had no other signs of
alcohol withdrawl with autonomic instability. She slowly
improved over time. She failed her speech and swallow test with
all liquid consistencies. Therefore, she required a PEG for
short term feeding and will need to undergo video swallow
testing and caloric count measurements prior to its removal to
ensure she can eat without aspirating and consume enough PO
calories.
##aspiration: see above
##Renal failure- patient had an increase in her cr likely
secondary to pre-renal etiologies. She responded well to IV
hydration. Her cr rose again the day after PEG placement, likely
secondary to one dose of gentamycin (that she recieved prior to
PEG placement). Urine lytes sent at the time indicated a renal
etiololgy of her ARF, and her cr responded well to hydration.
##Please restart [**Name10 (NameIs) 4532**] (for PVD) and [**Name10 (NameIs) **] on [**2-17**]
##[**Name (NI) 2638**] Patients husband was very involved in patient
care, and he was given daily updates on patients progress.
Medications on Admission:
zocor, zetin, [**Last Name (LF) 4532**], [**First Name3 (LF) **]
Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed. neb
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day): continue until patient
ambulating. ml
5. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO 8PM ().
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Erythromycin 5 mg/g Ointment Sig: 0.5 % Ophthalmic QID (4
times a day) for 3 days: in OD.
15. Phenytoin 100 mg/4 mL Suspension Sig: Eight (8) mL PO every
eight (8) hours.
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
17. Haloperidol 1 mg Tablet Sig: 0.5-1 Tablet PO TID (3 times a
day) as needed.
18. Impact/Fiber Liquid Sig: One [**Age over 90 8821**]y (140) ml/hr
PO 12hr/day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
Subdural Hematoma s/p craniotomy with evacuation
HTN
Hypernatremia
Prerenal azotemia
CHF
Paronychia
Secondary:
Dementia
hypercholesterolemia
Discharge Condition:
stable
Discharge Instructions:
if you develop increase headache, trouble breathing, fever
contact your physician or call 911.
Followup Instructions:
Follow up with Podiatry for infected toe, call [**Telephone/Fax (1) 543**] for
an appointment
Follow up with Dr. [**Last Name (STitle) 55858**], phone [**Telephone/Fax (1) 1669**], for f/u
appointment for staple removal and f/u CT results in within 2
weeks.
Follow up with your PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**First Name8 (NamePattern2) **] [**Name (STitle) 18412**], phone number
[**Telephone/Fax (1) 59340**]. Address: [**Location (un) 59341**]. [**Location (un) 8641**], [**Numeric Identifier 59342**].
Please obtain a head CT 2 weeks from [**2109-1-24**] and before seeing
your neurosurgeon. Contact radiology department at phone: ([**Telephone/Fax (1) 18969**] to make an appointment.
|
[
"428.0",
"401.9",
"852.21",
"E884.9",
"428.30",
"780.39",
"E849.0",
"584.9",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"01.31",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
11871, 11941
|
6824, 10228
|
318, 433
|
12135, 12143
|
2822, 2822
|
12286, 13049
|
2094, 2106
|
10343, 11848
|
11962, 12114
|
10254, 10320
|
12167, 12263
|
2121, 2803
|
274, 280
|
2842, 6801
|
461, 1798
|
1820, 1949
|
1965, 2078
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,686
| 142,315
|
8666
|
Discharge summary
|
report
|
Admission Date: [**2173-3-8**] Discharge Date: [**2173-3-16**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
male with a history of coronary artery disease, atrial
fibrillation on Coumadin, gastroesophageal reflux disease who
was brought to the Emergency Department by the EMT after he
complained of intermittent chest pain for three days, nausea
and lethargy. The patient has had some episodes of
constipation as well as dark stools, increasing lower
extremity edema for the past two to three weeks. He denies
any vomiting, abdominal pain or diarrhea. The chest pain
resolved after arrival to the Emergency Department. The EMTs
found him to have a heart rate in the 200s, irregular and he
was given Diltiazem which decreases heart rate to the 70s.
Electrocardiogram was consistent with rapid atrial
fibrillation. In the Emergency Department, his heart rate
was in the 70s and electrocardiogram showed atrial
fibrillation with inferolateral ST segment depressions.
Hematocrit was noted to be 18. His baseline is 30. His
stool was black and guaiac positive. Systolic blood pressure
was 88 to 100. Nasogastric lavage was performed and noted to
be negative. The wife reports multiple urinary tract
infections since [**2172-7-22**] with courses of Augmentin,
Keflex and now ciprofloxacin. The patient had noted diarrhea
in [**Month (only) 404**] and constipation for the last three to four weeks.
He denies any dysuria, shortness of breath, paroxysmal
nocturnal dyspnea, headache, fevers, chills or coughs. He
has noted increasing lower extremity edema and weight gain
since early [**2171-2-20**]. He manages with an increased Lasix
dose. He also noted an increased blood sugar over the
weekend and his wife gave him glyburide.
PAST MEDICAL HISTORY:
1. Atrial fibrillation on Coumadin
2. Noninsulin dependent diabetes mellitus
3. Coronary artery disease, myocardial infarction x3 with
stents to his LAD x2 and circumflex in [**2172-5-22**]
4. Atrial stenosis
5. Congestive heart failure with an ejection fraction of 40%
to 45%
6. Status post CEA on the right
7. Gastroesophageal reflux disease
8. Status post abdominal hernia repair
9. Recurrent urinary tract infection
10. Umbilical hernia repair in [**2172-8-22**]
11. Gout
ALLERGIES: LEVAQUIN CAUSES HIGH INR. CAPTOPRIL CAUSES LOW
BLOOD PRESSURE. HE IS QUESTIONABLY ALLERGIC TO CELEXA AND
ZOLOFT.
MEDICATIONS:
1. Allopurinol 300 mg po q day
2. Lipitor 20 mg po q hs
3. Lasix 40 mg po qd
4. Aspirin 81 mg po qd
5. Potassium chloride 40 milliequivalents [**Hospital1 **]
6. Prevacid 30 mg q day
7. Aldactone 25 mg q day
8. Flomax 0.8 mg q hs
9. Iron sulfate 325 mg po qd
10. Coumadin 10 mg alternating with 7.5 mg q day
11. Calcium
12. Multivitamin tablet
13. Vitamin E
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] denies
any alcohol use. He has a remote smoking history.
FAMILY HISTORY: Noncontributory
PHYSICAL EXAM:
VITAL SIGNS: Temperature 96.3??????, pulse 80, blood pressure
89/39, respiratory rate 23, O2 saturation 97% on 2 liters.
GENERAL: He is a pale, alert elderly gentleman in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT: Head is normocephalic,
atraumatic. Pupils equal, round and reactive to light.
Conjunctivae is pale. Mouth and oropharynx are clear without
any erythema or exudate.
NECK: Supple. There is no lymphadenopathy.
PULMONARY: He has deep bibasilar rales, no wheezes.
CARDIOVASCULAR: Irregularly irregular with 2/6 systolic
ejection murmur at the right upper sternal border.
ABDOMEN: Soft, nontender, nondistended with palpable liver
edge approximately 4 cm below the costophrenic angle.
EXTREMITIES: 3+ edema to the knees. Feet are warm with no
palpable pulses.
RECTAL: Per the Emergency Department, is black. OB is
positive.
LABS: White cell count 15/6, hematocrit 18.2, platelets 334.
His hematocrit on discharge was 31.7. PT 21.8, INR 3.3, PTT
36.2, creatinine 1.3, BUN 97. Troponin on admission was 7.4.
IMAGING: Electrocardiogram showed atrial fibrillation with
heart rate in the 70s. Chest x-ray showed cardiomegaly with
mild congestive heart failure, linear opacities in the mid
right lung, no change from [**2172-8-21**].
ASSESSMENT: This is an 83-year-old man who presents with a
history of coronary artery disease, rapid atrial fibrillation
who presents with severe anemia and guaiac positive stool
consistent with a gastrointestinal bleed.
HOSPITAL COURSE:
1. GASTROINTESTINAL: The patient was admitted to the
Medical Intensive Care Unit with a hematocrit of 18 thought
to be secondary to an active gastrointestinal bleed.
Nasogastric lavage was negative in the Emergency Department,
but he was noted to have dark black melanotic guaiac positive
stools. The gastroenterology team was consulted and they
initially recommended transfusing to keep his hematocrit over
30 with plans for endoscopy when he troponin decreased. He
was transfused 3 units of packed red blood cells initially
with an adequate increase in his hematocrit. He underwent an
esophagogastroduodenoscopy on hospital day #3 which showed
gastritis. Because his hematocrit continued to trend
downward, the patient underwent a colonoscopy to rule out a
lower gastrointestinal bleed. Colonoscopy showed a few
diverticula as well as a single 13 mm nonbleeding polyp of
benign appearance which was removed for biopsy. He was also
noted to have some diverticulosis of the sigmoid colon. His
hematocrit has been subsequently stable with no evidence of
active gastrointestinal bleeding.
2. HEMATOLOGY: The patient was admitted with a hematocrit
of 18 thought to be secondary to a gastrointestinal bleed in
the setting of a supratherapeutic INR. He was given a dose
of vitamin K subcutaneously to reverse his INR and his
Coumadin withheld throughout his hospitalization. He was
transfused periodically to keep his hematocrit above 30 given
his history of coronary artery disease. His hematocrit was
stable upon discharge and his Coumadin was restarted upon
discharge.
3. CARDIOVASCULAR: He was found to be in atrial
fibrillation with rapid ventricular response that slowed with
Diltiazem. Troponins were elevated with flat CKs. This was
felt to be secondary to demand ischemia in a setting of an
acute blood loss. His troponin was trending downward and
given a history of coronary artery disease, a Persantine
thallium was performed for further risk stratification. The
study showed global hypokinesis with an ejection fraction of
39% and a severe fixed defect in the distal anterior apical
myocardial wall. He was also started on Lasix and aldactone
as he was felt to be in congestive heart failure.
4. RENAL: His increased creatinine on admission was felt to
be secondary to intervascular depletion given his blood loss
and his creatinine decreased with blood transfusions and
intravenous fluids.
5. INFECTIOUS DISEASE: The patient had a history of
recurrent urinary tract infection. A routine urinalysis was
sent and noted to be negative. The patient was afebrile and
his white cell count was stable throughout his
hospitalization.
DISPOSITION: The patient has been severely deconditioned
over the past few months given his multiple hospitalizations
and his comorbidities. He was screened by the physical
therapy team who recommended a short term stay in
rehabilitation prior to being discharged to home.
DISCHARGE MEDICATIONS:
1. Digoxin 0.125 mg po q day
2. Lipitor 20 mg po q day
3. Protonix 40 mg po q day
4. Iron sulfate 325 mg po q day
5. Multivitamin tablet 1 tablet po q day
6. Allopurinol 100 mg po q day
7. Flomax 0.4 mg po q hs
8. Lasix 40 mg po q day
9. Spironolactone 25 mg po q day
10. Colace 100 mg po bid
11. Coumadin 7.5 mg po q day with potentially variable doses
related to his INR levels
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3847**], M.D. [**MD Number(1) 3848**]
Dictated By:[**Name8 (MD) 17311**]
MEDQUIST36
D: [**2173-3-15**] 14:18
T: [**2173-3-15**] 14:28
JOB#: [**Job Number **]
|
[
"530.81",
"250.00",
"412",
"V45.82",
"428.0",
"427.31",
"799.3",
"535.41",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.42",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
2933, 2950
|
7439, 8090
|
4474, 7416
|
2965, 4457
|
112, 1772
|
1794, 2789
|
2806, 2916
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,227
| 171,135
|
17767
|
Discharge summary
|
report
|
Admission Date: [**2119-6-9**] Discharge Date: [**2119-6-23**]
Date of Birth: [**2059-5-5**] Sex: M
Service: MEDICINE
Allergies:
adhesive
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
liver mass
Major Surgical or Invasive Procedure:
percutaneous transhepatic cholangiogram with drain placement
chest tube placement
History of Present Illness:
60 yo Vietnamese male with history of HCV genotype 1B with stage
1 fibrosis s/p treatment with SRV presenting for a percutaneous
transhepatic cholangiogram given recent evidence of interval
growth of a large mass measuring 6.1 x
6.6 x 4.4 cm centered in segment [**Doctor First Name 690**], IVb and segment VIII of
the
liver in the region of the porta hepatis. Right anterior and
left
intrahepatic biliary tree obstruction and peripheral enhancement
are features seen as well as tumor thrombus in the right portal
vein and fat content within the lesion, as well as elevated AFP
lead to concern for mixed-type hepatocellular
cholangiocarcinoma. PTC was done in preparation for targeted
liver biopsy for tissue diagnosis for CC vs. HCC and oncology
referral for TACE/CK.
Past Medical History:
1. History of HCV genotype 1B s/p treatment in [**2115**] with SVR.
2. HBV exposure (but HBsAg negative.)
3. Depression/anxiety without SI.
Social History:
Born in [**Country 3992**] and emigrated in [**2105**]. He has
five children, all whom are healthy. Lives with his wife.
Previously worked in construction, but is currently unemployed.
Tobacco use, quit 20 years ago with 10-pack per year history. No
history of alcohol excess, no current alcohol use. No tattoos,
no transfusions, no IV drug use, no cocaine use.
Family History:
1) Son with chronic B hepatitis.
2) Mother with history of diabetes.
3) No known family history of cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: T98.4| BP 125/84| HR 92| RR20 satting 97% on 3L
GENERAL: NAD
HEENT: PERRL, EOMI, anicteric
NECK: no carotid bruits, JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, R and central biliary drains in place
with serosanguinous drainage collecting.
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3. No asterixis.
DISCHARGE EXAM:
Vitals: 97.8, 140s-160s/80s-90s, 80s-90s, 20 97%RA
General: Thin Vietnamese male, A+Ox3, NAD
HEENT: Sclera mildly icteric, EOMI
Neck: supple, JVP not elevated
CV: regular, normal S1 + S2, no M/R/G
Lungs: CTAB, decreased breath sounds at R base and left base.
Crackles at bases on R more than left but present on both sides
Abdomen: soft, mildly distended, non tender. RUQ, RLQ, bowel
sounds present clean dry dressing over prior drain site
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, PICC in LUE
Neuro: CN2-12 intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, no asterixis, oriented
x3
Pertinent Results:
ADMISSION LABS:
[**2119-6-9**] 02:05AM PLT COUNT-191
[**2119-6-9**] 02:05AM WBC-10.1 RBC-4.67 HGB-14.4 HCT-44.4 MCV-95
MCH-30.9 MCHC-32.5 RDW-13.7
[**2119-6-9**] 06:26AM PT-11.4 PTT-30.8 INR(PT)-1.1
[**2119-6-9**] 06:26AM PLT COUNT-212
[**2119-6-9**] 06:26AM WBC-10.4 RBC-4.84 HGB-14.8 HCT-45.8 MCV-95
MCH-30.6 MCHC-32.4 RDW-13.3
[**2119-6-9**] 06:26AM PHOSPHATE-4.2 MAGNESIUM-1.7
[**2119-6-9**] 06:26AM ALT(SGPT)-118* AST(SGOT)-100* ALK PHOS-213*
TOT BILI-1.4
[**2119-6-9**] 06:26AM estGFR-Using this
[**2119-6-9**] 06:26AM GLUCOSE-125* UREA N-12 CREAT-0.8 SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-24 ANION GAP-18
RELEVANT LABS:
[**2119-6-11**] 05:55AM BLOOD WBC-22.3* RBC-4.88 Hgb-15.0 Hct-46.2
MCV-95 MCH-30.7 MCHC-32.5 RDW-13.5 Plt Ct-214
[**2119-6-11**] 05:55AM BLOOD Neuts-89.1* Lymphs-6.9* Monos-3.8 Eos-0.1
Baso-0.1
[**2119-6-14**] 06:05AM BLOOD Neuts-76* Bands-7* Lymphs-0 Monos-11
Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-1*
[**2119-6-14**] 06:05AM BLOOD PT-13.5* INR(PT)-1.3*
[**2119-6-18**] 05:50AM BLOOD Glucose-115* UreaN-24* Creat-3.1*# Na-143
K-3.7 Cl-104 HCO3-26 AnGap-17
[**2119-6-14**] 06:05AM BLOOD ALT-56* AST-69* LD(LDH)-425* AlkPhos-89
TotBili-3.4* DirBili-1.9* IndBili-1.5
[**2119-6-15**] 04:41AM BLOOD ALT-58* AST-54* AlkPhos-90 TotBili-3.4*
[**2119-6-16**] 04:30AM BLOOD ALT-40 AST-39 AlkPhos-91 TotBili-3.6*
[**2119-6-17**] 04:21AM BLOOD ALT-29 AST-43* LD(LDH)-288* AlkPhos-95
TotBili-3.4*
[**2119-6-13**] 11:13PM BLOOD Lactate-3.6*
[**2119-6-14**] 12:06PM PLEURAL WBC-[**Numeric Identifier 49352**]* Hct,Fl-5* Polys-74*
Lymphs-3* Monos-23*
[**2119-6-14**] 12:06PM PLEURAL TotProt-3.7 Glucose-60 LD(LDH)-752
Amylase-243 TotBili-8.4 Cholest-59
DISCHARGE LABS:
[**2119-6-23**] 05:15AM BLOOD WBC-14.3* RBC-3.65* Hgb-11.2* Hct-34.3*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.3 Plt Ct-404
[**2119-6-23**] 05:15AM BLOOD PT-12.3 INR(PT)-1.1
[**2119-6-23**] 05:15AM BLOOD Glucose-95 UreaN-19 Creat-1.5* Na-141
K-3.8 Cl-107 HCO3-24 AnGap-14
[**2119-6-23**] 05:15AM BLOOD ALT-36 AST-56* AlkPhos-176* TotBili-1.3
[**2119-6-23**] 05:15AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
[**2119-6-19**] 01:42PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2119-6-19**] 01:42PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2119-6-19**] 01:42PM URINE RBC-2 WBC-5 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
PERTIENT MICRO/PATH:
[**2119-6-10**] 9:09 am URINE Source: Catheter.
**FINAL REPORT [**2119-6-11**]**
URINE CULTURE (Final [**2119-6-11**]): NO GROWTH.
[**2119-6-10**] 9:10 am BILE CENTRAL BILIARY DRAIN.
**FINAL REPORT [**2119-6-14**]**
GRAM STAIN (Final [**2119-6-10**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2119-6-14**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2119-6-14**]):
ANAEROBIC GRAM POSITIVE COCCUS(I). RARE GROWTH.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
[**2119-6-10**] 9:10 am BILE FROM R BILIARY DRAIN.
**FINAL REPORT [**2119-6-16**]**
GRAM STAIN (Final [**2119-6-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2119-6-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2119-6-16**]): NO GROWTH.
[**2119-6-10**] 11:00 am BLOOD CULTURE
**FINAL REPORT [**2119-6-16**]**
Blood Culture, Routine (Final [**2119-6-16**]): NO GROWTH.
[**2119-6-10**] 12:55 pm BLOOD CULTURE
**FINAL REPORT [**2119-6-16**]**
Blood Culture, Routine (Final [**2119-6-16**]): NO GROWTH.
[**2119-6-13**] 6:34 pm BILE
GRAM STAIN (Final [**2119-6-13**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
GRAM NEGATIVE ROD #1. MODERATE GROWTH.
GRAM NEGATIVE ROD #2. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
[**2119-6-14**] 7:07 am URINE Source: Catheter.
**FINAL REPORT [**2119-6-15**]**
URINE CULTURE (Final [**2119-6-15**]): NO GROWTH.
[**2119-6-14**] 12:06 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2119-6-14**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
Reported to and read back by MR. [**Last Name (Titles) 49353**] @ 10:10 AM ON
[**2119-6-16**].
GRAM NEGATIVE ROD(S). RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
[**2119-6-14**] 5:00 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Site: PLEURAL
Fluid Culture in Bottles (Preliminary):
GRAM NEGATIVE ROD(S).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
AMPICILLIN------------ R
AMPICILLIN/SULBACTAM-- R
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
MEROPENEM------------- S
TOBRAMYCIN------------ S
Anaerobic Bottle Gram Stain (Final [**2119-6-15**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 3078**] ON [**2119-6-15**] AT
0600.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2119-6-15**]): GRAM NEGATIVE
ROD(S).
[**2119-6-15**] 10:21 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE RODS.
Anaerobic Bottle Gram Stain (Final [**2119-6-15**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**3-/3227**] [**2119-6-15**]
3:15PM.
GRAM POSITIVE ROD(S).
[**2119-6-16**] 1:26 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2119-6-18**]**
C. difficile DNA amplification assay (Final [**2119-6-17**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final [**2119-6-18**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2119-6-18**]): NO CAMPYLOBACTER
FOUND.
[**2119-6-14**] 12:06 pm PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT [**2119-6-20**]**
GRAM STAIN (Final [**2119-6-14**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2119-6-17**]):
Reported to and read back by MR. [**Last Name (Titles) 49353**] @ 10:10 AM ON
[**2119-6-16**].
KLEBSIELLA OXYTOCA. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 49354**]
FROM [**2119-6-14**].
ANAEROBIC CULTURE (Final [**2119-6-20**]): NO ANAEROBES ISOLATED.
[**2119-6-13**] 6:34 pm BILE
GRAM STAIN (Final [**2119-6-13**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
KLEBSIELLA OXYTOCA. MODERATE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
Ertapenem Susceptibility testing requested by [**First Name5 (NamePattern1) 1575**]
[**Last Name (NamePattern1) 49355**]
[**8-/3892**] [**2119-6-20**].
ENTEROBACTER CLOACAE COMPLEX. SPARSE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Ertapenem Susceptibility testing requested by [**First Name5 (NamePattern1) 1575**]
[**Last Name (NamePattern1) 49355**]
[**8-/3892**] [**2119-6-20**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA OXYTOCA
| ENTEROBACTER CLOACAE
COMPLEX
| |
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S =>64 R
CEFTRIAXONE----------- <=1 S =>64 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2119-6-17**]): NO ANAEROBES ISOLATED.
[**2119-6-15**] 10:21 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE RODS.
Anaerobic Bottle Gram Stain (Final [**2119-6-15**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**3-/3227**] [**2119-6-15**]
3:15PM.
GRAM POSITIVE ROD(S).
[**2119-6-18**] 10:30 am SWAB Site: RECTAL Source: Rectal
swab.
**FINAL REPORT [**2119-6-20**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2119-6-20**]):
No VRE isolated.
Pathology:
Cytology Report COMMON BILE DUCT BRUSHINGS Procedure Date of
[**2119-6-8**]
REPORT APPROVED DATE: [**2119-6-13**]
SPECIMEN RECEIVED: [**2119-6-9**] [**-1/2206**] COMMON BILE DUCT
BRUSHINGS
SPECIMEN DESCRIPTION: Received in cytolyt.
Prepared 1 ThinPrep slide.
CLINICAL DATA: Pt with HCC and biliary obstruction.
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DIAGNOSIS: Biliary brushing through PTC:
POSITIVE FOR MALIGNANT CELLS.
Consistent with carcinoma, favor hepatocellular carcinoma,
see note.
Note: The brushing shows sheets and single cells with
atypical enlarged and pleomorphic nuclei that have high
N:C ratio. Some of the cells show intranuclear inclusions.
Focally there are groups of cells that have a suggestion
of endothelial wrapping. These findings support a
component of hepatocellular carcinoma. However, a mixed
hepatocellular/cholangiocarcinoma cannot be entirely
excluded.
Immunostains will be reported separately. This result was
communicated to Dr. [**Last Name (STitle) 497**] on [**2119-6-12**].
PERTINENT IMAGING:
PTC AND PTBD
IMPRESSION: Uncomplicated percutaneous cholangiogram,
demonstrating isolated right anterior and left ductal
dilatation, likely as a result of obstruction caused by the
large central hepatic mass. Uncomplicated placement of 8 French
internal-external biliary drainage catheters via the right
anterior and left ductal systems. Both catheters were left
connected to external bags.
[**Numeric Identifier 49356**] CATH/STENT FOR INT/EXT BILIARY DRAINAGE Study Date of
[**2119-6-8**] 4:12 PM
IMPRESSION: Uncomplicated percutaneous cholangiogram,
demonstrating isolated right anterior and left ductal
dilatation, likely as a result of obstruction caused by the
large central hepatic mass. Uncomplicated placement of 8 French
internal-external biliary drainage catheters via the right
anterior and left ductal systems. Both catheters were left
connected to external bags.
PORTABLE ABDOMEN Study Date of [**2119-6-10**] 9:18 AM
1) Multiple loops of dilated small bowel, with air in the colon,
concerning for early or partial small-bowel obstruction. Ileus
is in the differential, but considered less likely.
2) No definite free air. If clinical concern for free air
remains high, then further assessment with upright or decubitus
views or with a CT scan would be recommended.
CHEST (PORTABLE AP) Study Date of [**2119-6-10**] 9:19 AM
1. Patchy opacity at both bases. While this may very well
represent
atelectasis, the possibility of an early infectious infiltrate
cannot be
entirely excluded.
2. No free air detected beneath the diaphragm
CT ABD & PELVIS WITH CONTRAST Study Date of [**2119-6-10**] 4:58 PM
Interval development of multiple dilated loops of both small
bowel with
findings also a small bowel feces sign involving the distal
small bowel.
Administered enteric contrast reaches the right colon. These
findings are concerning for partial/early small bowel
obstruction remains a concern.
Interval placement of right and left approach internal and
external biliary drainage catheters with decrease in the amount
of intrahepatic biliary ductal dilation. Redemonstration of
large mass centered within the liver which was previously
described to be either HCC or cholangiocarcinoma.
Interval development of ill-defined fluid
attenuation/phlegmonous changes
involving the left upper abdomen. No evidence of abscess. A
small amount of hemoperitoneum which could be secondary to the
recently placed biliary drainage catheters.
Extensive bullous emphysematous changes involving the upper
lobes bilaterally. No evidence of pneumonia, however, there is
lower lobe atelectasis and small bilateral pleural effusions.
CT CHEST W/CONTRAST Study Date of [**2119-6-10**] 4:58 PM
Interval development of multiple dilated loops of both small
bowel with
findings also a small bowel feces sign involving the distal
small bowel.
Administered enteric contrast reaches the right colon. These
findings are concerning for partial/early small bowel
obstruction remains a concern.
Interval placement of right and left approach internal and
external biliary drainage catheters with decrease in the amount
of intrahepatic biliary ductal dilation. Redemonstration of
large mass centered within the liver which was previously
described to be either HCC or cholangiocarcinoma.
Interval development of ill-defined fluid
attenuation/phlegmonous changes
involving the left upper abdomen. No evidence of abscess. A
small amount of hemoperitoneum which could be secondary to the
recently placed biliary drainage catheters.
Extensive bullous emphysematous changes involving the upper
lobes bilaterally. No evidence of pneumonia, however, there is
lower lobe atelectasis and small bilateral pleural effusions.
CHEST (PA & LAT) Study Date of [**2119-6-12**] 4:45 PM
Heart size and mediastinum are stable. Right pleural effusion
is moderate, with unchanged location of the pigtail catheter
through the right upper quadrant. Small amount of left pleural
effusion and left basal atelectasis are unchanged as well.
Overall, no evidence of interval development of acute
abnormality seen.
[**Numeric Identifier 49357**] CHANGE PERC TUBE OR CATH W/CONTRAST Study Date of [**2119-6-13**]
3:43 PM
IMPRESSION:
1. Kinking of the existing drain, exchange of the existing 8
French
right-sided biliary drain for a new 8 French biliary drain.
2. Exchange of an 8 French left-sided biliary drain for a 10
French biliary drain due to leaking.
3. Samples from both drains were obtained for
culture/sensitivity/gram stain
CHEST (PORTABLE AP) Study Date of [**2119-6-13**] 10:31 PM
As compared to the previous radiograph, there is evidence of a
right upper quadrant drain. The extent of the right pleural
effusion has
minimally increased, as has the atelectasis at the right lung
bases.
Otherwise, no relevant change is seen. In particular, there is
no evidence for pneumonia. Crowding of the vascular structures
in the perihilar areas is caused by a decrease in lung volumes.
CHEST (PORTABLE AP) Study Date of [**2119-6-14**] 5:06 PM
Heart size and mediastinum are unchanged. Bilateral pleural
effusions are grossly unchanged on the left and may be slightly
decreased on the right due to interval insertion of the pigtail
catheter. The biliary drain is in place. Minimal pulmonary
edema cannot be excluded. No pneumothorax is seen
CHEST (PORTABLE AP) Study Date of [**2119-6-15**] 7:39 AM
As compared to the previous radiograph, there is a minimal
increase
of the right pleural effusion. The right pigtail catheter and
the abdominal drains are in unchanged position. Minimal
atelectasis at the right lung base. No evidence of right
pneumothorax. The appearance of the left lung is not
substantially changed.
CHEST (PORTABLE AP) Study Date of [**2119-6-15**] 10:30 AM
As compared to the previous image, there is a mild increase in
extent of the pre-existing right pleural effusion. The position
of the right pleural pigtail catheter is unchanged. There is no
evidence of a right pneumothorax. Minimal increase in extent of
a left retrocardiac atelectasis. Unchanged size of the cardiac
silhouette.
CHEST (PORTABLE AP) Study Date of [**2119-6-16**] 2:32 AM
As compared to the previous radiograph, there is no relevant
change. Unchanged right-sided pigtail catheter without evidence
of the right pneumothorax. The right effusion has minimally
decreased in extent. Unchanged minimal left pleural effusion.
Unchanged areas of bilateral basal atelectasis. Unchanged
normal size of the cardiac silhouette. No new parenchymal
opacities.
CHEST (PORTABLE AP) Study Date of [**2119-6-17**] 4:31 AM
As compared to the previous radiograph, there is an increase in
extent of a left retrocardiac atelectasis. The extent of the
right
pre-existing pleural effusion is constant. Today's radiograph
shows evidence of minimal blunting of the left costophrenic
sinus, suggesting the presence of a left pleural effusion.
Moreover, there is increasing opacity at the bases of the right
upper lobe, concerning for developing pneumonia. The size of
the cardiac silhouette is constant. There is unchanged position
of the right pigtail catheter.
CHEST (PORTABLE AP) Study Date of [**2119-6-18**] 12:38 PM
As compared to the previous radiograph, the right pigtail
catheter
in the pleural space is in unchanged position. The pleural
effusions
bilaterally are overall unchanged in extent. Also unchanged are
bilateral basal areas of atelectasis. No evidence of right
pneumothorax. Borderline size of the cardiac silhouette. No
evidence of pneumonia.
RENAL U.S. Study Date of [**2119-6-18**] 3:07 PM
The right kidney measures 12.8 cm, and the left kidney
measures 12.5 cm. There is no stone, hydronephrosis or
suspicious renal mass. The bladder is moderately distended and
appears normal. Doppler flow is visualized at the bilateral
ureterovesical junctions.
IMPRESSION: Normal renal son[**Name (NI) **].
CHEST (PORTABLE AP) Study Date of [**2119-6-19**] 10:05 AM
As compared to the previous radiograph, the pleural effusions
bilaterally have not substantially changed. The pigtail
catheter on the right has obviously been pulled back. It is not
sure whether the catheter is still located in the pleural space.
Moderate cardiomegaly, moderate retrocardiac atelectasis
BILIARY CATH CHECK Study Date of [**2119-6-20**] 1:26 PM
1. Pull-back cholangiogram demonstrating patent metallic stent
on the left, however a significant narrowing remains superior to
the stent. Further intervention including ballon dilation and
possible extension of the stent may be performed under
appropriate anesthesia prior to removal of the biliary catheter.
2. Successful exchange of 6 Fr biliary drainage catheter which
was capped. There does remain leakage along the catheter track
and at the time of catheter removal, the track may be embolized.
BILIARY CATH CHECK Study Date of [**2119-6-22**] 4:04 PM PRE-LIMINARY
REPORT
1. Balloon plasty and stenting of left biliary stricture.
Post-stenting
cholangiogram demonstrating free flow of contrast from the
periphery of the left hepatic biliary system into the small
bowel.
2. Removal of biliary catheter with Gelfoam embolization of the
track.
Brief Hospital Course:
60 yo male with HCV and recent imaging studies concerning for
HCC vs CC vs combination, s/p IR guided biliary drainage and PTC
drain placement, presenting with hemoperitoneum and distended
abdomen.
Active Issues:
# Liver mass (HCC vs CC):
IR guided procedure was performed [**2119-6-8**] without issue. 2 8-F
percutaneous transhepatic cholecystostomy drains placed.
Specimens were sent for cytology brushings. He was put on
empiric ampicillin/sulbactam. On [**2119-6-14**], the L PTC was leaking
profusely. He was taken back to the OR for postop cholangiogram
and both drains were found to be in place. He had rigors postop
in the IR sweet, both biliary drains were cultured. The cultures
were subsequently positive for Klebsiella and Enterobacter. He
was placed on meropenem to complete a 14 day course. He
clinically improved following initiation of meropenem. He
required further IR procedures to place stents both in the left
and right biliary systems. His final cholangiogram demonstrated
a patent biliary system. Upon discharge he was w/o abdominal
pain, his abdomen was soft / non distended and he was tolerating
oral nutrition. A follow up appointment was made with heme/onc
for discussion of further treatment.
#Septic shock:
Two days postop on the [**Doctor Last Name 3271**] [**Doctor Last Name 679**] service, the patient was in
mild abdominal pain and found to have features of SIRS (WBC 21,
temp 99.2, HR 110s) and modest rise in LFTs. Meanwhile, his Cr
bumped from 0.8 to 1.1 and he became oliguric. He was given IVF
and abx were broadened to vanc and zosyn from unasyn. He was
found to have worsening abdominal distension and SBO with
hemoperitoneum on imaging. Surgery was consulted and he was
managed non-surgically for SBO with NGT and NPO. Albumin was
given for prerenal [**Last Name (un) **]. After these interventions, his renal
function and abdominal distension improved. However, he
continued to be tachycardic with low grade temps. He was taken
for repeat cholangiogram, drain placement verified and bile
sampled for culture. Postop, he had rigors in the PACU. On the
floor he developed worsening rigors, tachypnea, and tachycardia.
He was then sent to the MICU. Cultures of the bile and pleural
fluid grew Klebsiella and Enterobacter resistant to Unasyn and
Zosyn. 1 blood culture grew GP rods which they were unable to
speciate due to loss of viability. Infectious disease believed
this was a contaminate. Antibiotics were switched to meropenem
from sensitivity data and the pt quickly improved. Sensitivities
to Ertapenem were obtained and showed the bacteria to be
susceptible to this medication. A PICC line was placed and he
was discharged to complete a 14 day course of Ertapenem. Safety
labs were prescribed to the VNA to be drawn on [**2119-6-28**] and the
results will be faxed to the liver center.
#Pleural Effusion:
The pt developed a new oxygen requirement on the floor. Repeat
CXR showed a R sided pleural effusion which was tapped by
interventional pulmonology. This was believed to be a
complication from biliary drain placement. A chest tube was
inserted which drained the effusion. The chest tube was removed
without difficulty and the pt was sat'ing in the mid 90s on RA.
Chronic issues:
#Depression/anxiety:
Per patient and family's request, he prefers not to know his
diagnosis. He takes aripiprazole at home.
MICU COURSE:
Patient was admitted because of hypoxia, rigors, and
tachycardia. The patient was noted to have a new right-sided
pleural effusion after PTC placement in the biliary system.
Patient was continued on Zosyn. He underwent PTC placement in
the right pleural effusion for drainage, approximately 600cc of
serosanguinous fluid was drained. The patient's pleural effusion
was noted to be bilious with growth of Gram negative rods. The
patient acutely developed hypoxia, rigors, and tachycardia
during which blood cultures were drawn. The patient's
antibiotics were broadened to vancomycin and ciprofloxacin. The
patient was followed by hepatology, ID, transplant surgery, and
IR during his ICU course. The patient was deemed not a surgical
candidate at tumor board meeting but the patient was eligible
for CyberKnife therapy via Radiation Oncology. Because of the
patient's bilious effusions and concern for tracking of the
biliary system into the pleural space, the patient was taken
back to the IR [**2119-6-16**]. During the patient's take-back
to the IR, suite, stents were placed in the right hepatic duct
into CBD and left anterior main into CBD. The right drain was
removed, and the left drain was exchanged and kept to hold
access. The right track to pleura was embolized, and a gold
fiducial seed was placed into tumors. The patient was intubated
for procedure and subsequently extubated without a problem.
There were no complications of the procedure. The patient
remained afebrile through his ICU course. Pain was managed with
scheduled APAP 500 mg q6hours and standing oxycodone 5mg
q6hours. The patient's serum creatinine was noted to be elevated
on his last day in the ICU, in part due to pre-renal causes
(poor po intake) and possible contrast-induced nephropathy in
light of multiple IR-take backs. The patient's white count was
acutely elevated and he was re cultured. The patient was
transferred to the floor for continued work-up/management of his
biliary drains, bilious effusion, leukocytosis, [**Last Name (un) **], and known
infections in the bile and pulmonary effusion.
Transitional issues:
#follow up with heme/onc
#follow up with liver center
#follow up with primary care
#Continue ertapenem for total a of 14 days
#Safety labs including cbc, LFTs, bun/cr will be drawn on
[**2119-6-28**] and faxed to liver center for follow up
Medications on Admission:
aripiprazole 5 mg Tablet 1 Tablet(s) by mouth daily
atenolol 25 mg Tablet 1 Tablet(s) by mouth as needed for anxiety
mirtazapine 45 mg Tablet 1 Tablet(s) by mouth daily
* OTCs *
aspirin 81 mg Tablet, Delayed Release (E.C.) 1 Tablet po qday
calcium carbonate [Calcium 500] TID
cholecalciferol (vitamin D3) [Vitamin D3] 800 U qday
multivitamin [Daily Multi-Vitamin] PO qday
Discharge Medications:
1. Aripiprazole 5 mg PO DAILY
2. Atenolol 25 mg PO DAILY:PRN anxiety
3. Mirtazapine 45 mg PO HS
4. Calcium Carbonate 500 mg PO TID
5. Vitamin D 800 UNIT PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. ertapenem *NF* 1 gram Intravenous daily abdominal infection
Duration: 10 Days Reason for Ordering: pt will be discharged
home, and would prefer once per day dosing
8. OxycoDONE (Immediate Release) 5 mg PO Q4H
HOLD for sedation, RR<10
RX *oxycodone 5 mg 1 tablet(s) by mouth q4-6 hours Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**]
Discharge Diagnosis:
Hepatocellular Carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 13004**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital following an
interventional radiology procedure for your liver cancer.
Biliary drains and stents were placed to help relieve
obstructions in your liver from the tumor present. We would like
you to follow up with the hematology/oncology team as well as
the liver team to discuss further treatment options for you in
the future.
The following changes have been made to your medications:
START:
Ertapenem for 9 more days
Oxycodone for pain
STOP:
Aspirin
Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) 4580**] [**Last Name (NamePattern1) **]
When: Tuesday [**2119-6-27**] at 2:00 PM
Location: [**Location (un) **] FAMILY MEDICINE
Address: [**Doctor Last Name 49358**], [**Hospital1 **],[**Numeric Identifier 26407**]
Phone: [**Telephone/Fax (1) 45479**]
Department: LIVER CENTER
When: THURSDAY [**2119-7-6**] at 9:45 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Hematology/ Oncology
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: Dr. [**Last Name (STitle) 49359**] office is working on a follow up appointment
for you in [**8-19**] days after your hospial discharge. You will be
called by the office with the appointment date and time. If you
have not heard from the office in 2 business days please call
the office number listed below.
Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 22249**]
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59,797
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|
Discharge summary
|
report
|
Admission Date: [**2124-8-14**] Discharge Date: [**2124-8-16**]
Date of Birth: [**2078-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Hematemasis
Major Surgical or Invasive Procedure:
EGD s/p banding
Intubation
History of Present Illness:
This is a 46 year old male with a history variceal bleeds who
woke up this morning in a pool of blood and then proceeded to
have hematemasis x2. He reports he drank about 6 beers and a few
mixed drinks for the fourth of [**Month (only) 205**]. Prior to that his last
drink had been a few weeks ago. His last variceal bleed was in
[**1-18**] and his last endoscopy was in [**2124-2-11**]. At that time
he had " Four cords of grade II varices were seen in the upper
third of the esophagus, lower third of the esophagus and middle
third of the esophagus. One band was placed successfully at 3 cm
above GEJ".
.
Prior to last night he did not report any fevers/chills,
N/V/C/D, Ab pain, rashes, jaundice. ROS otherwise negative.
.
His mother found him early this morning in a pool of blood.
After some more hematemasis he was sent to [**First Name4 (NamePattern1) 46**] [**Last Name (NamePattern1) **]. From there
he was sent to [**Hospital1 **] ED.
.
In the ED initial vitals were 98.5 98 111/60 18 96. He was given
protonix 80mg IV at [**Hospital1 46**] and started on PPI gtt and octreotide
gtt. He recieved 1 u PRBC and crossed for two more. His hct was
noted to be 22.3 23 at [**Hospital1 46**] (b/l 27-32). Pt had guaiac pos
exam. He has a 20 and 18 PIV.
.
On the floor, He is currently asymptomatic. No further
hematemasis. He does not complain of any pain.
Past Medical History:
-ETOH hepatitis/cirrhosis, portal hypertension, esophageal
varices. No history of hep ancephalopathy, no Hx of SBP.
-Subacute pancreatitis
-Hypertension
-Appendectomy
-Repeated surgeries for facial trauma
-Unknown surgery on bilateral shoulders
Social History:
Heavy ETOH abuse with binge drinking episodes. Previously
drinking 6 pack per day +/- Whiskey. Now has binge drinking
with his friends. Smokes 1pack per week. No IVDA.
Family History:
CAD, father deceased at 64, grandfather deceased at 61, both
from MI
Physical Exam:
General Appearance: Well nourished, No acute distress, Thin
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : b/l)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed, Bruising
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
Admission Labs:
[**2124-8-14**] 08:00AM BLOOD WBC-3.2* RBC-2.69*# Hgb-7.0*# Hct-22.3*#
MCV-83 MCH-25.8* MCHC-31.2 RDW-19.7* Plt Ct-74*
[**2124-8-14**] 08:00AM BLOOD Neuts-70.1* Lymphs-12.9* Monos-13.3*
Eos-1.9 Baso-1.8
[**2124-8-15**] 04:04AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2124-8-14**] 08:00AM BLOOD PT-19.1* PTT-31.3 INR(PT)-1.7*
[**2124-8-14**] 08:00AM BLOOD Glucose-141* UreaN-13 Creat-0.8 Na-144
K-3.7 Cl-108 HCO3-22 AnGap-18
[**2124-8-14**] 08:00AM BLOOD ALT-17 AST-57* AlkPhos-127 TotBili-2.7*
[**2124-8-14**] 02:44PM BLOOD Calcium-7.3* Phos-4.1 Mg-1.4*
RUQ U/S - IMPRESSION:
1. Cirrhotic liver with patent vasculature demonstrating
appropriate flow.
2. Splenomegaly and trace ascites.
CXR - IMPRESSION: Small right pleural effusion.
EGD:
- 5 bands were successfully placed in the lower third of the
esophagus.
- 1 band was could not be placed in the lower third of the
esophagus.
- Impression: Varices at the lower third of the esophagus and
middle third of the esophagus. Blood in the stomach body. No
gastric verices were seen. There was an episode of hypotension
during the procedure with systolic BP to 70mmHg for less that 3
minutes. This was responsive to fluid bolus. Otherwise normal
EGD to third part of the duodenum.
Brief Hospital Course:
This is a 46-yo man with EtOH abuse, cirrhosis c/b portal
hypertension & esophageal varices, p/w hematemesis and found to
have evidence of esophageal variceal hemorrhage now s/p banding.
.
#. Acute Blood Loss Anemia: The patient was admitted to the ICU.
He was intubated and EGD was performed which demonstrated 4
cords of grade III varices seen in the lower third and middle
third of the esophagus. There were stigmata of recent bleeding.
There was one varicx at 32cm that had a blister consistent with
recent hemorrhage. He recieved one unit of PRBC prior to the ICU
and two in the ICU for tachycardia. He was extubated after his
EGD. He was started on prophylatic ciprofloxacin. He remained on
a protonix and octreotide drip overnight. A social work consult
was initiated. His Hct initially remained somewhat low but then
began to increase appropriately. He received a total of 4 units
of PRBCs while in the ICU. Octreotide was stopped upon transfer
from the ICU to the floor. Sucralfate was initiated and his
Nadolol was restarted. He did not have any further episodes of
GI bleeding. His hematocrit continued to trend upwards and was
30 the morning of his discharge. His vital signs remained stable
and his diet was advanced to regular. He was discharged home
with instructions to complete a 7 day course of his cipro
regimen, and to continue taking his nadolol, PPI, and
sucralfate.
.
.
#. ETOH Abuse: Patient had minimal anxiety his last night in the
MICU and was well controlled with IV valium. A CIWA protocol was
in place and he had no further triggers for the rest of his
stay. He admits that he has a problem and seems to have insight
into this problem. At his request, social work provided him with
information on addiction counseling services. He received
thiamine, folate, and MVI while in house and was discharged home
with scripts for all three.
.
.
#. Cirrhosis: This patient has known cirrhosis and portal
hypertension. Based on labs, there was no evidence of acute
decompensation from his liver. His Leukopenia and
thrombocytopenia consistent with cirrhosis. Liver US confirmed
cirrhosis. He did not have encephalopathy nor did he develop
ascites. He is to follow up with Dr. [**Last Name (STitle) 497**] on [**9-5**].
Medications on Admission:
- lactulose 30ml PO BID-TID
- nadolol 20mg PO daily
- omeprazole 40mg PO BID
- sucralfate 10mg PO BID
- folic acid PO daily
- multivitamin PO daily
- thiamine PO daily
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
Disp:*QS * Refills:*0*
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Sucralfate 100 mg/mL Suspension Sig: Ten (10) mL PO four
times a day.
Disp:*QS * Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Upper GI variceal bleed.
.
Secondary Diagnosis:
- cirrhosis c/b portal hypertension, esophageal varices, and
variceal bleeding
- hypertension
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**] for further evaluation of vomiting
bright red blood and were found to have an upper
gastrointestinal bleed related to your previously known
esophageal varices. While you were here you had an endoscopy
that identified the source of the bleeding in your esophagus and
had a banding procedure to stop it. You should stop drinking
alcohol altogether to help prevent this from happening again in
the future. While you were here, you met with social work who
provided you with several phone numbers to call for alcohol
rehabilitation.
.
We changed your medications in the following ways:
-You should take ciprofloxacin twice a day for 4 more days.
-You should increase your home sucralfate to 1 gram four times
daily.
Followup Instructions:
You should follow-up at all of the medical appointments listed
below:
.
1. Provider: [**Name Initial (NameIs) 703**] (H3) GENERAL 2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2124-9-5**] 8:00
.
2. Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2124-9-5**] 10:00
.
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2124-9-5**] 10:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"285.1",
"998.11",
"571.2",
"288.50",
"E937.8",
"287.4",
"303.01",
"456.20",
"577.0",
"572.3",
"458.29",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
7748, 7754
|
4366, 6609
|
326, 354
|
7959, 7959
|
2999, 2999
|
8890, 9490
|
2217, 2288
|
6827, 7725
|
7775, 7775
|
6635, 6804
|
8110, 8867
|
2303, 2980
|
275, 288
|
382, 1744
|
7842, 7938
|
3015, 4343
|
7794, 7821
|
7974, 8086
|
1766, 2013
|
2029, 2201
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,761
| 162,328
|
10095
|
Discharge summary
|
report
|
Admission Date: [**2152-7-12**] Discharge Date: [**2152-7-18**]
Date of Birth: [**2081-2-11**] Sex: M
Service: NEUROSURGERY
Allergies:
Lipitor
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
consulted for bilateral SDH, xfer from Dr.[**Initials (NamePattern4) 6767**] [**Last Name (NamePattern4) **]
clinic
Major Surgical or Invasive Procedure:
Bilateral frontal crani for SDH evacuation
History of Present Illness:
71y M with afib on warfarin, now 2mos s/p resection of grade I
left sphenoid-[**Doctor First Name 362**] meningioma (by Dr. [**Last Name (STitle) **] on [**2152-4-13**],
followed
by Dr. [**Last Name (STitle) 724**] in [**Hospital **] clinic since that time) who p/w 1-1.5wk
of lethargy (per wife) and progressive [**Name (NI) 14245**] pain and weakness
(arm and leg, now cannot walk; "drags foot"). MRI showed
evolving/heterogeneous large Left-sided SDH as well as smaller
anterior right SDH. He was sent to our ED for Neurosurgical
evaluation.
Past Medical History:
Atrial Fibrillation(on coumadin)
Osteoarthritis
s/p hemithyroidectomy for multinodular thyroid
Dyslipidemia
Hypertension
s/p hernia repair
s/p APPY
Social History:
Patient lives with Wife and has 7 grown kids. He denies ETOH,
tobacco, or h/o IVDU. He worked for the power company for 40
years.
Family History:
Non contributory
Physical Exam:
PHYSICAL EXAM:
T 97.9 HR 80 BP 113/78 RR 16 SaO2 97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to
2mm 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
EXCEPT
for R>L brow elevation.
VIII: Hearing intact to voice and equal to finger rub bilat.
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. Mild Right pronator
drift. No abnormal movements or tremors. Strength full power [**3-29**]
throughout EXCEPT for Right deltoid (4+/5), Right IP (4+/5).
Sensation: Intact to light touch, propioception, and pinprick
bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes mute on Right and mute to down-going on left.
Coordination: substantial dysmetria on finger-nose-finger
testing
on the Right and on rapid alternating
hand movements on the Right. Left [**Last Name (LF) 11140**], [**First Name3 (LF) **], and HKS relatively
normal.
Exam on discharge:
A&OX3
PERRL
EOMs intact
Face symmetrical
tongue midline
Motor: [**3-29**] throughout
No pronator drift
sensation intact
Incision: c/d/i with dissolvable sutures
Pertinent Results:
ADMISSION LABS:
[**2152-7-12**] 03:00PM PT-19.0* PTT-25.8 INR(PT)-1.7*
[**2152-7-12**] 03:00PM WBC-9.3# RBC-4.13* HGB-13.5* HCT-39.1* MCV-95
MCH-32.7* MCHC-34.6 RDW-13.5
[**2152-7-12**] 03:00PM UREA N-19 CREAT-0.9 SODIUM-142 POTASSIUM-3.8
CHLORIDE-108 TOTAL CO2-27 ANION GAP-11
[**2152-7-12**] 04:20PM PT-19.6* PTT-23.3 INR(PT)-1.8*
DISCHARGE LABS:
IMAGING:
MRI Head [**7-12**]:
IMPRESSION:
1. Interval development of large, left greater than right,
subdural
hematomas. This was discussed with [**First Name8 (NamePattern2) 6744**] [**Last Name (NamePattern1) **], neurology
nurse
practitioner, at 4:45 p.m. on [**2152-7-12**]. She was already aware
of the results
and the patient was in the emergency room being treated.
2. Status post resection of left sphenoid [**Doctor First Name 362**] meningioma with
no definite
residual or recurrent tumor although this region is largely
obscured by
hematoma.
CT Head [**7-12**]"
No change since prior MRI.
Interval development of large left greater than right subdural
hematoma
compared to prior CT of [**4-13**].
CT Head [**7-13**]:
1. Post prior partial evacuation of bifrontal SDH with residual
blood
products.
2. Small amount of new SAH along the right frontal convexity,
likely
postoperative.
Brief Hospital Course:
[**Date range (1) 31970**] The patient was admitted from the Emergency department
for reversal of INR to less than 1.5 and Q1 neurochecks. In the
evening, he was taken to the OR for bilateral craniotomies for
evacuation of subdural hematomas. Postoperatively, he returned
to the ICU for continued neuro checks, tight BP control to less
than 140 and anti-seizure prophylaxis. A post op head CT
demonstrated good evacuation of the subdural collections. The
patient's neurologic status remained stable post-operatively.
Two subdural drains were placed at 10 cm below the EAM and
drained continuously for three days.
The patient's subsequent hospital course showed improved speech.
On [**2152-7-14**], subdural drains were removed without complication on
this day. Pt did get OOB to chair with the help of nursing staff
with plan to see physical therapy on the morning of [**7-17**] who
recommended one more visit and then patient can be discharged
home with a home safety evaluation.
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth qam
COLESEVELAM [WELCHOL] - 625 mg Tablet - 3 Tablet(s) by mouth
twice a day
DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day
EZETIMIBE [ZETIA] - 10 mg Tablet - 1 Tablet(s) by mouth once a
day
LEVETIRACETAM [KEPPRA] - 500 mg Tablet - 2 Tablet(s) by mouth
twice a day
METOPROLOL SUCCINATE - 200 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
MODAFINIL [PROVIGIL] - 100 mg Tablet - 1 Tablet(s) by mouth
twice
a day
NIACIN [NIASPAN] - 500 mg Tablet Sustained Release - 1
Tablets(s)
by mouth twice a day
WARFARIN - 5 mg Tablet - 2 Tablet(s) by mouth once a day
Medications - OTC
FISH OIL-DHA-EPA - 1,200 mg-144 mg Capsule - 2 Capsule(s) by
mouth once a day
FOLIC ACID - (Prescribed by Other Provider; OTC) - 0.8 mg
Tablet
- Tablet(s) by mouth daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Modafinil 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
DAILY (Daily).
8. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Bilateral subdural hematomas.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 shower 1 week after your procedure
?????? 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 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 after follow up with Dr. [**First Name (STitle) **].
?????? 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.
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 call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast at follow
up.
-Please return to the neurosurgery office for removal of staples
on [**2152-7-23**]. An appointment can be made by calling [**Telephone/Fax (1) 1669**]
-You have absorbable sutures that do not require suture removal.
Completed by:[**2152-7-18**]
|
[
"427.31",
"V58.61",
"348.4",
"715.90",
"272.0",
"V45.89",
"432.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
6998, 7047
|
4469, 5456
|
389, 433
|
7121, 7121
|
3190, 3190
|
12120, 12613
|
1344, 1362
|
6333, 6975
|
7068, 7100
|
5482, 6310
|
7272, 10262
|
3550, 4446
|
1393, 1611
|
10289, 12097
|
233, 351
|
461, 1008
|
1863, 2989
|
3008, 3171
|
3207, 3533
|
7136, 7248
|
1030, 1180
|
1196, 1328
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,109
| 105,742
|
46176
|
Discharge summary
|
report
|
Admission Date: [**2132-11-21**] Discharge Date: [**2132-11-28**]
Date of Birth: [**2064-4-19**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
unresponsive at skilled nursing facility
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 year old male with history of MS, neurogenic bladder with
suprapubic catheter and multiple drug resistant UTIs, with
recent admission for MRSA PNA, who presented with hypoxia and
unresponsiveness at nursing home requiring ICU admission for
sepsis, now transferred to medical floor. He was recently
admitted from [**10-28**] - [**2132-11-6**] with the same presentation, at
which time he was found to have a LLL infiltrate with sputum
culture growing MRSA. He was treated briefly with positive
pressure ventilation with improvement, and discharged back to
the nursing home with a PICC, to complete a 14 day course of
vancomycin and levofloxacin which would have finished on [**11-20**].
However, the patient was readmitted from [**11-15**] - [**2132-11-17**] when
his PICC line came out. He had the PICC line replaced by IR on
[**11-17**], and was discharged with orders to continue vancomycin
with end date as previously scheduled, as well as a 7 day course
of ciprofloxacin 500 mg [**Hospital1 **] for reasons that are unclear. Of
note, during this admission his creatinine was noted to be
elevated; urine lytes were not consistent with a pre-renal
etiology, it did not improve with hydration, and a renal
ultrasound was unrevealing. They did not investigate this
further, and discharged him with creatinine 1.5.
.
Per report, the patient was doing alright at the nursing home
until this morning when he was found to have an O2 sat of 86% on
RA, and unresponsive.
.
On arrival to the ED, T 101.8, HR 70s, BP 110/80 but with
occasional drops to the 80s systolic, 96-97% on NRB. He received
2 liters of IVF with eventual urine output, although initally
was anuric. Labs were notable for acute renal failure with
creatinine 2.5, up from 1.5 last week. He was given a dose of
linezolid and zosyn. DNR/DNI status was confirmed.
Past Medical History:
# Recent MRSA pneumonia ([**10/2132**])
# Progressive, relapsing, multiple sclerosis for the last 30
years. The patient is treated with monthly steroids, Solu-Medrol
and Avonex.
# Prostate cancer status post brachytherapy.
# Depression with multiple admissions in the past and history of
overdose of isopropyl alcohol.
# Neurogenic bladder with recurrent urinary tract infections.
The patient has a suprapubic foley.
# History of right elbow bursitis with MRSA.
# Hypertension.
# Chronic lower back pain with cervical and lumbar spinal
stenosis.
# Osteoarthritis.
# Impotence with penile prosthesis.
# Chronic polyps.
# History of peptic ulcer disease with upper GI bleed in the
setting of chronic NSAIDs use.
# History of alcohol abuse with history of generalized tonic
clonic seizures in the setting of alcohol (see neuro note
written in [**2130-3-6**]).
# Pemphigus
Social History:
Lives in [**Location **]. Denies alcohol or tobacco. [**Location **] involved in his
care.
Family History:
Non-contributory.
Physical Exam:
PHYSICAL EXAMINATION: 96.9, 80, 132/86, 20, 99% on 2l NC
GENERAL: Obese caucasian male, responds to questions
intermittently
HEENT: Dry mucous membranes.
NECK: Unable to locate JVP.
COR: nl rate, S1S2, no gmr
LUNGS: coarse BS anteriorly
ABDOMEN: obese abdomen, firm, +BS, unable to assess HSM.
PELVIS: Suprapubic catheter in place with surrounding bandage.
EXTR: 1+ non-pitting edema.
Pertinent Results:
PORTABLE AP: Heterogeneous opacification at the left lung base
is largely atelectasis, explaining the elevation of the left
hemidiaphragm. Right lung is low in volume but grossly clear.
Heart is not enlarged. Right PIC catheter tip projects over the
junction of the brachiocephalic veins. No pneumothorax.
.
CT HEAD: Bifrontal periventricular white matter hypodensities
unchanged from before. No hemorrhage.
.
MRI BRAIN WITH AND WITHOUT CONTRAST: A moderate to large amount
of foci of T2/FLAIR hyperintensity involving the deep central,
pericallosal, and periventricular white matter compatible with
multiple sclerosis plaques are essentially stable when compared
to [**2129-9-15**]. Prominence of the sulci and ventricles
compatible cortical atrophy is also unchanged. Post- gadolinium
administration, no areas of abnormal enhancement are identified
to suggest acute demyelination. Within the left frontal region,
a linear area of contrast enhancement is more compatible with a
developmental venous anomaly, rather than an enhancement of a
demyelinating plaque.
Within the region of the medullary pyramids, there is increased
T2-weighted signal, which is not well visualized on the previous
MRI. There is no abnormal enhancement or diffusion-weighted
imaging abnormality in this region. There is no evidence of
abnormal mass, shift of normally midline structures, or edema.
IMPRESSION: Aside from regions within the medullary pyramids of
T2/FLAIR hyperintensity, areas of demyelination compatible with
multiple sclerosis are unchanged dating back to [**2129-9-15**]. Thus, this medullary lesion could represent interval
development of an additional area of demyelination. No areas of
abnormal enhancement identified to indicate acute demyelination.
Brief Hospital Course:
68 year old male with MS, neurogenic bladder with suprapubic
catheter and multiple drug resistant UTIs, with recent admission
for MRSA PNA, who presented unresponsive possibly secondary to
infection.
.
# mental status change: had been alert enough to elope from
nursing home during the week prior to this hospitalization but
transferred here because minimally responsive. Head MRI showed
new focus of demyelination in the medulla, other areas of
demyelination essentially unchanged from [**2129**]; it is not clear
if this new medullary demyelination is contributing to current
symtpoms. Likely multifactorial, from hypercarbia, methadone use
in setting of decreasing renal function, and infection in
addition to MS. Improved with BiPAP in ICU, consistent with
combination of hypoxia and hypercarbia. Appreciate sleep
consult; will continue BiPAP 12/8 with back up rate 8 and 2L O2
flow by. Has recovered/woken up to what seems to be baseline
mental status, will continue to monitor. Avoiding all narcotis
and benzodiazepines.
.
# Recurrent PNA: recently treated with full course of vancomycin
for MRSA pneumonia with improvement of infiltrate on CXR.
However, febrile on admission and sputum did grow Proteus and
MRSA, so continuing with ceftriaxone and vancomycin through
[**2132-12-3**] as recommended by ID consult.
.
# Acute renal failure: Improving gradually from Cr 2.5 on
admission to 1.6, with good diuresis after lasix, probably also
autodiuresis.
.
# MS: Continue baclofen and gabapentin. PT/OT for LE
contractures
.
# Neurogenic bladder/autonomic instability?: Autonomic
instability causing labile blood pressures. Continue oxybutinin.
.
# Depression: Continue celexa and duloxetine.
.
# Microcytic Anemia: Cont iron. He does have a history of
esophagitis on EGD in [**2131**]. We have scheduled repeat EGD as
outpatient.
.
# HTN: BP trending up after sepsis resolved. Have added back
metoprolol, titrate up to 50mg tid and resumed home amlodipine
5mg daily.
.
# Decubitus ulcers: Wound care for pressure ulcers
.
# PPX: Continue PPI, SQ heparin, bowel regimen.
.
# Code: DNR/DNI, confirmed with HCP who is his [**Name (NI) **]. OK with
pressors, mask ventilation if necessary.
.
# Contact: [**Name (NI) **], HCP, [**Name (NI) 14573**] [**Name (NI) **].
Medications on Admission:
1. Baclofen 20 mg PO QID
2. Citalopram 40 mg PO DAILY
3. Gabapentin 200 mg PO TID
4. Pantoprazole 40 mg PO Q24H
5. Diazepam 5 mg PO HS
6. Vancomycin One (1) gram Intravenous Q18H
7. Duloxetine 40 mg PO HS
8. Heparin 5000 units Injection TID
9. Metoprolol Tartrate 50 mg PO TID
10. Ipratropium Bromide NEB Q6H for 3 days
11. Simethicone 80 mg PO QID PRN
12. Ferrous Sulfate 325 (65) mg PO DAILY
13. Albuterol Sulfate NEB Q6H for 3 days
14. Bisacodyl 10 mg PR DAILY
15. Trazodone 100 mg PO HS PRN
16. Senna 2 tabs PO BID
17. Oxybutinin SA 10 mg daily
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
6. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
13. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: through [**12-1**].
14. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
15. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
18. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q24H (every 24 hours) for 5 days: through
[**12-3**].
19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 5 days: through
[**12-3**].
20. BiPAP
BiPAP 12/8 with back up rate 8 and 2L O2 flow by
21. PICC line
PICC line care per protocol
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
primary: recurrent MRSA and Proteus pneumonia
secondary: multiple sclerosis
Discharge Condition:
Stable. Wheelchair dependent. Discharge to acute level rehab
Discharge Instructions:
Take all medicines as prescribed.
.
Call your doctor for any medical concerns.
Followup Instructions:
Call your primary care doctor for an appointment in two weeks.
.
You should have a repeat endoscopy since you have a history of
esophagitis and anemia. We have scheduled this for you:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2133-1-15**] 10:00
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2133-1-15**] 10:00
|
[
"482.83",
"038.11",
"995.92",
"V09.0",
"584.9",
"518.81",
"482.41",
"707.07",
"340"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10162, 10241
|
5407, 7676
|
310, 316
|
10361, 10424
|
3631, 3939
|
10551, 10977
|
3191, 3210
|
8276, 10139
|
10262, 10340
|
7702, 8253
|
10448, 10528
|
3225, 3225
|
3247, 3612
|
230, 272
|
344, 2173
|
3948, 5384
|
2195, 3066
|
3082, 3175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,330
| 177,542
|
1790+55326
|
Discharge summary
|
report+addendum
|
Admission Date: [**2105-8-4**] Discharge Date: [**2105-8-12**]
Date of Birth: [**2048-10-2**] Sex: M
Service: MEDICINE
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Dyspnea, hypoxia and pleuritic chest pain
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
This is a 56 y/o male with coronary artery disease s/p LAD stent
placement, IDDM, and tracheomalacia s/p tracheal stent, who
presented to the ED after 5 days of progressive shortness of
breath and cough. His symptoms first developed 5 days ago as
progressive SOB (can walk 2 flights of stairs at baseline, then
down to 1/2 flight), cough productive of yellow and pink tinged
sputum, and pleuritic right-sided chest pain, rated [**2108-7-9**]. The
pain was present all of the time and worse with coughing or
movement. He also began using home O2 that he does not normally
require. In addition he complained of increasing bilateral lower
extremity edema and increasing abdominal girth. He called his
primary care physician and was told to take extra lasix
(apparently up to 240mg daily per patient report) without
success. He then presented to an episodic visit yesterday where
a chest xray showed a new right upper lobe pneumonia. He was
hypoxic (87% on RA) in clinic and he was referred to the ED for
further evaluation. He denies any recent sick contacts,
antibiotic exposure, or travel. He has had no chest pain,
fever, chills, night sweats, abdominal pain, diarrhea, bright
red blood per rectum, melena, or rash. He denies orthopnea or
paroxysmal nocturnal dyspnea.
Of note, patient was pushed down a flight of stairs in spring
[**2104**], and he sustained multiple rib fractures and continues to
experience low back pain. In the ED, his BLE edema was evaluated
with LENIs which showed no evidence of DVT. Initial O2 Sat in
the ED was 90% on 4L NC.He was also given levofloxacin for
pneumonia prior to being admitted to the floor. On exam he was
resting and talking comfortably in bed with mild wheezing and
productive cough. Cough and small movements elicited extreme
pain.
The pt was scheduled to get a CTA on his first night. He was
sitting watching television and had sudden onset worsening of
his right pleuritic chest pain. He got up to try to walk it off
but as he walked he developed a tightening/pressure sensation in
his mid-abdomen which then moved up towards his chest and
ultimately developed acute "throat-closing" sensation. He called
the nurse and was found to be 83% 6L NC. He was acutely short of
breath and had difficulty speaking. He was most comfortable in a
standing position. Initial SBP 170s. He was given 2 mg IV
Morphine, 2 SL NTG, 125 solumedrol, combivent neb, 20 mg Lasix
and was started on heparin IV with initial bolus, empirically.
Pt was transferred to the MICU for respiratory distress and
hypoxia. He responded to 97% on 5L at transfer to the MICU.
When transferring from the stretcher to the bed, the patient
again had an acute shortness of breath with pressure in his
chest and a throat-closing sensation. He responded to standing
and slow deep breathing after approximately 1 minute. The pt was
started on Heparin drip empirically for presumed PE and
vancoymcin was added to antibiotic regimen. CTA the next day did
not show evidence of PE, hypoxia was resolved, and patient was
transferred back to medicine floor.
Past Medical History:
1. IDDM - complicated by gastroparesis and peripheral
neuropathy. On insulin pump.
2. Hypothyroidism
3. Hyperlipidemia
4. CAD - s/p LAD stent in [**2097**]
5. Bipolar disorder
6. ADD
7. OSA - on BIPAP at home but has not been using it.
8. Tracheobronchomalacia s/p tracheal bronchoplasty [**2104-6-5**]
9. Right pleural effusion s/p pleurodesis(FEVI 1.95, FVC
2.13)[**2104-7-4**]
10. Osteoarthritis
11. GERD
12. Lactose intolerance
13. Constipation
14. H/O fundic gland polyp with focal low grade dysplasia [**11-3**]
Social History:
Married with 4 children (2 daughters and 2 adopted sons). [**Name2 (NI) 1403**]
as a teacher for 6th-8th grade special education children.
Denies any tobacco, EtOH, or drug use
Family History:
Mother with CAD and DM. Father with HTN. Brother healthy. [**Name2 (NI) **]
history of UC/Crohn's.
Physical Exam:
INITIAL MEDICINE ADMISSION EXAM:
GENERAL: Resting comfortably in bed, with obvious pain when
coughing, and no acute distress. Pleasant and cooperative during
exam.
VITALS: T98.1 BP118/58-68 HR66 RR18 O2Sat96% on 3.5L Pain [**6-9**]
at rest and [**8-10**] with movement.
HEENT: NC/AT. PERRL. EOMI. Sclera anicteric. Conjunctiva pink.
MMM. No oropharyngeal exudate or erythema.
CV: Regular rate and rhythm. Normal S1/S2. No murmurs, rubs,
gallops appreciated. No JVD or pulsatile liver appreciated.
LUNGS: >20cm arc-shaped scar from posterior to anterior on R
side at site of prior pleuridisis. Lungs largely clear to
auscultation with vesicular breath sounds. E/A changes noted
over posterior and anterior R upper lung fields. No wheezes,
rales, rhonchi appreciated.
ABD: Normoactive bowel sounds. Tense abdomen, dull to precussion
and difficult to palpate. Hepatosplenomegaly not appreciated. No
fluid wave.
EXT: 2+ pitting edema to the high right shin. Trace pitting
edema on left to mid-calf. DP pulses 1+.
SKIN: Warm and dry. No ecchymoses, rashes, or petechiae.
NEURO: Appropriate in conversation. Ambulates easily without
assistance. UE and LE strength 5/5. Sensation to light touch
midly decreased in feet, right>left. Proprioception grossly
intact bilateral LE and UE. Cranial Nerves II-XII grossly
intact.
MICU ADMISSION EXAM:
PE: 98.6, 140/62, 72, 19, 97% 5L
Gen: Sitting in chair, speaking in full sentences, no distress,
pleasant
HEENT: MMM, O/P clear, EOMI
Neck: no JVD
CV: RRR, no M/R/G appreciated
Lungs: R mid field, anterior and basilar crackles, clear left,
no wheezes, no crackles
Abd:distended, tense, nontender, +BS
Ext: 1+ LE pitting edema to the high shins bilaterally-symmetric
Neuro: Appropriate in conversation, moves all extremities, CN
II-XII intact
Pertinent Results:
LABS:
.
CBC: [**2105-8-4**] 05:10PM WBC-6.0 RBC-3.76* HGB-11.2* HCT-32.6*
MCV-87 MCH-29.7 MCHC-34.2 RDW-15.9* [**2105-8-4**] 05:10PM PLT
COUNT-176
[**2105-8-4**] 05:10PM NEUTS-75.5* LYMPHS-13.7* MONOS-7.5 EOS-2.8
BASOS-0.5
.
ELECTROLYTES:
[**2105-8-4**] 05:10PM GLUCOSE-126* UREA N-17 CREAT-1.2 SODIUM-139
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-30 ANION GAP-13
.
OTHER:
[**2105-8-4**] 05:10PM LACTATE-0.7
.
STUDIES:
MICROBIOLOGY:
BLOOD CULTURE [**2105-8-4**]: No growth.
BLOOD CULTURE [**2105-8-4**]: No growth.
.
URINE CULTURE [**2105-8-5**]: NEGATIVE FOR LEGIONELLA SEROGROUP 1
ANTIGEN.
.
EXPECTORATED SPUTUM [**2105-8-6**]:
GRAM STAIN
[**9-24**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2105-8-8**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
ACID FAST SMEAR (Final [**2105-8-7**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
.
BRONCHOALVEOLAR LAVAGE [**2105-8-7**]:
GRAM STAIN (Final [**2105-8-7**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2105-8-9**]):
>100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
ACID FAST SMEAR (Final [**2105-8-10**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
.
ECHO [**2105-8-6**]: The left atrium is mildly dilated. The right
atrium is moderately dilated. A left-to-right shunt across the
interatrial septum is seen at rest through an ostium secundum
atrial septal defect. No right-to-left shunt is seen. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Secundum-type ASD with left-to-right shunting.
Normal global and regional biventricular systolic function.
Mild pulmonary hypertension.
.
CTA CHEST [**2104-8-6**]:
1. No pulmonary embolism or aortic dissection.
2. Enlarged mediastinal lymph nodes along with ill-defined
patchy opacities in the right upper lobe, likely represent
pneumonic consolidation and reactive mediastinal lymph nodes.
This may be followed up with chest radiographs or a CT as per
clinical need to assess resolution.
3. Tracheobronchomalacia with soft tissue in the upper trachea,
likely representing tracheal secretions.
.
BRONCHOSCOPY WITH BRONCHOALVEOLAR LAVAGE [**2105-8-7**]
1.BRONCHIAL WASHINGS CYTOLOGY: Atypical. Rare groups of atypical
cells, probably reactive. Numerous pulmonary macrophages and
inflammatory cells.
2.TBNA: NON-DIAGNOSTIC, insufficient cellular material.
Scattered bronchial cells and macrophages. No lymphoid cells of
lymph node sampling seen.
.
MRI/MRA ABDOMEN and PELVIS [**2105-8-12**]:
No evidence of inferior vena cava or of pelvic venous
thrombosis. No pelvic mass identified.
Brief Hospital Course:
This is a 56 y/o male with coronary artery disease s/p LAD stent
placement, IDDM, and tracheomalacia s/p tracheal stent, found to
have community acquired pneumonia. Brief hospital course
presented below by problem.
1.Community-acquired Pneumonia: Chest XRay obtained on day of
admission showed right upper lobe infiltrate. Pt started on
levofloxacin and continued while in hospital with good response.
Pt started vancomycin while in MICU, but this was d/c'd three
days later. Blood cultures x2 were negative. Induced sputum
cultures and BAL cultures grew oropharyngeal flora. Patient
afebrile throughout hospital course. Patient maintained on
supplemental O2 for several days and albuterol nebulizers prn.
Due to mediastinal adenopathy and calcified granuloma seen on
CTA, and RUL infiltrate, suspicion was raised for TB despite low
risk factors. Pt was on respiratory precautions for several days
until TB ruled out with induced-sputum and BAL AFB smears.
Patient was discharged on levofloxacin to complete 14-day
course.
.
2.Hypoxia/Respiratory distress: Pt noted to be hypoxic (87% on
RA) in outpatient clinic on day of admission. O2 Sat improved
with supplemental O2 on medicine floor to 100% on 3L NC. Pt
became markedly hypoxic with respiratory distress while lying
down on his first night in hospital and did not respond to
atavan, nebs, or O2 via non-rebreather mask. Pt was transferred
to MICU but O2 Sats improved markedly without intubation.
Positional hypoxia may have been related to anatomic
problem(blood vs. secretions in trachea) and/or anxiety. CTA was
obtained and was negative for PE. Cardiac enzymes were negative
for MI. Pt had no further hypoxic episodes following transfer
back to medicine floor. He was weaned from O2 several days prior
to discharge and ambulatory O2 sats were 95%. Follow-up
appointment was scheduled with pulmonology.
.
3. Abdominal distention and LE swelling: Pt had had increasing
concern over abdominal and bilateral lower extremity swelling
for the past year. Pt has history of diabetic gastroparesis and
chronic constipation, as well as an admission for abdominal pain
and bowel ischemia in 12/[**2103**]. Abdominal ultrasound showed no
ascites. Hypoalbuminemia, nephrotic syndrome, DVT, and severe
right-sided heart failure were ruled out during admission.
Abdominal distention and tenderness resolved somewhat with bowel
movements. LE edema improved dramatically with compression
stockings. MRI/MRA of pelvis and abdomen showed no mass lesions
and no evidence of IVC thrombus. Echocardiogram showed new
atrial septal defect with mild pulmonary HTN. LE edema
attributed to mild right-sided heart failure in setting of mild
pulmonary HTN and venous insufficiency. Abdominal distention
likely due to constipation and recent weight gain. Follow-up
appointment was scheduled with cardiology and PCP.
.
4. CAD: We continued outpatient medical management with
metoprolol and statin.
.
5. HTN: Pt had one hypertensive episode in setting of
respiratory distress. He was maintained on outpatient
metoprolol.
.
6. IDDM: Pt maintained on insulin pump and was seen multiple
times by [**Last Name (un) **] consult service. Patient's blood glucose was not
well-controlled despite adjustments made by [**Last Name (un) **]. Patient will
follow-up with PCP regarding tighter glucose control. Neurontin
for neuropathy and reglan for gastroparesis were continued.
.
7. Acute Renal Failure: Patient's Cr slightly elevated on
admission, with bump to 1.3 following CTA. ARF resolved over
several days. Pt did receive mucomist and NAHCO3 before CTA, but
ARF was likely due to contrast-induced nephropathy. Creatinine
was stable at discharge.
.
8. Hypothyroidism: Levothyroxine was continued.
.
9. Bipolar disorder/ADD: Abilify, adderal, lamotrigine, amd
fluoxetine were continued.
10. Pulmonary nodule noted on CT chest - defer to PCP for
followup. CT chest as below scheduled (non-contrast) in a few
weeks.
Medications on Admission:
- Abilify 15mg''
- Adderal XR 20mg'
- Atorvastatin 80mg'
- Levothyroxine 225mcg'
- Doxazosin 8mg'
- Lamotrigine 100mg''
- Gabapentin 800mg'''
- Nortriptyline 100mg'
- Fluoxetine 40mg'
- Modafinil 100mg'
- Lanzoprazole 30mg''
- Metoprolol 37.5mg''
-Amitiza 1 capsule''
- Finasteride 5mg'
- Reglan 10mg''''
Salsalate 1000mg''
- Trazodone 50-150mg prn
- Furosemide 80mg'
- oxygen 2liters as needed
- Novalog insulin pump (0.9u/h basal rate w/ 20:1 carb counting)
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Last Name (un) **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Levofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
3. Finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
5. Aripiprazole 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
6. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release 24
hr [**Hospital1 **]: One (1) Capsule, Sust. Release 24 hr PO daily ().
7. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Levothyroxine 75 mcg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
9. Doxazosin 4 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
10. Lamotrigine 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
11. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2
times a day).
12. Gabapentin 400 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3
times a day).
13. Nortriptyline 25 mg Capsule [**Hospital1 **]: Four (4) Capsule PO HS (at
bedtime).
14. Fluoxetine 20 mg Capsule [**Hospital1 **]: Two (2) Capsule PO DAILY
(Daily).
15. Lanzoprazole [**Hospital1 **]: One (1) 30 mg tab once a day.
16. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
17. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: One (1) Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
18. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
19. trazodone
20. Modafinil
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Community Acquired Pneumonia
Secondary: Atrial septal defect, Tracheomalacia, reactive airway
disease, diabetes mellitus, Hypothyroidism
Discharge Condition:
Improved respiratory function, normal sat on room air ambulating
Discharge Instructions:
You were admitted with shortness of breath and cough which was
found to be due to a pneumonia. You improved with antibiotics
and nebulizer treatments. You were sent to the intensive care
unit after having an acute episode of shortness of breath. You
were evaluated with a CT scan of your chest that showed you did
not have a any blood clots in your lungs. Additionally you had a
bronchoscopy of your lungs that did not show signs of infection,
including tuberculosis.
You were also put on isolation precautions for several days
before we confirmed that you did not have a tuberculosis
infection. Also you had an echocardiogram that showed you have a
tiny hole between the top [**Doctor Last Name 1754**] of your heart. For this you
should also be followed by your cardiologist. We also did an
abdominal ultrasound and abdominal MRI to evaluate your
increasing abdominal girth and confirmed that there was no free
fluid, masses or clots in your arteries. For your lower
extremity swelling, we got ultrasounds of your legs which showed
no blood clots. Your lower extremity swelling also improved with
using the compression stockings.
Your pneumonia contined to improve through your hospital stay on
antibiotics and you should continue the antibiotics for a total
of 14 days (six more days). Please follow up with a repeat chest
xray within the next 3-4 weeks as directed below. Also, follow
up with all your scheduled physician [**Name Initial (PRE) 4314**].
You should go to the ER or call your doctor if you have any
fever, chills, worsening chest pain, shortness of breath,
passing out or any other concerning symptoms.
Please take all your medications as prescribed and keep all
follow up appointments
Followup Instructions:
1.You should follow up with your primary care physician [**Name Initial (PRE) **] [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], on Wednesday, [**9-2**] at 11:10am.
[**Telephone/Fax (1) 250**].
2.You should follow up with Dr. [**Last Name (STitle) **] in Interventional
Pulmonology at at appointment on Monday, [**10-5**]. At 11:30
you will have a Chest CT scan on the [**Hospital Ward Name 517**], CC3, and then
see Dr. [**Last Name (STitle) **] at 12:00 at his office. ([**Telephone/Fax (1) 10084**].
3.Please follow up with Dr. [**Last Name (STitle) 120**], your cardiologist, at an
appointment on [**Last Name (LF) 2974**], [**8-28**] at 9:30am. ([**Telephone/Fax (1) 10085**]
4.Please follow up with Dr. [**Last Name (STitle) 6821**] [**Month (only) **] in Dermatology on
[**9-1**] at 11:15am. 67-[**Telephone/Fax (1) **]
.
5.Psychiatry Appointment: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7676**]
Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2105-8-21**] 11:40
.
6.STRESS/EXERCISE LAB Phone:[**Telephone/Fax (1) 1566**] Date/Time:[**2105-10-26**] 7:30
.
7.Rheumatology Appointment: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2105-11-2**] 4:00
.
8.Please obtain a Chest Xray within the next 3-4 weeks. You can
go to [**Hospital Ward Name 23**] 4 on the [**Hospital Ward Name 516**] or Clinical Center 3 on the
[**Hospital Ward Name 516**] anytime, M-F between 8am and 4:30pm. The results
will be sent to Dr. [**Last Name (STitle) **].
Name: [**Known lastname 1453**],[**Known firstname 441**] K Unit No: [**Numeric Identifier 1454**]
Admission Date: [**2105-8-4**] Discharge Date: [**2105-8-12**]
Date of Birth: [**2048-10-2**] Sex: M
Service: MEDICINE
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 1455**]
Addendum:
Called patient on [**2105-8-31**] to confirm he was continuing to take
trazodone and modafinil at home, since these were not included
in the discharge med list (now updated). Patient confirms he was
taking these meds. He also reported increasing cough/dyspnea. He
was advised to go to ER or call his PCP if this worsens. He has
a follow up appointment with PCP [**Last Name (NamePattern4) **] 2 days. Pt conprehends above
information.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**]
Completed by:[**2105-8-31**]
|
[
"272.4",
"530.81",
"296.7",
"428.0",
"584.9",
"327.23",
"486",
"357.2",
"V45.82",
"799.02",
"416.8",
"585.9",
"519.19",
"745.5",
"250.63",
"414.01",
"244.9",
"493.90",
"536.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
20398, 20543
|
9574, 13515
|
312, 327
|
16112, 16179
|
6091, 9551
|
17935, 20375
|
4175, 4276
|
14027, 15892
|
15942, 16091
|
13541, 14004
|
16203, 17912
|
4291, 6072
|
231, 274
|
355, 3422
|
3444, 3964
|
3980, 4159
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,230
| 104,170
|
45662+58845
|
Discharge summary
|
report+addendum
|
Admission Date: [**2164-7-13**] Discharge Date: [**2164-7-21**]
Date of Birth: [**2088-8-19**] Sex: F
Service: UROLOGY
Allergies:
Aspirin / Bactrim / Tenormin / A.C.E Inhibitors / Serevent
Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
Renal Tumor
Major Surgical or Invasive Procedure:
Left Open Nephrectomy
Exploration of retroperitoneum for surgical bleeding
History of Present Illness:
75yF with left kidney mass. Her Ultrasound indicated a moderate
sized left kidney mass amenable to possible nephrectomy.
Past Medical History:
PMH:
1. Congenital nystagmus
2. Asthma (albuterol inhaler PRN)
3. Nasal polyps with chronic rhonitis
4. Hypertension
5. Chronic Anxiety
6. Osteoporosis
7. GERD
PSH:
1. S/p 4 C sections
2. Sinus surgery
Social History:
Born and raised in [**State 350**]. She was a house wife and is
now a retired child care worker. She has 3 daughters, one of
whom is mentally retarded, and lost a daughter to an illness.
She is a widow who lives alone but has family in [**State 2690**].
Family History:
CAD father, mother with depression died at age 37 with CVA.
Maternal cousin with leukemia, brother with bladder CA
Physical Exam:
No acute distress. Alert and oriented x 3. Regular rate and
rhythm no murmurs rubs or gallops. Clear to auscultation no
wheezes rales or rhonchi. Soft Nontender, nondistended, bs+
normoactive. No clubbing, cyanosis, edema. Pulses 2+ equal
bilaterally.
Pertinent Results:
Path report DIAGNOSIS:
1. Kidney, left total nephrectomy (A-J):
A. Renal cell carcinoma, clear cell type with focal rhabdoid
morphology. See synoptic report.
B. Non-neoplastic renal parenchyma with no diagnostic
abnormalities recognized.
C. Adrenal gland with nodular hyperplasia.
2. Rib, left 11th, excision (T):
Benign bone. See note.
[**7-13**] cxr
1. Left pneumothorax.
2. Right subclavian central venous line with tip in the expected
region of the right atrium. For optimal positioning the tip may
be withdrawn approximately 3 cm.
3. Endotracheal tube is well positioned.
4. Nasogastric tube should be advanced approximately 5 cm for
optimal positioning.
[**7-19**] cxr
The left chest tube was removed. The left subcutaneous emphysema
is slightly decreased in size but still present. No evidence of
pneumothorax is demonstrated. Bibasal atelectases are again
noted as well as a right pleural effusion. The left central
venous line tip terminates at the junction of brachiocephalic
vein and SVC. No evidence of congestive heart failure is
present.
Brief Hospital Course:
The patient tolerated the initial surgery (EBL 150cc) and was
taken to the PACU. In the PACU, she became unresponsive and
hypotensive. She was subsequently intubated without sedation and
a code blue was called; a femoral a line and right subclavian
triple lumen were placed (after failed attempt at left
subclavian and right IJ complicated by arterial puncture). Per
nursing there was a brief episode of ? PEA/Asystole, but once
the MICU code team responded they noted a DP/femoral pulses. She
was responsive and following commands (squeezed hand to
command). There was attempted resuscitation in the PACU for one
hour after which the patient was taken to the OR for exploration
as her blood pressure remained labile despite tansfusion of 4
units. Of note, the patient was able to move all limbs during
this time and the patient seemed to respond to her family prior
to returning to the OR.
In the OR, the patient was found to be bleeding from the the
renal left renal artery into her RP. Her retroperitoneum was
evacuated and the bleeding site was oversewn. Assistance was
provided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] of Transplant Surgery. The patient had
strong pulses and stable vitals throughout the procedure. She
was given 2gm cefazolin periop.
In sum, the estimated blood loss was -2.5 L. She received 2.7L
of PBRC (~ 18 U), many of which were not cross-matched ([**9-26**])-pt
has autoantibodies: anti-[**Doctor Last Name **], anti-JKa. She also received 8 [**Location 97341**] and 3L of LR.
Postoperatively she was transferred to the MICU for further
management including central monitoring, delayed extubation, and
transient requirement for neosynephrine. In the [**Hospital Unit Name 153**] the patient
was noted to have a left pneumothorax and required Gen [**Doctor First Name **] to
place a chest tube on POD #0. During the several days in the
ICU, pt required fluid management with hydration and lasix,
respiratory support with intubation until POD2 and O2
supplementation until leaving the ICU.
Once transfered to Urology, the patient required a PT consult
[**2-17**] difficulty ambulating and a nutrition consult [**2-17**] decreased
po intake.
Upon discharge, pt afebrile with vital signs stable. Pt going
to rehab center for PT. Pt tolerating po feeds and requires
supplements that she normally takes as an outpatient. Pt pain
controlled with po pain meds.
Medications on Admission:
Meds on admit:
10mg po oxazepam qd prn
flovent 110 2 puffs [**Hospital1 **]
FLUTICASONE PROPIONATE 50MCG 2 SPRAYS EACH NOSTRIL DAILY
hctz 12.5mg po qd
pantoprazole 40mg po qd
ventolin 90mcg q4 prn
verapamil SR 240mg qd
Discharge Medications:
1. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every
4-6 hours as needed for pain for 2 weeks.
Disp:*40 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
2 weeks: Take with Tylenol #3 hold for loose stool.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Renal CA
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or come to the ER if you notice blood
from the wound, fever greater than 101.5, severe pain not
controlled by medication, inability to void, or any other
concerns. Okay to shower. Please resume taking your home meds.
Followup Instructions:
Please call Dr. [**First Name (STitle) **]??????s office to schedule a follow up
appointment. The phone number is [**Telephone/Fax (1) **].
Name: [**Known lastname 12486**],[**Known firstname 511**] Unit No: [**Numeric Identifier 15530**]
Admission Date: [**2164-7-13**] Discharge Date: [**2164-7-21**]
Date of Birth: [**2088-8-19**] Sex: F
Service: UROLOGY
Allergies:
Aspirin / Bactrim / Tenormin / A.C.E Inhibitors / Serevent
Attending:[**First Name3 (LF) 15531**]
Addendum:
Please see updated discharge medication list.
Discharge Medications:
1. Tylenol-Codeine #3 300-30 mg Tablet Sig: 1-2 Tablets PO every
4-6 hours as needed for pain for 2 weeks.
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
2 weeks: Take with Tylenol #3 hold for loose stool.
3. Albuterol 0.083% neb soln 1 NEB IH every 4 hours
4. Albuterol 0.083% neb soln 1 NEB IH every 6 hours as needed
for SOB, wheeze
5. Fluticasone propionate NASAL 2 sprays NU twice a day
6. Ipratropium Bromide Neb 1 NEB IH four times a day
7. Oxazepam 10mg PO every night as needed for insomnia,
agitation
8. Pantoprazole 40mg PO every day
9. Qvar 80mcg/actuation inhalation twice a day
10. Fluticasone propionate 110mcg 2 PUFF IH twice a day
11. Verapamil SR 120mg PO twice a day, hold for SBP<90
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11903**] MD [**MD Number(2) 15532**]
Completed by:[**2164-7-21**]
|
[
"285.29",
"276.8",
"998.11",
"189.0",
"300.00",
"493.90",
"401.9",
"518.5",
"512.1",
"458.29",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05",
"96.04",
"38.86",
"07.22",
"34.04",
"38.93",
"55.51",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7354, 7585
|
2564, 4992
|
330, 406
|
5698, 5707
|
1478, 2541
|
6000, 6585
|
1071, 1187
|
6608, 7331
|
5666, 5677
|
5018, 5238
|
5731, 5976
|
1202, 1459
|
279, 292
|
434, 557
|
579, 784
|
800, 1055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,154
| 172,430
|
2225+55362
|
Discharge summary
|
report+addendum
|
Admission Date: [**2154-12-13**] Discharge Date: [**2155-2-17**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3075**] is an 85 year-old
male with a history of gastrointestinal bleeds, known AVMs,
and a complicated pulmonary history, which dates back to [**Month (only) 205**]
when he developed a right upper lobe pneumonia and treated
with Levofloxacin, complicated by right exudative
peripneumonic effusion, which was treated with Levofloxacin
and Flagyl. In [**Month (only) 216**] a bronchoscopy revealed an apical
right endobronchial lesion with biopsy and BAL negative for
malignancy. In [**Month (only) **] he developed alpha streptococcus
pneumonia complicated by empyema and underwent decortication.
He was initially treated with Ceftriaxone and Flagyl and
then was changed to Penicillin G times two weeks and
discharged to rehab. A follow up bronchoscopy on [**12-12**]
was unremarkable and showed no endobronchial lesion. A few
hours after the procedure the patient had desaturation to 75%
on room air and was febrile to 101.
The patient's gastrointestinal history includes prior
gastrointestinal bleed times two presumed secondary to
gastric AVMs seen on esophagogastroduodenoscopy in [**2154-11-30**]. He has had two colonoscopies one in [**2153-6-30**]
revealing an adenomatous polyp and one in [**2154-7-31**],
which was normal. In the Emergency Room his chief complaint
was decreased energy. He also reported cough and dyspnea.
He was found to be afebrile with stable blood pressure,
however, his saturation was 68% on room air and came up to
97% on 6 liters. He had course sounds bilaterally. His
arterial blood gases in the Emergency Room was 7.42/42/70/28
on 5 liters nasal cannula. Chest x-ray revealed increased
air space opacities in the right, mid and lower lung zones
consistent with pneumonia, as well as a stable right pleural
thickening/effusion. A chest CT showed multiple prominent
mediastinal lymph nodes, loculated pleural fluid on the right
decreased in size from the previous study, new air space
consolidation in the right upper middle and lower lobes and
the left lower lobe. He was started on Levofloxacin, Flagyl
and Vancomycin. In the Emergency Department it was also
discovered that his hematocrit was 14. He had a benign
abdominal examination, dark brown guaiac positive stool.
Nasogastric lavage revealed one small clot, positive bile, no
blood or coffee grounds. An abdominal CT showed infrarenal
aortic aneurysm measuring up to 6.9 by 6.2 cm increased from
6.2 by 5.3 cm on a study in [**2152-12-30**], no
retroperitoneal hemorrhage, extensive sigmoid diverticulosis.
He was subsequently admitted to the MICU where he received a
total of 6 units of packed red blood cells and underwent
endoscopy, which revealed gastric AVMs none of which were
actively bleeding and some of which were cauterized. In the
unit he was also continued on triple antibiotics. At the
time of call out to the floor he was without coplaints,
denied shortness of breath, chest pain or abdominal pain.
PAST MEDICAL HISTORY: 1. Recurrent pneumonias as detailed
above. 2. Empyema status post decortication as above. 3.
Congestive heart failure, diastolic function, normal systolic
function on [**2153-6-30**] echocardiogram. 4. Hypertension. 5.
Chronic renal insufficiency, baseline creatinine 2.3 to 3.
6. Abdominal aortic aneurysm. 7. History of
gastrointestinal bleeds secondary to gastric AVMs. 8. Iron
deficiency anemia, baseline hematocrit 25 to 30. 9. Peptic
ulcer disease. 10. Negative colonoscopy in [**2154-7-31**]. 11.
Chololithiasis. 12. Nephrolithiasis. 13. Left carotid
endarterectomy. 14. 90% right internal carotid artery
stenosis. 15. History of sundowning. 16. Osteoarthritis.
17. Macular degeneration.
MEDICATIONS ON ADMISSION FROM REHAB: Lasix 20 mg po once a
day, Norvasc 10 mg po once a day, Lopresor 50 mg po twice a
day, aspirin 325 mg po once a day, Epogen 3000 units subQ q
week, Niferex 50 mg po twice a day, Pericolace one capsule po
twice a day, Lactulose 30 cc q.h.s.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with wife and daughter.
Smoking history of three cigars per day. Quit three months
ago. Remote cigarette smoking history. Quit in [**2112**].
Drinks two beers and two glasses of brandy per night.
Retired mechanic.
PHYSICAL EXAMINATION: Temperature 97.6. Heart rate 87.
Blood pressure 166/80. Respiratory rate 32. 96% on 3.5
liters. In general sleeping, easily arousable, breathing
rapidly, but not appearing to be in acute distress. HEENT
pupils are equal, round and reactive to light. Oropharynx
clear. Neck no LAD. JVP 9 to 10 cm. Lungs bilateral
crackles and wheezing almost all the way up, question coarse
breath sounds, possible transmission of upper respiratory
sounds. Cardiac regular rate and rhythm. No murmurs, rubs
or gallops. Abdomen soft, nondistended, nontender. No
organomegaly or masses. Normoactive bowel sounds.
Extremities warm 2+ pitting edema to just above ankles
bilaterally. Skin positive spider angiomata. Neurological
grossly nonfocal.
LABORATORY: White blood cell count 13.6, hematocrit 14.6,
platelets 354, INR 1.1, sodium 139, potassium 3.8, BUN 44,
creatinine 2.1, glucose 130. CK 35, troponin less then .3.
Micro studies, blood cultures times two negative. BAL gram
stain 1+ gram positive coxae in pairs and chains. BAL
culture consistent with respiratory flora. AFB stain
negative. BAL, fungal and AFB cultures negative. Radiology
studies as above in history of present illness.
HOSPITAL COURSE: The patient is an 85 year-old male with a
complicated pulmonary history status post resent bronchoscopy
presenting with hypoxia, patient with history of
gastrointestinal bleeding secondary to gastric AVMs
presenting with hematocrit of 14.6.
1. Pulmonary and infectious disease: The patient was
started on Levofloxacin, vancomycin and Flagyl for presumed
post bronchoscopy pneumonia. His antibiotic coverage was
narrowed to Levofloxacin and Flagyl after his micro studies
returned. On admission to the floor the patient appeared
clinically to be in failure with elevated JVP, crackles and
wheezing on examination and bilateral pitting edema. He was
status post transfusion of 6 units of packed red blood cells,
therefore he was diuresed with intravenous Lasix with
subsequent improvement in his O2 saturation.
2. Gastrointestinal: Patient with a hematocrit of 14.6 on
admission, which came up to 34.8 after transfusion of 6
units. The patient underwent esophagogastroduodenoscopy,
which showed gastric AVMs, which were not bleeding. Some of
them were cauterized. The patient was continued on Protonix.
He was followed by the GI team who recommended that should he
have a recurrence of bleeding in the future, estrogen should
be considered.
3. Cardiovascular: Patient with a history of hypertension
and abdominal aortic aneurysm. He was continued on his
outpatient cardiac medications including Lopressor and
Norvasc. He received Lasix diuresis as detailed above. His
aspirin was held secondary to gastrointestinal bleeding.
DISCHARGE CONDITION: Discharged to home in stable condition.
DISCHARGE DIAGNOSES:
1. Post bronchoscopy pneumonia.
2. Gastrointestinal bleeding secondary to gastric AVMs.
3. Congestive heart failure.
DISCHARGE MEDICATIONS: Levofloxacin 250 mg po once a day
times fourteen day course, Flagyl 500 mg po q 8 hours times
fourteen days, Protonix 40 mg po once a day, Lasix 20 mg po
twice a day, Norvasc 10 mg po once a day, Lopressor 50 mg po
twice a day. Epogen 3000 units subQ q week, Niferex 50 mg po
twice a day. Pericolace one cap po twice a day. Lactulose
30 cc po q.h.s.
DISCHARGE TREATMENTS: VNA for blood draws, hematocrit,
potassium and creatinine, monitoring of O2 sats, home health
aid, weekly weight for congestive heart failure, home
physical therapy evaluation.
FOLLOW UP: Follow up with Dr. [**Last Name (STitle) 11825**] and Dr. [**Last Name (STitle) 2146**].
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Name8 (MD) 4925**]
MEDQUIST36
D: [**2155-2-17**] 18:15
T: [**2155-2-19**] 12:54
JOB#: [**Job Number 11826**]
Name: [**Known lastname **], [**Known firstname **] J. Unit No: [**Numeric Identifier 1673**]
Admission Date: [**2154-12-13**] Discharge Date:
Date of Birth: [**2069-6-14**] Sex: M
Service:
ADDENDUM: The remainder of the [**Hospital 1325**] hospital stay was
uneventful. The patient's delirium continued to improve. He
was able to have ambulate with the Physical Therapy Service.
After a discussion with the family, it was decided that an
acute rehabilitation stay would be the best option for this
patient. The patient was subsequently discharged to
rehabilitation.
[**Name6 (MD) 116**] [**Name8 (MD) 117**], M.D. [**MD Number(1) 118**]
Dictated By:[**Last Name (NamePattern1) 1674**]
MEDQUIST36
D: [**2155-2-26**] 13:15
T: [**2155-2-26**] 13:51
JOB#: [**Job Number 1675**]
|
[
"593.9",
"441.4",
"369.4",
"481",
"537.83",
"428.0",
"782.1",
"280.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
7189, 7230
|
7251, 7372
|
7396, 7951
|
5625, 7167
|
7963, 9142
|
4408, 5607
|
122, 3070
|
3093, 4132
|
4149, 4385
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,137
| 161,152
|
46393
|
Discharge summary
|
report
|
Admission Date: [**2183-5-2**] Discharge Date: [**2183-5-3**]
Date of Birth: [**2129-9-1**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 53 year old man with HTLV-1 induced paraplegia and
depression/suicide attempts and decubitus ulcers who presents
with temperature to 101.2 degrees at nursing home, as well as
loose stools and abdominal destension with no stool in the
rectal vault. He had recently been diagnosed with bibaslilar
pneumonia on [**2183-4-28**] and E coli UTI. He got tylenol for this and
was sent to the ED at [**Hospital1 882**]. A CT scan showed colitis. He was
transferred to the [**Hospital1 18**] when the ED went off diversion.
.
In the ED he was afebrile with initially hypertensive blood
pressures that fell to the 80's systolic without intervention.
He got 5 liters of normal saline. Two peripheral IV's were
placed and he was considered for a central line but was
hemodynamically stable after this. Blood cultures were drawn and
he was given vancomycin, ceftriaxone, and flagyl. He was
clinically felt to have an infection and possible bowel
obstruction. Surgery was consulted and recommended CT scan,
which showed no colitis. The recommendation was to send stool
for C dif. In addition, plastic surgery was consulted for
decubitus ulcers and felt there was no clear evidence of
cellulitis, and recommended changing dressings twice daily.
.
He says he felt warm at [**Hospital 883**] hospital but not at the [**Hospital1 **]. He
has no complaints of abdominal pain, diarrhea, SOB, chest pain,
nausea, vomiting, chills. He wants to return to the home and
doesn't understand medically why he needs to stay here.
Past Medical History:
PMHx:
1) HTLV-1-induced paraplegia, neuro deficits began about 10yrs
ago
2) Decubitus ulcers
3) HCV
4) COPD
5) Depression
- admit [**3-24**] after being found with a telephone cord around his
neck
- OD ?medication error, requiring Narcan in [**2181**].
- suicide attempt with barbituates 25 yrs ago requiring
hospitalization.
6) h/o recurrent UTIs, most recent organism cultured P.
mirabilis.
Social History:
Lives in [**Location **]. Has been disabled from HTLV-1 for about 10 yrs.
Smoked 2ppd for 30 yrs, 1/2-1ppd more recently, rare etoh, h/o
heroin and cocaine abuse.
Family History:
Father died of MI at 45, mother of breast cancer at 65. Brother
committed suicide [**3-24**]
Physical Exam:
T98.3 BP 131/70 P82 R19 94% RA
Gen: no apparent distress, conversational
HEENT: PERRLA, MM dry
Resp: rhonchi at bases bilaterally
CV: RRR nlo s1s2 no MGR
Abd: soft, NT +resonant +slight distension +BS
Ext: no cyanosis, clubbing, edema
Neuro: A+Ox3. moves upper extremities well. LE hyperreflexic
bilaterally
Back: patient refused examination of his decubitus ulcers,
saying it hurts too much to turn over
Pertinent Results:
CXR: Left lower lobe collapse and less severe atelectasis in the
right lower lobe are new. Peribronchial opacification in the
suprahilar right lung could be pneumonia. Vascular deficiency
in the upper lungs, exacerbated on the left by lower lobe
collapse, indicates emphysema. Heart is normal size. There is
no significant pleural effusion or other evidence of cardiac
decompensation. Intestines and the upper abdomen are moderately
to severely distended with gas.
.
Abd CT [**2183-5-2**]
IMPRESSION:
1. No dilatation or wall thickening of colon to suggest the
presence of colitis.
2. Cholelithiasis with a possible pericholecystic fluid. An
ultrasound could be performed for further evaluation if there is
clinical concern for cholecystitis.
3. Opacity at both lung bases representing consolidation versus
less likely atelectasis.
4. Sub-5-mm non-calcified pulmonary nodules at the right lung
base. Given the presence of calcified granulomas in the right
lung base, a followup chest CT could be performed in one year if
clinically warranted.
5. Unchanged decubital ulcer extending to the posterior aspect
of the sacrum compared to [**2182-2-27**].
6. Single prominent loop of small bowel in the central abdomen
with no evidence of obstruction or bowel wall thickening.
.
RUQ ultrasound:
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in
echotexture without focal hepatic mass. Some mild prominence of
the right intrahepatic biliary duct without overt distention.
The main portal vein is patent with appropriate hepatopetal
flow. The common bile duct measures up to 6 mm. The
gallbladder is moderately distended. Some tenderness is present
about the gallbladder, more so than in adjacent areas. There is
layering sludge within the neck of the gallbladder and multiple
large shadowing stones. There is diffuse bladder wall
thickening with intraluminal edema in some areas with a
maximal wall thickness of up to 8 mm in the fundus. There is
urrounding pericholecystic fluid. No perihepatic ascites is
identified. Limited views of the right kidney demonstrate no
hydronephrosis or calculi.
.
IMPRESSION: High suspicion for cholecystitis. (*Note - surgery
diagrees with this interpretation on clinical grounds and
reviewed scan)
.
[**2183-5-3**] 04:45AM BLOOD WBC-5.4 RBC-4.07* Hgb-10.8* Hct-32.7*
MCV-80* MCH-26.6* MCHC-33.1 RDW-16.3* Plt Ct-189
[**2183-5-2**] 07:20AM BLOOD WBC-6.7 RBC-4.41* Hgb-11.4* Hct-35.0*
MCV-79* MCH-25.8* MCHC-32.4 RDW-16.3* Plt Ct-247
[**2183-5-3**] 04:45AM BLOOD Neuts-74.5* Lymphs-16.9* Monos-5.6
Eos-2.7 Baso-0.2
[**2183-5-2**] 07:20AM BLOOD Neuts-70.6* Lymphs-21.0 Monos-6.5 Eos-1.4
Baso-0.6
[**2183-5-3**] 04:45AM BLOOD Plt Ct-189
[**2183-5-3**] 04:45AM BLOOD ESR-30*
[**2183-5-3**] 04:45AM BLOOD Glucose-68* UreaN-10 Creat-0.5 Na-140
K-3.6 Cl-110* HCO3-24 AnGap-10
[**2183-5-2**] 07:20AM BLOOD ALT-11 AST-17 AlkPhos-142* Amylase-81
TotBili-0.3
[**2183-5-3**] 04:45AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9
[**2183-5-2**] 07:20AM BLOOD GGT-38
[**2183-5-2**] 07:20AM BLOOD Lipase-20
[**2183-5-2**] 07:20AM BLOOD Iron-32*
[**2183-5-2**] 07:20AM BLOOD TotProt-7.3 Albumin-3.6 Globuln-3.7
Calcium-8.9 Phos-3.5 Mg-2.1
[**2183-5-2**] 07:20AM BLOOD calTIBC-192* Ferritn-268 TRF-148*
[**2183-5-2**] 07:20AM BLOOD CRP-21.3*
[**2183-5-2**] 07:33AM BLOOD Lactate-1.0
MICRO: from nursing home: sensitive to ceftriaxone, cefuroxime,
imipenem, resistant to amp, augmentin, levo, tetracycline, sulfa
Brief Hospital Course:
53 year old man presented with fever, hypotension, and abdominal
distension. The patient was admitted to the MICU after being
briefly hypotensive in the ED.
.
#) fever, hypotension - Patient hemodynamically stable upon
admission to MICU. Although it was concerning for sepsis, his
pressure normalized with IVF, so patient is not in septic shock.
It was thought that he may have a component of autonomic
dysfunction as well given his paraplegia. Cultures were sent,
and were still pending at the time of discharge. The patient
had a slightly positive UA, and had recently been on Cefpodoxime
for UTI treatment. Given this recent abx use, C-diff may also
be a possibility, although patient is afebrile without a
leukocytosis. His abdominal exam is completely benign, and
imaging thought to not be consistent with active infection. The
patient was initially continued on Vanc, Levo, and Flagyl, but
after being afebrile and hemodynamically stable x 24 hours, the
antibiotics were weaned to only coverage for the UTI. He was
started back opn Cefpodoxime to complete a fourteen day course
which he should continue upon discharge.
.
#) Abdominal distension - He was evaluated by surgery who felt
the patient does not have an acute abdomen and does not have
acute cholecystitis, rather he has a collapsed, calcified,
uninflamed gallbladdes. Alk Phos slightly elevated but could be
from bone destruction given GGT normal. ESR and CRP mildly
elevated, not suggestive of osteomyelitis or other significant
inflammation/infection. The patient tolerated clears well and
was quickly advanced to a normal diet. It was felt that he may
have c-Diff given his recent antibiotics, and a stool sample was
sent.
.
#) sacral decubitus ulcers - He was evaluated by the plastic
surgery service who recommended wet to dry dressings. An ESR
and CRP were mildly elevated, and the wounds were monitored and
dressed according to recommendations. Given that the ulcers did
not probe to bone and appeared relatively clean with healthy
granulation tissue, the Vancomycin was discontinued.
.
#) Psychiatric history - The patient has a history of depression
and suicide attempts, and was continued on his home psych meds,
with no acute issues during this hospitalization.
.
Medications on Admission:
cefpodoxime 200 mg po bid x 14 days start [**2183-4-28**]
Mirtazapine 45 mg PO HS Order date: [**5-2**] @ 2050
Multivitamins 1 CAP PO DAILY Order date: [**5-2**] @ 2050
Albuterol-Ipratropium 2 PUFF IH Q6H
Oxycodone 5 mg PO Q8H:PRN
Baclofen 20 mg PO QID
Oxybutynin 5 mg PO TID
Docusate Sodium 100 mg PO TID
Pantoprazole 40 mg PO Q24H
Ferrous Sulfate 325 mg PO TID
Senna 1 TAB PO BID:PRN
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Folic Acid 1 mg PO DAILY
Vitamin E 400 UNIT PO DAILY
Lactulose 30 ml PO TID
Vitamin B Complex w/C 1 TAB PO DAILY
Methylphenidate HCl 5 mg PO BID
Zinc Sulfate 220 mg PO DAILY
Methadone HCl 40 mg PO TID
traZODONE HCl 50 mg PO HS:PRN
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
13. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
16. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO TID (3 times a day).
17. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
19. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
20. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Discharge Disposition:
Extended Care
Facility:
RosCommon on the Parkway
Discharge Diagnosis:
UTI
Discharge Condition:
good
Discharge Instructions:
Please continue to take the antibiotics as instructed for a
total of fourteen days.
.
Please follow-up with your PCP as needed, and maintain the
appointments listed below
Followup Instructions:
You have this scheduled appointment:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2183-7-16**] 11:30
Completed by:[**2183-5-3**]
|
[
"344.1",
"599.0",
"707.03",
"311",
"070.70",
"996.64",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11106, 11157
|
6453, 8711
|
292, 298
|
11205, 11212
|
2988, 6430
|
11431, 11637
|
2452, 2547
|
9440, 11083
|
11178, 11184
|
8737, 9417
|
11236, 11408
|
2562, 2969
|
233, 254
|
326, 1839
|
1861, 2255
|
2271, 2436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,513
| 173,094
|
25325
|
Discharge summary
|
report
|
Admission Date: [**2148-10-13**] Discharge Date: [**2148-10-23**]
Date of Birth: [**2110-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Implantable Cardioverter Defibrillator (ICD) placed.
History of Present Illness:
38 M with 2V CABG [**5-30**], BiV pacer, dilated CM, CHF EF 20-25%
[**8-1**], p/w CP and NSVT, now with stable VS, CP-free.
Pt reports that fifteen minutes after participating in sexual
activity at ~3am, patient acquired a chest pain that ran across
both sides of his chest, with a predomination toward the right
side, with subsequent radiation down his right arm. The pain was
constant and was not resolving, which prompted a call to EMS.
Patient is unsure if the pain resolved, and even how, admits to
continued pain to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] degree. Associated with the pain was a
period of diaphoresis. Patient states that he has had "6 heart
attacks" in the past and each had a different type of pain, and
this pain is not exactly like the others. He does admit to a
chronic, left-sided pain that is there "all-the-time" without
resolution that is worse when he breathes.
Other ROS is essentially negative, except for shortness of
breath, which he states is chronic for him and his CHF. He also
admits to an insiduous, intermittent visual clouding that began
six months ago. He is passing his urine and bowels well, denying
dysuria, hematuria, hematochezia. States he is mostly compliant
with his medications but admits to missing a few doses as he
dislikes medications.
In the ED,EKG NSR, no PVCs. Short runs of VT but hemo stable and
no syncope per EMS, no EKGs, no strips, but VT stopped on lido
gtt from OSH. Transferred from [**Hospital3 417**] Hospital, where he
had just been admitted for CHF exac. In ED, on heparin gtt, lido
gtt from OSH continued here, nitro gtt, plavix, was given ASA at
OSH. Pt did not take am meds this am, but has been compliant. Pt
was told about "ripped mitral valve" and ?MVR per pt told to him
by Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**] (outpt attg). He was
told he would have mitral valve surgery after dentition surgery
later this month, but hasn't been scheduled yet. Goes to [**Hospital 6451**], [**Hospital3 5097**], [**Hospital1 18**].
.
Last hospitalization [**2148-8-11**] - worsening shortness of breath x
1-2 days, CP x 2 days, cough and LE edema x 1 day. The patient
originally presented to [**Hospital3 417**] Hospital, where EKG
showed frequent PVCs and telemetry showed runs of VT < 10 beats,
given lidocaine. Admitted at [**Hospital1 **] for admitted for moderately
decompensated CHF and rest angina. On telemetry throughout his
stay he was noted to have numerous PVCs and a number of episodes
of non-sustained ventricular tachycardia (5-10 beats). Had I&D
of superficial abscess on right lower abdomen, +MRSA, completed
14 days of Bactrim. DC plan for medical management, started on
digoxin.
.
Last CATH [**2147-9-14**] - 3VD, occluded SVG-RPDA, patent LIMA-LAD.
Last ECHO [**2148-8-12**]: Apical LV aneurysm, 1+MR, 1+TR. No EP report
on when BiV pacer was placed.
Past Medical History:
2V CABG (question of CABG x2): SVG-RPDA occluded [**8-31**], LIMA-LAD
patent
CHF EF 20-25% in [**8-1**]
Dilated cardiomyopathy
HTN
Hyperlipidemia
BiV pacemaker - unsure of installation
Social History:
He is divorced and has one daughter. [**Name (NI) **] spent two months in
prison secondary to domestic abuse charges. He quit smoking
after his CABG. He does not use alcohol or illicit drugs. He
does not work and is on disability. His mother is very ill and
has hospice services. She is his main source of support.
Family History:
CAD - mother
Physical Exam:
T: 96-7 BP:117/77 HR: 85 RR: 20 96 O2 % RA
Gen: Pt in NAD, A/Ox3, cooperative, watching television. Mild
effort to breath as he returned from BR, resolved somewhat after
return.
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
Dentition poor, no upper teeth, [**6-1**] incisors inferiorly with
poor quality.
NECK: Supple, No LAD, (+)JVD on right to about 5cm, none
appreciated on lef. No thyromegaly.
CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. Distant.
LUNGS: CTAB, poor air movement. No overt W/R/C
ABD: NABS. Soft, NT, ND.
EXT: 2+ DP/PT pulses BL, edema [**1-29**] bil, pitting.
SKIN: numerous psoriatic-like scaly patches on upper anterior
torso and bilaterally on lower extremities around knees and
shins. Healing I&D wound on right lower quadrant, mild erythema.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact, did not do
fundoscopy. Preserved sensation throughout. 5/5 strength
throughout. [**1-29**]+ reflexes, equal BL. Normal coordination. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
CXR [**2148-10-13**]:
1. Cardiomegaly. Status post sternotomy. Pacemaker present.
2. Prominent hila, which raises the question of pulmonary
hypertension. The lungs are hyperinflated, which may indicate
COPD.
3. Mild upper zone redistribution and increased perihilar
interstitial markings. This could represent early CHF.
4. Small (approximately 12 mm) opacities in the right suprahilar
region. These may be related to the acute process about the hila
and are in areas where bones, vessels, and oxygen tubing are
overlapping. However, repeat PA and lateral views when the
patient is stable is recommended to further assess this area.
.
ECHO [**2148-8-12**]: LVEF 20-25%, LV apical aneurysm, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1914**]
4.5x7.0 cm, no E/A ratio noted, E/E' 21 (<15) suggesting PCWP >
18, PASP 36
1+ MR, 1+ TR
.
CATH [**2147-9-14**]:
Coronary artery disease, s/p 2V CABG with rest angina.
FINAL DIAGNOSIS:
1. Severe three vessel coronary artery disease.
2. Occluded SVG --> PDA.
3. Patent LIMA --> LAD.
4. Left ventricular diastolic dysfunction.
LMCA - patent
LAD - occ mid (after takeoff of D1 and septal 1)
LCX - large OM1 which fills collaterals to RCA, mid-AV groove
occ
RCA - dominant vessel, occ mid
RPDA - fed by R->L collaterals
Large acute marginal branch - patent
Brief Hospital Course:
# Chest pain - Patient had risk factors for active acute
coronary syndrome, but he had no EKG changes and his cardiac
enzymes were negative. He had a p-MIBI to further evaluate his
myocardial perfusion which showed significant, fixed, diffuse
perfusion defects but no reversible changes and no new changes
from prior. He was therefore, not a candidate for further
investigation by catheterization. He was continued on aspirin
and plavix. His metoprolol and lisinopril were increased over
the course of his hospitalization. He complained of a vague
chest discomfort throughout the course of his hospitalization
which was worked up with EKGs without acute changes. However,
he had no further chest pain episodes similar to the complaints
he had on initial persentation. The patient's lisinopril was
discontinued for a period of several days after a creatinine
elevation. Hydralazine 10mg Q6h was used during this time to
improve forward flow. Prior to discharge (after improvement in
Cr toward baseline) the patient was switched back onto
lisinopril and hydralazine was discontinued. The patient was
without chest pain for 48 hours prior to discharge.
.
# Ventricular arrhythmia - Patient had a history of 23 seconds
of Ventricular tachycardia associated with syncope in [**2146**]. He
also had NSVT by report on transfer to [**Hospital1 18**] and continued to
have occasional episodes of asymptomatic NSVT on telemetry
during his hospitalization. The patient has decreased systolic
dysfunction, CAD, and a history of VTach so he was seen as an
excellent candidate for ICD placement. Patient had refused ICD
placement in the past but was amenable to placement this
admission. However, given his extremely poor dentition, he
required tooth extractions prior to proceding with the ICD
placement with concern for hardware infection. Patient had his
remaining teeth extracted in the OR by the oral surgeons and
required a one night stay in the CCU for hypotension likely
secondary to pain medications. However, he returned to the
floor the following day and went for ICD placement the following
Monday. He was maintained on clindamycin 450 mg Q 6 hours
before and 1 week after ICD placement for prophylaxis. The
patient had no episodes of ICD firing and was without telemetry
issues. He was without significant pain at the ICD site 24 hours
after placement.
.
# Heart failure: Patient had no evidence of decompensated CHF
during admission. He had no crackles on exam and had no lower
extremity edema. His lisinopril and Metoprolol were increased.
He continued to be hypotensive but asympatomatic even with
ambulation with average SBPs in the 90s. He was also continued
on his home dose lasix, spironolactone, and dixogin throughout
admission. Soon after the lisinopril was increased the patient
had a creatinine bump. This medication was held with improvement
in his Cr and then was restarted at his original dose on
discharge. While the lisinopril was held, the patient received
hydralazine 10mg Q6 to reduce afterload. This was discontinued
prior to discharge.
.
# Creatinine elevation- His creatinines wavered around a steady
baseline throughout admission. His lisinopril was held for a
short period of time but was then restarted. He was continued on
his lasix and spironolactone throughout admission.
.
# COPD - The patient had no clinical signs of an active
exacerbation. However he did state that he uses Advair and
albuterol at home, despite no medications on his prior discharge
summaries. He was continued on atrovent and flovent nebs as
needed for symptomatic relief of shortness of breath. Beta
agonists were avoided given his significant cardiac disease.
.
# Psoriasis- The patient had psoriatic skin lesions on abdomen,
upper, and lower extremities which he said were at his baseline
and were never symptomatic. He was maintained on Betamethasone
cream [**Hospital1 **].
.
# MRSA history- he had a history of a prior MRSA
cellulitis/abscess on his abdomen and was kept on precautions
throughout admission. He had no evidence of further infection
during the course of admission.
Medications on Admission:
Pantoprazole 40 mg QD
Aspirin 325 mg QD
Clopidogrel 75 mg QD
Folic Acid 1 mg QD
Gemfibrozil 600 mg [**Hospital1 **]
Atorvastatin 80 mg QD
Ezetimibe 10 mg QD
Metoprolol XL 25 mg QD
Lasix 80 mg QAM, 40 mg QPM
Lisinopril 5 mg Tablet QD
Spironolactone 25 mg QD
Digoxin 125 mcg QD
Betamethasone Dipropionate 0.05% Cream topical [**Hospital1 **]
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours) for 6 days.
Disp:*72 Capsule(s)* Refills:*0*
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*QS * Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Outpatient Lab Work
Blood draw: BUN, Cr.
To be drawn prior to your follow-up appointment with your
primary care physician on [**2148-10-29**].
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Arrhythmia - non-sustained ventricular tachycardia
2. Congestive heart failure
3. Dilated Cardiomyopathy
4. COPD
Discharge Condition:
Good
Discharge Instructions:
Take all medications as prescribed.
.
Attend all follow-up appointments.
.
Have your creatinine checked by your primary care provider now
that you have restarted lisinopril, which can affect kidney
function.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: less than 1.5 L per day.
.
Call your doctor or return to the hospital if you are having
worsening shortness of breath, significant chest pain, dizziness
or lightheadedness.
Followup Instructions:
Follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7047**]
([**Telephone/Fax (1) 40023**]) Tuesday, [**2148-10-29**] 12:00. Have your blood
drawn for creatinine measurement prior to this appointment as
you are on lisinopril.
.
Follow-up with cardiology:
- DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2148-10-29**] 3:00
- Dr. [**Last Name (STitle) 63352**], [**2148-11-1**], 11:20AM [**Last Name (un) 469**] 7
.
For dentures please schedule an appointment with [**University/College **] dental:
[**Telephone/Fax (1) **]
|
[
"V15.82",
"521.00",
"428.0",
"401.9",
"458.29",
"414.01",
"496",
"427.1",
"425.4",
"790.6",
"424.0",
"V60.0",
"V45.01",
"414.02",
"998.11",
"V17.3",
"412",
"V09.0",
"696.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"23.19",
"37.89"
] |
icd9pcs
|
[
[
[]
]
] |
12604, 12610
|
6395, 10494
|
328, 383
|
12770, 12777
|
5065, 5985
|
13328, 13913
|
3939, 3953
|
10885, 12581
|
12631, 12749
|
10520, 10862
|
6002, 6372
|
12801, 13305
|
3968, 5046
|
278, 290
|
411, 3381
|
3403, 3590
|
3606, 3923
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,967
| 140,874
|
9550
|
Discharge summary
|
report
|
Admission Date: [**2117-6-30**] Discharge Date: [**2117-7-3**]
Date of Birth: [**2064-9-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
52F who works as court reporter who developed jaundice for
which she was attuned to due to a previous episode of
choledocholithaisis after a cholecystectomy due to the onset of
juandice. At this time she had immediatley sought medical
attention by Dr [**Last Name (STitle) **]. At that time her bilirubin climbed to
over 70, and endoscopic treatment revealed a malignant biliary
stricture which was stented; brushings of which were
unfortunately consistent with adenocarcinoma. This finding was
further delineated by a CT angio, which suggested adenoca
of the pancreatic head. After seeking the advice and
consultation of Dr [**Last Name (STitle) 468**] in his clinic on Monday, the tumor
was
deemed to be resect w/o evidence of metastatic disease.
To that end, she went to Pre-operative testing for her scheduled
Whipple procedure next coming Wednesday. At home, she was
alerted to her blood gluc value, which had come back as 450 from
her testing. Since this finding is a poor prognostic indicator
of underlying disease and may be considered malignant
hyperglycemia, she was called at home and instructed to come
straight to the ED for evaluation and admission to the West 2A
surgical service.
Past Medical History:
PMHx: [**Doctor Last Name 933**] disease, postpartum cardiomyopathy (resolved), HTN,
hypothyroidism,
PSHx: tubal ligation s/p re-anastomosis, L knee meniscus
surgery,
ophthalmologic decompression (lateral orbitotomy),
cholecystectomy
Social History:
SOCHx:
* court reporter
* five kids, four over 21, one daughter is 13;
* she has been given a dx of pre dm but not diabetic right now.
*
she smoked tobacco until 5y ago when she quit
* EtOH occasional
*lost 20lb over the last three months stated "due to poor
appetite"
Family History:
NC
Physical Exam:
Physical Exam on admission:
Vitals:
98.2 80 137/69 14 97
A+O x 3, anicteric, NAD
CTAB
softly, non-distended, well healed incisions, non-tender, +BS
MAE, no edema
Physical Exam on discharge:
VS: T 98, HR 66, BP 115/58, RR 18, O2 Sat 96%RA
GEN - A&Ox3, NAD
CVS - RRR
PULM - CTAB
ABD - obese, S/NT/ND
EXTREM - warm/dry, no C/C/E
Pertinent Results:
[**2117-6-30**] 08:40AM BLOOD WBC-5.4 RBC-4.72 Hgb-14.2 Hct-42.6 MCV-90
MCH-30.2 MCHC-33.5 RDW-14.4 Plt Ct-316
[**2117-7-2**] 08:00AM BLOOD WBC-4.2 RBC-4.24 Hgb-12.6 Hct-38.1 MCV-90
MCH-29.7 MCHC-33.0 RDW-14.3 Plt Ct-282
[**2117-6-30**] 08:40AM BLOOD Neuts-74.7* Lymphs-20.1 Monos-3.6 Eos-1.0
Baso-0.6
[**2117-6-30**] 07:50PM BLOOD Neuts-68.9 Lymphs-26.1 Monos-3.3 Eos-1.2
Baso-0.6
[**2117-6-30**] 09:00AM BLOOD PT-11.2 PTT-22.4 INR(PT)-0.9
[**2117-7-1**] 01:48AM BLOOD PT-11.4 PTT-23.3 INR(PT)-0.9
[**2117-6-30**] 08:40AM BLOOD UreaN-11 Creat-0.7 Na-135 K-4.5 Cl-97
HCO3-26 AnGap-17
[**2117-7-2**] 08:00AM BLOOD Glucose-288* UreaN-9 Creat-0.6 Na-135
K-4.3 Cl-103 HCO3-27 AnGap-9
[**2117-6-30**] 08:40AM BLOOD ALT-295* AST-180* LD(LDH)-163
AlkPhos-461* TotBili-1.8* DirBili-1.0* IndBili-0.8
[**2117-7-2**] 08:00AM BLOOD ALT-124* AST-47* AlkPhos-300* TotBili-0.9
[**2117-6-30**] 08:40AM BLOOD TotProt-7.0 Albumin-4.3 Globuln-2.7
[**2117-7-2**] 08:00AM BLOOD Calcium-9.4 Phos-3.3 Mg-1.9
[**2117-6-30**] 08:40AM BLOOD %HbA1c-10.3* eAG-249*
Brief Hospital Course:
The patient was admitted to the West 2a surgical service and
sent directly to the ICU for an insulin drip to control her
blood glucose. She was allowed to have a regular diabetic diet.
The next day, [**Last Name (un) **] was consulted in order to get an
appropriate insulin regimen that could be administered on the
floor. They recommended giving the patient a one-time dose of 20
units of lantus and then to start the patient on a humalog
sliding scale with 20 units of lantus every morning at
breakfast. The patient was therefore transferred to the floor.
Her blood sugars improved and were generally between 180 and
280. [**Last Name (un) **] continued to follow the patient while she was
inpatient and recommended that she be admitted the day prior to
her operation just to optimize her blood glucose control. In
addition, the day of discharge, they recommended increasing her
AM dose of lantus to 22units. The patient received insulin
teaching and was discharged home in good condition.
Medications on Admission:
levothyroxine 100', Lisinopril 20'
Discharge Medications:
1. One Touch Basic System Kit Sig: One (1) Miscellaneous as
directed.
[**Last Name (un) **]:*1 kit* Refills:*0*
2. Lancets Misc Sig: One (1) Miscellaneous as directed.
[**Last Name (un) **]:*1 box* Refills:*2*
3. one touch test strips Sig: One (1) as directed.
[**Last Name (un) **]:*1 box* Refills:*2*
4. Alcohol Prep Swabs Pads, Medicated Sig: One (1) Topical
as directed.
[**Last Name (un) **]:*1 box* Refills:*2*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
[**Last Name (un) **]:*60 Tablet(s)* Refills:*2*
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty Two (22)
units Subcutaneous at breakfast.
[**Last Name (un) **]:*150 units* Refills:*2*
9. Humalog 100 unit/mL Cartridge Sig: per sliding scale per
sliding scale Subcutaneous per sliding scale: SLIDING SCALE:
BS 71-119 - 2 units
BS 120-159 - 6 untis
BS 160-199 - 8 units
BS 200-239 - 10 units
BS 240-279 - 12 units
BS 280-319 - 14 untis
320-359 - 16 units
360-400 - 18 units
> 400 - notify MD.
[**Last Name (Titles) **]:*qs days* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Continue to check your blood glucose levels as instructed at
least 4 times a day. Call the [**Hospital **] Clinic or return to the
hospital if they are still uncontrolled (>350)
Followup Instructions:
Please call [**Telephone/Fax (1) 2378**] ([**Hospital **] Clinic) for any questions or
issues with Blood sugar control
Please return to the hospital on Tuesday ([**2117-7-6**]) to be admitted
one day prior to your operation in order to ensure your blood
glucose is under optimal control.
|
[
"157.0",
"576.2",
"250.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5844, 5850
|
3554, 4547
|
326, 333
|
5908, 5908
|
2493, 3531
|
7403, 7694
|
2127, 2131
|
4632, 5821
|
5871, 5887
|
4573, 4609
|
6059, 7380
|
2146, 2160
|
2337, 2474
|
273, 288
|
361, 1565
|
2174, 2309
|
5923, 6035
|
1587, 1824
|
1840, 2111
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,825
| 103,369
|
48378
|
Discharge summary
|
report
|
Admission Date: [**2167-1-27**] Discharge Date: [**2167-1-30**]
Service: MEDICINE
Allergies:
Vasotec / Niacin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 86 y.o. male with pmh significant for CAD s/p
PCI to LAD, LMCA and LCX in [**2163**], chronically occluded RCA with
L->R collaterals, dilated cardiomyopathy of [**11-5**]% presenting to
his outpatient Cardiologist with several weeks of lethargy, and
found to be bradycardic with HR in the 30's. EKG in office
showed Junctional bradycardia at a rate of 30, blood pressure
60/palp. He was given atropine 2mg with increased Hr to 40's,
and then transferred to the ED. In the ED his HR remained in the
30-40's with blood pressure of 110/50. He developed an increased
oxygen requirement with O2 saturation 60-70% on NRB. Head CT was
performed to rule out CVA as cause of bradycardia and was found
to be negative for acute bleed. Patient was also found to be in
acute renal failure with creatinine of 5.5 from baseline 2.5.
His potassium was also initially found to elevated at 9.0 in a
hemolyzed sample. Repeat K was 5.0. Diqoxin level was found to
be 0.7. Repeat K was 5.0. Given his progressive hypoxia he was
intubated with O2 saturation of 100% on FiO2 100%. In the ED his
rhythm alternated between sinus and junctional bradycardia.
His vitals were HR 37-39, blood pressure (77-116)/(33-46). He
was given aspirin, atropine, sodium bicarbonate, insulin 10
units, an amp of D50, albuterol nebs.
Per medical records, the patient has been hospitalized several
times in the past for both acute on chronic congestive heart
failure and acute renal failure attributed to poor forward flow
from CHF. he was most revcently admitted from [**2166-12-18**] through
[**2166-12-25**], during which he was diuresed 10L in the CCU on a lasix
drip with BP support from milrinone and phenylephrine. Upon
discharge, bumex was added and torsemide was discontinued. On
[**1-13**] the patient had increased creatinine detected on routine
labs, which resulted in a decrease of his bumex from 4mg to 3mg
PO BID. He then experienced a 5lb increased weight gain and had
his bumex increased to 4mg PO BID on [**2167-1-23**].
.
Per wife, patient has had increased confusion over past three
days, in addition to abdominal pain and diahrrea.
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:
BP : 95 / 46 mmHg
Weight: 70.2 kg
T current: 94 C
HR: 45 bpm
RR: 12 insp/min
O2 sat: 100 % on Supplemental oxygen: FiO2 .40
Eyes: Conjunctiva and lids: WNL
Ears, Nose, Mouth and Throat: Oral mucosa: left pupil dilated
5cm, reactive. right pupil 3mm, minimally reactive
Neck: Jugular veins: JVP, 9cm
Respiratory: Effort: Abnormal, intubated, Auscultation:
Abnormal, crackles
Cardiac: Rhythm: Regular, Auscultation: S1: WNL, S2: normal,
Murmur / Rub: Absent
Abdominal / Gastrointestinal: bowel sounds: WNL, Pulsatile mass:
No, Hepatosplenomegaly: No
Extremities / Musculoskeletal: Dorsalis pedis artery: Right:
dopplerable, Left: dopplerable, Posterior tibial artery: Right:
dopplerable, Left: dopplerable, Edema: Right: 2+,
Pertinent Results:
Admission labs:
[**2167-1-27**] 02:40PM WBC-7.7 RBC-4.19* HGB-10.4* HCT-32.5* MCV-78*
MCH-24.7* MCHC-31.9 RDW-22.1*
[**2167-1-27**] 02:40PM NEUTS-69.1 LYMPHS-16.7* MONOS-7.3 EOS-6.5*
BASOS-0.4
[**2167-1-27**] 02:40PM GLUCOSE-101 UREA N-109* CREAT-5.5*#
SODIUM-130* POTASSIUM-9.5* CHLORIDE-100 TOTAL CO2-18* ANION
GAP-22*
[**2167-1-27**] 02:40PM CALCIUM-8.8 PHOSPHATE-6.9*# MAGNESIUM-3.0*
Cardiac labs:
[**2167-1-27**] 02:40PM CK(CPK)-217*
[**2167-1-27**] 02:40PM CK-MB-6
[**2167-1-27**] 02:40PM cTropnT-0.12*
[**2167-1-27**] 08:03PM proBNP-[**Numeric Identifier 101895**]*
[**2167-1-28**] 03:05AM BLOOD CK-MB-NotDone cTropnT-0.13*
Brief Hospital Course:
**The patient expired on [**2167-1-30**].**
An 86 man with a history of CAD, dilated cardiomyopathy with
LVEF 15%, presented with junctional bradycardia, hypoxia,
hypothermia, hypotension.
.
#Hypotension: MAP on admission was 55. Recent vitals from
outpatient records show baseline BP 95/40. Hypotension was
likely secondary to systolic congestive heart failure. BNP
elevated at >24 000 was consistent with this. Sepsis was also
on the differential, and vancomycin and zosyn were initially
started. No arterial line or central line was placed because of
elevated INR 7.9 on admission. Peripheral dopamine and fluid
boluses were initially given to maintain MAP >60. He became
hypertensive with frequent ectopy. Dopamine was weaned off and
levophed briefly added as a bridge to milrinone which was also
started. After conversation with his wife, the decision was
made to pursue comfort measures only. All pressors were
stopped. The patient became progressively more hypotensive and
expired.
.
#Bradycardia: On admission he was fluctuating between sinus and
junctional bradycardia. Contributions likely included hypoxia,
hypothermia, and acute renal failure. Cardiac ischemia was on
the differential as well, but EKG without ischemic changes and
elevated troponin likely [**2-23**] renal failure. Pressors were
initiaed as above. Peripheral dopamine was initially started to
maintain MAP >60. This was changed to milrinone as above.
.
#Respiratory Status: He was intubated for hypoxic respiratory
failure in ED, was 70% on NRB. CXR with pulmonary infiltrates
suggestive of CHF. He was not diuresed because of hypotension.
He oxygenated well on the ventilator with 100% FiO2. After
comfort measures were initiated, the decision was made in
conversation with his wife to extubate. Shortly after
extubation he expired.
.
#Acute renal failure: Creatinine was 5.5, up from baseline of
2.5. This was likely secondary to exacerbation of congestive
heart failure with low cardiac output with a possible component
of overdiuresis. [**Month/Day (2) **] lytes showed a pre-renal state. Renal
was consulted and saw no need for CVVH or HD.
.
#Hypothermia: A bear hugger was placed. Infection was suspected
as a cause. His wife was reporting three days of confusion,
abdominal pain and diahrrea. Sputum grew staph aureas. Blood
and [**Month/Day (2) **] cultures as well as stool for c diff were negative.
He was initially treated with vancomycin and levofloxacin.
These were stopped when comfort measures only was initiated.
.
# Coronaries: History of CAD s/p PCI to LAD, LMCA and LCX in
[**2163**], and chronically occluded RCA with L->R collaterals. EKG
was without ischemic changes, troponin was elevated, likely
secondary to renal failure, but CK was normal and there was low
suspicion for acute ischemia.
.
#Bullous Pemphigoid: Minocycline and hydroxyzine were in setting
of acute illness. Sarna cream was continued.
Medications on Admission:
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: [**1-23**] 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: 2 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.
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2167-1-31**]
|
[
"414.01",
"427.89",
"428.43",
"427.1",
"458.9",
"518.81",
"780.65",
"425.4",
"584.9",
"427.32",
"V43.3",
"428.0",
"585.9",
"403.90",
"V10.05",
"694.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8890, 8899
|
4853, 7781
|
241, 247
|
8950, 8959
|
4181, 4181
|
9015, 9053
|
3336, 3418
|
8858, 8867
|
8920, 8929
|
7807, 8835
|
8983, 8992
|
3433, 4162
|
193, 203
|
275, 2405
|
4197, 4830
|
2427, 3136
|
3152, 3320
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,546
| 112,012
|
41220
|
Discharge summary
|
report
|
Admission Date: [**2113-4-10**] Discharge Date: [**2113-4-22**]
Service: MEDICINE
Allergies:
Zocor / Lipitor
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Worsening shortness of breath for 5-6 months. Critical AS.
Major Surgical or Invasive Procedure:
Core Valve placement
Endotracheal intubation
Cardioversion
History of Present Illness:
Mr. [**Known lastname 6330**] is a a very articulate [**Age over 90 **] year old [**Location 7972**] man
who has been in good health until the past two years when his
activity level has diminished. Over the past three months, he
had increasing dyspnea with exertion. He does not have chest
pain or syncope-presyncope but is limited to a few stairs or
walking across the room. His dyspnea resolves rapidly with rest.
He has not had PND, orthopnea, or other cardiovascular symptoms.
As part of assessment for percutaneous aortic valve therapy he
was found to have iliofemoral peripheral vascular disease. He
underwent stenting (x2 Bare Metal Stents) of his right iliac
artery on [**2113-3-2**], with excellent result. He was
discharged home on [**2113-3-3**] with VNA and has been doing well
since. He did complain of back pain to the VNA who sent a U/A
via his PCP. [**Name10 (NameIs) **] was positive for a UTI (unknown bacteria) and pt
is on day [**3-25**] of Cephalexin. Able to ambulate only 20 steps
before has DOE causing him to rest. Also has incontinance at
baseline, uses pads at home.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope. He does have DOE after 20 ft. He has had TIA s/p
stenting of left cartotid artery [**2105**].
Past Medical History:
1. Hypercholesterolemia
2. Recurrent UTIs ([**12-21**] Foley catheters), urinary incontinence
3. Left carotid stenting in [**2105**] due to a TIA with mild left eye
droop
4. Bilat Total hip replacement [**2106**]
5. Stage III chronic kidney disease
6. Essential Thrombocytopenia
7. Stage 3 CKD
8. Aortic valve stenosis with valve area 0.5 cm2
9. Hypertension
10. NYHA class III CHF
Social History:
He lives with his wife in [**Name (NI) 89789**] MA. He has much support at
home including daily nursing and home health aide from VNA of
[**Hospital3 **]. One son lives next door and is frequently over to see
him several times a day; another son is also in to visit several
times a day. He uses a cane and has not had any falls. He does
not have lifeline in the home but son states there is almost
someone there during the day but not at night. He will be
accompanied by his son [**Name (NI) **] [**Name (NI) 6330**] (cell) [**Telephone/Fax (1) 89790**]. Uses a
walker at home. No history of falls.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Average Daily Living:
Live independently Yes [X] No [ ]
Bathing [X] Independent [ ] Dependent
Dressing [X] Independent [ ] Dependent
Toileting [X] Independent [ ] Dependent
Transferring [X] Independent [ ] Dependent
Continence [X] Independent [ ] Dependent
Feeding [X] Independent [ ] Dependent
Family History:
There is no history of hypertension, diabetes,stroke and
premature coronary artery disease. His mother and father both
died at age 85 of natural causes.
Physical Exam:
ON ADMISSION:
Pulse: 50-57 SR B/P: Right 136/73 Left 131/63 Resp: 18 O2
Sat: 99% RA Temp: 98.4
Height: 68 inches Weight: 76.8 kg
General: Alert, comfortable, sitting in bed.
Skin: no open areas, warm, dry
HEENT: supple, JVD 1/2 up bilat. PERLA, EOM's intact. MM moist.
Sclera non-icteric.
Chest: CTAB posteriorly
Heart: regular, 3/6 systolic murmur across precordium, no
radiation to carotids.
Abdomen: soft, NT, ND
Extremities: trace peripheral edema, bilat at ankles and feet.
No bruits.
Neuro: A/O HOH, appropriate.
.
ON ADMISSION TO CCU:
BP 130/74 (on .5 neo), HR 70, RR 18, O2 sat 100% on 500/16, 60%,
PEEP 5, T 34.9
General: initially intubated, sedated, paralyzed. Later, still
intubated but awake and following commands
HEENT: intubated, JVD difficult to visualized, moist mucosa
Chest: clear anteriorly
Heart: regular with frequent premature beats, very faint
systolic murmur
Abdomen: soft, nontender, nondistended
Groin: bilateral bandages in place, no evidence of swelling or
tenderness (R hip firm, which seems to be his baseline [**12-21**] THR).
No bruit.
Extremities: trace peripheral edema bilaterally, pulses
dopplerable faintly at PT (obtained by one examiner and not
another), warm but slightly mottled feet bilaterally
Neuro: after withdrawal of sedation, patient able to squeeze
hands, blink eyes to command. PERRL
.
On discharge:
Gen: alert, oriented x2
HEENT: supple,
CV: RRR, no M/R/G
RESP: [**Month (only) **] at bases, no crackles or wheezes
ABD: soft, NT, pos BS, had BM
EXTR: left groin with large resolving hematoma, no bruit noted.
right groin wtih pos bruit. No tenderness
NEURO: alert, conversant, less confused. Oriented x 2
Extremeties: no edema
Pulses:
Right: DP 1+ PT 1+
Left: DP 2+ PT 1+
Skin: intact
Pertinent Results:
ADMISSION LABS:
[**2113-4-10**] 12:40PM WBC-6.7 RBC-3.56* HGB-11.7* HCT-33.8* MCV-95
MCH-33.0* MCHC-34.7 RDW-15.3
[**2113-4-10**] 12:40PM PLT COUNT-191
[**2113-4-10**] 12:40PM NEUTS-66.0 LYMPHS-20.0 MONOS-6.4 EOS-6.4*
BASOS-1.1
[**2113-4-10**] 12:40PM PT-14.5* PTT-32.5 INR(PT)-1.2*
[**2113-4-10**] 12:40PM GLUCOSE-99 UREA N-32* CREAT-2.2* SODIUM-139
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
[**2113-4-10**] 12:40PM ALBUMIN-4.1 CALCIUM-9.8 PHOSPHATE-3.6
MAGNESIUM-2.3
[**2113-4-10**] 12:40PM ALT(SGPT)-17 AST(SGOT)-28 LD(LDH)-252*
CK(CPK)-56 ALK PHOS-133* TOT BILI-0.4
[**2113-4-10**] 12:40PM CK-MB-4
.
DISCHARGE LABS:
[**2113-4-22**] 06:50AM BLOOD WBC-9.8 RBC-2.93* Hgb-9.4* Hct-29.0*
MCV-99* MCH-32.2* MCHC-32.6 RDW-19.0* Plt Ct-217
[**2113-4-22**] 06:50AM BLOOD PT-44.0* INR(PT)-4.6*
[**2113-4-22**] 06:50AM BLOOD Glucose-91 UreaN-51* Creat-2.7* Na-138
K-4.6 Cl-106 HCO3-19* AnGap-18
[**2113-4-12**] 03:25PM BLOOD LD(LDH)-362* CK(CPK)-185 TotBili-1.5
.
ECHO ([**4-11**]): The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). with
mild global free wall hypokinesis. The aortic valve leaflets are
severely thickened/deformed. Mild (1+) aortic regurgitation is
seen.There is severe aortic stenosis. Moderate (2+) mitral
regurgitation is seen, with a restricted posterior leaflet.There
is also a mitraal valve cleft bettween P1 and P2. Moderate [2+]
tricuspid regurgitation is seen. There is no pericardial
effusion.
Post TAVI
There is 2+ aortic regurgitation.The regurgitation is
parvalvular,
2+ mitral regurgitation similar to preprocedure
No pericardial effusion is seen
LV function is preserved
.
ECHO ([**4-18**]): The left atrium is mildly 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%). The right ventricular cavity is dilated
with mild global free wall hypokinesis. The aortic root is
mildly dilated at the sinus level. An aortic CoreValve
prosthesis is present. The prosthetic aortic valve leaflets
appear normal. The transaortic gradient is normal for this
prosthesis. There are two small paravalvular aortic
regurgitation jets, together constituting no more than mild (1+)
aortic regurgitation is seen. Moderate (2+) mitral regurgitation
is seen. Moderate [2+] tricuspid regurgitation is seen. There is
severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normally-functioning CoreValve aortic prosthesis.
Symmetric LVH with normal global and regional systolic function.
Severe pulmonary hypertension with dilated right ventricle and
mild global systolic dysfunction and moderate to severe
functional tricuspid regurgitation.
.
EKG ([**4-19**]): Sinus bradycardia with first degree atrio-ventricular
conduction delay. Low QRS voltage in limb leads. Inferior wall
myocardial infarction of indeterminate age. Lateral myocardial
infarction of indeterminate age. Compared to the previous
tracing of [**2113-4-18**] multiple abnormalities persist without major
change.
.
Brief Hospital Course:
[**Age over 90 **]yoM with NYHA Class 3 CHF and severe AS, now s/p COREvalve
with post-procedure course complicated by hemodynamic
instability and new onset AF with RVR.
.
# Aortic stenosis: Corevalve procedure was without
complications. He was extubated immediately post-op.
Subsequent TTEs showed appropriate positioning and functioning
of the valve. Aspirin and Plavix were continued.
.
# Hypotension: In the immediate post-procedure period, he was
recurrently hypotensive, and did several hours after the
procedure, lose his pulse briefly. He regained blood pressure
and consciousness after 1 round of CPR. However, over the next
48 hours he had 3 more episodes of sudden, profound hypotension
to the 40s systolic with loss of consciousness. Each time he
regained consciousness within seconds without intervention.
This was all thought to be due to profound systemic dilatation
in the setting of the sudden relief of his outflow tract
obstruction He required intermittent neosynephrine in the first
48 hours post-procedure. Echo showed a collapsed LV and outflow
tract obstruction, prompting fluid resuscitation. His blood
pressures improved, but subsequently decreased due to atrial
fibrillation. His blood pressures again stabilized with rate,
and eventually rhythm control.
.
# Atrial Fibrillation. New diagnosis of Afib. On [**4-14**] amio
loaded and anticoagulation started with hep ggt. He was
cardioverted on [**4-18**] and continued on amiodarone and coumadin.
He remained in sinus bradycardia with stable blood pressures.
The decision was made to discontinue coumadin on [**2113-4-22**] given
bleeding risk and interaction with amio. Amiodarone was changed
to 200 mg daily.
.
# Thrombocytopenia. Patient with 191 -> 83 drop in platelets in
the several days post-procedure. D-dimer and FDP were elevated
but fibrinogen was not low and no evidence of hemolysis. RBC
morphology did not demonstrated schistocyes. HIT was thought to
be unlikely. Platelets returned to baseline over the next week.
.
# Anemia: HCT stable after 2u of pRBC on [**4-13**]. CT showed Left
pelvic hematoma with layering blood in the pelvis and a small
amount of peri-hepatic hemoperitoneum. No retroperitoneal
hematoma. Repeat b/l LE duplex - Normal appearance to right CFA,
and CFV Pseudoaneurysm no longer seen. Hct stabilized and no
further transfusions were required.
.
# Acute on chronic Diastolic CHF: After core-valve procedure
patient was hypotensive and very pre-load dependent with bedside
echo demonstrating low filling. Was treated with IVF boluses.
BP??????s subsequently stabilized and patient was LOS balance
positive upto 5L. Subsequently appeared clinically fluid
overloaded with crackles and wheezing on lung auscultation and
congested appearance of chest x ray, this prompted diuresis with
boluses of 10mg IV lasix. He was approximately euvolemic upon
discharge.
.
# Delirium. Patient developed confusion and disorientation
during hospitalization, which was likely secondary to prolonged
ICU course. He had no signs of active infection. He was given
seroquel prn and daily ECG was followed to monitor for QTc
prolongation. Seroquel was discontinued on discharge due to
sedation.
.
# CORONARIES: No history of CAD. ASA and pravastatin were
continued.
.
# Peripheral Vascular disase: S/P BMS to right iliac artery.
Pulse exam was stable - PT pulses dopplerable, DP very faint on
doppler
.
# CKD, Stage 3: Creatinine increased to 2.7 from baseline 2.2.
Believed to be pre-renal given FeUrea <25%. He was given 1 liter
NS bolus on the day of discharge. He will require daily Cr
checks.
.
# Dyslipidemia: Pravastatin was continued
.
CODE: Full
.
COMM: [**Name (NI) **]: [**Name (NI) **] [**Name (NI) 6330**], [**First Name3 (LF) **]. [**Telephone/Fax (1) 89791**]. Pt is illiterate.
.
Transitions of Care:
- Daily Cr checks
Medications on Admission:
confirmed with son and list
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. pravastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lumigan 0.01 % Drops Sig: Two (2) drops Ophthalmic at
bedtime.
7. Cephalexin 500 mg po QID, day #5 of 7 for UTI
8. Tylenol 500 mg PO BID for back pain
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
11. Outpatient Lab Work
please check daily Cr, until begins trending down to baseline
2.2.
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Cape Regency, A [**Hospital 671**] HealthCare Center - [**Location 41366**]
Discharge Diagnosis:
Severe Arotic Stenosis s/p CoreValve placement
Delerium
Atrial fibrillation
Acute on Chronic kidney disease
Chronic thrombocytopenia and anemia
Acute on chronic diastolic congestive heart failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had a naortic CoreValve placed that has fixed your severe
aortic stenosis. The procedure went well but you had some
complications that include bleeding at the right and left groin
site, delerium and atrial fibrillation. Your groin sites have
been stable with no evidence of bleeding at present. The atrial
fibrillation was converted to a normal rhythm via a
cardioversion procedure and you were started on a medicine
called amiodarone to keep you in a normal rhythm. You will need
to have your thyroid, liver and lung function followed regularly
while you are on this medicine. You thyroid and liver function
tests were OK here in the hospital. You were also started on
coumadin to prevent a blood clot from the atrial fibrillation.
Your coumadin level is high now, probably from the interaction
with the amiodarone. This level will be followed closely from
now on. You were confused from being in the hospital and this is
clearing slowly.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. START amiodarone to keep you in a normal rhythm
2. START senna, colace and miralax to treat your constipation
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2113-5-12**] at 12:20 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], 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: CARDIAC SERVICES
When: FRIDAY [**2113-5-12**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"997.1",
"599.0",
"276.2",
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icd9cm
|
[
[
[]
]
] |
[
"35.96",
"35.22",
"37.23",
"99.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
13975, 14077
|
8517, 12318
|
282, 342
|
14317, 14317
|
5364, 5364
|
15756, 16365
|
3432, 3587
|
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|
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|
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|
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|
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|
3602, 3602
|
4958, 5345
|
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|
370, 2040
|
5380, 5995
|
3616, 4944
|
14332, 14468
|
12339, 12358
|
2062, 2445
|
2461, 3416
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,374
| 102,961
|
34484
|
Discharge summary
|
report
|
Admission Date: [**2159-4-8**] Discharge Date: [**2159-4-10**]
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
Decreased responsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a [**Age over 90 **]-year-old right-handed woman with history of
HTN, CAD s/p MI, and CHF who has had progressive cognitive and
physical decline over the past 5-6 months now transferred for
further evaluation of her mental status. Her mental status had
started worsening in [**2158-11-1**] when she was admitted to [**Hospital1 **]
[**Location (un) 620**] with group B Strep bacteremia possibly related to lung
infection. Prior to this, she had been living alone
independently in her apartment. She was discharged to a nursing
home in [**2158-12-2**]. She was transferred to a [**Hospital1 1501**] on [**2159-1-2**],
for worsening mental status, confusion, agitation, and
screaming.
She was admitted to [**Hospital1 **] [**Location (un) 620**] in [**2159-1-2**] for further
evaluation of agitation and mental status changes. During that
admission, she was found to have an Enterococcus positive UTI.
Then, she was admitted to [**Hospital 1191**] Hospital for further management
of her mental status changes which was attributed to increasing
anxiety. She was prescribed trazadone. She had further decline
in her mental status which was thought to be secondary to
psychosis so she was started on twice daily risperidone and
required a 1:1 sitter. While at [**Doctor First Name 1191**], she developed a right
facial droop and was unresponsive. She was also noted to have
generalized muscular hypertonicity. She was transferred to [**Hospital6 38673**] on [**2159-4-7**] to rule out stroke. She was started
on
ASA PR. Head CT did not show large territorial infarct or
intracranial hemorrhage. In the ED at [**Hospital3 **], she received
a
dose of vancomycin and levoquin. This was not continued as she
was afebrile and did not have a leukocytosis. Cardiac enzymes
were negative times three. She was consulted by neurology who
considered that she may be in a drug-induced state from the
risperidone. However, it was felt that nonconvulsive status
epilepticus should also be ruled out. Therefore, she was
transferred to [**Hospital1 18**] for bedside EEG monitoring to rule out
seizure.
ROS: per HPI. No recent fever. She is noted to have
progressively worsening decline, both in mental status, in p.o.
intake, and also, to have depressive symptoms.
Past Medical History:
COPD
h/o Ventricular tachycardia, after long discussion w/family
decision was made not to place ICD in [**11-6**]
History of breast cancer
History of urinary tract infections, Streptococcus bacteremia,
hypothyroidism, congestive heart failure, macular degeneration,
cataracts, osteoarthritis, gastroesophageal reflux disease,
COPD,
coronary artery disease status post MI and status post stenting,
hyponatremia which is chronic, chronic back pain, hypertension,
peripheral edema, and aortic, regurgitation with last
echocardiogram showing an EF of 55%.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Vitals: T: 100.2 P: 88 R: 10 BP: 129/49 SaO2: 96% RA
General: She was sleeping and difficult to arouse.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Both hands appear arthritic.
Skin: no rashes noted.
Neurologic:
-Mental Status: She was sleeping and difficult to arouse
initially. She did not speak. She followed commands to smile,
stick out her tongue, and to grasp.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. +blink to threat
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Not wearing her hearing aids and so the examiner must yell
loudly for her to hear bilaterally
IX, X: Did not cooperate with checking palate elevation.
[**Doctor First Name 81**]: Did not participate in this part of the exam.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, increased tone in all extremities. Did not
participate in testing for pronator drift. No adventitious
movements, such as tremor, noted. Moves all extremities in
response to light touch.
-Sensory: Moves all extremities to light touch. Opened eyes to
sternal rub.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Toes mute
-Coordination: unable to test
-Gait: unable to test
Pertinent Results:
CBC: 9.6> 9.7/ 29.7 < 352
Chemistry: 135 100 24 93
4.4 23 1.2
Ca 9.4 Mg 2.1 P 3.3
ALT 50; AST 54
UTox negative
UA pH 5.5, sp gr 1.015; tr protein, 40 ketone, hazy, otherwise
negative
Brief Hospital Course:
Confusion
Ms. [**Known lastname 4223**] was transferred to [**Hospital1 18**] for diminished
responsiveness. She had recently been given risperidone which
was held on admission. On the morning after admission she was
alert and interactive with the team. She is very hard of hearing
which can contribute to confusion, but the most likely etiology
to her delerium was medication-induced. We suggested Seroquel 25
mg PRN as a substitiute if she becomes agitated. We spoke to her
daughter who requested that she not be hospitalized in the
future. She states that she has made her facilty aware of this
do not hospitalize order. There was no evidence of seizure on
exam and she was moving extremities well.
Medications on Admission:
ACETAMINOPHEN SUPPOSITORY 650 MG Every 6 Hours
Rectal
ALBUTEROL 0.042% NEB [**Male First Name (un) **] 1 NEB Every 4 Hours
Nebulizer
NEBULIZER (Accuneb 0.042% 1.25 MG/3 Ml)
ALBUTEROL INHALER 0 GM Every 6 Hours
PRN Inhalation
ALBUTEROL/IPRATROPIUM 1 NEB Every 6 Hours
(Duoneb 2.5 MG-0.5 MG Nebulizer)
ASPIRIN SUPPOSITORY 300 MG Every Day
Rectal
BISACODYL SUPPOSITORY 10 MG Every Day
Rectal
BISACODYL SUPPOSITORY 10 MG Daily as
needed
Rectal
LEVOTHYROXINE VIAL 25 MCG Every Day
Intravenous
(note home dose of PO levothyroxine is 50 mcg PO daily)
SODIUM BIPHOSPHATE/SODIUM 133 ML Daily as
needed
Per rectum
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. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. Seroquel 25 mg Tablet Sig: One (1) Tablet PO QHS: PRN as
needed for Agitation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Delerium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after being transferred from
an outside hospital for concern of possible seizures. You had
recently been started on Trazadone and Risperdal. These
medications were held and on the following morning you were
speaking clearly and said that you felt good. On examination you
were very hard of hearing and mildly disoriented. In addition
you had some subtle weakness on your right side. You had a
normal CT from the outside hospital and there was no idication
for EEG. You had no issues related to agitation or confusion.
We would recommend the following.
1. No risperidone in the future
2. No trazadone in the future
3. If agitated, please use small dose of Seroquel (25 mg prn
agitation)
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-5**] weeks.
Completed by:[**2159-4-10**]
|
[
"496",
"401.9",
"414.01",
"E939.0",
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"412",
"348.39",
"V45.82",
"E939.3",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7211, 7284
|
5273, 5977
|
244, 251
|
7337, 7337
|
5043, 5250
|
8266, 8377
|
3274, 3356
|
6837, 7188
|
7305, 7316
|
6003, 6814
|
7522, 8243
|
4093, 5024
|
3371, 3920
|
180, 206
|
279, 2556
|
7352, 7498
|
2578, 3132
|
3148, 3258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,902
| 135,491
|
29398
|
Discharge summary
|
report
|
Admission Date: [**2193-12-5**] Discharge Date: [**2193-12-31**]
Date of Birth: [**2115-9-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Right upper lobe lung mass
Major Surgical or Invasive Procedure:
1. Right thoracoscopic right upper lobectomy with pleural tent
2. Cervical mediastinoscopy with biopsy.
3. Mediastinal nodal dissection.
4. Flexible bronchoscopy.
History of Present Illness:
The patient is a delightful 78-year-old gentleman with severe
COPD who was noted to have a small right upper lobe nodule in
[**2189**] and has been followed with serial imaging since. At that
time, a PET/CT scan showed no evidence of FDG activity within
the lesion. Due to his severe COPD, he was followed carefully.
Subsequent CT scans demonstrated growth in the lesion, which is
nearly doubled in size overall. In addition, there has been the
appearance of a new second nodule in the posterior segment of
the right upper lobe, which has also grown with time. These
nodules were separated by about 3-4 cm and normal lung tissue. A
recent PET/CT scan obtained in [**2193-6-25**] demonstrated FDG
uptake within both right upper lobe nodules as well as two small
lymph nodes adjacent to the left parotid gland. There is no
uptake within the mediastinal lymph nodes or of elsewhere within
the body of concern. He underwent a bronchoscopy on [**2193-7-16**], which showed no endobronchial lesions, and a
bronchoalveolar lavage was nondiagnostic. He subsequently
underwent a CT-guided
fine needle biopsy on [**2193-8-2**], which confirmed the
presence of an adenocarcinoma consistent with bronchoalveolar
type. The patient presents for surgical resection of his right
upper lobe.
He does suffer from dyspnea on exertion becoming dyspneic after
walking up two flights of stairs. He is able to walk
approximately three blocks without much dyspnea.
Other than some nocturia, he has otherwise been asymptomatic. He
specifically denies chest pain, hemoptysis, cough, chest pain,
fevers, chills, sweats, recent pulmonary infection, weight loss,
anorexia, or new neurological or new musculoskeletal complaints.
All other systems reviewed were otherwise negative.
Past Medical History:
1. severe COPD
2. spontaneous pneumothorax in [**2184**] on the right
3. prostate cancer treated with radioactive seed in [**2189**]
4. hemorrhoidectomy
5. decreased hearing.
Social History:
He is married, lives with his family. He smoked two packs a day
for 50 years, continues to smoke one pack per week. He worked as
a boiler man and also worked in the navy and was exposed to
asbestos. He has no significant alcohol use.
Family History:
COPD and lung cancer in siblings.
Physical Exam:
T 98.8 P 78 BP 114/58 R 20 SaO2 95% RA
Heent - pupils are equal, round, and reactive, sclerae are
anicteric, no
supraclavicular or cervical adenopathy.
Lungs - clear to auscultation bilaterally, equal.
Heart - regular without murmur.
Skin - no rashes or skin tumors near the future operative site
abdomen - benign without masses or tenderness.
Extrem - no clubbing or edema.
Neuro - grossly nonfocal with intact and appropriate mental
status.
Lymph - no axillary or groin adenopathy.
Pertinent Results:
[**2193-12-5**] 03:31PM BLOOD WBC-14.2*# RBC-3.03* Hgb-10.6* Hct-30.5*
MCV-101* MCH-35.0* MCHC-34.8 RDW-15.1 Plt Ct-225
[**2193-12-5**] 03:31PM BLOOD Glucose-159* UreaN-23* Creat-0.8 Na-141
K-4.5 Cl-105 HCO3-28 AnGap-13
[**2193-12-30**] 06:50AM BLOOD WBC-9.9 RBC-3.22* Hgb-10.7* Hct-31.6*
MCV-98 MCH-33.2* MCHC-33.8 RDW-16.7* Plt Ct-269
[**2193-12-5**] 03:31PM BLOOD WBC-14.2*# RBC-3.03* Hgb-10.6* Hct-30.5*
MCV-101* MCH-35.0* MCHC-34.8 RDW-15.1 Plt Ct-225
[**2193-12-25**] 01:55AM BLOOD PT-11.3 PTT-40.3* INR(PT)-1.0
[**2193-12-30**] 06:50AM BLOOD Glucose-97 UreaN-43* Creat-0.9 Na-141
K-4.2 Cl-101 HCO3-36* AnGap-8
[**2193-12-19**] 02:51AM BLOOD CK(CPK)-108
[**2193-12-23**] 03:33AM BLOOD Type-ART pO2-101 pCO2-56* pH-7.42
calTCO2-38* Base XS-9 Intubat-INTUBATED
[**2193-12-5**] 12:27PM BLOOD Type-ART pO2-135* pCO2-67* pH-7.29*
calTCO2-34* Base XS-3 Intubat-INTUBATED
CXR - [**12-31**]
The right apical pneumothorax appears a tiny bit larger than it
was on the last two chest radiographs, although the change is
marginal. Otherwise, the right lung volume loss, pleural
thickening, and mediastinal shift remain stable. The right-sided
chest tube is unchanged in position. Chain sutures are again
noted in the right suprahilar region. There are now asbestos-
related pleural calcifications and aortic calcification. Heart
size is unchanged.
CONCLUSION: Minimally increased right apical pneumothorax,
likely insignificant and related to projection. Otherwise,
stable appearance.
[**12-23**] CTA
IMPRESSION:
1. No PE.
2. Severe emphysema. Calcified pleural plaques.
3. Small residual right pneumothorax. Two right-sided chest
tubes appear in good position.
4. 3.1-cm infrarenal aortic aneurysm. Extensive atherosclerotic
disease.
5. Small hypodense lesions in the liver are incompletely
characterized but may represent cysts or hemangiomas.
Brief Hospital Course:
The patient was admitted and had a right thoracoscopic right
upper lobectomy, cervical mediastinoscopy with biopsy,
mediastinal nodal dissection, and flexible bronchoscopy which he
tolerated well. The patient had a chest tube and a mediastinal
drain placed in his right pleural space. This was placed to
suction with a leak present. On post-op day 1, the patient had
an episode of repiratory distress with SaO2 in the 80s on 3
liters O2 via nasal cannula. Wheezes and rhonchi were
auscultated. The patient was given albuterol/ipratropium
nebulizer treatments, nasal canula was switched to shovel mask,
and SaO2 increased to 100%. An ecg showed no acute changes. On
post-op day 2, the patient had another episode of respiratory
distress and was transferred to the ICU for further management.
The patient was started on Levoquin empirically. Steroids were
also started for the patient's history of COPD. In the ICU, the
patient also developed atrial flutter. The patient was placed
on a diltiazem drip and converted back to sinus rhythm. Serial
ABGs were obtained to ensure that the patient was not becoming
hypoxemic or hypercarbic. On [**12-21**] chest tube was d/c'd, [**Doctor Last Name **]
was left to bulb. He had an episode of destauration in the ICU
that reslved after bronchoscopy suctioned out a lot of thick
secretions. Pulm was alos consulted to help manage his COPD.
He was treated with Solumedrol and weaned to PO steroids for his
COPD. He was also placed on BIPAP which helped as well. He was
transfused 1 PRBC for a HCT of 26 on [**12-22**] and given lasix. He
was out of bed an remained in the ICU only as long as he did
mostly because of a bed issue. On [**12-25**] [**Doctor Last Name **] was d/c'd. small
leak in remaing CT. Remained chest tube was clamped and removed
and he was started per pulm recs on an outpt COPD regimine. he
was transferred to the floor where he did well, worked with PT
and was discharged home in good condition.
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Atorvastatin 80 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
Disp:*1 mdi* Refills:*2*
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
Disp:*1 mdi* Refills:*2*
11. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for pain.
12. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days: take on [**2194-1-1**] and [**2194-1-2**] thrn proceed w/
taper.
Disp:*6 Tablet(s)* Refills:*0*
13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: take on [**2194-1-3**], [**2194-1-4**] and [**2194-1-5**] the proceed w/
taper.
Disp:*3 Tablet(s)* Refills:*0*
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: take on [**2194-1-7**], [**1-8**], and [**1-9**] then stop.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
VATS RUL-now s/p pleural tent [**12-13**]
Discharge Condition:
good-oxygen dependent
Discharge Instructions:
Call Dr.[**Name (NI) 1816**] office if you develop chest pain, shortness of
breath, swelling in your chest, neck or face due to trapped air.
Redness or drainage from your chest incision.
continue to wear your oxygen at all times.
Followup Instructions:
call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] for a follow up
appointment
|
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icd9cm
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[
[
[]
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[
"33.22",
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291, 319
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554, 2312
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2527, 2763
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,260
| 124,847
|
1405
|
Discharge summary
|
report
|
Admission Date: [**2130-10-26**] Discharge Date: [**2130-10-30**]
Date of Birth: [**2051-7-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain, respiratory failure
Major Surgical or Invasive Procedure:
[**2130-10-26**] - Intubation with sedation, mechanical ventilation
[**2130-10-26**] - Cardiac catheterization
[**2130-10-26**] - Intra-aortic balloon pump placement
[**2130-10-30**] - intubation, mechanical ventilation
[**2130-10-30**] - cardiac catheterization
[**2130-10-30**] - intra-aortic balloon pump placement
History of Present Illness:
79 year-old Male with h/o CAD s/p CABG [**35**] years ago, MI and HTN
initially presented with chest pain. Pt has known 3vd, was
evaluted by cath for chest pain with a positive stress test in
[**1-27**]. Initially pt presented to [**Location (un) 745**] [**Location (un) 3678**]. He has
reportedly had chest pain intermittently for months. Chest pain
started 2 hrs prior to presentation at OSH, described as
substernal chest pressure, sudden onset and gradually worsening,
radiating to L arm. Pt denied radiation to back or tearing
senation on initial presenation to OSH ED, pain was [**8-28**]. At
OSH pt was started on nitro gtt and heparin gtt, and then was
chest pain free. EKG from OSH while chest pain showed [**Street Address(2) 2051**]
elevation in aVR, [**Street Address(2) 1766**] depressino in I, II, aVF, V3-V6, which
improved somewhat after chest pain free. No fevers, chills,
nausea, vomiting, diarrhea, abd pain, neck pain, or other
complaints. Pain is similar to prior MI, has had episodes of
short lived chest pain intermittently since CABG but never had
to use nitroglycerin until today. Pt transferred to [**Hospital1 18**] for
further management.
.
In [**Hospital1 18**] ED initial VS were 97.4 90 148/76 16 95% 3L Nasal
Cannula. Pt was initially [**12-29**] CP and then CP free here on nitro
gtt, received aspirin 325 mg as well. Cardiology consulted in ED
and recommended addition of integrillin gtt instead of plavix
given known 3vd, also received metoprolol 25 mg PO. Trop
elevated at 0.18, CK/MB flat. Admitted to [**Hospital1 1516**] service cath in
the am.
.
Right femoral artery was used for IABP, RHC via right femoral
vein, and Left femoral artery for PCI. During cath, patient
had sudden onset of respiratory distress thought secondary to
CHF (ischemic-induced), this lead to intubation in the cath lab.
RHC was done and observed a PCWP of 40, which lead to placement
of IABP. Cath showed left main disease and OM disease, these
were interveined on sequentially. His PCWP was noted to have
dropped to 20s at the end of the case. Findings during his LHC
included right dominant coronary arteries. LMCA with diffuse
70-80% with ostial 90%. LAD TO origin. LCX prox 70%, OM1 origin
90%. RCA proximal and ostial 50-60%. SVG none. LIMA to LAD: free
LIMA patent to LAD. He had placement of DES to LM and DES/BMS to
CX OM. He received heparin, integrilin, nitroglycerine drip,
lasix, bivalirudin, norepinephrine, cefazolin.
.
In CCU, he was intubated, sedated. The patient had an IABP in
place.
.
Per floor team, review of systems: he denies any prior history
of stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. he denies recent fevers,
chills or rigors. he denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. Coronary artery disease (CAD s/p MI, ischemic cardiomyopathy
EF 35-40%, CABG: [**2112**] LIMA-LAD, SVG-OM1-OM2)
2. Hypertension
3. Hyperlipidemia
4. Peripheral vascular disease (s/p left carotid endarterectomy)
5. Chronic totally occluded right internal carotid artery
6. s/p appendectomy
7. Diverticulitis
8. Cholelithiasis
9. Herniated disc (status-post back surgeries)
10. Reflux esophagitis, GERD
11. Arthritis
12. s/p Tonsillectomy
Social History:
- Tobacco history: smoked 1/2-1 ppd x 40-50 years, quit in [**2112**]
- ETOH: rare
- Illicit drugs:denies
- Herbal Medications: denies
Patient lives with his wife and children
Family History:
Two brothers who had CABG both are deceased. Father passed away
at the age of 66 of an MI. No family history of arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION EXAM:
VS: 97.6 127/73 67 18 96% 3L
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: 1+ pedal edema bilaterally, No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Patient expired
Pertinent Results:
[**2130-10-26**] 02:30AM BLOOD WBC-12.7* RBC-4.76 Hgb-13.6* Hct-40.2
MCV-84 MCH-28.6 MCHC-33.9 RDW-13.9 Plt Ct-257
.
[**2130-10-26**] 02:30AM BLOOD Neuts-75.0* Lymphs-17.1* Monos-6.8
Eos-0.7 Baso-0.4
.
[**2130-10-26**] 02:17PM BLOOD PT-18.3* PTT-67.6* INR(PT)-1.7*
.
[**2130-10-26**] 02:45AM BLOOD Glucose-201* UreaN-28* Creat-1.7* Na-140
K-4.2 Cl-103 HCO3-29 AnGap-12
.
[**2130-10-26**] 02:17PM BLOOD ALT-43* AST-217* LD(LDH)-586*
CK(CPK)-[**2074**]* AlkPhos-132* TotBili-0.5
.
[**2130-10-26**] 02:17PM BLOOD CK-MB-203* MB Indx-10.4* cTropnT-6.58*
[**2130-10-27**] 01:11AM BLOOD CK-MB-66* MB Indx-3.6 cTropnT-6.50*
[**2130-10-27**] 06:38AM BLOOD CK-MB-41* MB Indx-2.8 cTropnT-5.62*
.
[**2130-10-26**] 02:17PM BLOOD Calcium-8.3* Phos-2.0* Mg-2.0
.
[**2130-10-27**] 06:38AM BLOOD %HbA1c-6.8* eAG-148*
.
MICROBIOLOGIC DATA:
[**2130-10-27**] Blood culture - pending
[**2130-10-27**] Blood culture - pending
[**2130-10-27**] Urine culture - negative
[**2130-10-27**] Sputum culture - no organisms, no growth
.
IMAGING STUDIES:
[**2130-10-26**] CARDIAC CATHETERIZATION - Selective coronary angiography
of this right dominant system revealed 3-vessel coronary artery
disease. There was an ostial 90% stenosis of the LMCA which was
diffusely diseased to 70-80%. The LAD was 100% occluded
proximally. The LMCA gave rise to a patent LCx with a proximal
70% stenosis at the take-off of OM1, which extended into OM1
narrowing the ostial segment of OM1 to 90%. There was diffuse
plaquing of the distal Lx. Venous conduit angiography was not
performed as the SVG to OM1/OM2 is known to be occluded.
Selective arterial conduit angiography of the LIMA arising from
the ascending aorta to the mid-LAD revealed this to be patent.
Initial hemodynamics revealed markedly elevated left and right
heart filling pressures with a mean right atrial pressure of
27mmHg and a mean PCW of 31 mmHg. There was mild pulmonary
artery hypertension with PA 45/30mmHg but no significant
transpulmonary gradient and a PVR of only 38dynes*sec*cm-5. The
cardiac output and index were reduced at 4.2L/min and 2.1 L/min
respectively. Repeat hemodynamics after insertion of the IABP
and baloon angioplasty of the LMCA showed a decrease in the PCW
to a mean of 18mmHg but persistently decreased mixed venous
saturation
(60%). Native 3-vessel coronary artery disease. Culprit lesion
for presentation likley 90% ostial LMCA. Respiratory failure
secondary to acute on chronic left ventricular systolic
dysfunction requiring mechanical ventilation. IABP insertion for
circulatory support in the setting of cardiogenic shock. Mild
pulmonary artery hypertension.
.
[**2130-10-27**] 2D-ECHO - Poor image quality (echo contrast used). The
left atrium is normal in size. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is moderate regional left ventricular systolic dysfunction with
mid to distal septal, anterior and apuical hypokinesis
suggested. No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. with borderline normal
free wall function. The ascending aorta is mildly dilated. 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. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
[**2130-10-26**] CXR (PORTABLE) - Single frontal view of the chest
demonstrates evidence of prior CABG and median sternotomy. The
lungs are mildly hyperinflated allowing for somewhat lordotic
patient positioning, suggestive of emphysema. There is minimal
interstitial edema. The heart is top normal in size. The
mediastinal and hilar contours are unremarkable.
Patient expired
Brief Hospital Course:
79 year-old Male with a PMH significant for coronary artery
disease (s/p CABG [**35**] years prior), prior MI, hypertension who
presented to an outside hospital with chest pain who underwent
PCI who was intubated for respiratory failure in the cardiac
catheterization lab and who required placement of an
intra-aortic balloon pump for cardiogenic shock and subsequently
expired due to ventricular tachycardia.
.
# CARDIOGENIC SHOCK - The patient presents with a known history
of ischemic cardiomyopathy, with recent EF of 35-40%. During his
left heart catheterization procedure this admission, the patient
began to experience acute respiratory failure, likely secondary
to worsening cardiogenic shock. The etiology of his cardiogenic
shock was likely secondary to a cathecholamine surge which
occurred during the catheterization procedure, as he was laid
supine. There was also a component of anxiety associated with
the procedure. His right heart catheterization revealed a PCWP
of 31 mmHg, which was improved with the placement of an
intra-aortic balloon pump (IABP) to 18 mmHg. The IABP was
maintained in good position and was assisting ventricular
contraction initially at a 1:1 ratio which supported his mean
arterial pressures to an average of 55-60 mmHg. He was slowly
weaned to a 2:1 ratio over the course of 48-hours with
subsequent removal of the IABP 3-days into admission. A
Norepinphrine gtt was utilized to support his systolic pressures
and peripheral vasculature while the balloon pump was being
utilized. His systolic pressures actually remained elevated
following the removal of the device and he requried transient
use of a Nitroglycerin gtt to control his systolic pressures.
While the IABP was in place, his distal pulses were closely
monitored and daily CXRs showed adequate balloon positioning.
His platelets and hematocrit were also closely monitoring, with
a drop in his platelets from 257 to 125 this admission. He
showed no evidence of bleeding nonetheless. We added back his
home anti-hypertensives once his blood pressure stabilized and
his cardiac function improved. His digoxin level remained
therapeutic this admission. He was also treated with IV Lasix as
needed, to promote diuresis.
.
# RESPIRATORY FAILURE AND HYPOXIA - The patient required urgent
intubation in the cardiac catheterization lab likely secondary
to pulmonary edema in the setting of his cardiogenic shock. He
received Lasix and Nitroglycerin in the cath lab, and once his
IABP was removed and diuresis was employed, he was successfully
extubated without issues. He transiently required Fentanyl and
Versed gtts to maintain sedation while intubated. Following
extubation, the patient was delirious. He had another episode of
flash pulmonary edema which was responsive to lasix,
nitroglycerin drip, morphine.
.
# CORONARIES - The patient presented with known coronary disease
involving 3-vessels. The patient was found to have a 90%
stenotic lesion of the left main coronary artery, which
underwent drug-eluting stent placement. He also has a known
history of prior CABG. Prior to his cardiac intervention, given
his chest pain, he was started on heparin gtt and maintained on
Aspirin therapy. Integrillin was added given continued chest
pain. His statin medication was optimized to high dose
Atorvastatin 80 mg PO daily. He was also Plavix loaded with 600
mg PO x 1 prior to his catheterization. Following his
catheterization, stenting and resolution of his cardiogenic
shock and removal of the balloon pump, he had no further issues
with chest pain. He will continue on Aspirin 325 mg PO daily,
Plavix 75 mg PO daily and a high dose statin medication. The
patient had an episode of VT but was hemodynamically stable
during the night of [**10-30**]. He had sudden onset of ventricular
fibrillation and was pulseless, he received ACLS including
intubation, electrical shocks, epinephrine, lidocaine,
magnesium. He was taken emergently to the cath lab, where his
LIMA was found to be occluded. The patient required IABP,
ventricular pacer wire and epinephrine drip. His family decided
to make the patient DNR and he expired on [**10-30**] around 1600.
.
# RHYTHM - The patient presented in sinus rhythm. He was
carefully monitored in the post-intervention period for the
development of arrhythmia. He was monitored via telemtry, his
electrolytes were optimized.
.
# CHRONIC RENAL INSUFFICIENCY - The patient presented with an
unclear baseline, but known chronic renal insufficiency. His
last creatinine in our records was 1.4 and he presented with a
creatinine in the 1.7 range, likely secondary to forward flow
issues. His creatinine stabilized following cardiogenic shock
treatment, with improvement in his cardiac index. We avoided
nephrotoxic medications and renally dosed his medications.
.
# HYPERTENSION - hold amlodipine, valsartan, hydralazine, imdur
for now
.
# GERD - He was continued on Omeprazole at his home dosing.
.
TRANSITION OF CARE ISSUES:
Expired.
Medications on Admission:
AMLODIPINE 2.5 mg Tablet - 0.5 (One half) Tablet(s) by mouth
daily
ATENOLOL 100 mg Tablet - 1.5 Tablet(s) by mouth daily
ATORVASTATIN 40 mg Tablet - one Tablet(s) by mouth daily
DIGOXIN 125 mcg Tablet - one Tablet(s) by mouth daily
FUROSEMIDE 80 mg Tablet - one Tablet(s) by mouth twice daily
HYDRALAZINE 25 mg Tablet - one Tablet(s) by mouth daily
ISOSORBIDE MONONITRATE 60 mg Tablet - one Tablet(s) by mouth
daily
OMEPRAZOLE - 20 mg Capsule - one Capsule(s) by mouth daily
POTASSIUM CHLORIDE 10 mEq Capsule - one Capsule(s) by mouth
daily
TERAZOSIN 1 mg Capsule - one Capsule(s) by mouth daily
VALSARTAN 160 mg Tablet - one Tablet(s) by mouth daily
ASPIRIN 325 mg Tablet - one Tablet(s) by mouth daily
Discharge Medications:
expired
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnoses:
1. Coronary artery disease
2. Acute myocardial infarction
3. Cardiogenic shock (placement of intra-aortic balloon pump
device)
4. Intubation and mechanical ventilation
.
Secondary Diagnoses:
1. Hypertension
2. Hyperlipidemia
3. Coronary artery disease
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired.
Patient Discharge Instructions:
.
You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 regarding management of your
coronary artery disease and cardiac issues. You initially
presented to [**Location (un) 745**] [**Hospital 3678**] Hospital with chest pain and your
electrocardiogram (EKG) showed concerning findings for a
myocardial infarction (heart attack). You were then transferred
here, to [**Hospital1 18**], and had a cardiac catheterization which showed a
blockage in your left main coronary artery which was stented.
You had some respiratory issues during the procedure and were
intubated and sedated (and mechanically ventilated) and required
placement of an intra-aortic balloon pump (a device that
supports your heart function and decreases the work on the heart
while it improves) for cardiogenic shock. Your cardiac status
steadily improved and the device was removed. You were
successfully extubated (the breathing tube was removed) without
issues. Your were overall in stable condition prior to
discharge.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
We CHANGED: increased your Atorvastatin from 40 mg to 80 mg by
mouth daily
START: Plavix 75 mg by mouth daily
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
Followup Instructions:
Patient expired.
|
[
"E879.0",
"585.9",
"403.90",
"414.04",
"416.8",
"785.51",
"414.01",
"272.4",
"428.21",
"530.81",
"518.81",
"287.5",
"V49.87",
"410.71",
"414.8",
"428.0",
"427.1",
"412",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"99.60",
"00.40",
"96.71",
"37.23",
"00.66",
"00.47",
"39.64",
"88.56",
"36.07",
"36.06",
"00.45",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
14979, 14994
|
9221, 14189
|
336, 656
|
15309, 15326
|
5242, 6248
|
17765, 17784
|
4411, 4607
|
14947, 14956
|
15015, 15204
|
14215, 14924
|
15399, 17742
|
4622, 5223
|
15225, 15288
|
3244, 3738
|
265, 298
|
684, 3225
|
3760, 4201
|
4217, 4395
|
6265, 9198
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,388
| 105,090
|
18050
|
Discharge summary
|
report
|
Admission Date: [**2147-8-13**] Discharge Date: [**2147-8-23**]
Date of Birth: [**2100-5-25**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Excision of ulcers.
3. Primary closure of ulcer, jejunum.
4. Greater omentum flap.
History of Present Illness:
42 yo F with s/p lap gastric bypass in [**2143**] transferred from
[**Hospital **] Hosp with dx of perferated bowel. Pt noted sudden
onset, [**10-3**] stabbing pain. "I could see my belly swelling."
OSH xray showed air under diaphragm.
Past Medical History:
anxiety
obesity
hypertension
asthma
Social History:
Current smoker. Occ EtOH, [**2-25**]/weekend. No rec drugs.
Physical Exam:
On admit:
T 100 P 99 BP 139/90 RR 17 O2 sat 96%
[**Name (NI) 2420**] pt in obvious discomfort
HEENT- NCAT, FROM
Pulm- CTA
CV- RRR
Abd- soft, tend all quads, mild dist, guaiac neg
GU- no CVA tend
Ext- FROM
Skin- no C,C,E
Neuro- sensation nl, strength 5/5, CNS III-XII nl
Psych- A&Ox3
On discharge:
T 96.9 P 80 BP 146/80 RR 16 O2 sat 98% RA
Gen- obese, often anxious, pleasant F in NAD
HEENT- NCAT
Pulm- CTAB. no W, R, R
CV- RRR. no M, R, G
Abd- obese, +BS, soft, tender around incision, nondistended
Skin- incision loosely stapled. no erythema or induration.
dressing clean and dry. steristrips between staples.
Ext- no C, C, E
Pertinent Results:
[**2147-8-13**] 08:52PM LACTATE-2.4*
[**2147-8-21**] 09:10AM BLOOD WBC-9.7 RBC-3.57* Hgb-11.8* Hct-34.6*
MCV-97 MCH-32.9* MCHC-33.9 RDW-14.3 Plt Ct-466*
[**2147-8-22**] 06:30AM BLOOD Neuts-65.5 Lymphs-26.9 Monos-4.8 Eos-2.6
Baso-0.3
[**2147-8-13**] 08:46PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2147-8-17**] 09:05AM BLOOD PT-11.6 PTT-23.5 INR(PT)-1.0
[**2147-8-17**] 09:05AM BLOOD Glucose-110* UreaN-5* Creat-0.5 Na-137
K-3.5 Cl-100 HCO3-25 AnGap-16
[**2147-8-14**] 03:45AM BLOOD ALT-86* AST-73* LD(LDH)-160 AlkPhos-50
Amylase-39 TotBili-0.9
[**2147-8-17**] 09:05AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.1 Iron-21*
[**2147-8-17**] 09:05AM BLOOD calTIBC-233* VitB12-328 Folate-4.8
Ferritn-373* TRF-179*
[**2147-8-14**] 02:39AM BLOOD freeCa-0.97*
Brief Hospital Course:
Mrs. [**Known lastname 49942**] is a 47 year old woman s/p roux-en-Y lap
gastric bypass ([**2143**])who presented with acute abdominal pain
([**10-3**]) with free air.
1. Due to the acute abdominal pain and free air, perforation
was suspected. She was sent to the OR emergently for a
laporascopic exploration where a marginal ulcer was found on the
anterior portion of her jejunum at the gastrojejunostomy. This
portion was resected and a primary anastomosis completed. She
was discharged to the SICU where she spent one night without
event. On POD2 she was transferred to the floor. She was
advanced to bariatric stage 3 on pod 6 without success. She was
brought down to bariatric diet stage 1 the following day.
Incision opened slightly on POD 7, and was closed with
additional strips as there were no signs of dehiscence.
Antibiotics were discontinued on pod 7. She developed a slight
rash on pod 7 which resolved with hydrocortisone cream. POD 8
the patient passed gas and was advanced to bariatric stage 2 and
then 3. She was discharged home [**Last Name (un) **] following day with
instructions to stop smoking and to f/u with Dr. [**Last Name (STitle) **] in 5 days
for staple removal and then two weeks for operative and
bariatric follow-up.
Medications on Admission:
Paxil 40mg po qday
Discharge Disposition:
Home
Discharge Diagnosis:
Marginal ulcer at the gastrojejunostomy with perforation.
Discharge Condition:
good
Completed by:[**2147-8-23**]
|
[
"534.50",
"997.4",
"E878.2",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.34"
] |
icd9pcs
|
[
[
[]
]
] |
3667, 3673
|
2336, 3598
|
328, 446
|
3774, 3809
|
1515, 2313
|
3694, 3753
|
3624, 3644
|
866, 1150
|
1164, 1496
|
274, 290
|
474, 713
|
735, 772
|
788, 851
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,499
| 147,412
|
4115
|
Discharge summary
|
report
|
Admission Date: [**2107-7-28**] Discharge Date: [**2107-7-31**]
Date of Birth: [**2055-9-13**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Mr [**Known lastname 15499**] is a 51 year old man with CAD s/p catheter
revascularization of diagonal in [**Month (only) **] 97, proximal RCA stent in
[**2101-9-23**], who presented to an OSH with chest pain, left-sided
and radiating to left arm. This is similar to past MI symptoms.
.
Last week, he began having periodic "twinges" of brief chest
pressure which did not linger, and some chest pressure. He
noticed that his exercise capacity was reduced when he and his
wife went hiking and he was falling behind compared to usual. He
also had some intermittent shortness of breath, which has not
persisted. On day of admission he had chest tightness and
squeezing sensation, left arm pressure/tightness, starting at
about 7 pm. He took ASA 650 at home and felt somewhat better;
after dinner however, he started having worse symptoms again. He
took some nitro which he had from 5 years ago, which did not
give him a headache (as it usually does) and did not improve his
chest pressure.
.
He and his wife called EMS and got an additional 81 in the
ambulance. He had nitro sprays x3 in the ambulance with some
improvement. At the OSH he continued to have some chest pain and
had nitro gtt started as well as morphine in the OSH ED. He had
small wavering variations in his EKG which were concerning--ST/T
wave changes in III and aVF. CK-MB was 2, Troponin I was "<0.10"
at 21:40 on Wednesday [**7-27**]. He had received his cardiology care
at [**Hospital1 18**] in the past and requested transfer here.
.
At the OSH, his initial vitals were: bp 154/68, hr 83, rr 12. 02
99% 2L. There he received nitro gtt as above; 5 mg IV
metoprolol; morphine 2 mg x2; 500 ml NS; and 20 meq potassium,
PO.
Past Medical History:
1. CARDIAC RISK FACTORS:: CAD, Family history of heart dz,
Hypertension, Hypercholesterolemia, Obesity
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: x2; PCI (POBA?) to diag
[**4-/2096**], proximal RCA stent in [**2101-9-23**] (see report below)
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Right hand carpal tunnel decompression
Chronic muscle pain, did not improve w removal of statin for 6
mos; improved somewhat w effexor starting 5 yrs ago; takes
ultram for back pain
Social History:
Works as a printing shop manager. Lives with wife. 2 adult
children (30 and 25), one of whom has been [**Hospital1 2025**] nurse.
-Tobacco history: none
-ETOH: occasional: single beer on Sat nights on w/e, other times
none for weeks at a time
-Illicit drugs: none; no prescription drugs that are not
prescribed to him
Family History:
Father with heart disease: progressive angina starting in 40s,
CABGs x2, died at 64 yo. Mother: d of lung CA (was smoker).
Brothers: both had [**Name (NI) 2320**]; one died of prostate CA.
Physical Exam:
VS: T 98.9 BP 124/63 HR 85 RR 16 O2 94% RA; wt 95.6 kg
GENERAL: Tired-appearing but alert and engaged middle-aged man
looking his stated age, somewhat overweight, NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple; no LAD; JVD not appreciated.
CARDIAC: Quiet heart sounds. No m/r/g. No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 1+ DP 2+
Left: Carotid 1+ DP 2+
.
Pertinent Results:
[**2107-7-28**] 03:30PM CK(CPK)-423*
[**2107-7-28**] 06:35AM GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-141
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-29 ANION GAP-11
[**2107-7-28**] 06:35AM estGFR-Using this
[**2107-7-28**] 06:35AM ALT(SGPT)-25 AST(SGOT)-29 CK(CPK)-409* ALK
PHOS-66 TOT BILI-0.5
[**2107-7-28**] 06:35AM CK-MB-34* MB INDX-8.3* cTropnT-0.38*
[**2107-7-28**] 06:35AM ALBUMIN-4.1 CALCIUM-9.2 PHOSPHATE-3.7
MAGNESIUM-1.9
[**2107-7-28**] 06:35AM WBC-10.4 RBC-4.66 HGB-12.7* HCT-37.8* MCV-81*
MCH-27.3 MCHC-33.6 RDW-13.3
[**2107-7-28**] 06:35AM NEUTS-63.9 LYMPHS-28.0 MONOS-4.9 EOS-2.8
BASOS-0.4
[**2107-7-28**] 06:35AM PLT COUNT-340
[**2107-7-28**] 06:35AM PT-13.4 PTT-52.0* INR(PT)-1.2*
CARDIAC CATH [**7-28**]
COMMENTS: 1. Coronary angiography of this right dominant system
revealed
one vessel coronary artery disease. The LMCA had no obstructive
disease.
The LAD had a thrombotic 90% mid stenosis with complex
trifurcation
lesion at D1. The LCx and RCA had minimal disease.
2. Limited resting hemodynamics revealed normal systemic
arterial
systolic and diastolic pressure with SBP of 132 mmHg and DBP of
83 mmHg.
3. Successful stenting of mid LAD at level of D1 with a
2.75x12mm Vision
bare metal stent. Jailing of D1 with TIMI 1 flow down D1 at end
of
procedure.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful stenting of mid LAD with bare metal stent at level
of D1
however origin D1 was jailed with TIMI 1 flow down the vessel at
the end
of the procedure.
ECHO [**2107-7-29**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with mild
hypokinesis of the mid- and distal septum, distal anterior wall
segment and apex (c/w mid-LAD territory). The remaining segments
contract normally (LVEF = 45%). There is no left ventricular
outflow obstruction at rest or with Valsalva. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction.
Compared with the rest portion of the prior stress study (images
reviewed) of [**2107-4-25**], LV regional systolic dysfunction is new.
Brief Hospital Course:
Assessment: 51M with CAD s/p catheter revascularization of
diagonal in [**Month (only) **] 97, proximal RCA stent in [**2101-9-23**], who
presents with STEMI.
.
# MI: Patient initially presented with ?NSTEMI that was later
labeled an STEMI based on re-review of the EKG. He had positive
cardiac enzymes, with CK-MBs that peaked in the 900s, and was
sent to the cath lab for cardiac catheterization. There, he was
found to have a stenosis of the LAD for which a BMS was placed.
However, the procedure was complicated by a jailed large
diagonal branching off the LAD (obstructed by the stent), and
the patient had EKG changes and CP during the procedure
consistent with new ischemia. Attempts were made to recannulize
the diagonal, but these attempts were initially not successful.
The patient was taken back to the cath lab a few hours later
with successful recannulization of the branching diagonal (TIMI
1 flow). He spent the next 24 hours in the CCU and returned to
the cardiology flow afterward. A repeat ECHO demonstrated LV
systolic dysfunction and an EF of 45%, compared to a baseline of
60% in [**2107-4-24**]. He remained chest pain free during the
remainder of his hospital stay and was discharged on ASA,
clopidogrel, atorvastatin, a beta blocker, and lisinopril. He
was also advised to attend cardiac rehabilitation.
.
# HYPERTENSION: Patient's blood pressure remained stable during
admission.
Medications on Admission:
ECASA 325 daily
Toprol XL 100 mg PO daily
Effexor 75 mg PO daily
Lipitor 10 mg PO daily
Zetia 10 mg PO daily
Ultram 50-100 mg PO prn ([**Hospital1 **])
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for pain.
3. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 12 months.
Disp:*30 Tablet(s)* Refills:*11*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tabs
Sublingual every 5 mintues up to three doses as needed for chest
pain: .
Disp:*30 tabs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ST-segment elevation myocardial infarction
Secondary:
- Right hand carpal tunnel decompression
- Chronic myalgias
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because of chest pain. We diagnosed you with
a heart attack and gave you medications to decrease the risk of
your heart function worsening. We also performed a cardiac
catheterization which showed a stenosis of one of your major
coronary arteries. For this, we placed a stent to improve blood
flow through that artery.
.
Please take all of your medications as prescribed. Please keep
all of your follow-up appointments. You will need to continue
clopidogrel for 12 months.
.
Please call your doctor or return to the hospital if you
experience fevers, chills, sweats, chest pain, shortness of
breath or anything else of concern.
Followup Instructions:
Please call Dr.[**Name (NI) 129**] office on Monday to make an
appointment with him in [**12-26**] weeks for follow up. Thanks. His
number is listed below.
.
Provider STRESS TESTING Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2108-5-2**]
8:15
Provider [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2108-5-16**] 10:00
Completed by:[**2107-8-1**]
|
[
"V45.82",
"410.01",
"729.1",
"414.8",
"V17.3",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"00.45",
"00.66",
"37.22",
"36.06",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
9150, 9156
|
6400, 7815
|
296, 322
|
9324, 9333
|
3862, 5155
|
10032, 10464
|
2917, 3107
|
8018, 9127
|
9177, 9303
|
7841, 7995
|
5172, 6377
|
9357, 10009
|
3122, 3843
|
2186, 2350
|
246, 258
|
350, 2041
|
2381, 2565
|
2063, 2166
|
2581, 2901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,923
| 114,772
|
20713
|
Discharge summary
|
report
|
Admission Date: [**2167-9-27**] Discharge Date: [**2167-10-2**]
Date of Birth: [**2099-1-22**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
pericardiocentesis
pacer lead revision
History of Present Illness:
Ms. [**Known lastname **] is a 68 year old female with h/o TIAs, HTN, PAF s/p SSS
s/p pacer presented to OSH with 1 week nausea, SOB,
palpitations. Found to have small left pleural effusion and
small pericardial effusion without tamponade. Also her atrial
fibrilliation was controlled initially with amiodarone, and now
she is on a diltiazem drip. Transferred to [**Hospital1 18**] for possible
lead revision versus removal of pacemaker if perforation. She
had slight CHF by BNP but actually sounding pretty clear on CXR.
Also with transient facial numbness.
Past Medical History:
cardiac tamponade
pericardial effusion
pleural effusion
atrial fibrillation
tachy/ brady syndrome
s/p pacemaker
h/o TIA
diverticulosis
hypertension
peptic ulcer disease
Social History:
Lives alone. No alcohol or tobacco. Retired.
Physical Exam:
98.8, 87, 140/61, 16, 96%2L, 98.7kg
Cor: irregularly irregular, normal rate, 10mmHg pulsus
Chest: decreased breathsounds at L>R base with egophany.
Pertinent Results:
[**2167-9-28**] 02:40AM BLOOD WBC-9.9 RBC-3.10* Hgb-10.1* Hct-29.4*
MCV-95 MCH-32.8* MCHC-34.5 RDW-12.9 Plt Ct-330
[**2167-9-28**] 02:40AM BLOOD Glucose-112* UreaN-20 Creat-0.9 Na-142
K-3.5 Cl-104 HCO3-26 AnGap-16
[**2167-9-29**] 01:05PM BLOOD Type-ART O2 Flow-2 pO2-69* pCO2-49*
pH-7.42 calHCO3-33* Base XS-5 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2167-9-29**] 01:00PM OTHER BODY FLUID WBC-5300* Hct,Fl-2.5*
Polys-48* Lymphs-43* Monos-5* Eos-2* Basos-1* Mesothe-1*
[**2167-9-29**] 01:00PM OTHER BODY FLUID TotProt-4.7 Glucose-82
LD(LDH)-2093 Amylase-18 Albumin-2.7
ELECTROCARDIOGRAM PERFORMED ON: [**2167-9-28**]
Atrial fibrillation.
Nonspecific ST-T wave changes
Echo [**9-28**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal (LVEF
60-70%). Right ventricular chamber size and free wall motion are
normal. Right ventricular systolic function is normal. The
aortic valve leaflets (3) are mildly thickened but not stenotic.
Trace aortic regurgitation is seen. Trivial mitral regurgitation
is seen. There is a moderate to large sized pericardial
effusion. The effusion appears circumferential. There is brief
right atrial collapse. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling and early cardiac
tamponade.
A pacemaker wire is seen in the right heart [**Doctor Last Name 1754**]; the tip is
at the apex of the right ventricle. Perforation cannot be
excluded with certainty, but the tip of the wire was not
visualized outside the epicardial surface of the heart.
Impression: moderate-to-large circumferential pericardial
effusion with early cardiac tamponade.
Catheterization:
INDICATIONS FOR CATHETERIZATION:
Pericardial effusion
FINAL DIAGNOSIS:
1. Successful pericardiocentesis.
2. Mild pulmonary hypertension.
COMMENTS:
1. Limited resting hemodynamics prior to pericardiocentesis
showed a
mildly elevated pulmonary pressure (PA mean 28 mmHg). The left
and right
sided filling pressures were elevated and entrained in the
pericardial
pressure (RA mean 14 mmHg, PCW mean 19 mmHg, RVEDP 19 mmHg,
Pericardium
mean 15 mmHg). The cardiac output was normal (CO 4.5 l/min, CI
2.15
l/min/m2).
2. The mean right atrial and pericardial pressure after
pericardiocentesis of 600 ml of fluid was 7 mmHg and 4 mmHg,
respectively. Cardiac output and index were essentially
unchanged (CO
5.0 l/min, CI 2.4 l/min/m2).
3. An echocardiogram after pericardiocentesis showed minimal
residual
fluid in the pericardium.
4. The pacemaker lead positions were confirmed with fluroscopy
together with the electrophysiology team.
Echo: [**10-1**]
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There is a small to moderate
sized pericardial effusion subtending the right atrial and right
ventricular free walls. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. There are
no echocardiographic signs of tamponade. No right atrial
diastolic collapse is seen.
Compared with the findings of the prior study (tape reviewed) of
[**2167-9-30**], no major change is evident; a small-to-moderate
sized pericardial effusion without evidence of cardiac tamponade
persists.
CXR:
FINDINGS: Note is made of dual chamber cardiac pacemaker, with
two leads, one
terminating in the right atria appendage and the other one
terminating in the
right ventricle. No evidence of pneumothorax. Again note is made
of
cardiomegaly. The mediastinal and hilar contours are unchanged
compared with
previous study. Again note is made of bilateral pleural
effusions with left
lower lobe atelectasis, which is likely increased compared to
prior study.
Pulmonary vasculatures are within normal limits, and there is no
evidence of
cardiac failure.
There is no suspicious lesion in skeletal structures.
IMPRESSION: Cardiac pacemaker leads as described above. No
pneumothorax.
Cardiomegaly. Increased bilateral pleural effusion and
atelectasis.
Brief Hospital Course:
Ms. [**Known lastname **] is a 68 yo woman who underwent pacemaker placement two
weeks prior to admission, found to have subsequent pericardial
and pleural effusions with moderate tamponade. She then
underwent pericardiocentesis draining 600cc of fluid. Following
the procedure she was observed in the CCU, where she remained
stable until returning to the cardiology service a few days
later. After her pericardiocentesis, she underwent pacer lead
revision. A repeat Echo showed stable small to moderate
effusion without evidence for tamponade. She did have bilateral
pleural effusions, which were not clinically significant given
that her ambulatory saturations were >90% on room air.
Regarding her atrial fibrilliation, we titrated up her
beta-blocker because she was tachycardic upon exertion.
Cardioversion was not completed because anticoagulation is
contraindicated after pericardiocentisis.
Discharge Medications:
1. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Dorzolamide HCl 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 3 days.
Disp:*9 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
cardiac tamponade
pericardial effusion
pleural effusion
atrial fibrillation
tachy/ brady syndrome
s/p pacemaker
h/o TIA
diverticulosis
hypertension
peptic ulcer disease
Discharge Condition:
stable
Discharge Instructions:
please call your doctor or go to the emergency room if you
develop worsening shortness of breath
Followup Instructions:
with Primary care physician within one to two weeks of discharge
please call your cardiologist for a follow up appointment in [**12-19**]
weeks after discharge
Please keep scheduled appointment with Dr [**Last Name (STitle) 1911**] ([**Telephone/Fax (1) 55291**] in [**Location (un) **].
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 55292**] Call to schedule
appointment
|
[
"401.9",
"428.0",
"996.72",
"511.9",
"423.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.75",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
7368, 7436
|
5572, 6478
|
355, 395
|
7649, 7657
|
1427, 3186
|
7802, 8242
|
6501, 7345
|
7457, 7628
|
3257, 5549
|
7681, 7779
|
1259, 1408
|
3219, 3240
|
296, 317
|
423, 988
|
1010, 1180
|
1196, 1244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,251
| 114,528
|
31464
|
Discharge summary
|
report
|
Admission Date: [**2200-7-28**] Discharge Date: [**2200-8-16**]
Date of Birth: [**2126-1-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Scheduled cardiac catherterization for further assessment of
aortic stenosis
Major Surgical or Invasive Procedure:
[**2200-7-31**] - 1. Aortic valve replacement with a 21 mm [**Last Name (un) 3843**]
[**Doctor Last Name **] magna pericardial valve. 2. Left atrial exploration and
ligation of left atrial appendage.
History of Present Illness:
Pt is a 74 yo man with h/o stroke in [**2186**] on warfarin, recent
TIA in [**5-1**], a. fib, HTN, and dyslipidemia who presents for
scheduled cardiac catheterization for further assessment of
aortic stenosis. Pt reports he was recently diagnosed by
echocardiogram in [**7-1**]. He planning for a AVR with Dr.
[**Last Name (STitle) **], [**First Name3 (LF) **] R.
.
Pt reports he is in his usual state of health. He denied any
chest discomfort or palpitations at rest or with exertion. He
does become DOE after 1 flight of stairs. This has been
progressively worse over the last few months, esp. after his TIA
(presented with general weakness and diplopia x 2-3 hours in
[**5-1**]) after which he had been "taking it easy." He had no
recent syncopal events. He does have a remote history of
syncope during a humid day after standing up too quickly.
.
Pt denied paroxysmal nocturnal dyspnea, orthopnea, ankle edema.
He also denied HA, cough, hemoptysis, N/V/D, abdominal pain,
melena, or BRBPR, and recent fevers or chills. He denies
exertional buttock or calf pain.
Past Medical History:
1. Aortic stenosis
2. A. fib
3. HTN
4. Hypercholesterolemia
5. h/o TIA (generalized weakness, diplopia, dysarthria) in
[**5-1**]
6. h/o stroke (R-sided paresthesias) in [**2186**]
7. h/o intermittent vertigo after L ear infection
7. h/o hernia repair
8. h/o L shoulder surgery
Social History:
Social history is significant for the 15 pack years, quit 37
years ago. He has 1 beer/day. He denies recreational drug use.
Family History:
Father died of stroke in his 40s. Brother has HTN and MS. Pt
is unaware of h/o MI, SCD.
Physical Exam:
VS - P76, BP165/68, R18, 97% RA
Gen: older male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple without JVD. No carotid bruits noted.
CV: PMI located in 5th intercostal space, midclavicular line.
Irreg. irreg, normal S1, S2. Grade II/VI high-pitched
crescendo-decrescendo murmur best heard at RUSB radiating to
apex. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: warm, no edema.
Skin: No stasis dermatitis, ulcers, scars.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2200-7-28**] 05:17PM PT-15.2* PTT-30.0 INR(PT)-1.4*
[**2200-7-28**] 05:17PM PLT COUNT-147*
[**2200-7-28**] 05:17PM WBC-8.3 RBC-5.16 HGB-14.7 HCT-42.5 MCV-82
MCH-28.5 MCHC-34.7 RDW-16.2*
[**2200-7-28**] 05:17PM GLUCOSE-92 UREA N-14 CREAT-1.3* SODIUM-140
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-31 ANION GAP-13
[**2200-7-29**] Cardiac Cath
1. Coronary angiography of this right dominant system revealed
moderate two vessel coronary artery disease with slow perfusion
consistent with microvascular dysfunction. The LMCA had ostial
20%
and distal 40% stenoses. The proximal LAD had a 40-50% stenosis
at S1.
The distal LAD wrapped well around the apex. The D1-D4 vessels
(D2
being the largest) were patent. The LCx had a 50% stenosis in a
small
distal AV groove just after takeoff of the major OM2. The RCA
had a 30%
stenosis at the origin, and mild diffuse disease was noted
throughout.
There was a large RPL.
2. Resting hemodynamics revealed elevated left sided filling
pressures with LVEDP of 21-23 mmHg. There was moderate
pulmonary
hypertension with PASP of 46-47 mmHg. The cardiac index was
depressed
at 1.1 L/min/m2 with modest augmentation of cardiac output with
dobutamine to 15 mcg/kg/min (with minimal change in heart rate
and only
mild increase in systemic systolic arterial pressure), based on
a
measured oxygen consumption post-sedation. The SVR and PVR were
elevated at 3994 and 222 dynes-sec/cm5.
3. The mean aortic valve gradient was 42 mm Hg at rest with a
calculated aortic valve area of 0.5 cm2 WIth dobutamine
infusion at 15
mcg/kg/min, the gradient rose to 56 mm Hg, with calculated valve
area of
0.5 cm2. The calculated valve area will UNDERESTIMATE the true
valve
area in the setting of his known aortic regurgitation.
4. Left ventriculography showed a moderate-severely calcified
aortic
valve, mild (1+) non-ectopic mitral regurgitation, and normal
wall
motion with estimated ejection fraction of 60%.
[**2200-7-30**] Carotid Study
There is a less than 40% right ICA stenosis and less than 40%
left ICA stenosis with antegrade flow in both vertebral
arteries.
[**2200-8-6**] Ultrasound
1. Limited study.
2. Gallstone, without evidence of cholecystitis.
3. Slightly echogenic liver, likely steatotic, however, other
forms of liver disease such as significant hepatic fibrosis or
cirrhosis cannot be totally excluded.
4. Bilateral pleural effusions.
[**2200-8-10**] CT Scan
1. Stranding seen adjacent to the pancreas tail, consistent with
mild uncomplicated pancreatitis. No evidence of pseudocyst
formation or other sequelae of pancreatitis.
2. Peripherally-enhancing relatively low attenuation lesion seen
within the spleen, most likely representing a hemangioma, or
possibly other vascular lesion.
3. Cholelithiasis.
4. Bilateral pleural effusions with associated atelectasis.
[**2200-8-14**] CXR
Left lower lobe atelectasis and pleural effusions have improved
and nearly resolved. No pneumothorax is identified. The left
subclavian line remains in the mid SVC.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2200-7-28**] for surgical
management of his aortic stenosis. As his coumadin had been
stopped 4 days prior to admission, heparin was started for
anticoagulation given his chronic atrial fibrillation. He
underwent a cardiac catheterization in preparation for surgery
which showed mild two vessel coronary artery disease, severe
aortic stenosis, mild pulmonary hypertension and a normal left
ventricular function. Given his past history of stroke, a
neurology consult was obtained. A head CT scan showed a moderate
degree of small vessel ischemic changes and scattered lacunes.
His risk of perioperative stroke was thus estimated to be around
4.8-8.8% and he was cleared for surgery. On [**2200-7-31**], Mr. [**Known lastname **] was
taken to the operating room where he underwent an aortic vakve
replacement using a 21mm pericardial valve and a left atrial
appendage ligation. Postoperatively he was taken to the
intensive care unit for monitoring. On postoperative day one,
Mr. [**Known lastname **] was found to not be appropriately following commands
but moved all extremities and remained intubated. He developed
rapid atrial fibrillation and cardioversion was attempted
unsuccessfully. Amiodarone was thus started for rate control. On
postoperative day three, Mr. [**Known lastname **] was extubated. He was slow to
improve neurologically however was making steady progress. He
was transfused with packed red blood cells for postoperative
anemia. Ceftriaxone was started for possible aspiration
pneumonia however his chest x-rays remained normal. His
ceftriaxone thus discontinued. Mr. [**Known lastname **] continued with high
nasogastric tube output and he was held NPO for a suspected
ileus. His output eventually decreased and his NG tube was
removed on postoperative day 6. Mr. [**Known lastname **] soon developed emesis
and his NG tube was replaced. Laboratory studies were consistent
with pancreatitis and TPN was started for nutrition. The genral
surgery service was consulted for assistance with his
pancreatitis. A CT scan was performed which showed stranding
seen adjacent to the pancreas tail which was consistent with
mild uncomplicated pancreatitis however no evidence of
pseudocyst formation or other sequelae of pancreatitis was
identified. Mr. [**Known lastname 50840**] nasogastric tube (NGT) output slowly
decreased. On [**2200-8-7**], he transferred to the step down unit for
further recovery. TPN continued for nutrition. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. Coumadin was continued for
anticoagulation for atrial fibrillation. He continued to be
gently diuresed towards his preoperative weight. Slowly Mr.
[**Known lastname 50840**] lipase and amylase trended back towards normal. An oral
diet was started and slowly advanced as tolerated. Stopped [**8-15**].
Pt stable for DC
Medications on Admission:
Metoprolol 175 mg po daily
lipitor 20 mg po daily
furosemide 20 mg po daily
quinopril 20 mg po daily
coumadin as directed
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Enalapril Maleate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO ONCE (Once):
follow INR goal is [**12-28**] (afib).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Quinapril 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
AS s/p AVR
Hyperlipidemia
HTN
AF
Sick Sinus Syndrome
Cholilithiasis
Stroke [**2186**]/ [**5-1**]
Postoperative pancreatitis
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 cardiologist/pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10543**] in [**11-26**] weeks.
[**Telephone/Fax (1) 4475**]
Please have thyroid studies done in 1 month. Newly started on
levothyroxine, a medication for hypothyroidism.
Completed by:[**2200-8-16**]
|
[
"293.0",
"577.0",
"424.1",
"272.4",
"427.31",
"401.9",
"V12.59",
"414.01",
"997.4",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"37.23",
"89.60",
"88.53",
"39.61",
"38.93",
"88.56",
"37.99",
"99.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10313, 10379
|
6153, 9096
|
352, 554
|
10546, 10554
|
3119, 6130
|
11297, 11672
|
2126, 2217
|
9268, 10290
|
10400, 10525
|
9122, 9245
|
10578, 11274
|
2232, 3100
|
236, 314
|
582, 1657
|
1679, 1966
|
1982, 2110
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,293
| 147,927
|
25085
|
Discharge summary
|
report
|
Admission Date: [**2103-8-9**] Discharge Date: [**2103-8-30**]
Date of Birth: [**2060-5-23**] Sex: M
Service: MEDICINE
Allergies:
Diflucan
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation- [**2103-8-9**] and [**2103-8-16**]
History of Present Illness:
This is a 43 year old male with HIV since [**2089**], last CD4 count
of 150 and [**Year (4 digits) 18617**] load of 200,000 with recent admission for PCP
and new onset/diagnosed renal failure ([**Date range (2) 62934**]) who
presented earlier today with increasing shortness of breath,
fevers and rigors over the last few days. The patient was found
by hotel staff (staying at the Comfort Inn) to be weak today,
"collapsed" by ED report. EMS was called and noted patient to be
hypoxic and dyspneic on arrival to ED with a respiratory rate in
the 40's, sats 50% on RA, temperature of 103, tachycardic to 115
and BP of 137/87. A 100% non-rebreather was placed with
improvement in saturations to 100% but still with respiratory
rate in 30's to 40's. A repeat chest x-ray showed bilateral,
interstitial infiltrates in a central distribution (hilar),
concerning for persistent PCP. [**Name10 (NameIs) **] was given 5 liters of
intravenous fluids in the emergency department, primaquine,
clindamycin, solumedrol 125 mg IV x 1, levofloxacin 750 mg IV x
1, ceftriaxone 1g IV x 1, and was admitted to the [**Hospital Unit Name 153**]. On
arrival to the [**Hospital Unit Name 153**], patient was in respiratory distress and
history was limited given his inability to speak in full
sentences. He reports feeling better after last admission and
reports taking his primaquine/clinda/levoflox as prescribed (ID
team counted pills and are suspicious of medicine
non-compliance). Of note, he was seen by his new primary care
physician, [**Name10 (NameIs) **] [**Last Name (STitle) **], for follow up last week and was doing
well, without any respiratory complaints. He felt recurrence of
fevers/ chills /malaise a few days ago. Denies dysuria, pain,
chest discomfort, but is actively rigoring during conversation,
with resp rate in 40's-50.
Past Medical History:
1. [**Name (NI) **] Pt was diagnosed in [**2089**]. Hic CD4 count at that time was
913. Pt has been on multiple HAART regimens in the past with
question of resistant viruses in the past although recent
testing did not show resistence.
2. HIV nephropathy
3. H/P pancreatitis
Social History:
Born in [**Location 652**] where he lived for 35 years. Patient then
moved to [**Location (un) 5953**] and then to [**State **]. He is
currently unemployed but reports he used to be an administrative
assistant. Not sexually active - last partner 9 months ago.
Reports multiple male partners, history of unprotected sex prior
to diagnosis, since HIV dx always uses condom. History of
tobacco x 27 years- quit 3 weeks ago. History of crack abuse but
sober x 22 months. No IVDA. No blood transfusions or tattoos.
Drinks alcohol socially.
Family History:
Noncontributory.
Physical Exam:
PE: T 103 in ED, now 99. 1 BP 136/75 P 111 R 44 sat 99% NRB
Gen: chronically ill appearing African American man in resp
distress, diaphoretic, tachpneic, rigoring, not able to speak in
full sentences
HEENT: sm amt white plaque on tongue; no oral lesions, mucous
membranes dry, temporal wasting present, beaded with
diaphoresis, non rebreather in place
neck:supple
chest: coarse breath sounds with crackling at bases, difficult
lung exam due to weakness and inabilty to get posterior exam
CV: tachy but no m/r/g, hyperdynamic
ABD: soft, non tender, limited exam performed
EXTRM clammy, diaphoretic, no edema, hyperdynamic pulses
NEURO: [**State 3584**], lethargic, oriented, following commands, rigoring;
difficult historian
skin: no rashes, diaphoretic, soaking sheets/pillow
Pertinent Results:
On Admission:
[**2103-8-9**] 11:20AM PT-13.3 PTT-32.6 INR(PT)-1.2
[**2103-8-9**] 11:20AM PLT SMR-NORMAL PLT COUNT-366
[**2103-8-9**] 11:20AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
[**2103-8-9**] 11:20AM NEUTS-89.1* BANDS-0 LYMPHS-9.5* MONOS-0.9*
EOS-0.3 BASOS-0.2
[**2103-8-9**] 11:20AM WBC-9.6 RBC-3.17* HGB-8.5* HCT-25.2* MCV-80*
MCH-26.8* MCHC-33.7 RDW-15.2
[**2103-8-9**] 11:20AM OSMOLAL-274*
[**2103-8-9**] 11:20AM TOT PROT-4.2* ALBUMIN-1.6* GLOBULIN-2.6
CALCIUM-6.0* PHOSPHATE-5.8* MAGNESIUM-1.2*
[**2103-8-9**] 11:20AM CK-MB-1
[**2103-8-9**] 11:20AM ALT(SGPT)-29 AST(SGOT)-70* CK(CPK)-154 ALK
PHOS-56 AMYLASE-230* TOT BILI-0.3
[**2103-8-9**] 11:20AM GLUCOSE-96 UREA N-45* CREAT-4.1*# SODIUM-129*
POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-24 ANION GAP-16
[**2103-8-9**] 11:34AM LACTATE-1.3
[**2103-8-9**] 12:35PM LACTATE-0.9
[**2103-8-9**] 12:35PM TYPE-ART PO2-252* PCO2-25* PH-7.51* TOTAL
CO2-21 BASE XS-0
[**2103-8-9**] 05:30PM [**Month/Day/Year 14246**] RBC-6* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0
[**2103-8-9**] 05:30PM [**Month/Day/Year 14246**] BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2103-8-9**] 05:30PM [**Month/Day/Year 14246**] COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2103-8-9**] 05:30PM [**Month/Day/Year 14246**] OSMOLAL-297
[**2103-8-9**] 05:30PM [**Month/Day/Year 14246**] HOURS-RANDOM CREAT-61 SODIUM-22
[**2103-8-9**] 05:30PM ETHANOL-NEG bnzodzpn-NEG barbitrt-NEG
[**2103-8-9**] 05:30PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-POSITIVE
[**2103-8-9**] 05:30PM CALCIUM-5.7* PHOSPHATE-6.6* MAGNESIUM-1.2*
[**2103-8-9**] 07:24PM freeCa-0.81*
[**2103-8-9**] 07:24PM TYPE-ART TEMP-34.7 RATES-14/4 TIDAL VOL-550
PEEP-5 O2-100 PO2-333* PCO2-27* PH-7.42 TOTAL CO2-18* BASE XS--4
AADO2-370 REQ O2-64 -ASSIST/CON INTUBATED-INTUBATED
.
INTERVAL DATA:
BRONCHIAL LAVAGE: Other Body Fluid Hematology:WBC: 0 RBC: 0
Polys: 26 Lymphs: 30 Monos: 27 Other: 17 Cell Counts Not
Performed Foamy Hisiocytes
GRAM STAIN (Final [**2103-8-9**]): 1+ (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2103-8-11**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final [**2103-8-19**]): NO LEGIONELLA ISOLATED.
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2103-8-10**]):
POSITIVE FOR PNEUMOCYSTIS CARINII
[**Month/Day/Year **] CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2103-8-10**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending): no growth to date
.
[**2103-8-10**] CMV [**Month/Day/Year **] Load (Final [**2103-8-13**]): CMV DNA not detected.
by PCR.
.
Rapid Respiratory [**Month/Day/Year **] Antigen Test (Final [**2103-8-10**]):
Respiratory [**Month/Day/Year 18617**] antigens not detected. SPECIMEN SCREENED FOR:
ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV.
[**Month/Day/Year **] CULTURE (Preliminary): VIRUS. CYTOMEGALOVIRUS-LIKE
CYTOPATHIC EFFECT, reported [**2103-8-22**].
.
Lumbar Puncture ([**8-16**]):
ANALYSIS WBC 0, RBC 8, Polys 1, Lymphs 0, Monos 0
CLEAR AND COLORLESS
CHEMISTRY TotProt 16 Glucose 52
HSV negative, [**Male First Name (un) 2326**] virus negative, RPR pending
cytology negative for malignant cells, rare small lymphocytes
GRAM STAIN (Final [**2103-8-16**]): NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN. NO MICROORGANISMS SEEN.
- FLUID CULTURE (Final [**2103-8-19**]): NO GROWTH.
- [**Month/Day/Year **] CULTURE (Preliminary): NO FUNGUS ISOLATED.
- ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
- [**Month/Day/Year **] CULTURE (Pending)
CRYPTOCOCCAL ANTIGEN (Final [**2103-8-17**]): CRYPTOCOCCAL ANTIGEN NOT
DETECTED.
.
Stool ([**8-22**], [**8-23**], [**8-24**])- culture negative for MICROSPORIDIA,
CYCLOSPORA, NO ENTERIC GRAM NEGATIVE RODS FOUND, SALMONELLA OR
SHIGELLA, CAMPYLOBACTER, OVA + PARASITES, VIBRIO, YERSINIA,
E.COLI 0157:H7, Cryptosporidium/Giardia and negative for C. Diff
x3
.
Toxo IgG/IgM - negative
Sputum [**2103-8-16**] Gram stain: >25 PMNs and <10 epithelial
cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS.
RESPIRATORY CULTURE (Final [**2103-8-18**]): SPARSE GROWTH
OROPHARYNGEAL FLORA.
[**Month/Day/Year **] CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
Blood cultures 9/15 and [**8-10**]: negative
Blood cultures 9/19 and [**8-16**]: negative
.
[**2103-8-23**] CMV [**Month/Day/Year **] Load (Final [**2103-8-25**]): 13,400 copies/ml. by
PCR.
Imaging:
CXR [**8-9**]: Multifocal opacities in both lung fields, consistent
with
multifocal pneumonia, progressed from as compared to the prior
x-ray. PCP,
[**Name10 (NameIs) 1065**] infections, and tuberculous infection remain in the
differential
diagnosis.
.
Head CT w/out contrast [**8-16**]: 1. Prominence of the sulci for the
patient's age that may indicate mild atrophic change. 2. White
matter hypodensity in the posterior centrum semiovale and
posterior periventricular region bilaterally that may represent
small vessel disease. If the patient has history of HIV, other
etiologies of white matter disease may be considered such as
direct HIV-related white matter disease. This appearance
is not typical for PML.
.
EEG [**8-17**]: IMPRESSION: This is a moderately abnormal EEG due to
the presence of a slow background consistent with a moderate
encephalopathy. The presence of beta activity likely represents
intercurrent or recently discontinued benzodiazepine use. No
evidence for ongoing seizures is seen at this time.
.
MRI Head [**8-18**] : 1. Bilateral globi pallidi T1 and T2
hyperintense lesions, which is a nonspecific finding. This can
appear in hepatic insufficiency and hyperalimentation. Diffuse
hypoxia is also a cause, although this is not likely, as there
is no evidence of restricted diffusion. No lesions
suggesting toxoplasmosis or lymphoma are identified. 2.
Scattered T2 and FLAIR hyperintense lesions in the
periventricular white matter, which may represent HIV
encephalopathy.
.
Brief Hospital Course:
Mr. [**Known lastname 31292**] is a 43 yo man w/ HIV CD4 150, VL 200K, admitted
with respiratory failure secondary to Pneumocystis carinii
pneumonia (Pneumocystis jiroveci pneumonia).
.
# Hypoxia/resp distress: Thought to be due to PCP, [**Name10 (NameIs) **] recent
history and positive testing for PCP in sputum. Was treated with
primaquine, clindamycin, and prednisone with initial
improvement, but then had questionable medicine non-compliance
in recent days and clinical deterioration. Of note, he was ruled
out for Tb on last admission and had negative infectious work up
otherwise. On admission, ID service counted pills and patient
had too many in bottle to have taken anti-PCP meds daily, so
unclear if this episode represents treatment failure or
incomplete treatment for PCP. [**Name10 (NameIs) 227**] patient's distress, patient
was semi-urgently intubated. Patient was started on IV bactrim
and solumedrol (allergy to bactrim very questionable). Given low
CD4 count, patient was also covered for other bacterial PNA.
Bronchoscopy was performed with BAL which was sent for gram
stain, PCP, [**Name10 (NameIs) 18617**] pathogens and came back positive for PCP.
[**Name10 (NameIs) **] histoplasma, legionella was also sent and were negative.
CMV [**Name10 (NameIs) 18617**] load was checked as well as coccidomycoses serology
which were negative. Empiric CAP coverage was started with
azithromycin and ceftriaxone. Patient then developed a rash,
maculopapular, initially over his anterior chest which then
spread to his face and legs. Bactrim was discontinued since
patient had had a questionable allergy to bactrim in the past.
ID was consulted regarding optimun treatement of PCP. [**Name10 (NameIs) **]
was made to restart bactrim since this is the preferred
treatment given his severe infection. Patient was
prophylactically treated one time with Benadryl and did not
subsequently develop the same rash. Patient was also switched to
Vancomycin and Ceftazidime for bacterial pneumonia coverage
after ID consultation. Patient as continued on Bactrim and
steroids for PCP [**Name Initial (PRE) 11091**]. Serial CXRs remained unchanged showing
bilateral diffuse pulmonary infiltrates with sparing of the
costophrenic/costodiaphragmatic angles. The patient's
respiratory status improved with good ventilation/oxygenation by
ABG. Patient was weaned off sedation and extubation was
attempted on [**2103-8-16**]. Patient did well in terms of his
respiratory status, saturating well with ABG 7.42/31/83. After
approximately one hour, the patient began to decompensate rather
acutely, became somnolent, unresponsive, with flaccid paralysis
and therefore he was re-intubated for protection of his airway
given the acute change in his mental status. After
re-intubation, patient spiked a temperature of 101.7. Patient
was pancultured, sputum showed 1+ gram positive cocci and
current antibiotics were continued with ID following the patient
closely. Since this time, his respiratory status has remained
stable with ongoing intubation pending workup of his mental
status changes. Patient was successfully extubated on [**2103-8-20**]
and saturating well with ABG 7.44/37/118 post-extubation.
Patient was eventually weaned off O2 and sating 98% on room air.
Patient continued on IV bactrim (to complete 21 day coarse) and
tapered off steroids (methylprednisolone 20mg IV 11 day coarse).
CMV grew from BAL culture and a repeat CMV [**Date Range 18617**] load was
13,400. For concern of CMV pneumonitis given the viremia and
positive bronchial fluid culture, IV gancyclovir was started for
a 1 week course (until [**8-31**]). Patient should then start PO
valgancyclovir 450mg PO QOD and this dose should be renally
adjusted until CD4 count increases. Patient should have CMV
[**Month/Day (4) 18617**] load checked on [**9-3**] to assess efficacy of treatment for
CMV viremia. If [**Month/Year (2) 18617**] load >600 copies would discontinue
valgancyclovir and restart IV gancyclovir and treat for another
2 weeks at which time a CMV [**Month/Year (2) 18617**] load should be rechecked. If
[**Month/Year (2) 18617**] load <600, then switch from IV gancyclovir to PO
valgancyclovir and continue as directed above. Patient completed
methylprednisolone 11 day taper on day of discharge. Patient
will also need to be on azithromycin 1200mg QWK as prophylaxis
for [**Doctor First Name **] and Bacrtim SS PO QD after completion of IV Bactrim for
PCP [**Name Initial (PRE) 1102**].
.
# Change in Mental Status: Patient acutely decompensated after
extubation, non-responsive, with flaccid muscle tone, reflexes
present in both upper and lower extremities, toes were
equivocal, no focal deficits but appeared to be in semi-comatose
state. Patient may have seized or post ictal since seen to be
posturing at times, tremor present intermittently. CT head was
negative for acute bleed or mass, although it was performed
w/out contrast. LP performed subsequently which was clear,
opening pressure 19, no WBC, protein/glucose wnl, crypto
negative. Toxo negative as well. Neuro consulted, considering
diagnosis of [**Male First Name (un) 2326**] virus as cause of PML. EEG showed diffuse
encephalopathy but no focal seizure activity. MRI showed
occipital periventricular T2 flash suggestive of watershed
stroke vs. HIV encephalopathy vs. PML. Neuro continues to
follow. CSF cultures pending for HSV, RPR, [**Male First Name (un) 2326**] virus. Now
avoiding sedating meds to further eval changes in mental status.
Patient seems more [**Male First Name (un) 3584**] and more responsive but still very
groggy and difficult to arouse. Patient's mental status
gradually improved to be [**Male First Name (un) 3584**] and oriented x3, back to
baseline.
.
# Dropping Hct: Patient's Hct baseline at approximately 25.
Gradually dropped down to a low of 20, requiring transfusion.
Later stabilized to 26-27 and not requiring transfusion for
several days. Likely low at baseline secondary to renal failure,
also question of bone marrow suppression from bactrim,
underlying HIV. Iron studies not helpful in setting of
transfusions. Patient likely needs EPO as outpatient given
chronic renal failure.
.
# HIV: Last CD4 150, [**Male First Name (un) 18617**] load 200K, not on HAART currently
given history of resistance to anti retrovirals and in setting
of acute infection. Likely to benefit from HAART once over acute
illness as outpatient, also in setting of possible CNS
infection. Patient monitored and treated for any associated HIV
infections. Patient noted to have a few episodes of diarrhea on
[**8-16**] likely [**12-27**] to aggressive bowel regimen, C. Diff negative.
Patient followed closely by infectious disease. HAART was held
initially and now resumed [**8-28**] on abacavir, lamuvidine,
fosamprenavir, ritonavir.
.
# Renal failure: Patient with FSGS/HIV nephropathy and baseline
Cr around 6. Renal consult placed a few days after admission and
did not recommend dialysis as patient has been making good
[**Month/Day (4) **], nor further worsening of Cr. In addition, Bactrim may
falsely elevate Cr. Patient treated with IVF, limited diuretics,
increased phoslo due to elevated phos, other electrolytes
followed closely. Patient also with low bicarb down to 15,
possibly due to RTA, improved with bicarb drip to 22, not
requiring further treatment. Hyponatremia [**8-28**] with no
improvement after 1L NS. Not fluid depleted given no [**Month/Day (4) **]
lytes and euvolemic on exam. Likely SIADH given Uosm>100, will
fluid restrict and monitor Na. Improved after fluid restriction
of 1500 cc.
.
# Access: left midline placed [**8-29**].
.
# Comm: With patient, does not have proxy and did not want
anyone to be informed of his admission. Patient clearly wanted
to be intubated during resp distress.
Required blood in emergency effort to treat dropping Hct. LP and
CT head done urgently given acute change in MS.
.
# Prophylaxis: sc heparin, ppi, pneumoboots.
.
# FEN: Electrolytes monitored and repleted as necessary, ionized
calcium low requiring repeated repletion. Patient was on tube
feeds, held several times for high residuals, treated with
reglan during tube feeding and then discontinued. IVF initially
with bicarb, I/Os even thereafter. Patient now taking ample PO.
Bowel regimen.
.
# Code: Full
Medications on Admission:
1. Clindamycin
2. Prednisone taper (on 20 mg qd now?)
3. Primaquine
4. Protonix
5. Phoslo
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: 1-2 tabs PO Q4-6H
(every 4 to 6 hours) as needed.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
3. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
4. Calcium Acetate 667 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
7. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Chlorpromazine 25 mg Tablet Sig: One (1) Tablet PO QID PRN.
10. Epoetin Alfa 4,000 unit/mL Solution Sig: 4000 (4000) unit
Injection QMOWEFR (Monday -Wednesday-Friday).
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
12. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Fosamprenavir 700 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
15. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
16. Trimethoprim-Sulfamethoxazole 80-400 mg/5 mL Solution Sig:
Four Hundred (400) mg Intravenous Q12H (every 12 hours): until
[**9-2**].
17. Ganciclovir Sodium 500 mg Recon Soln Sig: Two Hundred (200)
mg Intravenous Q24H (every 24 hours): until [**8-31**].
18. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
19. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO once a
week.
20. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day:
Start [**9-3**].
21. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO QOD:
Start [**9-1**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis:
PCP [**Name Initial (PRE) 1064**]
Secondary diagnosis:
Bacterial pneumonia
HIV
Hypertension
Renal failure
Anemia of chronic disease
Probable HIV encephalopathy
Discharge Condition:
Stable
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all follow-up appointments.
3. Seek medical attention for fevers, chills, chest pain,
shortness of breath, abdominal pain, or any other concerning
symtpoms.
4. Continue IV gancyclovir until [**8-31**] and IV bactrim until [**9-2**].
Patient should then start valgancyclovir 450mg PO QOD renally
adjusted until CD4 count reaches a level that does not require
prophylaxis for CMV and HSV. Start Bacrtim SS PO QD after
completion of IV Bactrim for PCP [**Name Initial (PRE) 1102**].
5. Patient will also need to be on azithromycin 1200mg QWK as
prophylaxis for [**Doctor First Name **].
6. Patient should have CMV [**Doctor First Name 18617**] load checked on [**9-3**] to assess
efficacy of treatment for CMV viremia. If CMV [**Month/Year (2) 18617**] is >600
copies, then would discontinue valgancyclovir and restart IV
gancyclovir for an additional 2 weeks and then recheck CMV [**Month/Year (2) 18617**]
load. [**Month (only) 116**] need foscarnet if CMV [**Month (only) 18617**] load is still elevated
after total of three weeks treatment with gancyclovir.
Followup Instructions:
Please follow-up with a physician in the facility to which you
are discharged.
Completed by:[**2103-8-30**]
|
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9,052
| 152,259
|
28207
|
Discharge summary
|
report
|
Admission Date: [**2120-9-27**] Discharge Date: [**2120-11-5**]
Date of Birth: [**2063-5-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Bactrim / Sudafed / Ifosfamide
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Intractable vomiting
Major Surgical or Invasive Procedure:
Left subclavian hemodialysis line insertion
Hemodialysis
Left salpingo-oophorectomy
Small bowel resection
History of Present Illness:
Patient transfer from OSH
.
HPI: Patient is a 57 y/o woman with a PMH of DM type II, HTN,
obesity and hyperlipidemia who presented to an OSH on [**9-16**] with
complaints of 5 days of intractable vomiting and fatigue. She
states she was unable to hold anything down and her vomitus
consisted of food, no blood. She denied diarrhea or abdominal
pain at the time. She also denied fevers, chills. On history she
also noted increasing abdominal girth over the last year with a
weight gain of 40 lbs in 1 year. Initially the patient was given
IVF hydration and kept NPO. A RUQ US was done which showed no
cholecystitis. 3 days after admission the patient c/o LLQ pain
and had some diarrhea so a CT abdomen was obtained. CT showed
diffuse peritoneal carcinomatosis with a complex cystic solid
mass in the left adnexa measuring 12x6x7cm. Patient then
underwent CT-guided intraperitoneal biopsy which was consistent
with Burkitts lymphoma. CA 125 was 1580 and CED was less than
0.5.
.
At the OSH the patient's Cr was found to increase to 1.9 and her
uric acid level was 18. She was started on IVF with bicarb.
Renal saw her and questioned the need for dialysis. Her hospital
course was complicated by acute renal failure felt to be
secondary to tumor lysis syndrome and possibly a component of
contrast nephrophathy. Creatinine fluctuated between 1.1-1.5
during OSH stay and then rose to 1.9 on the day of transfer to
[**Hospital1 18**]. The patient also had an episode of a fib [**2120-9-21**].
Cardiology was consulted. She was rate contolled with
beta-blockers and anticoagulation was not continued because of
hematocrit drop. The decision was made to transfer her to [**Hospital1 18**]
for further treatment of her lymphoma.
.
At [**Hospital1 18**], she was transferred to BMT service on [**9-27**]. She was
started on chemotherapy for lymphoma and received 4 doses of
chemotherapy. She developed acute renal failure and had urgent
HD. Following her HD treatment on [**2120-9-30**] she spiked to 101.8
and developed new oxygen requirements and placed on 100% NRB.
CXR [**9-30**] with clear lungs. On the morning of [**10-1**] the patient
became hypotensive to SBP in 80's responsive to fluid bolus. ABG
7.40/41/101. The decision was made to transfer patient to ICU
for close monitoring in the setting of hypotension, anuria and
hypoxic respiratory failure.
.
In the ICU, she was found to have perforation and sent to OR.
Ultimately, she was found to have a perforated jejunum and s/p
ex-lap/small bowel resection/left salpingo-oophorectomy ([**10-2**]).
She had a CVL placed for CVVH, and was extubated on [**10-4**]. She is
currently on TPN, and last PM developed atrial fibrillation,
given amiodarone and converted to NSR.
.
She is now being transferred back to the BMT service. Currently,
she is feeling well with no complaints except mild abdominal
tenderness which a controlled with percocet. She denies any
fever, chills, nausea, vomiting, headache, chest pain,
palpitations, lightheadedness, shortness of breath.
Past Medical History:
DM type II
HTN
Obesity
Psoriasis
h/o GI bleed [**2-8**] AVM on recent colonoscopy
h/o squamous cell cancer of R leg
Social History:
Lives with husband and step-son in [**Name2 (NI) 10358**] Mass. Works as a
bookkeeper in a bicycle shop. Denies tobacco use. Occasional
EtOH use. States that husband is an alcoholic.
Family History:
Sister died of a brain tumor, unknown type. No other h/o
malignancy
Physical Exam:
VS: T 97 BP 98/48 P 70 RR 20 O2 sat 92% RA
General: pale, well-nourished woman lying in bed, NAD
HEENT: EOMI, PERRL, mucous membranes dry, no lesions in OP
Neck: supple, no LAD
CV: RRR, no m/r/g
Chest: Mild crackles at bases, otherwise CTA
Abdomen: Distended, firm but no rebound or guarding, no palpable
masses, normoactive BS
Ext: LE wrapped in ACE bandages, 2 small non-helaing ulcers on
each lower leg.
Skin: Psoriatic lesions on b/l LE and upper extremities
Neuro: AAO x3, moving all 4 extremities, non-focal
Pertinent Results:
WBC 9.6
Plt 473
Hct 27.1
Na: 138
K: 4.4
Cl: 98
HCO3: 25
BUN: 51
Cr: 2.2
Ca 8.2
Phos: 4.9
Uric acid: 17.6
.
Studies performed at OSH:
TTE at OSH: Normal LVEF
.
CT abdomen: Diffuse peritoneal carcinomatosis with high
attenuation throughout omentum, complex cystic solid mass in the
left adnexal region, large area of extensive massive soft tissue
metastatic tumor occupying a vast majority of the left side of
the abdomen, encasing some bowel loops. many gallstones. Fluid
within peritoneum. Bilateral plueral effusions.
.
LE US: Negative for DVT
.
DIAGNOSIS:
Biopsy, "omental cake" High grade malignant lymphoma:
The specimen consists of a core needle biopsies of soft tissue
and fat, which is diffusely infiltrated by sheets of
mediam-sized to large lymphocytes. These lymphocytes are
somewhat monomorphic, with a moderate amount of basophilic
cytoplasm and one mostly a single prominent nucleolus. While
many of these lymphocytes have smooth nuclear contours, others
have irregularly-shaped nuclei. These are mitotic figures and
apoptotic bodies, and scattered tingible-body macrophages
present. There is no recognizable architecture present.
Immunoperoxidase studies performed at the outside hospital show
the lymphoma to be positive for CD20 and CD79a; there is strong
co-expression of CD10; the MIB-1 fraction is estimated at >90%;
CD3 and CD5 stain scattered admixed T-cells. A cytokeratin
AE1/AE3 is negative. A bcl-2 stain performed at our institution
stains scattered smaller lymphocytes, and rare larger cells.
The submitted peripheral smears show no evidence of circulating
Burkitt's lymphoma. The above histologic and reported
immunohistochemical findings are consistent with a high-grade
non-Hodgkin B-cell lymphoma. Given the strong CD10 staining with
high (>90%) MIB-1 fraction, Burkitt's or atypical Burkitt's
lymphoma needs to be considered. FISH study for c-myc
translocation may be helpful in confirming Burkitt lymphoma.
.
echo: [**2120-10-2**]: Conclusions:
1. The left atrium is normal in size. The left atrium is
elongated.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left
ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function appears depressed.
4.The aortic valve leaflets are mildly thickened. There is no
aortic valve
stenosis.
5. Normal mitral valve leaflets with trivial mitral
regurgitation is seen.
6.There is no pericardial effusion.
7. The RV function is hard to assess but suspect that it may be
slightly
decreased.
Brief Hospital Course:
This is a 57 y/o woman with h/o DM type II, HTN with newly
diagnosed high grade lymphoma who had hospital course
complicated by anuric renal failure requiring dialysis, acute
respiratory failure, and jejunal perforation s/p ex-lap/small
bowel resection/left salpingo-oophorectomy on [**10-2**].
.
1. Heme/onc (Lymphoma): The patient presented with large ovarian
and omental masses and the OSH did a biopsy and felt the patient
had Burkitt's lymphoma. The patient was transferred to [**Hospital1 18**]
for therapy. She was treated with (maggrath protocol) 4 days of
CODOX-M ([**Date range (1) 68538**]), but unfortunately developed tumor lysis
syndrome, hypotension and renal failure. She was transferred to
the ICU in the setting of hypotension, anuria and hypoxic
respiratory failure. In the ICU, she was found to have
perforation and sent to OR. Ultimately, she was found to have a
perforated jejunum and s/p ex-lap/small bowel resection/left
salpingo-oophorectomy ([**10-2**]), once the patient was stable she
returned to BMT. On return she was treated with IT-ARA- C
([**10-10**]) and on [**10-12**] IVAC chemo (2 doses of ifosfamide, 2 doses
of cytarabine and 1 dose of etoposide). The patient developed
mental status changes and was only responsive to pain. This is
a rare side effect of ifosfamide, and so she was given methylene
blue as a treatment and her mental status improved. During her
course her cytogenetics returned and she was c-myc negative and
her biopsy was consistent with high-grade non-Hodgkin B-cell
lymphoma. She remained clinically stable on the floor and given
the new diagnosis she was treated with CHOP-R on [**2120-10-29**] (one
dose). She tolerated the CHOP-R well and remained afebrile and
without complications from the treatment. Her blood counts were
closely followed, and she did not require any interventions
after her CHOP. The patient will follow up with Dr. [**Last Name (STitle) 410**]
regarding future plan of treatment and will also be on
filgrastim to prevent neutropenia.
.
2. Pulmonary (Cough): As above, the patient was transferred to
the ICU for hypotension and respiratory failure, and was treated
with oxygen as needed, nebs, and Zosyn for empiric coverage.
She was intubated for her bowel surgery and was successfully
extubated. Her serial CXR's revealed LLL infltrate and pleural
effusion, that remained stable, though on [**10-14**] her CXR revelaed
new increased infiltrate/pulm edema on LUL. She was continued on
Vanc and Zosyn (which she was on after her bowel surgery). She
improved with diuresis, and atrovent neb. In addition to the
above measures as she was noted to have a persistent cough
refractory to many anti-tussives, we stopped her lisinopril on
[**2120-10-26**] and switched to valsartan. Although she continued to
have a slight dry cough, it was much improved and she remained
afebrile and without exam findings through the remainder of her
course.
.
3. Infectious disease: As noted above, the patient developed
abdominal tenderness and pneumoperitoneum, and was sent to OR.
Ultimately, she was found to have a perforated jejunum. She had
an ex-lap/small bowel resection/left salpingo-oophorectomy
([**10-2**]). During the patient's course she developed multiple
infections. She was noted to have enterococcus infection in her
peritoneal fluid and was treated with vancomycin. She was
originally on several medications (zosyn, flagyl and vancomycin)
for her bowel perforation but as she had no need for these
medications they were all stopped. Later in her course, she
spiked a fever to 103 and was restarted on Vanc and Zosyn, and
when she spiked again levofloxacin was added to better cover
gram negsatives in gut. She was found on CT abdomen to have a
fluid collection in the pelvis, but this was likely related to
her post-op state. Though, as above to cover for possible GI
abscess she was remained on zosyn, vanc and levo. As her
abdominal pain and fevers resolved all of the above medications
were discontinued. Finally, in terms of infection, the patient
was noted during her course to have oral lesions consistent with
HSV (swab was positive), her pain and lesions improved with
acyclovir treatment. By discharge she was afebrile and with no
active ID issues.
.
4. Cardiology: During the patient's course she was noted to
have paroxysmal atrial fibrillation. She was on an amiodorone
drip in ICU, then oral and tapered off. On the floor she
developed afib with RVR and responded to IV lopressor and IV
diltiazem. Cardiology was consulted and felt the patient most
likely had peri-op MI and recommended continued beta-blockade.
They did not feel she needed amiodorone and thought once her
chemo is finished and her hemotocrit, coags and platelets are
stabilized coumadin/anti-coagulation could be readdressed. As
an inpatient though, they did not think she should receive
anti-coagulation. In addition to the above, the patient's ECHO
showed depressed EF from > 55% to 45%, she was thought to have
mild CHF, but she imporved with diuresis. On discharge she no
longer displayed signs of fluid overload, and she was rate
controlled with metoprolol.
.
5. Endocrine (DM): The patient is an insulin-dependent type II
diabetic. The patient was on TPN after her bowel surgery and
difficulty with food after her IVAC therapy. While on TPN she
was given insulin, but as her sugars remained poorly controlled
she was restarted on her home lantus. Her sugars were followed
closely as she was transitioned to a PO diet and she remained
better controlled on lantus, SSI and a diabetic diet.
.
6. Renal: As above, at the OSH, the patient was found to have
acute renal failure felt to be secondary to tumor lysis
syndrome. Creatinine fluctuated between 1.1-1.5 during OSH stay
and then rose to 1.9 on the day of transfer to [**Hospital1 18**]. At [**Hospital1 18**],
she received rasburicase prior to chemo, and she was started on
chemotherapy for lymphoma and received 4 doses of chemotherapy.
She developed acute renal failure and had urgent HD. In the
unit, she was treated with CVVHD (her original line clotted off)
and by transfer back to the floor her renal function improved.
By discharge, her renal function was completely stable and no
further intervention was needed.
.
7. Dermatology (Psoriasis): The patient was concerned as she has
bad psoriasis that was coming back because she has not been
taking her etanercept. She should not take this anymore given
the fact that it could cause lymphoma. Her psoriasis remained
stable, and treatment in the future should be readdressed as an
outpatient
Medications on Admission:
Medications at home:
Lipitor 40 mg QD
lisinopril 40 mg QD
Avandia 4 mg [**Hospital1 **]
Lantus 40 U QHS, Regular ISS
MVI
Calcium
Bowel regimen
Discharge Medications:
1. Prochlorperazine Edisylate 5 mg/mL Solution Sig: [**1-8**]
Injection Q6H (every 6 hours) as needed.
2. Insulin Glargine Subcutaneous
3. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection
Q24H (every 24 hours).
4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
5. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): please take 125 mg po tid.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: please take metoprolol 125 mg PO tid.
7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ipratropium Bromide 0.02 % Solution Sig: [**1-8**] Inhalation Q6H
prn as needed for wheezing, sob.
9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
12. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-15**]
MLs PO Q6H (every 6 hours) as needed for cough.
13. Senna 8.6 mg Capsule Sig: [**1-8**] Capsules PO q daily prn as
needed for constipation.
14. Colace 100 mg Capsule Sig: [**1-8**] Capsules PO q daily prn as
needed for constipation.
15. Insulin Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 6978**] House of [**Location (un) 5871**]
Discharge Diagnosis:
Primary
1. High grade lymphoma
2. Acute renal failure
3. Insulin dependent diabetes
4. Paroxysmal atrial fibrillation
5. Perforated small bowel tumor
6. Left ovarian tumor
Discharge Condition:
stable
Discharge Instructions:
1. Please return to the hospital for increasing fevers,
shortness of breath, worsened cough, new chest pain.
2. Please continue to have your glucose closely monitored and
have your insulin regimen adjusted to maintain goal Hemoglobin
A1C less than 7.
3. You will have your oncology follow-up with Dr. [**Last Name (STitle) 410**]
4. You will take filgrastim until Dr. [**Last Name (STitle) 410**] advises otherwise,
to prevent neutropenia.
Followup Instructions:
1. You should follow up with Dr. [**Last Name (STitle) 3657**] regarding your
diabetes management. Once your chemo is finished, you should
have your doctor readdress the need for
coumadin/anti-coagulation given your atrial fibrillation. We
also stopped your lipitor, this will likely be restarted by your
primary care doctor as well.
2. Please attend the following appointment:Provider: [**Name10 (NameIs) **] [**Name8 (MD) 68539**], MD [**First Name (Titles) **] [**Last Name (Titles) 10341**],[**First Name3 (LF) **] HEMATOLOGY/ONCOLOGY-CC9
Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2120-11-13**] at 2:30 pm
|
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15569, 16010
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275, 297
|
471, 3490
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3512, 3630
|
3646, 3830
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,428
| 152,771
|
16935+16936
|
Discharge summary
|
report+report
|
Admission Date: [**2119-11-3**] Discharge Date: [**2119-11-9**]
Date of Birth: [**2095-5-6**] Sex: F
Service: MEDICINE
Allergies:
Sulfamethizole / Zosyn / Penicillins / Sulfa (Sulfonamides) /
Iodine / Vancomycin / Zofran
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
removal of tunneled hemodialysis catheter
lumbar puncture
IR guided hemodialysis catheter placement x 2
History of Present Illness:
24 yo F with history of lupus complicated by lupus nephritis and
ESRD, presented to hospital with fever and rigors. Was in
dialysis this morning and noted to have white exudate coming
from around her left tunneled dialysis line. Additionally,
patient notes that she has had a fever, shaking chills,
headache, sore throat, odynaphagia, neck ache, and diarrhea
since Wednesday [**2119-11-1**]. As for sick contacts, she reports
that her sister and her twin nieces have had cold symptoms in
the last week; however, the symptoms were slightly different and
not as severe as her symptoms. Patient had a seasonal influenza
vaccine this year, but did not receive the H1N1 vaccine. Related
to her HD line, she had a portion of her catheter exchanged at
the Advanced Vascular Center in [**Location (un) 583**] 2 weeks ago after her
HD line was found to be occluded. Patient reports being anuric
at baseline. She does note some new chest pain today that
radiates to her back. The pain is not severe and does not appear
to be related to respiratory cycle. The back pain is a familiar
pain to her and it usually controlled by acetaminophen.
Vitals upon presentation to the ED were: T 99.4, HR 110, BP
137/89, RR 16, O2Sat 100% on RA. Rigors and spiked temp to 103
with tachycardia to 140s. Blood pressure drifted down to 80s
through ED course. Received IVF. Was started on norepinephrine
peripherally after failed attempt in ED to place right IJ, due
to resistance threading wire so procedure aborted. Patient
refused femoral line. Two peripheral IVs were placed. Received
daptomycin and meropenem per ID recs. Prior to transfer to the
ICU vitals were: T 101, HR 120, BP 122/64, RR normal and O2 sat
was normal on RA.
REVIEW OF SYSTEMS:
(+)ve: fever, shaking chills, fatigue, diarrhea, myalgias, sore
throat, odynaphagia, headache, chest pain, back pain
(-)ve: night sweats, loss of appetite, palpitations, rhinorrhea,
nasal congestion, cough, sputum production, hemoptysis, dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting,
constipation, hematochezia, melena, focal numbness, focal
weakness, arthralgias
Past Medical History:
1) Lupus (diagnosed [**2115**]) c/b lupus nephritis and ESRD on HD.
Outpt nephrologist is Dr. [**First Name (STitle) 805**]. Goes to [**Location (un) **] on MWF. No
longer on any BP meds given borderline low BPs.
2) Hypertension in the past.
3) Sjogren's
4) She has a swollen gland that was removed by ENT last year
5) BOOP/COP
6) Inflammatory arthropathy
7) Hx of myositis
8) History of pericarditis and pericardial effusion
9) Numerous line infections
10) Genital herpes
11) Depression
12) History of thrombosed AV fistula- L tunneled catheter placed
on [**2119-6-30**]
Social History:
Lives in [**Location 583**]. College student at Baypath College. Lives
with mother, grandmother.
[**Name2 (NI) 1139**]: Denies
EtOH: Denies
Illicits: Denies
Family History:
Sister: SLE
Mother: Diabetes mellitus
Father: Healthy
Maternal grandmother: asthma and HTN
Physical Exam:
VS: T 99.8, HR 107, BP 144/51, RR 17, O2Sat 100% RA
GEN: NAD
HEENT: PERRL, EOMI, scleral injection bilaterally, oral mucosa
moist, oropharynx benign
NECK: Supple, left anterior cervical chain tenderness though no
[**Doctor First Name **] throughout neck, no JVP distention
THORAX: CTAB, left anterior tunneled HD line without exudates at
skin entrance, appearance of ointment around catheter skin
entrance
CARD: Tachy, nl S1, nl S2, no M/R/G
ABD: BS+, soft, NT, ND
EXT: no C/C/E
SKIN: no rashes or lesions identified
NEURO: Oriented x 3, CN II - XII intact, BLE strength intact
PSYCH: Mood and affect appropriate
Pertinent Results:
Labs on admission:
WBC-2.7* Hgb-14.4# Hct-44.7# MCV-83 MCH-26.9* MCHC-32.3
RDW-15.7* Plt Ct-208
diff: Neuts-91.0* Lymphs-6.4* Monos-1.2* Eos-1.1 Baso-0.2
Glucose-70 UreaN-18 Creat-6.7* Na-140 K-4.8 Cl-100 HCO3-28
AnGap-17
ALT-3 AST-11 CK(CPK)-46
Calcium-8.2* Phos-4.1 Mg-1.3*
HCG-<5
Lactate-2.2*
Labs on discharge:
WBC-4.3 Hgb-12.1 Hct-38.2 MCV-83 MCH-26.5* MCHC-31.8 RDW-15.7*
Plt Ct-159
diff: Neuts-43* Bands-0 Lymphs-13* Monos-9 Eos-33* Baso-0
Atyps-2* Metas-0 Myelos-0
Glucose-67* UreaN-45* Creat-11.2*# Na-140 K-4.5 Cl-99 HCO3-26
AnGap-20
Calcium-9.5 Phos-5.5* Mg-2.3
Micro:
Wound Cx [**11-3**]:
[**2119-11-3**] 9:44 pm CATHETER TIP-IV Source: left tunneled HD
line.
**FINAL REPORT [**2119-11-7**]**
WOUND CULTURE (Final [**2119-11-7**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Blood Cx [**11-3**]:
[**2119-11-3**] 6:30 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
Anaerobic Bottle Gram Stain (Final [**2119-11-4**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16800**] AT 2129 ON
[**2119-11-4**].
Wound Culture
GRAM STAIN (Final [**2119-11-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Daptomycin REQUESTED BY DR.[**Last Name (STitle) 18569**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 2 S
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2119-11-4**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2119-11-4**]):
Negative for Influenza B.
LP [**11-4**]:
1st tube: WBC 7, RBC 636 with 76% poly, 19% lymph
2nd tube: prot 17, gluc 44
4th tube: WBC 2, RBC 49 with 85% poly
Gram stain negative.
[**2119-11-4**] 11:25 pm CSF;SPINAL FLUID Site: LUMBAR PUNCTURE
GRAM STAIN (Final [**2119-11-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2119-11-8**]): NO GROWTH.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
CXR [**11-3**]:
The left subclavian dual lumen dialysis catheter tip terminates
within the proximal right atrium. Low inspiratory lung volumes
are present which accentuates the cardiac silhouette size, which
is mildly enlarged. Chain sutures are noted within the right mid
and lower lung fields. However, no focal consolidation, pleural
effusion, or pneumothorax is seen. The pulmonary vascularity is
within normal limits given the inspiratory effort. The osseous
structures are unremarkable.
Brief Hospital Course:
24 yo F with history of lupus complicated by lupus nephritis and
ESRD admitted with bacteremia and sepsis.
.
# Septic Shock: Given the patient's indwelling HD line with
reported pustular exudate, her hypotension was felt to be
consistent with a septic shock due to an infected line.
Hypovolemic shock was also considered a possibility, because the
patient had received dialysis on the day of admission. However,
she remained hypotensive and required pressors after 5 L of IVF,
which is most consistent with septic shock. She was empirically
treated with daptomycin and meropenem given her past antibiotic
allergies to more traditional agents. Blood cultures were
drawn, and the patient's HD line was removed; Blood cultures
were positive for multi-drug resistant coagulase negative
staphylococcus. Her blood pressure stabilized after aggressive
fluid resuscitation, and she was weaned off of pressors. She
was also treated empirically with oseltamivir, which was stopped
when influenzae DFA returned negative. She was eventually
narrowed to daptomycin given sensitivities. She should complete
the last dose of her 7 day course (after line removal), with one
dose after HD on Friday.
.
# Fevers: Felt to be most likely infectious in etiology and
less likely to be a flare of one of her numerous rheumatologic
conditions given the height of the fever spike and the
association with hypotension. She was ruled out for influenza,
as noted above, HD line was removed and she was treated with
antibiotics. Additionally, the patient complained of
photophopia, HA and neck stiffness and an LP was performed. The
LP revealed mildly elevated numbers of wbcs and rbcs not
consistent with either a bacterial or viral meningitis; this was
felt to be most consistent with a vasculitic process. Her
symptoms resolved with treatment of her infection.
.
# Leukopenia/eosinophilia: WBC count was decreased to 2.7 from
baseline of 5 - 8, which could be consistent with septic
physiology or an acute viral infection. Influenza was ruled
out, as above, and her leukopenia resolved with treatment of her
infection. Of note, she had a significant eosinophilia during
her hospitalization (33% on day of discharge), felt likely to be
due to an antibiotic being used for treatment of her infection.
She had no other symptoms of an allergic reaction, other than
pruritus, but this was not a new complaint. She was given sarna
lotion for her itch.
# ESRD: HD line was removed due to likely infection; pt had
temporary HD line placed in IR on [**11-6**] to prepare for dialysis
on Monday [**2119-11-6**]. She then underwent ultrafiltration on [**11-7**]
and HD again on wednesday. She was continued on cinacalcet and
sevelemer. Pt was also hyperkalemic to 5.8 without symptoms or
ECG changes on [**11-5**] and received kayexalate. She had a
permanent HD line placed in IR on [**2119-11-7**].
.
# Patient enrolled in a research study, and was continued on
study protocol during her admission (per study coordinator Dr.
[**Last Name (STitle) **]. This protocol ended with her discharge.
#HTN: Pressures elevated to 160's systolic. Discussed with Dr.
[**First Name (STitle) 805**] of nephrology, who will see her Friday as an outpatient
and discuss treatment at that time. He asked not to restart her
anti-hypertensives in house.
Medications on Admission:
1) Cinacalcet [Sensipar] 30 mg DAILY
2) Hydroxychloroquine 200 mg QHS
3) Sevelamer HCl [Renagel] 800 mg Tablet TID with meals
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Daptomycin 500 mg Recon Soln Sig: Five Hundred (500) mg
mg Intravenous Q48H (every 48 hours) for 1 doses: Give after HD
on HD days. .
5. Acetaminophen-Codeine 300-15 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for pain for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coagulase Negative Staph Bacteremia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to [**Hospital3 **] after you were found to have an
infection of your hemodialysis catheter. You were briefly in
the intensive care unit, however with IV antibiotics and removal
of your infected PICC line your blood pressures came up and your
fever resolved. You were dialyzed twice and improved
symptomatically enough to continue your antibiotics as an out
patient in dialysis.
The following changes were made to your medications:
You were started on Daptomycin which you should receive after
your HD sessions until further notice from your kidney doctors
(last dose likely Friday).
If you experience high fever (greater than 101), not thinking
clearly, light headedness, nausea, vomitting, shortness of
breath, chest pain, abdominal pain or other concerning symptoms
you should return to the [**Hospital1 18**] ED.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9501**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2119-11-14**]
3:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4900**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2119-11-27**] 11:30
Completed by:[**2119-11-9**] Admission Date: [**2119-11-10**] Discharge Date: [**2119-11-10**]
Date of Birth: [**2095-5-6**] Sex: F
Service: MEDICINE
Allergies:
Sulfamethizole / Zosyn / Penicillins / Sulfa (Sulfonamides) /
Iodine / Vancomycin / Zofran
Attending:[**First Name3 (LF) 826**]
Chief Complaint:
HD catheter dysfunction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
24 yoF w/ a h/o Lupus and lupus nephritis on HD for the past 4
years presents with HD catheter dysfunciton. She was recently
discharged after an admission for sepsis with coag negative
staph bacteremia related to her line. Currently completing a
course of daptomycin qHD 500mg. After this admission she was
sent home with a temporary line and recieved dialysis Monday,
Tuesday, Wednesday. On Wednesday the temporary catheter was
replaced with tunneled line. Line was not functional at Dialysis
today at outside facility. The line was infused with TPA and
patient brought to dialysis unit at [**Hospital1 18**] to attempt dialysis.
If unable to dialyze pt with need an IR procedure for line
placement.
.
Initial VS in the ER were: T 99.2 HR 86 BP 149/105 RR 12 O2
sat 100% on RA. No intervention in the ER.
.
In the dialysis unit, pt is resting comfortably, upset about
readmission. Pt denies any recent chills, fevers, nausea,
vomiting, diarrhea, chest pain, shortness of breath. Pt is
anuric, no changes have been noted in bowel function.
Past Medical History:
1) Lupus (diagnosed [**2115**]) c/b lupus nephritis and ESRD on HD.
Outpt nephrologist is Dr. [**First Name (STitle) 805**]. Goes to [**Location (un) **] on MWF. No
longer on any BP meds given borderline low BPs.
2) Hypertension in the past.
3) Sjogren's
4) She has a swollen gland that was removed by ENT last year
5) BOOP/COP
6) Inflammatory arthropathy
7) Hx of myositis
8) History of pericarditis and pericardial effusion
9) Numerous line infections
10) Genital herpes
11) Depression
12) History of thrombosed AV fistula- L tunneled catheter placed
on [**2119-6-30**]
Social History:
Lives in [**Location 583**]. College student at Baypath College. Lives
with mother, grandmother.
[**Name2 (NI) 1139**]: Denies
EtOH: Denies
Illicits: Denies
Family History:
Sister: SLE
Mother: Diabetes mellitus
Father: Healthy
Maternal grandmother: asthma and HTN
Physical Exam:
Vitals: 169/113, 87, 97.9 20, 100%
General: Alert, oriented, no acute distress, Upset about
readmission
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
Skin: Tunneled Catheter placed in the left chest wall. Scar left
forearm.
Neuro: Strength intact upper/lower extremity. Sensation intact
to light touch upper/lower extremity. CN II-XII intact.
Pertinent Results:
LABS:
No Labs were drawn during admission.
Brief Hospital Course:
24 yoF w/ a h/o Lupus and lupus nephritis on HD for the past 4
years presents with HD catheter dysfunciton
.
# ESRD/HD Catheter Dysfunction: Previous HD catheter removed
secondary to line infection. Patient dialyzed on the three days
prior to admission. Temporary Catheter replaced on day prior to
admission. On day of admission new HD catheter was unable to be
accessed at dialysis unit. Transfered to [**Hospital1 18**]. In dialysis unit
were able to perform suboptimal dialysis. New catheter needs to
be placed. Patient will be discharged and readmitted on Monday
for tunnelled HD catheter placement with IR. Attempted dialysis
today failed secondary to HD catheter dysfunction. Dialysis will
be attempted again at [**Hospital1 18**]. Continued on Sevelamer, Cinacalcet
.
# Bacteremia: Identified during previous admission secondary to
indwelling HD line. Developed hypotension requiring 5L IVF and
pressors consistent with septic shock. HD line removed. Tip
cultured with coagulase negative staph sensitive to Daptomycin.
Last dose of Daptomycin scheduled for today after hemodialysis.
Daptomycin given prior to discharge.
.
# Lupus: Continued on Hydroxychloroquine.
.
# HTN: Patient hypertensive during previous admission and today.
Dr. [**First Name (STitle) 805**] (nephrology) would like wait to start
antihypertensives at this time.
Medications on Admission:
1. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS
2. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Daptomycin 500 mg Recon Soln Sig: Five Hundred (500) mg
mg Intravenous Q48H (every 48 hours) for 1 doses: Give after HD
on HD days. (Last Dose 12/11 after Dialysis)
5. Acetaminophen-Codeine 300-15 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for pain for 6 doses.
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
HD catheter malfunction
Discharge Condition:
Stable, s/p short session of dialysis [**2119-11-10**]
Discharge Instructions:
You were admitted to the hospital for difficulty with your HD
catheter. Your catheter is working but not ideally, this will
need to be replaced on Monday [**2119-11-13**].
Call your doctor if you have any questions. Also call your
doctor if you develop bleeding, chest pain, confusion or any
other symptoms that confuse you.
Followup Instructions:
You have the following appointments:
Line placement for dialysis: XSP WEST INPATIENT RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2119-11-13**] 3:00
Primary care appointment:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9501**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2119-11-14**]
3:40
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11,587
| 179,805
|
53977
|
Discharge summary
|
report
|
Admission Date: [**2128-2-23**] Discharge Date: [**2128-3-26**]
Date of Birth: [**2058-2-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Transferred for mgt of abdominal/pelvic hematoma
Major Surgical or Invasive Procedure:
1.)Central Line Placement
2.)PICC line Placement
3.)Respiratory Intubation/Extubation
History of Present Illness:
69yo woman with PMH as below which includes CAD s/p MI/CABG,
A-fib on coumadin who presented to [**Hospital3 934**] Hospital on
[**2128-2-13**] with fever, shortness of breath and cough. She was
diagnosed with a LLL pneumonia and initially treated with
Ceftriaxone and Azithro. Her respiratory status worsened, she
was transferred to their ICU and intubated for respiratory
failure. Echocardiogram showed a normal EF and BNP was
equivocal making cardiogenic pulmonary edema less likely as a
cause for her resp failure. She was continued on abx and given
stress dose steroids given her chronic Prednisone for RA. Her
status improved until [**2128-2-22**] when she became acutely
hypotensive and was noted to have a drop in hematocrit from 34
to 25 with new abdominal distention. CT revealed a large
abdominal/pelvic mass thought to be a large hematoma and she was
transferred to [**Hospital1 18**] for further mgt. Of note, her INR was
supratherapeutic on arrival to [**Location (un) **] and was corrected with
FFP. She had been restarted on Heparin after her INR on [**2-17**]
was 1.2.
ICU course was remarkable for episodes of hypertension
requiring labetalol and nitroglycerin gtts. Surgery had been
consulted for the hematoma and recommended only monitoring. In
the ICU the patient was successfully extubated on [**2-25**] and
continued on bronchodilators. She had been started on
ceftriaxone/Vancomycin and changed to Ceftazidime for concerns
of VAP. Blood cultures from [**2-26**] were [**2-3**] positive for VRE from
an arterial line. This culture also grew 2 different isolates of
coag negative staph. Antibiotics were altered on [**3-2**] from Vanco
to linezolid given the continued fevers and antibiotic
resistance profile of the enterococcus. The patient's mental
status waxed and waned in the ICU prompting a head CT that was
negative for bleed on [**2-26**]. Her mental status mildly improved
upon transfer to the medical floor. The ICU team was called to
evaluate the patient today secondary to worsening mental status
and hypercarbic respiratory failure. ABG was 7.37/64/144 on 50%
facemask. There had been concern for possible CHF as the cause
of her declining respiratory status on the floor and was
diuresed with 20mg iv furosemide x 2 on [**3-2**] and 20mg iv
furosemide x 1 on [**3-1**]. Her urine output was reported to be
500cc to the last dose of furosemide on [**3-2**].
Past Medical History:
1. CAD s/p MIx2, s/p CABG in [**2115**]
2. A-fib on Coumadin
3. Rheumatoid arthritis on MTX and prednisone s/p Remicade
therapy in past, osteoarthritis
4. Mild COPD
5. Hyperlipidemia
6. HTN
7. Depression
8. Right adrenal adenoma
9. CBD dilatation 2.3 cm noted [**5-2**]
10. Hearing loss
Social History:
Married, Quit smoking 6 months ago - [**2-1**] PPD prior, no ETOH
Family History:
Father died of Lung CA from asbestosis. Mother had CHF
Physical Exam:
99.8 109/60 88 10 100% on AC 500x10 PEEP 5, FiO2 0.40
Gen: Intubated, adequately sedated
HEENT: pupils equal, OGT in place
Neck: no JVD
CV: irreg irreg, no murmur
Resp: coarse rhonchi at left base, otherwise clear
Abd: distended, minimal bowel sounds, large firm pelvic mass
palpable
Ext: no C/C/E, 1+ DP pulses, 2+ femoral pulses b/l
Pertinent Results:
[**2128-2-24**] 05:17PM BLOOD Hct-34.1*
[**2128-2-25**] 04:16AM BLOOD WBC-21.4* RBC-3.85* Hgb-12.0 Hct-34.9*
MCV-91 MCH-31.1 MCHC-34.3 RDW-16.8* Plt Ct-189
[**2128-2-26**] 05:00AM BLOOD WBC-19.1* RBC-3.73* Hgb-11.5* Hct-34.6*
MCV-93 MCH-30.9 MCHC-33.3 RDW-16.7* Plt Ct-220
[**2128-2-29**] 04:30AM BLOOD WBC-12.4* RBC-4.34 Hgb-13.0 Hct-37.8
MCV-87 MCH-30.0 MCHC-34.4 RDW-16.3* Plt Ct-227
[**2128-3-2**] 06:00AM BLOOD WBC-12.3* RBC-4.29 Hgb-13.2 Hct-39.7
MCV-93 MCH-30.8 MCHC-33.3 RDW-16.7* Plt Ct-181
[**2128-3-4**] 04:20AM BLOOD WBC-11.8* RBC-4.05* Hgb-12.7 Hct-37.4
MCV-92 MCH-31.3 MCHC-33.9 RDW-16.9* Plt Ct-180
[**2128-3-5**] 04:14AM BLOOD WBC-10.7 RBC-3.97* Hgb-12.2 Hct-35.2*
MCV-89 MCH-30.8 MCHC-34.7 RDW-16.9* Plt Ct-187
[**2128-2-23**] 06:04PM BLOOD PT-13.2 PTT-25.5 INR(PT)-1.1
[**2128-3-2**] 06:00AM BLOOD PT-12.5 PTT-20.4* INR(PT)-1.0
[**2128-2-23**] 06:35PM BLOOD Glucose-113* UreaN-38* Creat-0.7 Na-145
K-3.9 Cl-113* HCO3-27 AnGap-9
[**2128-2-25**] 04:16AM BLOOD Glucose-122* UreaN-32* Creat-0.6 Na-146*
K-3.6 Cl-111* HCO3-28 AnGap-11
[**2128-2-29**] 04:30AM BLOOD Glucose-89 UreaN-9 Creat-0.3* Na-138
K-3.7 Cl-103 HCO3-29 AnGap-10
[**2128-3-3**] 04:28AM BLOOD Glucose-135* UreaN-16 Creat-0.4 Na-137
K-3.8 Cl-96 HCO3-37* AnGap-8
[**2128-3-5**] 04:14AM BLOOD Glucose-84 UreaN-17 Creat-0.5 Na-135
K-3.7 Cl-95* HCO3-31* AnGap-13
[**2128-2-23**] 06:04PM BLOOD ALT-31 AST-32 LD(LDH)-371* CK(CPK)-405*
AlkPhos-48 Amylase-23 TotBili-0.5
[**2128-3-3**] 04:28AM BLOOD Lipase-82*
[**2128-2-23**] 06:04PM BLOOD CK-MB-8 cTropnT-0.10*
[**2128-3-3**] 04:28AM BLOOD CK-MB-8 cTropnT-0.04*
[**2128-2-23**] 06:35PM BLOOD Albumin-2.6* Calcium-8.1* Phos-4.3 Mg-2.1
[**2128-2-29**] 04:30AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9
[**2128-3-2**] 06:00AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
[**2128-3-5**] 04:14AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.6
[**2128-2-23**] 06:04PM BLOOD TSH-1.7
[**2128-2-23**] 07:51PM BLOOD Type-ART Temp-37.6 Rates-[**11-11**] Tidal
V-500 PEEP-5 FiO2-40 pO2-112* pCO2-40 pH-7.42 calHCO3-27 Base
XS-0 -ASSIST/CON Intubat-INTUBATED
[**2128-2-25**] 05:18AM BLOOD Type-ART pO2-62* pCO2-36 pH-7.48*
calHCO3-28 Base XS-3
[**2128-2-25**] 04:30PM BLOOD Type-ART Temp-38.2 FiO2-70 pO2-90 pCO2-41
pH-7.40 calHCO3-26 Base XS-0 Intubat-NOT INTUBA
[**2128-2-27**] 10:14AM BLOOD Type-ART Temp-37.0 pO2-133* pCO2-43
pH-7.42 calHCO3-29 Base XS-3
[**2128-3-3**] 04:45PM BLOOD Type-ART pO2-115* pCO2-51* pH-7.47*
calHCO3-38* Base XS-12
[**2128-3-3**] 04:45PM BLOOD Type-ART pO2-115* pCO2-51* pH-7.47*
calHCO3-38* Base XS-12
[**2128-3-11**] ABG O2=72 CO2=32, pH=7.48
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
[**2128-3-8**] 01:37PM LG NEG NEG NEG NEG NEG NEG 9.0* NEG
[**2128-3-7**] 09:45AM LG NEG TR NEG NEG NEG NEG 7.0 NEG
RBC WBC Bacteri Yeast Epi TransE RenalEp
[**2128-3-8**] 01:37PM 21* 0 NONE NONE <1
[**2128-3-7**] 09:45AM 2 6* FEW NONE <1
[**2128-2-29**] 08:18AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2128-2-26**] 10:44AM URINE RBC-21-50* WBC-0-2 Bacteri-NONE
Yeast-NONE Epi-[**4-3**]
[**2128-2-29**] 08:18AM URINE RBC-6* WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
URINE CULTURE (Final [**2128-3-16**]):
ENTEROBACTERIACEAE. 10,000-100,000 ORGANISMS/ML..
URINE CULTURE (Final [**2128-3-23**]):
KLEBSIELLA PNEUMONIAE- [**Last Name (un) 36**] to Meropenem
[**2128-3-14**] BLOOD CULTURE -no growth
[**2128-3-14**] BLOOD CULTURE -no growth
[**2128-3-14**] BLOOD CULTURE -no growth
[**2128-3-12**] BLOOD CULTURE -no growth
[**2128-3-12**] BLOOD CULTURE -no growth
**FINAL REPORT [**2128-3-5**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2128-3-5**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2128-3-11**]
2:38p
CK: 66 MB: 7 Trop-*T*: 0.04
Comments: Note Updated Reference Ranges As Of [**2126-7-30**]
Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Other Blood Chemistry:
Cortsol: 11.9
Normal Diurnal Pattern: 7-10am 6.2-19.4 / 4-8pm 2.3-11.9
[**2128-3-4**] 04:20AM URINE HISTOPLASMA ANTIGEN-PND
[**2128-3-4**] 4:20 am SEROLOGY/BLOOD
**FINAL REPORT [**2128-3-4**]**
CRYPTOCOCCAL ANTIGEN (Final [**2128-3-4**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
Performed by latex agglutination.
Reference Range: Negative.
A negative serum does not rule out localized or
disseminated
cryptococcal infection.
Appropriate specimens should be sent for culture.
Reports:
CXR [**2-23**]
1) Cuff of endotracheal tube is overdistended and tip of
vascular catheter abuts the apparent lateral wall of the
superior vena cava. Findings communicated to clinical service
caring for the patient.
2) Lingular and left lower lobe consolidation suggestive of
pneumonia
CXR [**3-3**]
SEMI-UPRIGHT AP CHEST: The patient is post median sternotomy.
The left subclavian line is unchanged in position, with the tip
in the proximal SVC. The NG tube is unchanged. The heart and
mediastinal contours are normal. Partial atelectasis of the left
lower lobe with elevation of the left hemidiaphragm is
unchanged. The remainder of the lung fields are normal.
CXR [**3-6**]
Comparison is made with the prior film from [**2128-3-3**]. The
position of the left central line is unchanged. The atelectasis
in the left lower lobe present in the prior chest x-ray has
resolved. No areas of consolidation are seen. There is no
significant failure or effusion.
CXR [**3-11**]
CT Head [**2-26**]
No evidence of intracranial hemorrhage, infarction or other
acute intracranial pathology.
MR HEAD [**3-5**]
IMPRESSION:
1. No evidence of acute infarction.
2. Apparent sinus mucosal thickening likely due to her previous
intubated state.
3. Bilateral mastoid air cell opacification.
4. Minimal chronic small vessel ischemic infarcts.
Chest CT [**3-5**]
Impression:
1. Patchy ground glass opacities in bilateral lungs, probably
representing edema due to CHF.
2. Bibasilar atelectasis and small pleural effusion.
3. Consolidative opacity in left lower lobe, which can represent
early pneumonia, however, this can also be edema. Please
correlated clinically, and if neccesarry, please follow up after
CHF is treated.
4. Somewhat nodular opacities in right loer lobe, which cannot
be further evaluated with the presence of edema. Please also
follow up the lesions after CHF is treated.
5. Left subcutaneous swelling, please correlate clinically.
6. Low density lesion in the kidney as described above.
Chest CTA [**3-8**]
1) Bilateral pulmonary emboli.
2) New upper lobe infiltrates right greater than left.
[**3-9**] C-Spine
No fracture or malalignment is identified of the cervical spine.
C1 and C2 articulate normally. Degenerative changes are noted at
multiple levels, most prominent in the lower cervical spine.
There is no evidence of spinal canal narrowing. Opacification of
the right mastoid is noted. There is focal parenchymal scarring
noted in the right lung apex. Soft tissues are otherwise
unremarkable. The study is limited by patient motion.
[**3-11**] XRAY Flex/Ex C-spine
These films are not labeled as to flexion or extension. Since
[**2128-3-4**], the nasogastric tube has been removed. The bones are
osteopenic. C1 through C7 vertebral bodies are visualized. There
is no listhesis or compression fracture. There is mild to
moderate loss of intervertebral disc space at C5/6 and [**7-6**].
There is no prevertebral soft tissue swelling.
IMPRESSION:
1. Inadequate evaluation to clear cervical spine. Please refer
to the recent CT of the cervical spine for clearance.
2. Although flexion and extension views were requested, these
are not labeled as such.
EMG [**3-4**]
Complex, abnormal study. The electrophysiologic findings are
most suggestive
of a severe, ongoing myopathy, superimposed on a generalized,
sensorimotor
polyneuropathy which is axonal in nature. Clinically, this is
consistent with
an acute quadriplegic or critical illness myopathy. Notably,
there are,
additionally, severe abnormalities of activation involving both
upper and
lower extremities, which indicate the presence of a superimposed
central or
upper motor neuron process contributing, in large part, to the
patient s
weakness. These results were conveyed to the Neurology consult
service
verbally on [**2128-3-4**].
CT HEAD W/O CONTRAST [**2128-3-13**]
Stable CT appearance of the brain, allowing for limitations due
to head motion. No acute intracranial hemorrhage or mass effect.
IVC GRAM/FILTER [**3-14**]
Successful placement of retrievable recovery IVC filter inferior
to the level of the renal veins via right common femoral access
CT ABD W&W/O C; CT PELVIS W&W/O C [**3-14**]
) A large, extraperitoneal heterogeneous mass representing a
hematoma is seen arising from the left rectus abdominis muscle
posteriorly. Additionally, there is a smaller hematoma within
the right rectus abdominis muscle. No free fluid is seen within
the abdomen.
2) Nonspecific areas of parenchymal consolidation are seen
within the left lung base, which likely represent aspiration.
Several foci of ground glass opacity tree-in-[**Male First Name (un) 239**] changes may
represent non-specific inflammatory change.
Echo [**3-15**]
The left atrium is moderately dilated. The left ventricular
cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right
ventricular chamber size appears borderline dilated and free
wall motion is
probably preserved (but views are suboptimal). The aortic valve
leaflets (3)
are mildly thickened. There is no aortic valve stenosis. No
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild
(1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no
pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of
[**2128-3-3**], tricuspid regurgitation is now more prominent and the
estimated
pulmonary artery systolic pressure is now higher.
[**2128-3-13**] Lower Ext U/S
No evidence for DVT
[**2128-3-13**] CXR
1) Increased left lower lobe opacity, which can represent
atelectasis versus pneumonia.
2) Mild CHF versus volume overload.
Brief Hospital Course:
MICU Course [**0-0-0**]
1. Hematoma: Surgery was consulted and felt that the mass was
likely a hematoma, which would require close monitoring due to
concerns over infection. Her hematocrit was stable throughout.
Initially, the mass caused the patient to become hypotensive
while lying on her R side, which resolved by discharge.
Throughout her hospital course, hematoma continued to resolve
and HCT remained stable.
2. HTN: The patient remained fairly hypertensive following
admission, and at one point required a NTG and then labetolol
drip. She was gradually changed to PO Metoprolol, captopril,
and HCTZ, which maintained good BP control. 3. Respiratory
failure: Pt was extubated without complications. Continued on
bronchodilators. She was initially on CTX/Vanco, which was
changed to Ceftaz/Vanco due to concerns about nosocomial
vent-associated PNA.
4. Rheum: Hydrocortisone was initially started, then changed to
Prednisone as the patient was taking prior to admission.
Course on Floor: [**0-0-0**]
In summary, this is a 69yo female with hx of respiratory failure
in the MICU, CAD, Afib( was on Coumadin), RA, HTN, and r adrenal
adenoma presents who from OSH w/ PNA, supratherapeutic INR, and
abdominal mass concerning for rectus sheath hematoma.
Neuro: MS slowly improving, still displaying signs of delirium
but intermittently lucid and following commands. CT head in MICU
r/o bleed/stroke. MRI would be ideal, but respiratory status
makes difficult. MS change possibly secondary to lacunar stroke,
embolus from AFIB, or benzos/opiates given for purpose of
intubation. During patients second day out of MICU on floor,
mental status improved. Patient able to communicate and follow
commands to some degree.
Fever: Despite current negative sputum cx, negative BCX, and
therapy w/ ceftaz and vanc, patient continued to spike fever.
Could be secondary to resolving hematoma or infected A-line.
[**2-26**] cx were positive for staph and enterococci. During HD#8 on
floor, patient continued to have temp with Tmax=100.4.
Hematoma: Currently appears to be receding, if HCT<30 transfuse.
Try and avoid turning patient on right side as hematoma puts
pressure on IVC.
HTN: BP is labile per MICU. C/w metropolol, HCTZ, Captopril.
During her first night out of MICU, HD#7 patient had systolic
pressure of 170. Given her normal renal function, patients
captopril was increase from 75mg qd to 100mg qd on HD#8
Resp: Extubated [**2128-2-25**], throughout hospital course, patients
O2 sats improved to 99% on 40% face mask. Portable Chest xray on
[**2128-3-2**] showed a resolving PNA in LLL. However, patient continued
to wheeze. On [**2128-3-3**], patient displayed respiratory distress
with ABG CO2 of 64. On [**2128-3-2**] patient was given dose of dilaudid
for pain. Subsequently the patient displayed decreased resp
ability and was transfered to the [**Hospital Unit Name 153**] on [**2128-3-3**].
Rheum: C/w maintenance prednisone for treatment of RA during her
hospital course.
FEN: During her hospital course tube feeds were increased to
45cc/hr.
Proph: Pneumoboots
Access: Central line
Code Status: Full
Dispo: Will follow
[**Hospital Unit Name 153**] Course [**2128-3-3**]- [**2128-3-5**]
Resp: On [**3-3**] patient was transfered from floor to [**Hospital Unit Name 153**] secondary
to ABG CO2 of 64 with HCO3 of 36. Given that the patient
received pain meds the night of [**2128-3-2**], it was hypothesized that
this reduced her respiratory effort. Patient received BIPAP and
improved.
Floor Course: [**2128-3-5**]-
Resp: Patient's breathing improved with better respiratory
effort, patient's sats were 95% on 2lNC. An ABG done on [**2128-3-6**]
revealed O2 of 82 and CO2 of 36, which indicated patient's resp
status was improving. Throughout the weekend [**Date range (1) 7601**] the
patients heart rate ranged from 60s to 120s. Given the patient's
tachycardia and dyspnea, a r/o PE CTA was ordered which was
positive for PE. The patient was immediately started on Heparin
600u IV q hour. The CTA also revealed evidence of bilateral
upper lobe infiltrates. ID was consulted as to whether ABX
should be restarted, and felt that the CT findings were not
concerning. On [**3-11**] the patient had an ABG which showed
improvement with O2=72 and Co2=32. Throughout the hospital
course the patient's respiratory status continued to improve and
the patient was weaned off nasal canula. Of note the patient had
intermittent periods of hypoxia thought to be secondary to
agitation. Each time these lasted for five to ten minutes and
spontaneously resolved. A CXR on [**3-11**] revealed no change from
prior studies, only a slight exacerbation of the LLL atelectasis
present in prior films. On [**3-11**] the patient's respiratory status
improved to 95%sat on room air.
Neuro: Neurology was consulted on [**2128-3-3**] and felt that
patient's mental status decline was secondary to a
toxic-infectious-metabolic etiology. It was suggested that the
patient avoid opiates and benzodiazepines and obtain an MRI to
rule out stroke. The MRI revealed no evidence of infarctions. On
physical exam neurology also reported the patient as being
areflexic/ quadriplegic with a positive babinski sign on the
right side. The patient was placed in a soft [**Location (un) 2848**] J Collar and
MRI of the Cervical Spine was ordered in order to rule of spinal
cord compression. Given the patient's history of rheumatoid
arthritis and report of difficult intubation, and an
inconclusive spine MRI, a CT myleogram was ordered which
revealed possible C4-C5 compression . The patient had an EMG/NCS
which revealed polyneuropathy. The etiology of the quadraplegia
was also thought to be secondary to ICU neuropathy. Neurology
felt that patient did not require further spinal cord imaging.
Between [**Date range (1) 80951**], the patient' mental status improved and she
began moving all extremities and intermittently followed
commands. A C-Spine CT and C-SPine xray revealed no fractures,
stenosis, or compression of the cervical spine. Only
degenerative changes were displayed. On [**2128-3-11**] the patient was
started on Zoloft after being discontinued per earlier neurology
recs for concern about serotonin syndrome. It was then
discontinued again per ID. Her free cortisol was obtained which
revealed a normal level.
CVS: Patient's echo on [**2128-3-3**] reveals LVH w/ good ef of 55%.
There is a question of enlarged septum that will require follow
up as an outpatient. On [**3-2**] patient received 20mg lasix x2 and
breathing status improved. Therefore it is possible that mild
CHF is contributory to her pulmonary status. Chest CT on
[**2128-3-5**] revealed some degree of CHF with bilateral ground glass
opacities, pulmonary edema, a small left pleural effusion and L
base consolidation which could be edema. Patient's afib
controlled on coumadin, she was started on heparin and coumadin
overlap on [**3-9**]. Throughout the hospital course after transfer
from the MICU, the patient occassionaly became tachycardic into
the 110s-120s. Serial EKGs revealed no evidence of MI, ischemia,
or arrythmia. However, there was a small troponin leak of .04
during this period.
ID: Patient con't to have fevers. On [**2128-3-5**] patient remained
afebrile. It was thought that fever could be secondary to
empyema, but CT ruled out. On [**2128-3-5**] patient was restarted on
Ceftazadime which was discontinued on [**2128-3-3**] and also started
on Flagyl for prophalaxysis against aspiration PNA. She
continues her course on linezolid. Endocarditis was also
considered as a cause but ruled out by echo on [**2128-3-3**].
Cultures of cryptococcous, histoplasmosis, c-diff, and blood cx
were all found to be negative. On [**3-7**] per ID all ABX were held
and the patient's vitals carefully followed for signs of
fever/infection. She was pan cultured with blood, urine, and
sputum cultures continuing to be negative. On [**3-7**] she had a
positive UA and as a result the foley catheter was changed and
UA repeated, which was negative. The patient remained afebrile
until the afternoon of [**3-11**] when she spiked a temp of 101 which
subsequently resolved. However, blood cultures were collected
and the patient was started on Flagyl and levofloxacin.
Heme: HCT stable and improved during the hospital course.
Hematoma continues to resolve by physical exam. ANCA was found
to be negative. Throughout her hospital course HCT stabalized
and Coumadin was restarted for proph against AFIB.
HTN: Patient has labile HTN being controlled on HCTZ, Metropolol
and Captopril.
Rheum: Patient continued on prednisone.
FEN: Tube feeds started at 10ml/hr and were advanced to 45ml/hr
between [**Date range (1) 59473**]. Speech and swallow saw patient on [**3-9**] and
cleared her for po trial. On [**3-9**] the NG tube was pulled and the
patient had trial which showed tolerance of pos. Her diet was
advanced to thin liquids on [**2128-3-9**]. Lytes were repleated prn.
Proph: Pneumoboots
Code: Full Code
Dispo: Pending Improvement.
MICU Course [**3-12**]- [**3-16**]
This is a 69yo female with hx of respiratory failure in the
MICU, CAD, Afib( was on Coumadin), RA, HTN, and r adrenal
adenoma presents who from OSH w/ PNA, supratherapeutic INR, and
abdominal mass concerning for rectus sheath hematoma. She was tx
from MICU on [**2128-3-1**]
after extubation on [**2127-2-24**]. Her current problems include,
likely resolving ICU neuropathy with mental status change,
fevers, compromised respiratory status from resolved LLL PNA and
bilateral PEs for which she was on heparin between [**Date range (1) 50572**], and
labile HTN. She has a resolving abdominal hematoma, which again
enlarged during her course of heparin between [**Date range (1) 50572**].
She was tx to the floor on [**2128-3-1**] and tx back to the MICU on
[**2128-3-3**] for decreased respiratory effort secondary to dose of
dilaudid. Patient returned to floor on [**2128-3-5**] and subsequently
retransfered to the MICU for respiratory distress, mental status
changes and a fever on [**2128-3-12**]. She returned to the floor on
[**2128-3-16**].
.
A/P:
.
1. Neuro: MS slowly improving, still displaying signs of
delirium but intermittently lucid and following commands. CT
head in MICU on [**3-13**] and r/o bleed/stroke. MRI does not
indicate brain lesion. Neuro suggests MS change secondary to ICU
neuropathy or benzos and opiates given during intubation. Neuro
reports that MS secondary to toxic-metabolic-infectious process.
EMG indicates polyneuropathy.
Today, [**3-16**], Patient's mental status improved, follows some
commands and moving all fours. She is AOx3. Some degree of MS
change thought to be secondary to UTI which developed during
floor course [**Date range (1) 108273**]. Patient was given haldol prn overnight
for hallucinations and is now on standing seroquel. On [**3-19**],
patient's mental status continued to demonstrate improvement. On
[**2128-3-21**] patient was AOX3 but demonstrated some degree of
paranoia
.
2. Fever: Patient remained afebrile while in ICU
.
3.ID: +UA, UCx for g- rods while in MICU, now on IV
Levofloxacin. Patient has blood, fungal, and c-diff cultures
which are all negative. Foley changed on [**3-18**] and discontinued
on [**3-21**]. UCX on [**3-21**] was positive for Klebsiella Pneumo
sensitive to Meropenem. Levo was discontinued and Meropenem
started at 1g q12
.
4. CVS: CT Chest shows CHF with mild Pulmonary edema. If she has
difficulty breathing consider one time lasix 20mg. CTA [**3-8**] shows
PE. Patient occasionaly tachy into 110's. No Coumadin for rate
controlled afib. CXR on [**3-18**] showed LLL PNA vs atelectasis.
.
5. Heme: During MICU course ([**Date range (1) 109553**]), patient had abdominal
CT revealing increasing abdominal hematoma, with HCT drop of 10.
While no DVTs or Pelvic thrombosis were noted on abd/pel CT or
lenis, IVC filter placed and patient now off heparin and
coumadin. Patient s/p transufsion for HCT drop while in MICU.
HCT stable at 28-32. Please follow HCT closely, and transfuse
for HCT<28.
.
6. HTN: C/w Lopressor, increase as tolerated.
.
7. Resp: Sat'ing well on room air, weaned slowly from oxygen,
has history of bilateral PE was on heparin/coumading, now with
IVC filter secondary to HCT drop and abdominal hematoma. Need to
keep HOB elevated as risk of aspiration PNA. CXR on [**3-18**]
revealed LLL PNA vs atelectasis slightly increased from prior
studies. [**3-18**] bilateral lower ext u/s revealed no evidence of
DVT
.
8. Rheum: c/w maintenance prednisone.
.
9. FEN: Tolerating POs, will agressively replete lytes prn.
Speech and swallow consulted for evaluation of risk of
aspiration PNA. Advanced patient's diet to soft solids and were
pleased with improvement
.
10. Access: Central line removed in MICU, has PICC.
.
11. Code Status: Full
.
12. Dispo: Family meeting on [**3-18**] came to decision to transfer
patient to rehab on tue [**3-23**] if patient continues current course
of improvement.
Medications on Admission:
Propofol gtt
Fentanyl gtt
Combivent inh
Ceftriaxone 1gm Q24
Levoflox 500 Q24
Protonix
Nystatin
KCl
Lopressor 25mg TID
Diflucan 150mg
EPO 40000U QSun
Hydrocort 100mg IV Q8
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2-4H (every 2 to 4 hours) as needed.
5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
6. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
8. Potassium Chloride 20 mEq Packet Sig: Three (3) PO QAM (once
a day (in the morning)).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
13. Quetiapine Fumarate 25 mg Tablet Sig: 0.5 Tablet PO QAM
(once a day (in the morning)).
14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-1**]
Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing.
15. Meropenem 1 g Recon Soln Sig: One (1) Intravenous every
twelve (12) hours.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
1.)Respiratory failure
2.)PNA
3.)Pulmonary Embolism
4.)Abdominal Bleed
5.)Myopathy
6.)Delirium
7.)Urinary Tract Infection
8.) Rheumatoid Arthritis
9.) Atrial Fibrillation
10.)Coronary Artery Disease
11.)Hypertension
12.)Congestive Heart Failure
13.)Line Sepsis
Discharge Condition:
stable
Discharge Instructions:
Please follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] within two weeks of
discharge. Please take all medications as directed and contact
your PCP with questions.
Followup Instructions:
Please follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] within two weeks of date
of discharge
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Completed by:[**2128-5-9**]
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icd9cm
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[
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3214, 3281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,807
| 104,929
|
4198
|
Discharge summary
|
report
|
Admission Date: [**2174-6-6**] Discharge Date: [**2174-6-16**]
Date of Birth: [**2121-12-16**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Reglan / Opioids-Morphine & Related
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Thoracentesis (multiple)
Chest Tube
History of Present Illness:
52 year old female with a history of lone atrial fibrillation
and Lyme meningitis presenting with progressive shortness of
breath over past 2 weeks. On [**5-23**], patient awoke with 10/10
pleuritic pain radiating down to left shoulder to left arm
associated with SOB and diaphoresis. She went to PCP who
ordered [**Name Initial (PRE) **] CTA which was negative for PE and diagnosed her with
pleurisy. She was prescribed motrin 800mg TID.
.
Her pain was mildy improved with the motrin but she developed
DOE which progressed to dyspnea at rest over the past 2 weeks.
Also endorsing chest heaviness, pleuritis left sided/LUQ pain,
orthopnea and PND. Her pain would be releived sitting forward.
Denies LE edema. 1 week ago she experienced 1 day of vomiting x5
episodes NBNB. In the past few days had fevers/chills and abd
distention associated with constipation and low grade headache.
TMax of 101.3. Also had dry cough. Saw PCP who took CXR which
showed pna with b/l pleural effusions.
.
In the ED, initial vitals were T 101 HR 120 BP 120/77 RR 18 Pox
89% RA. Resp distress. CXR L>R effusion and pericardial
effusion. Triggered in the ED for hypoxia to 89% RA, placed on
O2 by N/C + abx(CTX and lev), 2L bolus, followed by 150/hr.
Cards c/s: resolving pericardial effusion, decided not to tap.
Labs notable for ALT: 146 AP: 483 Tbili: 2.4 Alb: 3.3 WBC to 17
(no bands). Believe that pleural effusion may be bigger issue.
Had thoracentesis in ED 1200cc straw colored fluid. Prior to
transfer, 99.4, 110, 122/85, 20, 100% by N/C 5L.
.
Upon arriving to the ICU, patient was in [**10-31**] left sided
pleuritic chest pain. She felt SOB slightly improved. Pain worse
and different after thoracentesis. Also endorsed "contact"
dermatitis with couple blisters on lower extremities worse 2
weeks ago thought to be a nickel allergy. She has been drinking
POs well recently but appetite poor. Endorsed 1 year of
nightsweats which she believes are postmenopausal. Of note, she
missed her [**2173**] mammogram.
.
ROS:
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No recent weight loss or gain.
HEENT: No sinus tenderness, rhinorrhea or congestion. CV: No
palpitations. PULM: No wheezing. GI: No nausea, diarrhea, or
abdominal pain. No recent change in bowel habits, no
hematochezia or melena. GUI: No dysuria or change in bladder
habits. MSK: No arthritis, arthralgias, or myalgias. NEURO: No
numbness/tingling in extremities. PSYCH: No feelings of
depression or anxiety. All other review of systems negative.
Past Medical History:
SHOULDER PAIN, LEFT-S/P LABRAL TEAR REPAIR AND AC REPAIR
FRACTURE, FINGER
OSTEOPENIA
MENOPAUSAL STATE
LYME DISEASE meningitis [**2170**] s/p 3 years of abx(seasonal
plaquinel plus doxycycline alternating with clarithromycin,
finished in [**12-31**]
ATRIAL FIBRILLATION-PAROXSYMAL since age 24
MIGRAINE
HERPES SIMPLEX
COSTOCHONDRITIS
Social History:
She has one dtr age 8. She is a landscape designer who runs her
own business. She does not smoke. Denies recent travel. Does
live in [**Location (un) 1514**] and has hiked recently but no noted ticks.
Denies ever having PPD placed
ETOH: [**1-23**] martinis a week.
Tobacco: none
Illicits: none
Family History:
Mother-MI [**95**] but survived
4 younger siblings healthy
father died of [**First Name9 (NamePattern2) 18275**] [**Last Name (un) 3711**] at 54, grandfather died of lung ca
in 50s, a smoker, paternal aunt had [**Name2 (NI) 18276**] cancer died in 50s
Physical Exam:
VS: 97.3 113 122/76 93%3L, pulsus 12mmHg
GEN: pleasant, visibly in discomfort from L sided chest pain
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, JVP to jaw, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: decreased bS at b/l bases with poor airmovement [**2-23**] effort
and pain
CV: RR, S1 and S2 wnl, no m/r/g
ABD: mild distension, +b/s, soft, TTP in b/l upper quadrants, no
masses or hepatosplenomegaly, no rebound or guarding
EXT: no c/c/e
SKIN: no jaundice/no splinters, left skin with 1inch diameter
round erythematous plaque, ? EN, right posterior LE with small 1
cm erythmatous bliser
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL:deffered
Pertinent Results:
EKG: sinus tachycardia at a rate of 117, normal axis,
non-specific ST,T changes, diffusly low voltage, RBBB pattern.
right bundeloid. ST, T changes are new since [**2-1**].
.
2D-ECHOCARDIOGRAM: ([**2174-6-6**])
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(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) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is a moderate sized pericardial effusion (1.3 cm
anteriorly and 1.8 cm around the right atrium). The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. Stranding is visualized within the
pericardial space c/w organization. No right ventricular
diastolic collapse is seen. There is brief right atrial
diastolic invagination. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling.
.
Compared with the prior study (images reviewed) of [**2174-3-9**],
the pericardial effusion is new. No overt tamponade is seen
however elevated intrapericardial pressure is suggested.
.
Echo: [**6-14**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The small pericardial effusion is echo dense, consistent with
blood, inflammation or other cellular elements and appears
largely organized with minimal free fluid. The pericardium may
be thickened.
.
Compared with the prior study (images reviewed) of [**6-8**]/201, the
pericardial effusion now appears slightly smaller
.
LABORATORY DATA:
140 104 14
---|----|---|------< 17.4 >------< 424
3.9 26 0.8 33
Troponin < 0.01
ALT: 146 AP: 483 Tbili: 2.4 Alb: 3.3
AST: 33 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 17
PT: 15.9 PTT: 30.5 INR: 1.4
.
Micro:
Pleural, Blood, Urine cultures, Urine Legionella negative.
RUBEOLA ANTIBODY IgG positive.
.
CXR [**6-6**]: Extensive left pleural effusion, that
occupies approximately one-half of the left hemithorax. A small
right basal pleural effusion. Additional mild fluid markings of
the fissures and slight distention of the vasculature suggests
mild pulmonary edema. Subsequent areas of bilateral atelectasis.
The contour of the cardiac silhouette cannot be reliably
determined.
.
CXR post [**Female First Name (un) 576**]: Infiltrate worse on right, improved on left, no
PTX
.
[**5-23**] CTA Grossly normal study, specifically no evidence of
pulmonary
embolism.
.
CXR: [**2174-6-15**]
INDICATION: Bilateral pleural effusions, status post right
thoracocentesis.
.
COMPARISON: [**2174-6-15**] at 01:33 p.m. (approximately three
hours earlier).
.
CHEST RADIOGRAPH, PORTABLE VIEW: Interval removal of left
pigtail catheter. When compared to the most recent study, there
has been decrease in bilateral pleural effusion, now small.
.
No pneumothorax is noted. Bibasilar atelectasis is again noted,
left more
than right.
.
The cardiomediastinal and hilar silhouettes appear unchanged.
.
Pleural fluid: [**2174-6-15**]
ATYPICAL.
Rare atypical epithelioid cell in a background of reactive
mesothelial cells, histiocytes, and lymphocytes; see note.
Note: One hematology slide labeled 1556E-[**2174-6-15**] was
reviewed and demonstrates mesothelial cells; no atypical
cells seen.
.
Brief Hospital Course:
52 year old female with a history of lone atrial fibrillation
and Lyme meningitis presenting with progressive shortness of
breath and DOE over past 2 weeks admitted to the MICU with
pleural effusions and a pericardial effusion in the setting of
presumed viral pleurisy and pericarditis that developed into an
effusion after chronic NSAID use possible aspiration/CAP PNA who
developed AFIB with RVR secondary to pain and pericardial
effusion, transaminitis with cholestasis and acute renal failure
in the setting of anemia and NSAID use who has a persistent O2
requirement with pleuritic pain and resolving pericardial
effusion. She improved clinically prior to discharge after CT
placement for her L effusion and a thoracentesis to remove her R
sided pleural effusion.
.
# SOB/CP/hypoxia: Likely multifactorial with most obvious
etiologies being pleural, pericardial effusions, and . PE was
less likely given [**5-23**] CTA negative. Due to her effusions, it was
thought she may have an underlying PNA and she was started on
levaquin for CAP. She was given a prolonged course due to
concern that she may have had infection in her pericardial
fluid. The day after admission ([**6-7**]) she was intubated for
hemodynamic control(Afib RVR 150s), pain control, and for
potential procedure for a possible pericardial window. From a
respiratory prospective she was comfortable prior to intubation
which was done under rapid sequence given signs of early
tamponade. She was extubated without event when it was
determined that cardiology did not think her pericardal effusion
needed to be drained. Instead, cardiology recommended serial
Echo's to follow the effusions size. An echo on [**6-14**] showed
that the effusion was reduced in size compared to prior imaging.
.
#Afib with RVR: The Patient has a history of lone atrial
fibrillation. On day of admission patient went to Afib to 200s
briefly sustaining in the 160s. This was thought [**2-23**] to pain
and infection vs tamponade physiology. She received metroprolol
IV and dilt drip. When patient was intubated, she converted back
to sinus rhythm and maintained in sinus rhythm. After
extubation and while on the floor the patient did not have any
palpitations or further episodes of Afib wtih RVR.
- She will need to discuss with her outpatient physician
[**Name9 (PRE) **] with aspirin when her pericardial effusion
resolves.
.
# Pleural Effusions: She presented with pleuritic chest pain
which was initially attributed to her pleural effusions.
Initially, the DDx was broad including infectious(Lyme/parvo
negative, [**Location (un) **] pending), malignant(cytology ultimately
negative), and rheumatologic([**Doctor First Name **] negative and C3/C4 normal). CHF
and cirrhosis unlikely based on H+P. Lipase normal makes
pancreatits unlikely. Thoracentesis reveals exudate, likely
parapneumonic given fevers, and a viral pleuritis was also
considered. ID was consulted who recommended empiric coverage
for CAP with a prolonged course of Levofloxacin (14 days -
finish on [**6-20**]) due to a concern that the pericardial fluid
could [**Hospital1 **] infection. Cytology negative, cultures negative.
Morphine and fentanyl pleuritic CP. The most likely diagnosis
was a viral infection with a superimposed bacterial process
possibly in the setting of aspiration 1 week prior. Of note her
effusions persisted despite antibiotic therapy and NSAID
therapy. She was given diuretics with lasix which did not
reduced the size of her effusion. Therefore, a L sided chest
tube placement by IP in addition to a right sided thoracentesis.
After subsequent removal of her bilateral pleural effusions,
her symptoms of SOB and O2 requirement resolved.
.
# Pericardial Effusion: Initially echo concerning for early but
not overt tamponade physiology and exam was concerning. Patient
was given IVF to maintain preload. Serologies were sent as
above. Her pulsus was monitored closely and was never above
12mmHG. Cardiology consult followed closely and serial echos
showed improvement in effusions. The decision was made not to
drain effusions for diagnostic purposes given the risks
involved. She was restarted on NSAID therapy for viral
pericarditis. Of note, her effusion improved by echo prior to
discharge.
.
# CAP: Given her exudative effusion and viral pleuritis there
was concern for CAP and possible aspiration. She was given a
two week course of levofloxacin to finish on the date listed
above.
.
# Diarrhea: She had transient episode of diarrhea while on
antibiotics, and her diarrhea resolved.
.
# [**Last Name (un) **]/Low UO: Dark urine and poor output early in ICU course.
Thought potentially from NSAIDs. Renal spun urine and it was not
active. She had low UOP, which improved with IVF.
.
Cholestasis and Hepatitis: She was noted to have to have
abnormal LFT's with cholestatsis in addition to pleuritic R
sided abdominal pain. There was concern that she could have
either a viral induced hepatitis with cholestasis versus a
congestive hepatopathy in the setting of mild volume overload.
Cholecystitis was less likely given the absence of a white
count. Her LFT's trended down independent of diuresis thereby
suggesting/confirming a possible viral etiology for her
hepatitis and cholestasis. Of note her hepatitis serologies
were negative.
.
# Anemia: Baseline hct 40s most recently in [**2171**]. No signs or
symptoms of bleeding. Likely from systemic process going on.
Normal colonoscopy in [**2171**]. Of note, she is currently
menopausal, and has iron studies that suggest she has anemia of
chronic disease, or at least anemia with acute inflammation.
- She will need a CBC as an outpatient.
Medications on Admission:
-ASPIRIN TAB 81MG EC (ASPIRIN) 1 QD
Discharge Medications:
1. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
pack PO DAILY (Daily) as needed for constipation.
Disp:*30 packets* Refills:*0*
2. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*5 Adhesive Patch, Medicated(s)* Refills:*0*
4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for Prior to Morphine: Please take before
Morphine as needed for itching. Please do not drive after
taking this medication.
Disp:*20 Capsule(s)* Refills:*0*
7. morphine 10 mg Capsule, Ext Release Pellets Sig: One (1)
Capsule, Ext Release Pellets PO every six (6) hours as needed
for pain: Please do not drive after taking this medication.
Disp:*20 Capsule, Ext Release Pellets(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pleuritis with Bilateral Pleural Effusion and Pericardial
Effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Discharge Instructions:
Dear Mrs. [**Known lastname 3271**],
You were admitted for worsening shortness of breath due to fluid
in your lungs and around your heart. The exact cause of this is
unknown. Your breathing has markedly improved and you are
presently able to breathe without use of supplemental oxygen.
You will need to be followed by your primary care physician.
[**Name10 (NameIs) **] were started on an antibiotics and ibuprofen.
The following medicaiton changes were made:
ADDED: levaquin, ibuprofen, miralax, morphine, lidocaine patch,
benadryl, morphine, colace
STOPPED: aspirin
Followup Instructions:
Please visit your primary care physician for [**Name9 (PRE) 702**] bloodwork
and to determine whether you will need to take more Lasix (the
'water-pill' that you during your stay in the hopsital).
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: PERSONAL [**Hospital **] HEALTH CARE, P.C.
Address: [**Location (un) 3881**], [**Apartment Address(1) 1823**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 1408**]
Appt: [**6-21**] at 4pm
Completed by:[**2174-7-12**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,460
| 110,836
|
49048
|
Discharge summary
|
report
|
Admission Date: [**2132-9-18**] Discharge Date: [**2132-9-21**]
Date of Birth: [**2060-9-5**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
[**2132-9-19**]: PICC Placement
History of Present Illness:
72-year-old female with a history of hypertension, [**Month/Day/Year **], and
multiple presentations concerning for
TIAs with dysarthria and various weaknesses, all found to be
DKA, who presents with altered mental status and hyperglycemia.
Patient was last seen in her usual state of health yesterday.
Today, her son found her walking around her house, confused and
dysarthric. He pressed the life line, and she was brought to the
[**Hospital1 18**] ED. Her glucose at home was found to be critically high.
In the ED, initial VS: 99.2 96 140/66 16 100%. Initial labs
significant for Sodium 128, Potassium 9.2 (hemolyzed), Bicarb
18, creatinine 1.2, and glucose 650. WBC count 12.5. ABG
revealed pH 7.21 pCO2 46 pO2 51 HCO3 19. CT head negative for
acute process. The patient was evaluated by neurology for
altered mental status, dysarthria, and a twitching episode noted
while in the ED. The patient underwent CTA to evaluate for
vascular event (poorly timed - incomplete study). An LP was
attempted to rule out meningitis, but was unable to be
performed. Due to concern for focal seizures, the patient was
loaded with IV keppra.
For her diabetic ketoacidosis, she was started on insulin at 7
units/hr and received 2L NS. Anion gap improved to 17 prior to
transfer. VS prior to transfer: 101.9 116 138/56 18 100%.
On arrival to the MICU, the patient was obtunded with minimal
response to sternal rub.
On the floor, patient reports never missing a dose of Insulin.
Taking SSI everyday and Lantus at night. On day of admission,
she was feeling poorly and lying in bed, however, she still took
her insulin. She reports the day before feeling fine. Denied any
other symptoms. The only differing dietary history is that she
had chicken mcnuggets the day prior to admission and she reports
not usually eating fried foods. She didn't have any soda/sweet
tea, just diet soda.
Review of systems: Unable to be performed due to altered mental
status.
Past Medical History:
Significant MVA in [**2092**], s/p facial reconstruction
Left eye prosthesis
Right Eye glaucoma
HTN
hyperlipidemia
type 2 DM
CAD
Breast mass (unclear etiology or diagnosis)
Question of TIAs and multiple admissions and evaluations by
neurology:
[**2124**]: Dysarthria. negative MRI/MRA and EEG.
[**2128**]: Dysarthria, left sided weakness. DKA. negative stroke work
up.
[**2131**]: Dysarthria. Hyperglycemia. negative CT/CTA.
Social History:
Lives with her husband who is sick. and she takes care of him.
Her son recently moved with them. Per OMR, no history of
smoking. She used to drink alcohol daily but has not done so in
many years.
Family History:
Family history is negative for strokes, seizures, or peripheral
nerve palsies. [**Year (4 digits) 982**] is present in her sister and aunt. [**Name (NI) **]
sister also had stomach cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 99.7 BP: 157/73 P: 116 R: 26 O2: 96%
Fingerstick 253
General: Appears mildly comfortable; withdraws to pain and
sternal rub; does not open eyes on command or verbally answer
questions
HEENT: Left prosthetic glob; right Sclera anicteric, MM dry,
oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic 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: feet cool bilaterally 1+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM:
VS - Temp 97.9/98.0F, 140-178/60-89BP , 58-84HR , 18R , O2-sat
99% RA
GENERAL - NAD, comfortable
HEENT - NC/AT, Left eye glass, Right EOMI, sclerae anicteric,
MMM, OP clear. [**Hospital1 **]-temporal wasting
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no w/r/r
HEART - RRR, 2/6 SEM in ULSB no rubs or gallops
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - 2+ distal pulses. No lower extremity edema. 1mm
lentigo on her R small toe
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-24**] throughout, sensation grossly intact throughout,
Pertinent Results:
ADMISSION
[**2132-9-18**] 11:40PM TYPE-[**Last Name (un) **] PO2-131* PCO2-29* PH-7.34* TOTAL
CO2-16* BASE XS--8
[**2132-9-18**] 11:40PM LACTATE-2.0
[**2132-9-18**] 11:34PM GLUCOSE-332* UREA N-20 CREAT-0.8 SODIUM-141
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-16* ANION GAP-21*
[**2132-9-18**] 11:34PM estGFR-Using this
[**2132-9-18**] 09:55PM GLUCOSE-499* K+-4.7
[**2132-9-18**] 09:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2132-9-18**] 09:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2132-9-18**] 08:23PM PO2-51* PCO2-46* PH-7.21* TOTAL CO2-19* BASE
XS--9 COMMENTS-GREEN TOP
[**2132-9-18**] 08:23PM K+-7.0*
[**2132-9-18**] 08:00PM GLUCOSE-650* UREA N-24* CREAT-1.2*
SODIUM-128* POTASSIUM-9.2* CHLORIDE-92* TOTAL CO2-18* ANION
GAP-27*
[**2132-9-18**] 08:00PM WBC-12.5*# RBC-4.65 HGB-13.0 HCT-41.3# MCV-89
MCH-27.8 MCHC-31.3 RDW-13.6
[**2132-9-18**] 08:00PM NEUTS-87.1* LYMPHS-9.7* MONOS-2.7 EOS-0.4
BASOS-0.2
[**2132-9-18**] 08:00PM PLT COUNT-252
[**2132-9-18**] 08:00PM PT-11.6 PTT-20.3* INR(PT)-1.1
[**2132-9-18**] 08:23PM BLOOD pO2-51* pCO2-46* pH-7.21* calTCO2-19*
Base XS--9 Comment-GREEN TOP
[**2132-9-19**] 09:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE:
[**2132-9-21**] 05:27AM BLOOD WBC-6.7 RBC-4.21 Hgb-11.8* Hct-36.1
MCV-86 MCH-28.1 MCHC-32.7 RDW-13.5 Plt Ct-184
[**2132-9-20**] 05:58AM BLOOD Neuts-61.7 Lymphs-29.4 Monos-7.4 Eos-1.3
Baso-0.2
[**2132-9-21**] 05:27AM BLOOD Glucose-118* UreaN-13 Creat-0.6 Na-142
K-4.0 Cl-106 HCO3-31 AnGap-9
[**2132-9-21**] 05:27AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
ABG:
[**2132-9-18**] 08:23PM BLOOD pO2-51* pCO2-46* pH-7.21* calTCO2-19*
Base XS--9 Comment-GREEN TOP
[**2132-9-18**] 11:40PM BLOOD Type-[**Last Name (un) **] pO2-131* pCO2-29* pH-7.34*
calTCO2-16* Base XS--8
[**2132-9-19**] 09:59AM BLOOD Type-[**Last Name (un) **] pO2-240* pCO2-28* pH-7.45
calTCO2-20* Base XS--2
MICRO:
UCx [**9-18**]: URINE CULTURE (Final [**2132-9-21**]):
PRESUMPTIVE GARDNERELLA VAGINALIS. 10,000-100,000
ORGANISMS/ML..
BCx [**9-18**]: No growth to date, pending final
IMAGING:
ECG [**9-18**]: Sinus tachycardia. Vertical axis. Early R wave
progression. Consider right ventricular hypertrophy and
pulmonary disease. Since the previous tracing of [**2131-9-23**] no
significant change.
CT Head [**9-18**]: IMPRESSION: No acute intracranial process.
CXR [**9-18**]: IMPRESSION: No acute cardiopulmonary process
CTA Head and Neck w/ and w/o contrast [**9-19**]: FINDINGS: There has
been only minimal opacification of the arterial system due to
poor timing of image acquisition in relation to the contrast
bolus. Although there is no obvious large occlusion, further
assessment cannot be performed on this study. A repeat study
with more optimized bolus timing is recommended for evaluation.
Brief Hospital Course:
72-year-old female with a history of hypertension, [**Month/Day (4) **], and
multiple episodes of DKA, who presents with altered mental
status, fevers, and DKA.
ACTIVE ISSUES:
1. Diabetic ketoacidosis: Pt presented with glucose in the 600s
and ketones in her urine with anion gap. There was no triggering
cause established. Likely secondary to infection, given fevers
and leukocytosis. Glucose improved and gap closed on insulin gtt
and she was transitioned over to her home insulin regimen
without difficulty. Infectious workup included U/A, BCx
(negative to date) and CXR which were negative. LP was
attempted and unsuccessful in ED; again considered in MICU but
deferred as pt's mental status improved. She was discharged with
stable blood sugars for 48+ hours after deminstrating her
ability to draw up her own insulin and give the correct amount
depending on her blood sugar without any impairment. [**Last Name (un) **]
recommended we increase her Lantus to 17units qhs. We also
slightly increased her HSSI to start at 200 at bedtime instead
of 250.
2. Altered Mental status: Likely secondary her DKA (similar
symptoms previously) which could have been due to infection
given fevers to 101 and elevated WBC count however no clear
source of infection on workup. CXR without evidence of
pneumonia, U/A negative for UTI. The patient was unable to
undergo LP, but received a dose of vancomycin and ceftriaxone to
cover for meningitis which was stopped on day #2 due to clinical
improvement with low suspicion for meningitis. The neurology
stroke service evaluated her. A CTA was inconclusive due to
inappropriate timing of sequences. She was briefly keppra loaded
with concern for epileptic activity. Her mental status returned
to baseline on hospital day #2 and further workup of her AMS was
stopped. Per records she has a history of severe AMS in the
setting of DKA in the past. An EEG can be considered on an
outpatient basis if felt to be clinically indicated.
3. Hypoxia on Presentation: Patient's ABG on presentation showed
hypoxia with pO2:56 and pCO2:46. With her metabolic acidosis,
you would expect a lower pCO2 and she should not be hypoxic only
from this. Patient denies any respiratory symptoms. CXR with
chronic changes, no acute process. Pulmonary vasculature
prominent. Received empiric antibiotics for possible meningitis
coverage initially, which could have suppressed a respiratory
infection. She could have mucous plugging as well. She
potentially will need follow up for any lung pathology.
4. Hypertension: Chronic. Antihypertensives had been held in
MICU due to being normotensive. When she was transferred to the
floor, they were readded in a step-wise fashion with first
metoprolol, and then lisinopril/amlodipine restarted at home
dose. On discharge, her Isosorbide mononitrate was being held
and this can be started as an outpatient.
CHRONIC ISSUES:
1. CAD: Patient was continued on aspirin, plavix, statin, and
metoprolol at home doses.
TRANSITIONAL ISSUES:
-[**Last Name (un) **] and PCP f/u after DKA event and to assess to see if any
etiology is found to trigger this event. She was told to
schedule with PCP [**Name Initial (PRE) 176**] 1 week and [**Last Name (un) **] within a couple
weeks.
-BCx's pending on discharge
-BP: Patient restarted on all home BP meds except Isosorbide
Mononitrate. After f/u with PCP, [**Name10 (NameIs) **] as clinically
indicated
-Potential lung follow up if hypoxia seems to have been an
inciting event
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from webOMR.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Glargine 16 Units Bedtime
5. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Glargine 16 Units Bedtime
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Diabetic Ketoacidosis
Secondary Diagnosis:
Altered Mental Status
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 102927**],
It was a pleasure taking care of you while you were at the [**Hospital1 1535**]. When you came to the hospital,
you were confused and had a very high blood sugar (Diabetic
Ketoacidosis). CT scan of your head did not show any new
problems causing your confusion, and your symptoms resolved when
your blood sugar corrected. After to talking with the [**Last Name (un) **]
on-call doctor, we increased your night time Lantus to 17 units
and slightly increased your insulin sliding scale to try to
prevent this from happening again.
We initially held some of your blood pressure medications
because your pressure was low. We restarted your Metoprolol,
Lisinopril, and Amlodipine, but did not give you your Isosorbide
Mononitrate. This can be restarted by your Primary Care
Physician.
Your appointment with Dr. [**Last Name (STitle) **] is currently for [**10-13**] but we would like you to call the office to move your
appointment to within 7 days of you being discharged. Also, you
should call your [**Last Name (un) **] doctor, Dr. [**First Name (STitle) **], to schedule an
appointment within a few weeks. Both of these numbers are listed
below.
The following medications were STOPPED during your admission:
Amlodipine
The following medications were CHANGED:
Lantus (Glargine)
Humalog Sliding Scale
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2132-10-13**] at 11:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Endocrinology
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
[**First Name (Titles) **] [**Last Name (Titles) 982**] Center
One [**Last Name (un) **] Place
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Fax: [**Telephone/Fax (1) 26643**]
Department: PODIATRY
When: WEDNESDAY [**2132-11-12**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
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|
[
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3856, 4440
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,630
| 127,360
|
47111
|
Discharge summary
|
report
|
Admission Date: [**2164-12-9**] Discharge Date: [**2164-12-14**]
Date of Birth: [**2096-1-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 80571**] is a 68 y/o woman with PMH notable for severe
kyphoscoliosis, reactive airway disease, and chronic diastolic
CHF who presents to the ED with increased dyspnea. Patient
reports increased dyspnea for the past several days which
progressively worsened on the day of admission. She laid in bed
most of the day and when she finally got out of bed, she noted
severe dyspnea and came to the ED. She reports no dietary
indiscretion (she did the [**Holiday 1451**] cooking) and has not
missed any of her lasix doses. She denies any fever, chills,
cough, sputum production, or hemoptysis. Of note the patient was
recently changed from verapamil 120 mg daily (started two months
ago) to diltiazem 120 mg daily due to increased dyspnea. She
states that when she originally started verapamil, she had more
dyspnea and this has been stable for the past few months.
.
On arrival to the ED, initial vitals were T97.7, BP 111/56, HR
92, RR 28. She was found to have an oxygen saturation of 45% in
with solumedrol 125 mg IV X 1 as well as stacked
albuterol/atrovent nebs. CXR demonstrated small bilateraly
effusions and ? hilar fullness (poor film). Saturations quickly
improved to 93-94% on 6L NC with nebs. She was then treated with
lasix 60 mg IV X 1 after CXR demonstrated pulmonary edema. She
was noted to drop her oxygen saturations to 86% on 4 L NC when
nebs were completed. At the time of transfer, her oxygen
saturations were 89-91% on 3 L NC (home oxygen).
.
On arrival to the ICU, the patient reports that her breathing is
improved. She denies any chest pain. She chronically sleeps with
her head elevated due to her reflux disease; she states she
wakes from sleep short of breath "sometimes" but has not noted
this any more frequently lately. She reports some decreased
urine output for the past few days but denies any recent chest
pain or diaphoresis. She denies dysuria, headache, nasal
congestion, sore throat, abdominal pain, hematuria, or increased
LE edema. She had one episode of diarrhea in the past few days
after taking laxatives.
Past Medical History:
# restrictive and obstructive lung disease due to asthma and
severe scoliosis
- followed by Dr. [**Last Name (STitle) 217**]
# severe scoliosis - status post [**Location (un) 931**] rods
# reflux esophagitis - Reglan and Nexium
# status post severe burns with multiple skin grafts as a child
# chronic low back pain
# hypertension
# osteoporosis
# hip pain
# proteinuria.
Social History:
Prior smoke (X 11 years) but quit in [**2138**]. No alcohol. Lives
with daughter and performs own ADLs (bathing, dressing,
cooking). Previously worked as a home health aide. Widowed.
Family History:
Father died of liver cancer. Daughter with breast cancer at 45.
Also history of colon cancer. No history of pulmonary disease.
Physical Exam:
T: 98.8 BP: 122/61 HR: 95 RR: 16 O2 88% on 4 L NC
Gen: Pleasant, middle aged woman in no distress, sitting up in
bed. Able to speak in complete though short sentences. Appears
slightly labored when speaks several sentences in a row.
HEENT: Sclerae injected bilaterally, PERRL, EOMI, MMM, tongue
midline
NECK: supple, no LAD, prominent EJ up to angle of mandible
CV: RRR, normal S1 & S2 with prominent S4, 3/6 systolic murmur
best heard at apex
LUNGS: decreased breath sounds bilaterally with poor air
movement, prominent scoliosis with barrel chest
ABD: firm but nontender, hypoactive bowel sounds
EXT: warm, no peripheral edema, DP pulses 2+ bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: alert, interactive, face symmetric, speech clear, answers
questions appropriately, moving all extremities without
difficulty
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission labs:
WBC-3.9* RBC-4.83 Hgb-12.7 Hct-43.4 MCV-90 MCH-26.4* MCHC-29.4*
RDW-14.8 Plt Ct-199
Neuts-90.7* Lymphs-7.5* Monos-1.2* Eos-0.5 Baso-0.1
PT-14.2* PTT-30.2 INR(PT)-1.2*
Plt Smr-NORMAL Plt Ct-199 LPlt-1+
Glucose-108* UreaN-20 Creat-1.7* Na-149* K-3.3 Cl-98 HCO3-44*
CK(CPK)-91 cTropnT-<0.01 proBNP-7885*
Calcium-9.6 Phos-3.1 Mg-1.9
Type-ART Temp-37.1 FiO2-50 pO2-54* pCO2-90* pH-7.29* calTCO2-45*
Base XS-12 Intubat-NOT INTUBA
Lactate-0.7
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE Hours-RANDOM UreaN-299 Creat-47 Na-68 Cl-90 Uric Ac-20.4
URINE Osmolal-344
.
Studies:
[**2164-12-9**] EKG: Sinus rhythm. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2162-11-24**] no change.
[**2164-12-9**] CXR - IMPRESSION:
1. CHF, bilateral pleural effusions.
2. Retrocardiac opacity, which could represent a combination of
atelectasis and hiatal hernia. Cannot rule out consolidation. A
repeat study after appropriate treatment is recommended.
[**2164-12-10**] CXR - IMPRESSION:
1. Bilateral pleural effusions and bibasilar atelectasis.
2. Mild congestive failure. Cardiomegaly.
[**2164-12-10**] Echo - Impression:
The left atrium and right atrium are normal in cavity size. The
right atrial pressure is indeterminate. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). The right ventricular cavity is markedly
dilated with moderate global free wall hypokinesis. There is
abnormal systolic septal motion/position consistent with right
ventricular pressure overload. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2164-5-9**],
the right ventricular cavity is now dilated with more prominent
free wall hypokinesis. Right ventricular pressure overload is
now suggested, though the estimated pulmonary artery systolic
pressure is similar.
Brief Hospital Course:
Mrs. [**Known lastname 80571**] is a 68 year old woman with a past medical history
notable for severe kyphoscoliosis, diastolic CHF, and reactive
and restrictive lung disease who presented with shortness of
breath and a CHF exacerbation.
# Shortness of breath / acute on chronic CHF: The patient
requires 3L O2 at home to maintain O2 sats 88-92% and desats
with ambulation at baseline. She required additional
supplemental O2 on presentation to the ED. EKG showed no
evidence of new ischemia and cardiac enzymes x 2 were negative.
She had an elevated BNP of 7885, CXR with bilateral pleural
effusions, and ECHO with worsened RVH. She was initially
admitted to the MICU and while there improved clinically with
nebulized bronchodilators and diuresis with IV lasix. She was
transfered to the general medical floor on [**12-11**] and had a good
diuresis with 40 mg IV lasix. By the following morning her
resting O2 saturation and requirement had returned to her
baseline and she reported feeling much better.
# Acute renal failure: Creatinine was elevated to 1.7 on
admission and initially felt to be related to poor forward flow
in setting of initiation of diltiazem and/or CHF exacerbation.
The patient had not taken any extra naproxen, but did report
decreased PO intake prior to admission. Her creatinine improved
with diuresis. Lisinopril and naproxen were held while her
creatinine remained elevated.
# Hypernatremia: On admisison the patient reported one episode
of diarrhea after taking laxatives during the week prior, but
otherwise no good explanation for hypernatremia. She has
continued her usual lasix prescription as directed by her
physician. [**Name10 (NameIs) **] improved during MICU stay with IV and PO
lasix boluses.
# Hypertension: The patient remained normotensive with SBP
100s-130s despite holding of both her lisinopril (due acute
renal insufficiency) and her diltiazem (due to CHF
exacerbation).
# Leukopenia: Near baseline and is chronic.
Medications on Admission:
ALBUTEROL 0.83MG/ML nebs q4h prn (uses about 4 X per day)
DILTIAZEM SR 120 mg daily (started [**12-3**])
ESOMEPRAZOLE 40 mg once a day
FEXOFENADINE 60 mg twice a day (during allergy season, currently
taking)
FLUTICASONE [FLOVENT HFA] 220 mcg 2 puffs INH [**Hospital1 **] (using once
daily per her report)
FOSAMAX 70MG Tablet ONCE A WEEK
FUROSEMIDE [LASIX] 60 mg once a day
IPRATROPIUM BROMIDE 21 mcg 2 sprays each nostril 2-4 times daily
(using once daily per her report)
IPRATROPIUM BROMIDE [ATROVENT HFA] 17 mcg/act 2 puffs inhaled 4
x daily ( uses at night before bed)
LIDEX cream to scalp prn
LISINOPRIL 10 mg once a day at night
METOCLOPRAMIDE 10 MG 30 MIN BEFORE MEALS AND HS
NAPROXEN 500 mg Tablet twice a day
SEREVENT DISKUS 50MCG ONE INHALATION TWICE A DAY (using once
daily per her report)
CALCIUM 500 mg [**Hospital1 **]
COENZYME Q10 daily
DOCUSATE [**Hospital1 11516**] [COLACE] 100 mg Capsule once a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] 400 U daily
MULTIVITAMIN WITH IRON-MINERAl once daily
OMEGA-3 FATTY ACIDS [FISH OIL]
OXYGEN-AIR DELIVERY SYSTEMS using 3 L at home
Discharge Medications:
1. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Flovent HFA 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
5. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
6. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day.
8. Ipratropium Bromide
21 mcg Aerosole spray, 2 sprays each nostril 2-4 times daily
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four
times a day: take 30 minutes before meals and at bedtime.
11. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain: Not to exceed 4 grams in 24
hours.
12. Docusate [**Hospital1 **] 100 mg Capsule Sig: One (1) Capsule PO once
a day.
13. Calcium Oral
14. Coenzyme Q10 Oral
15. Ergocalciferol (Vitamin D2) Oral
16. Multi-Vitamin W/Minerals Oral
17. Omega-3 Fatty Acids Oral
18. Serevent Diskus 50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
19. Lidex 0.05 % Cream Sig: One (1) Topical once a day as
needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Acute on chronic diastolic CHF
2. Acute renal failure
Secondary Diagnoses:
1. Severe kyphoscoliosis
2. Pulmonary hypertension
3. Reactive airway diease
4. Hypertension
Discharge Condition:
Stable, afebrile, satting in the mid to low 90s on 3L O2. 88% on
3L with amublation. SBP 100s-130s.
Discharge Instructions:
You were admitted to the hospital for evaluation of shortness of
breath and increased oxygen requirement. Your breathing
improved with extra doses of lasix to remove extra fluid in your
body. On admission, you were also found to have some kidney
dysfunction, however, that has improved back to normal with
removal of the extra fluid.
The following changes were made to your medications.
Please stop taking diltiazem.
You should not take your lasix for tomorrow [**2164-12-15**]. But then
you should start taking daily again.
Please follow-up with your physicans as noted below.
Please call your physician or return to the hospital if you
develop worsening shortness of breath, chest pain, abdominal
pain, fevers, or any other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2164-12-20**]
9:50
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2165-1-24**] 8:25
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2165-1-24**] 8:45
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4131**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2165-2-4**] 3:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2165-2-14**]
1:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11042, 11048
|
6474, 8452
|
336, 342
|
11283, 11386
|
4106, 4106
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370, 2439
|
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|
2461, 2836
|
2852, 3036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
109
| 173,633
|
14801
|
Discharge summary
|
report
|
Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
abdominal pain & hypertension
Major Surgical or Invasive Procedure:
Hemodialysis
PICC Line [**12-11**]
History of Present Illness:
Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD)
from lupus nephritis, chronic intermittent abdominal pain, and
multiple prior ICU admissions for hypertensive urgency who
presented to the ED complaining of two days' of abdominal pain,
nausea, and loose stools. She was feeling well until after her
hemodialysis session on Wednesday. Thereafter, she complained of
nausea with occasional vomitting and has been unable to keep
down any of her oral medications. She also has had diffuse
abdominal pain consistent with her prior flares of pain as well
as her typical diffuse headache. The headache in particular was
worsening and, for her, this is a sign of poorly-controlled
hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the
ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room
air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste,
1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a
labetalol drip which had to be increased up to 2 mg/min. A head
CT showed no acute abnormality (including hemorrhage) and an
abdominal CT showed some possible mild colitis, though it is
unclear if this is due to her recent peritoneal dialysis.
Past Medical History:
1. Systemic lupus erythematosus:
- Diagnosed [**2134**] (16 years old) when she had swollen fingers,
arm rash and arthralgias
- Previous treatment with cytoxan, cellcept; currently on
prednisone
- Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
2. CKD/ESRD:
- Diagosed [**2135**]
- Initiated dialysis [**2137**] but refused it as of [**2140**], has
survived despite this
- PD catheter placement [**5-18**]
3. Malignant hypertension
- Baseline BPs 180's - 120's
- History of hypertensive crisis with seizures
- History of two intraparenchymal hemorrhages that were thought
due to the posterior reversible leukoencephalopathy syndrome,
associated with LE paresis in [**2140**] that resolved
4. Thrombocytopenia:
- TTP (got plasmapheresisis) versus malignant HTN
5. Thrombotic events:
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy: may be etiology of episodes of
worse hypertension given appears quite labile
.
PSHx:
1. Placement of multiple catheters including dialysis.
2. Tonsillectomy.
3. Left eye enucleation in [**2140-4-10**].
4. PD catheter placement in [**2141-5-11**].
5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**]
Social History:
Single and lives with her mother and a brother. She graduated
from high school. The patient is on disability. The patient does
not drink alcohol or smoke, and has never used recreational
drugs.
Family History:
Negative for autoimmune diseases including sle, thrombophilic
disorders. Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra
Gen: mildly fatigued, but no distress
HEENT: oropharynx clear
Neck: no JVP, no LAD
Chest: clear to auscultation throughout, no w/r/r
CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard
Abdomen: soft, tender diffusely to moderate palpation without
rebound or guarding; hyperactive bowel sounds; no masses or HSM,
PD catheter in palce
Extr: no edema, 2+ PT pulses
Neuro: alert, appropriate, strength grossly intact in all four
limbs
Skin: no rashes
Pertinent Results:
[**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6*
MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148*
[**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7*
[**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5
[**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138
K-5.3* Cl-105 HCO3-24 AnGap-14
[**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1
[**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3
[**2141-12-10**] 05:10AM BLOOD Lipase-72*
[**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7
[**2141-12-10**] 05:10AM BLOOD Hapto-142
[**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5
Ferritn-220* TRF-106*
ON ADMISSION:
[**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2*
MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158
[**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9
Baso-0.4
[**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3*
[**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5
[**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139
K-4.8 Cl-104 HCO3-26 AnGap-14
[**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3
[**2141-12-7**] 09:50PM BLOOD Lipase-89*
[**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9*
Mg-1.9
[**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8
Cl-101 calHCO3-23
Micro:
Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth
FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2141-12-8**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
CT HEAD [**2141-12-8**]:
IMPRESSION:
1. No acute intracranial pathology including no hemorrhage.
2. The hypodensities noted in the parietal white matter are
stable. However
in the setting of the hypertension, PRES cannot be excluded. If
further
evaluation is required MR can be obtained.
CT Abdomin/Pelvis [**2141-12-8**]
IMPRESSION:
1. Moderate amount of free fluid in the pelvis is compatible
with the
patient's known peritoneal dialysis. Unchanged peritoneal
enhancement.
2. Stable liver hemangioma.
CXR [**12-11**]
IMPRESSION: Small left pleural effusion. Left lower lobe opacity
which is
either atelectasis versus pneumonia.
Brief Hospital Course:
24 year old woman with CKD V and severe hypertension due to SLE
admitted with flare of chronic abdominal pain and hypertensive
urgency.
MICU course:
Current plan on transfer
24 year old woman with CKD V and severe hypertension due to SLE
admitted with flare of chronic abdominal pain and hypertensive
urgency.
1. Hypertensive urgency:
The patient was initially maintained on a labetalol drip and
hydralazine iv prn until oral anti-hypertensives lowered her
blood pressure. Initially her blood pressure over-corrected to
SBPs in the 80s (patient was asymptomatic). Her clonidine patch
and hydralazine was held and she again became hypertensive with
SBPs 190s. The patient was restarted on a low dose clonidine
0.1 mg/24 hr patch, and hydralazine. The following dialysis the
patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic
again. Her hydralazine was stopped and continued on all her
other home medications at the advice of renal. The patient was
transferred to the floor on [**12-10**] after resolution of her
hypertensive urgency with a decreased blood pressure regimen due
to her hypotension in response to home doses of her medications.
On [**12-11**] the patient's SBP dropped to the 80's and due to her
pain medications she was extremely lethargic, but arousable. A
PICC line was placed because lack of access and she was bolused
250cc NS. The patient's pressures responded and additional
narcotics were held due to her mental status. The patient's
blood pressures continued to be labile and her clonidine patch
was increased to 0.3mg/24hr and her hydralazine was titrated
back to 100mg daily. The patient did require IV hydralazine prn
for control of her blood pressures initially, but was stablized
back on her home regimen. A possible component to the patient's
malignant hypertension is likely due to OSA. An inpatient sleep
study was performed overnight on [**12-13**] and the patient was sent
home on BiPAP for OSA. The patient was continuned on her
admission hypertensive regimen.
.
2. Abdominal pain: The etiology of her abdominal pain is
unclear, but has been a chronic issue for her. A CT scan was
performed that showed bowel wall changes that are likely
secondary to recent peritoneal dialysis and unrelated to pain.
The patient also had diarrhea, but stool studies were negative.
The patient's pain was initially treated with hydromorphone, but
because of the patient's lethargy on [**12-11**] they were initially
held. She continued to complain of severe abdominal pain. She
was slowly restarted back on her home regimen was 4mg po
hydromorphone q6 as her mental status improved. Surgery was
consulted in regards to removal of her PD catheter, but given
that she may return to PD it was deferred to the outpatient
setting.
3. CKD V from lupus nephritis: The patient was continued on HD
during her admission. She was also continued on her home
prednisone dose. She was closely followed by the renal team.
.
4. History of SVC/subclavian vein thrombus: The patient was
found to have a subtherapeutic INR on admission 1.3. She was
started on a heparin gtt and continued on coumadin. The
patient's heparin gtt was hled on [**12-10**] because of access
issues, but was restarted on [**12-11**] after her PICC line was
placed. She was therapetuic the same day and her heparin gtt
was stopped. On discharge her coumadin was supratherapeutic
(4.7) and was held. She will have her INR checked at HD.
.
5. Anemia: The patient's Hct slowly trended down. She was
guaiac negative and hemolysis labs were negative. She was
transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD.
Medications on Admission:
prednisone 4 mg daily
clonidine 0.3 mg/day patch qWeek
ergocalciferol 50,000 units qMonth
nifedipine SR 90 mg daily
hydralazine 100 mg q8h
citalopram 20 mg daily
warfarin 2 mg qhs
gabapentin 300 mg [**Hospital1 **]
hydromorphone 4 mg q4h prn
clonazepam 0.5 mg [**Hospital1 **]
alikiren 150 mg [**Hospital1 **]
docusate 100 mg [**Hospital1 **]
senna 8.6 mg [**Hospital1 **] prn
acetaminophen prn
labetalol 800 mg q8h
bisacodyl 5 mg daily prn
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
[**Hospital1 **]:*84 Tablet(s)* Refills:*0*
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid ().
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed: please take as needed for anxiety prior to CPAP at
bedtime.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
14. CPAP
Home CPAP
Dx: OSA
Prefer: AutoCPAP/ Pressure setting [**5-20**]
Alt: Straight CPAP/ Pressure setting 7
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypertensive Urgency
Abdominal Pain
ESRD on HD
SVC Thrombus
Secondary:
Systemic lupus erythematosus
Malignant hypertension
Thrombocytopenia
HOCM
Anemia
History of left eye enucleation
History of vaginal bleeding
Thrombotic microangiopathy
Discharge Condition:
Stable
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted to [**Hospital1 18**] because of elevated blood
pressure and abdominal pain. You were initially admitted to the
ICU and your blood pressure was controlled. You were stabilized
and transferred back to th floor. Your pressures remained
stable throughout the rest of your stay. Additionally, you had
abdominal pain and diarrhea. Your stool was tested for
infections and was negative. Your diarrhea resolved without
intervention. Your abdominal pain was controlled with pain
medications. You had a sleep study in the hospital which showed
that you had sleep apnea.
Please continue to take your medications as prescribed.
1. Please do not take your coumadin until your doctor tells you
to.
Please follow up with the appointments below.
Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.
Followup Instructions:
You will have dialysis at [**Location (un) **] Dialysis on your normal
schedule. You need to go to dialysis on Saturday.
Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 612**]
Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**]
Completed by:[**2141-12-16**]
|
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"285.21",
"583.81",
"327.23",
"228.04",
"287.5",
"789.00",
"790.92",
"403.01",
"710.0",
"458.29",
"338.29",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12442, 12448
|
6990, 10627
|
313, 349
|
12741, 12750
|
4251, 4943
|
13793, 14297
|
3592, 3717
|
11119, 12419
|
12469, 12720
|
10653, 11096
|
12774, 13770
|
3732, 4232
|
244, 275
|
377, 1595
|
4957, 6967
|
1617, 3364
|
3380, 3576
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,529
| 172,162
|
16873
|
Discharge summary
|
report
|
Admission Date: [**2115-9-20**] Discharge Date: [**2115-9-26**]
Date of Birth: [**2032-12-31**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Norvasc
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
simvastatin
coumadin
B 12
FeSo4
MVI
prilosec
bisacodyl
mirtazepine
senna
Past Medical History:
1. CARDIAC RISK FACTORS: hypertension, dyslipidemia.
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: s/p PTCA x1 15 years ago
records not at the [**Hospital1 18**]
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
GASTRITIS
H.pylori + (treated)
GOUT
SYNCOPE
RENAL INSUFFICIENCY (creat ~ 1.6)
VENOUS INSUFFICIENCY and lower extremity edema
BENIGN PROSTATIC HYPERTROPHY
ATRIAL FIBRILLATION
diastolic dysfunction with volume overload treated with lasix
RETINAL VASCULAR OCCLUSION in [**2115-4-19**] thought [**1-21**] plaque
rupture not thrombotic event as therapeutic on coumadin at the
time
Social History:
Originally from Poland. Worked in [**Doctor First Name 533**] labor camp for a few
years before emmigrating. Also was in the service in the US.
Lives in [**Location **], MA with his wife. [**Name (NI) 1139**] history: Former 15
pack-year smoker, quit 60 years ago. Rare ETOH use. No recent
travel. No sick contacts.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
98.4 132/62 57 18 94RA
Laying in bed, pleasant, no distress, speaks and understands
English well.
Pale conjuctival mucosa. Mouth moist, normal appearing, blood
blister on edge of tongue, otherwise no lesions seen
No JVD noted. No cervical, supraclav LAD
Early 3-6 systolic murmur best at LUSB, irregularly irregular
CTAB no w/c/r/r
Soft, NT ND, BS hyperactive
No BLE edema noted. PT more easily palpated than DP's. Radial's
2+. No c/c/e and cap refill <2 seconds.
Pertinent Results:
On admission
WBC 5.4 rose to 13.7 while febrile but dropped down to 9.8 after
starting ABx
h/h 8.4 / 25.5 on admission and was stable around 28.7 on d/c
Plts 138 on admission and 264 on d/c
PT/PTT/INR 17.1/29.1/1.5 --> normal by d/c
Chems significant for BUN/Cr 37/1.5 --> by d/c 27/1.5 and rest
of chems within normal limits
CE's negative x2
UA positive for mild infxn [**2115-9-24**]
URINE CULTURE (Final [**2115-9-26**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
[**2115-9-20**] GIB study
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for minutes were obtained. A left lateral
view of the pelvis was also obtained.
Blood flow images show a small active bleed in the right lower
quadrant.
Dynamic blood pool images show a small active bleed in the right
hepatic flexure
IMPRESSION: Small active right hepatic fexture gastrointestinal
bleed.
[**2115-9-20**] mesenteric angiography
PROCEDURE AND FINDINGS: After the risks, benefits and
alternatives of the
proposed procedure were thoroughly explained to the patient,
informed consent
was obtained. The patient was taken to the angiography suite and
placed
supine on the imaging table. The right groin was prepped and
draped in the
usual sterile fashion. A preprocedure timeout was performed.
After local
anesthesia with 10 mL of 1% lidocaine, access was gained into
the right common
femoral artery with a 19-gauge needle. A 0.035 [**Last Name (un) 7648**] guide
wire was
advanced through the needle into the abdominal aorta. The needle
was removed
and a 5 French sheath was inserted. The sheath was connected to
a continuous
side arm flush. A 5 French C2 catheter was then placed through
the sheath
over the wire into the right common femoral artery with the tip
ending in the
abdominal aorta. The [**Last Name (un) 7648**] wire was then removed. The C2
catheter was
lodged into the superior mesenteric artery. Arteriogram of the
superior
mesenteric artery taken in multiple projections was recorded
digitally and
showed no active bleeding site or vascular abnormalities
involving branches of
the ileocolic, right colic or middle colic arteries. The [**Last Name (un) 7648**]
wire was
then placed through the C2 catheter and the catheter was then
removed over the
wire. A 5 French SOS catheter was then placed over the wire into
the right
common femoral artery and further advanced into the aorta and
formed in the
thoracic aorta. The wire was then removed. The SOS catheter was
then used to
selectively catheterize the inferior mesenteric artery.
Arteriogram of the
inferior mesenteric artery did not show any active bleeding site
or other
vascular abnormalities at the branches of the left colic artery,
sigmoid
branches, and superior rectal arteries. The C2 catheter was then
removed. The
sheath at the right groin was removed and hemostasis was
achieved by manual
compression of the right groin site for 15 minutes. A sterile
dressing was
applied.
The patient tolerated the procedure well and there were no
immediate
complications.
IMPRESSION: Mesenteric arteriogram of the SMA and [**Female First Name (un) 899**] did not
show any active
bleeding or vascular abnormalities. If the patient continues
lower GI
bleeding, a repeat superselective arteriogram of the ileocolic
and right colic
and middle colic arteries could be repeated with possible
transcatheter
embolization.
[**2115-9-24**] CXR
FINDINGS: In comparison to the previous chest radiograph of
[**2115-8-20**],
the multifocal pneumonia has almost completely resolved with
subtle residual
airspace opacities in the right lower lung. The
cardiomediastinal silhouette
is normal and unchanged. Calcification in the thoracic aorta is
stable,
degenerative changes throughout the thoracic spine are moderate
to severe.
IMPRESSION:
Resolving multifocal infection with persistent subtle airspace
opacities in
the right lower lobe
Brief Hospital Course:
82yo M with h/o Afib on Coumadin, dCHF, CRI, and s/p recent EGD
on [**2115-9-11**] showing erosive gastritis with some coffee grounds,
polypectomy of 2 polyps at hepatic flexure, and diverticulosis
in sigmoid colon, presented to [**Hospital1 18**] with significant amount of
bleeding per GI tract. Was admitted to unit and resuscitated
with blood products, 9U PRBC's and 4U FFP, and s/p tagged RBC
scan showing bleeding at hepatic flexure (at site of previous GI
procedure), unsuccessful angiography, and s/p repeat colonscopy
with clips applied to ulcers seen at hepatic flexure.
1. GIB--Pt went to unit and resuscitated with blood products,
tagged RBC scan showed bleeding at sight of hepatic flexure. Pt
went to IR (after prophylactic Bicarb and Mucomyst) for
angiography but no vessel was found for coiling. By morning
bleeding had stopped entirely and he went for colonoscopy which
showed two deep ulcers around the site of polypectomy from his
prior colonoscopy. Five clips were placed. Another polyp was
also discovered during the colonoscopy, but clipping was held in
the setting of acute GI bleed.
Serial Hct's initially showing some drop which required
transfusion of one more U PRBC's which were stopped early due to
low grade fever as below. However, pt's vitals stable through
continued stay on the floor and Hct finally stabilized and was
stable around 28 by the time of d/c.
Coumadin was held on first admission and continued to be held
while pt was admitted. This will need to be addressed at further
visits with PCP as pt has high risk for stroke with high CHADS2
score. ASA at 325mg qday was continued.
Pt will also likely need repeat colonoscopy in the future as
another polyp at the hepatic flexure was seen that was not
removed due to pt already bleeding. We left this to the pt and
his PCP to discuss the timing of this.
2. AFib--Pt did not have RVR and did not require rate control
though stay. Coumadin was held as above.
3. UTI--While on the floor, the pt began having temperature in
low 100's while receiving blood products. Transfusion stopped,
and pt continued to spike fevers through the next day, BCx and
UCx, CXR done. UCx ended up being positive for pan sensitive
Klebsiella, and pt received 2d worth of Fluoroquinolones (first
Cipro then Levaquin) and was d/c'd with 5 day course more of
Cipro, renally dosed. The UCx coincided with pt's subjective
feeling of increased urination and burning on urination as well.
By time of d/c pt had not had fevers for a couple days and was
clinically well. Was never hemodynamically compromised during
febrile episodes.
4. dCHF/HTN--Pt's bp meds were held on amdission and slowly
added back until day of discharge when pt was on full home
regimen of Clonidine, Felodipine, Lasix, Hydralazine, and Imdur.
Pt did not have symptomatic heart failure and did not require
diuresis above his home PO regimen except twice for a small amt
of increased BLE edema.
5. CAD s/p distant PTCI--Was not an active issue during this
admission and didn't have CP. CE enzymes negative x2. No
evidence of ischmia on EKG. ASA was restarted without incident.
Continued home simvastatin
6. CRI--Pt's baseline 1.5-1.7. Got IVF's, bicarb and Mucomyst
for angio procedure and Cr was stable and within baseline
through rest of admission. By d/c was 1.5.
7. H/o Gout--Wasn't active issue, continued home Allopurinol.
Medications on Admission:
ISMN 60 mg S.R. Daily
Simvastatin 40 mg qHS
Hydralazine 150 mg po tid
Felodipine 10 mg daily
Clonidine 0.1 mg Tablet [**Hospital1 **]
Allopurinol 300 mg Daily
Aspirin 81 mg Tablet daily
Omeprazole 40 mg po bid
Warfarin 5 mg po daily
Lasix 120mg PO qdaily
B12 dosage uncertain, prescribed by other provider
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Four
(4) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Hydralazine 50 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Active issues during this admission:
1. GIB most likely from hepatic flexure where biopsies had been
taken on recent colonoscopy in late [**8-21**]. Atrial fibrillation
3. Diastolic congestive heart failure
4. Coronary artery disease
5. Chronic renal insufficiency
6. Urinary tract infection with pan sensitive Klebsiella
Discharge Condition:
By the time of discharge, the pt had a stable hematocrit, vital
signs were normal and stable, no evidence of bleeding from
anywhere, was ambulating without difficulties, and was taking
good PO food and liquids.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with blood in your stools and found
to be anemic from blood loss. You received blood products at an
outside hospital and when you arrived to [**Hospital1 18**] you were admitted
to the intesive care unit. You were given more blood products
and your blood level stabilized. You also underwent procedures
to localize the source of the blood loss. You then underwent a
colonoscopy and the ulcers that appeared to be bleeding were
clipped. Your blood level stabilized and was stable.
While you admitted, your blood thinner Coumadin was held. Your
Coumadin was NOT restarted on discharge, and you will need to
discuss with your primary care physician when you should restart
this medication.
Your blood pressure meds were also held out of concern for low
blood pressures while you were actively bleeding. As your
bleeding problem resolved, your blood pressure meds were
restarted, and by the time of discharge you were taking all of
your blood pressures meds: Clonidine, Felodipine, Lasix,
Hydralazine, and Isosorbide Mononitrate.
Finally, you will also need to complete a short course of oral
antibiotics for the urinary tract infection that you developed
while admitted. Please continue a 5 more day course of
Ciprofloxacin for a total of 7 days. You primary care doctor can
then reassess whether you still have a urinary tract infection.
Please return to the hospital if you experience fevers, chills,
night sweats, more bleeding with your bowel movements or
evidence of bleeding from any other source, abdominal pain, or
any other concerns.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Please follow up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] on
Tuesday [**2115-10-1**] at 2:15pm.
During this visit please make sure you address the following 2
VERY IMPORTANT ISSUES:
1. If and when you should restart your anticoagulation drug
(Coumadin/Warfarin) for your Atrial Fibrillation
2. When to follow up with your GI doctors about a repeat
colonoscopy to address the remaining polyp in your GI tract.
They can schedule this for you, and they advised doing so in
about 2-3 weeks. For your information, the physicians who
performed your colonscopy were: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 452**], and Dr. [**First Name (STitle) **] [**Name (STitle) **].
We have also made an appointment for you with Dr. [**Last Name (STitle) 1918**]
[**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 62**] on [**10-10**] at 4pm. Your
original appointment in [**Month (only) **] has been cancelled so that you
can follow up with him sooner, on [**10-10**].
For your information, you also have the following previously
made appointment:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2115-11-27**] 9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2115-9-26**]
|
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"274.9",
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"285.1",
"569.82",
"578.1",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.43",
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icd9pcs
|
[
[
[]
]
] |
11278, 11284
|
6619, 9993
|
313, 326
|
11650, 11863
|
2033, 6596
|
13617, 15068
|
1419, 1533
|
10350, 11255
|
11305, 11629
|
10019, 10327
|
11887, 13594
|
1548, 2014
|
524, 658
|
246, 275
|
354, 429
|
689, 1068
|
451, 504
|
1084, 1403
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,367
| 110,425
|
10668
|
Discharge summary
|
report
|
Admission Date: [**2153-8-2**] Discharge Date: [**2153-8-22**]
Date of Birth: [**2095-10-27**] Sex: M
Service: [**Company 191**]
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
male with no significant past medical history. He presented
with a three-day history of right upper quadrant and
intermittent at first and made better by food; however, he
had decreased appetite by the time of admission. He had
nausea with one episode of non-bloody vomiting after drinking
one cup of soup. He also complained of chest pain, but he
did not have any shortness of breath. He reported symptoms
of nausea and vomiting one month prior to admission; however,
at that time no intervention was taken. He has a primary
week.
He denied any orthopnea, paroxysmal nocturnal dyspnea, lower
extremity edema. He denied fevers or chills.
He denied melena, bright red blood per rectum, hematochezia,
or [**Doctor Last Name 352**] stool. He did report have report having dark urine.
He has decreased appetite.
He was initially sent to [**Hospital 8**] Hospital, but he was
transferred over here with an Amylase of 2660, total
bilirubin of 11, with a direct bilirubin of 7.7. Right upper
quadrant ultrasound showed two stones at the common bile duct
at 11 mm.
PAST MEDICAL HISTORY: He has no past significant medical
history or surgical history.
MEDICATIONS: Ranitidine 150 mg p.o. q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: He is married with a daughter. [**Name (NI) **] works in
the trucking business. He reported smoking. Occasional
alcohol use. He denied any drug abuse.
PHYSICAL EXAMINATION: Vital signs: On admission temperature
was 98.8??????, blood pressure 143/77, heart rate 113,
respirations 35, oxygen saturation 97% on room air. General:
He was alert, awake, and oriented times three. He was in no
apparent distress. HEENT: He had icteric sclerae. Pupils
equal, round and reactive to light and accommodation. He had
no jugular venous distention. Pulmonary: Lungs had
decreased breath sounds at the bases. Cardiovascular: He
was tachycardiac. No murmurs, rubs or gallops. Abdomen:
Nondistended but tender to palpation diffusely, especially at
the midepigastric and right upper quadrant area. He had no
[**Doctor Last Name 515**] sign. Extremities: He had no clubbing, cyanosis or
edema. Neurological: The patient was alert, awake, and
oriented times three. Cranial nerves II-XII intact. No
motor or sensory deficits.
LABORATORY DATA: On admission white blood cell count 7.1,
hematocrit 42.5, platelet count 114,000; sodium 137,
potassium 4.3, chloride 99, bicarb 22, BUN 32, creatinine
1.9, glucose 115; neutrophils 37, lymphocytes 8, monocytes,
9, 6 bands; ALT 129, AST 77, alkaline phosphatase 191, total
bilirubin 6.7, amylase 858, lipase 937.
Chest x-ray was with poor inspiratory effort with left
hemidiaphragm, elevated and large amount of dilated loops of
bowel with gas. He had a right pleural effusion which was
moderate to large. Right upper quadrant ultrasound showed a
common bile duct of 7.3 mm, thickened gallbladder walls, no
fluid, two stones in the gallbladder, non-obstructing, with
an echogenic liver.
HOSPITAL COURSE: The patient was thought to have acute
pancreatitis possibly due to gallstones.
1. GI: The patient was thought to acute pancreatitis
possibly secondary to gallstones. He had an ERCP done in
which a large stone was found impacted in the distal common
bile duct. It was removed with along with a sphincterotomy.
His cystic duct was patent though. The biliary tree had
mild, diffuse dilatation. Before the procedure and after, he
was started on Ampicillin, Ciprofloxacin, and Metronidazole
for empiric coverage of possible cholangeitis. He was
continued NPO. He did have some postresidual distention of
his abdomen. KUB was consistent with ileus, but no
obstructions were visualized. He continued to have right
upper quadrant pain. He was given Demerol IM 50-75 mg. He
reported great relief with the Demerol.
Because of his ileus, and orogastric tube was inserted;
however, the patient had denied a nasogastric tube because of
previous deviated septum. He felt very uncomfortable
accepting a nasogastric tube. He was placed on Protonix. He
had not been able to tolerate clear sips. He was started on
TPN which continued until [**8-21**].
During this time, his LFTs had resolved to essentially
normal. He continued to have somewhat elevated amylase and
lipase but overall had a general decline. On discharge, his
amylase and lipase were still elevated. On [**8-14**], the
patient's white blood count increased from the mid teens to
19. His hematocrit was in the low 30s, so a CT was
performed. The CT did not show any evidence of bleeding. It
did show subphrenic collection of fluid. It also showed
bilateral pleural effusion. Radiology aspirated the
subphrenic collection draining approximately 30 ml. The
abdominal fluid did not grow any bacteria. During this time,
he was also started on Ampicillin, Levaquin, and
Metronidazole.
Past cultures returned back negative, and the antibiotics were
discontinued. He had one other event of
decreased hematocrit. It came back as 25, so a gastric
lavage was performed which was negative. Repeat hematocrit
was 29.6. The 25 hematocrit may have been a spurious value.
Repeat CT was again performed which showed similar subphrenic
fluid collection with bilateral pleural effusions. A repeat
CT was done because of increased pain after the aspiration of
his subphrenic collection. The CT was done to rule out any
source of bleed.
Surgery consult was also requested. Surgery did not feel
that surgical intervention was needed at this time; however,
they felt that after this episode had resolved, the patient
should be followed up in the Surgery Clinic for future
cholecystectomy. The patient was able to tolerate some clear
sips. His diet was advanced, and TPN was stopped. He now
leaves with an abdomen that is less distended, soft, with
normal bowel sounds. He has had bowel movements with the
encouragement of suppositories. He has not really had any
nausea or vomiting for much of his admission. His amylase
and lipase are still somewhat elevated. His ALT and AST are
within normal limits; however, his alkaline phosphatase,
amylase, and lipase remained somewhat elevated.
2. Pulmonary: The patient came in with a moderate to large
right pleural effusion. He also had left-sided pleural
effusions. He been intubated during the ERCP and was easily
extubated; however, he had increased oxygen requirements. He
had required face mask. He was given Lasix a few times. He
responded well to 10 mg IV Lasix. However, not much fluid
was taken off based on repeat chest x-rays. He had
complained of some chest pain but had no electrocardiogram
changes. After the thoracentesis procedure, he had some
right-sided chest pain and right flank pain. He became
tachypneic greater than usual at a rate in the 50s. An ABG
was done which showed respiratory alkalosis. No
electrocardiogram changes were noted. He was given Lasix and
had improved respirations. The patient has had right lateral
wall chest pain, particularly on movement, respirations,
coughing, or sneezing. Chest x-ray did not show any
pneumothorax. He is not in any respiratory distress and has
no shortness of breath. This was considered to be
postprocedural from reexpansion of the right lower lung.
Throughout the whole time, the patient never really
complained of any shortness of breath; however, he was always
somewhat tachypneic in the low 30s. He was also started on
Combivent and Albuterol/Atrovent nebulizers which had some
moderate affect. The tachypnea was thought to be due to 1)
atelectasis, 2) pleural effusions, 3) splinting from the
right upper quadrant abdominal pain after the CT, and he had
a subphrenic fluid collection which was thought to have
increase his abdominal pain and subsequently his shallow,
rapid respirations. He was eventually switched to nasal
cannula, and now he is on room air with oxygen saturations of
94%.
He has received one diagnostic thoracentesis and two attempts
at therapeutic thoracentesis; the second one removing a large
amount of fluid from the right lung. Chest x-rays after the
procedure did not reveal any pneumothorax. After the third
and final thoracentesis, the patient had a much more aerated
right lung. Repeat chest x-ray did show some right lower
lobe and possibly right middle lobe atelectasis.
3. Cardiovascular: The patient never really had an ischemic
event. He had an echocardiogram done which showed an
ejection fraction of 40%, and within the echocardiogram, he
had no gross evidence of abdominal cardiac function.
4. Renal: The patient had an elevated creatinine after the
ERCP which increased to 2.9; however, with hydration, the
patient's creatinine had decreased gradually. On discharge
it is 1.4, slightly increased from his 1.2 low. On admission
his creatinine had been 1.9.
5. Heme: The patient had a slowly drifting hematocrit. He
was transfused with 1 U of red blood cells once the
hematocrit had been recorded as 25, and he responded to the 1
U.
6. Pain: The patient had been controlled with Demerol
initially 50-75 mg IM; however, it was switched to 100 mg
Demerol and then finally converted to a PCA. When he was on
PCA, the patient required less pain medication. He was
converted to oral Dilaudid on [**8-21**] because of some right
flank pain. He required Dilaudid 4 mg almost every 6 hours;
however, he has decreased pain.
FOLLOW-UP: The patient will be seen by Surgery in two week,
[**9-11**], at 10:15 with Dr. [**Last Name (STitle) 34985**], at the [**Hospital6 1760**]. He will be considered for a
possible cholecystectomy. He will also be followed up with
his primary care physician either in [**Name9 (PRE) 8**] or with the
[**Hospital3 **] at [**Hospital6 256**]
where he will be assessed for his pleural effusions and
subphrenic fluid collection, pulmonary status, and resolution
of the gallstones, and pancreatitis.
DISCHARGE MEDICATIONS: Dilaudid 2-4 mg p.o. q.4 hours
p.r.n., Heparin 5000 U subcue b.i.d., Protonix 40 mg p.o.
q.d., Dulcolax 10 per rectum q.8 hours p.r.n., Combivent 2
puffs q.4 hours.
CONDITION ON DISCHARGE: The patient will be discharged to
[**Hospital **] [**Hospital **] Hospital.
DISCHARGE DIAGNOSIS: Gallstone pancreatitis.
DISCHARGE STATUS: The patient is stable.
[**Last Name (LF) **], [**Name8 (MD) **] M.D. [**MD Number(1) 9783**]
Dictated By:[**Name8 (MD) 4877**]
MEDQUIST36
D: [**2153-8-22**] 10:09
T: [**2153-8-22**] 11:41
JOB#: [**Job Number **]
[**Hospital3 **], [**Hospital1 34986**], [**Hospital1 8**], [**Numeric Identifier 34987**], phone
[**Telephone/Fax (1) 34988**](cclist)
|
[
"789.5",
"560.1",
"276.5",
"577.0",
"511.9",
"518.0",
"574.91",
"305.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"51.84",
"51.85",
"34.91",
"51.88",
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10170, 10336
|
10460, 10894
|
3255, 10146
|
1675, 3237
|
167, 184
|
213, 1310
|
1333, 1479
|
1496, 1652
|
10361, 10438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,923
| 133,392
|
9319
|
Discharge summary
|
report
|
Admission Date: [**2197-1-13**] Discharge Date: [**2197-1-19**]
Date of Birth: [**2116-1-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Presyncopal episode. cardaic cath with ulcerated left main
Major Surgical or Invasive Procedure:
CABG x2 ( LIMA-LAD, SVG to RCA)
History of Present Illness:
81m with presyncope [**1-12**] at [**Company 3596**] during his 3xwk aerobics. To
ED w/o ECG changes. Cath [**2197-1-13**] for ulcerated LM 70%. Syncope
w/ 2:1HB during cath.
Past Medical History:
LT THR 10yr,Hernia repairs, radium seeding prostate 10yr
lt TKR 20yrs,Lap chole [**11-6**],hyperchol,HTN,Thalessemia minor
Social History:
retired hair dresser. Lives with wife.
[**Name (NI) **] etoh use.
quit smoking 30+ years ago
Family History:
Non- contributory
Physical Exam:
Pulse: Resp:12 O2 sat: 99
B/P Right:148/63 Left: 144/64
Height:66 Weight:167#
General:WDWN NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused x[] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right: 2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
[**2197-1-13**] 08:16PM GLUCOSE-140* UREA N-21* CREAT-1.2 SODIUM-139
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2197-1-13**] 08:16PM WBC-9.5 RBC-4.43* HGB-14.2 HCT-41.7 MCV-94
MCH-32.1* MCHC-34.1 RDW-12.7
ECHO: [**2197-1-14**]
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
mild regional left ventricular systolic dysfunction with
hypokinesia of the apex, apical and mid portions of the anterior
and anteroseptal walls. . Overall left ventricular systolic
function is mildly depressed (LVEF= 40 %). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**1-30**]+)
mitral regurgitation is seen. Tip of IABP seen in good position.
Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2197-1-14**] at 800am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
LVEF= 55%. Mild mitral regurgitation persists. Aorta is intact
post decannulation.
Brief Hospital Course:
Mr. [**Known lastname **] was taken emergently to the operating room for
revascularization on [**1-14**] for CABG x2 (LIMA-LAD, SVG to distal
circ). Post operatively he was admiited to the ICU intubated and
sedated on phenyleprine and propofol. With in 24 hours he was
weaned from his pressors and awoke neurologically intact and was
weaned and extubated. He was started on diuetics and stain
therapy. He required placement of a pacermaker post operatively
for complete heart block on [**2197-1-17**]. His chest tubes and
temporary pacing wires were removed per ptotocol. He was started
on betablockers post pacer. He was transferred from the ICU to
the stepdown unit for ongoing post operative care. He was
evaluated by physical therpay for strength and conditioning. On
POD# 5 he was cleared for discharge to home with VNA services by
Dr. [**First Name (STitle) **].
Medications on Admission:
HCTZ 50mg daily, Atenolol dose unknown, finasteride 5mg daily,
diovan 160mg daily, proair
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. metoprolol tartrate 50 mg Tablet Sig: 1 [**1-30**] Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
9. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 5 days.
Disp:*40 Capsule(s)* Refills:*0*
10. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation q4hrs.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Left Total hip replacement 10yr, Hernia repairs,
radium seeding prostate 10yr
left TKR 20yrs,Lap chole [**11-6**],hyperchol,HTN,Thalessemia minor
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Edema -trace
Discharge Instructions:
Discharge Instructions
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] will see you for Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at
[**Hospital6 **] on [**2197-2-9**] at 09:15 am
Cardiologist: Dr. [**Last Name (STitle) 31888**] [**2197-2-16**] at 1:30
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2197-1-26**] 1:00
Please call to schedule appointments with your
Primary Care DR. [**Last Name (STitle) 349**] in [**5-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2197-1-19**]
|
[
"426.0",
"716.90",
"272.4",
"V43.64",
"V10.46",
"V15.82",
"414.01",
"401.9",
"V43.65",
"282.49",
"780.2",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"39.61",
"37.83",
"36.15",
"36.11",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
4868, 4927
|
2825, 3696
|
368, 402
|
5117, 5332
|
1541, 2802
|
6196, 6984
|
880, 899
|
3836, 4845
|
4948, 5096
|
3722, 3813
|
5356, 6173
|
914, 1522
|
270, 330
|
430, 607
|
629, 754
|
770, 864
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,089
| 137,462
|
8238
|
Discharge summary
|
report
|
Admission Date: [**2109-4-2**] Discharge Date: [**2109-4-8**]
Date of Birth: [**2055-3-18**] Sex: M
Service: EMERGENCY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Abdominal pain, difficulty breathing
Major Surgical or Invasive Procedure:
Paracentesis
NG tube placement
Intubation, extubation
History of Present Illness:
54 y/o gentleman with hep C cirrhosis presented to OSH with
generalized weakness in the last one week. Patient also had
nausea and vomitted twice yesterday, nonbloody and nonbilious.
He also states that he has had on and off abdominal pain in the
last two weeks. Abdominal pain in located in the epigastric
area. Unable to recall any exacerbating or alleviating factors.
Unable to characterize the pain any further. Patient has
stopped taking lactulose recently due to nausea and vomitting.
Patient was initially taken to [**Hospital3 3583**]. He was
hemodynamically stable there. His K was found to be 5.6 and he
received kayaxelate 15 grams PO. Diagnostic tap of peritoneal
fluid with 30 ml removal under radiology there. Received 100
gram of albumin there. Here for transplant workup.
ROS: He denies any fever, chills, nightsweats, focal weakness,
change in sensation, headache, neck stiffness, change in vision,
change in hearing, dysuria, hematuria, blood in stool. Patient
states that he has been making two to three bowel movements a
day even though he has stopped lactulose in the last two to
three days.
Past Medical History:
- Hepatitis C cirrhosis
- Hypertension
- H/o Esophageal varicose veins noted in OMR
- Non-insulin-dependent diabetes noted in OMR but patient [**Doctor First Name 1638**]
it
Social History:
Married. Denies recent alcohol, last drink 10 years ago.
States that he drank heavily in the past. 1 ppd of active
smoking for approx 20 years. Denies street drugs. Living in
[**State 108**] but recently moved here.
Family History:
Noncontributory
Physical Exam:
Gen: Sleeping comfortably, easily arousable, Oriented to x 2
(not to place thought this is [**Hospital1 112**])
HEENT: PERRL, EOM-I, MMM, dried blood inside mouth, poor
dentition, distended neck vein, unable to assess JVP
Heart: S1S2 RRR
Lungs: CTAB in anterior lung fields
Abdomen: BS present, soft, markedly distended with fluid wave,
TTP in bilateral upper quadrants, no rebound or guarding
Ext: WWP, 2+ DP, 2+ pitting edema
Neuro: CN II-XII grossly intact, strength 5/5 bilat
Pertinent Results:
[**2109-4-2**] 09:15PM WBC-3.8* RBC-3.36* HGB-7.4* HCT-23.0* MCV-69*
MCH-22.0* MCHC-32.0 RDW-21.5* NEUTS-85* BANDS-0 LYMPHS-4*
MONOS-7 EOS-0 BASOS-1 ATYPS-2* METAS-1* MYELOS-0
[**2109-4-2**] 09:15PM PLT SMR-VERY LOW PLT COUNT-47*
[**2109-4-2**] 09:15PM PT-21.6* PTT-32.2 INR(PT)-2.1*
[**2109-4-2**] 09:15PM ALT(SGPT)-32 AST(SGOT)-104* LD(LDH)-1147* ALK
PHOS-88 AMYLASE-52 TOT BILI-4.8* DIR BILI-2.7* INDIR BIL-2.1
[**2109-4-2**] 09:15PM LIPASE-263*
[**2109-4-2**] 09:15PM ALBUMIN-3.2* CALCIUM-11.8* PHOSPHATE-5.5*
MAGNESIUM-2.4
[**2109-4-2**] 09:15PM GLUCOSE-122* UREA N-110* CREAT-2.7*
SODIUM-140 POTASSIUM-5.1 CHLORIDE-107 TOTAL CO2-21* ANION GAP-17
Brief Hospital Course:
54 y/o gentleman with Hep C cirrhosis transfered from OSH with
hepatic encephalopathy p/w acute on chronic renal failure and
worsening respiratory status.
In the MICU, he was found with elevated calcium (11.8 initially,
rose to 12.2 on [**4-4**]). Lipase also mildly elevated at 263. Mental
status improved with Lactulose and holding morphine. A
paracentesis was performed with 3 liters removed.
Following transfer to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service, he subsequently
developed gallstone pancreatitis with a lipase that peaked at
2774. He was treated with aggressive IVF and bowel rest. On
[**4-6**] a CT torso w/ contrast was performed to evaluate for a
primary malignancy given patient's hypercalcemia of unknown
etiology. On the evening of [**4-6**], a trigger was called for
acute hypoxia when patient was found to have SpO2 80% on RA and
subjective dyspnea. SpO2 improved to 95% on 6L NC. ABG
7.3/41/80 and lactate 2.9.
On the morning of transfer back to the MICU, patient's WBC
increased from 5K to 11K. He was pan-cultured and antibiotics
were broadened to vancomycin & zosyn. He was also noted to be
oliguric. A foley was placed at 7 AM and patient subsequently
only had 30 cc's UOP. Per renal recommendations, he received
Lasix 80 mg IV then 160 mg IV 1 hour apart, which combined
resulted in a total of 50 cc's of urine. He is being
transferred to the MICU due to concerns regarding his worsening
respiratory status. Vital signs on transfer: SpO2 90% on 6L NC,
RR 30's, HR 60, BP 125/57. Given continued oliguria and
worsening of metabolic acidosis, hemodialysis was deemed
necessary for survival. This was discussed with his wife, who
is also his health care proxy. She stated that she had had many
discussions with her husband prior to his illness and that he
would not want this therapy. Given these discussions and the
HCP's wishes, hemodialysis was not pursued. Mr. [**Known lastname 29253**] was
then made comfort measures only and extubated per his family's
wishes. He expired on [**2109-4-8**] at 2:56 PM with his family at his
side.
Medications on Admission:
MSContin 160 mg [**Hospital1 **]
Lactulose
Propanolol 40 [**Hospital1 **]
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Hepatic encephalopathy
Acute renal failure
Respiratory failure
Hypercalcemia
Pancreatitis
Cirrhosis
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"250.00",
"567.23",
"574.20",
"995.92",
"038.9",
"507.0",
"070.44",
"275.42",
"456.21",
"585.9",
"571.5",
"518.81",
"584.5",
"403.90",
"577.0",
"276.2",
"572.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"96.04",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5509, 5518
|
3242, 5353
|
351, 406
|
5661, 5670
|
2545, 3219
|
5726, 5736
|
2009, 2026
|
5477, 5486
|
5539, 5640
|
5379, 5454
|
5694, 5703
|
2041, 2526
|
275, 313
|
434, 1559
|
1581, 1756
|
1772, 1993
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,648
| 118,565
|
46483
|
Discharge summary
|
report
|
Admission Date: [**2130-9-27**] Discharge Date:
Date of Birth: [**2074-9-17**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 56 year old woman with
metastatic colon cancer to her liver, pancreas and abdominal
wall, status post hemicolectomy in [**2130-3-16**], who was
transferred from [**Hospital3 2558**] for management of her
hypokalemia. The patient initially admitted to [**Hospital1 346**] status post one week of nausea,
vomiting, diarrhea, and abdominal pain and refusing
intravenous and laboratory draws at [**Hospital3 2558**].
In the Emergency Department, peripheral intravenous was
placed but after many attempts a central line was not able to
be placed. In the Emergency Department, the patient refused
to have any blood draws.
PAST MEDICAL HISTORY:
1. Colon cancer diagnosed in [**2129-12-16**], status post
right hemicolectomy in [**2130-3-16**], recent CAT scan
demonstrating metastases to pancreas, stomach and liver. The
patient has been refusing chemotherapy. The patient has had
several complications secondary to partial small bowel
obstruction.
2. Seizure disorder felt to be secondary to bilateral water
shed infarcts.
3. Methicillin resistant Staphylococcus aureus line
infection.
4. Right lower extremity deep vein thrombosis diagnosed from
prior admission in [**2130-8-16**].
5. FVC syndrome.
6. Status post cesarean section.
7. Status post appendectomy.
MEDICATIONS ON ADMISSION:
1. Depakote 250 mg p.o. b.i.d. The patient was refusing this
in the Emergency Department.
2. Folate 1 mg p.o. q.d.
3. Oxycontin 10 mg p.o. q.d. which the patient is refusing.
4. Lovenox 50 mg subcutaneous b.i.d.
5. Oxycodone 10 mg p.o. q6hours.
6. APAP 650 mg q4hours p.r.n. pain.
7. Milk of Magnesia 30 cc p.o. q.d. p.r.n.
8. Multivitamin with meals p.o. q.d.
9. Senna two tablets p.o. q.d.
ALLERGIES:
1. Iodine contrast.
2. Sulfa drugs (
The patient was not willing to explain her specific reactions
to these medications.
SOCIAL HISTORY: The patient is a retired nursing aid from
[**Hospital1 69**]. She denies any alcohol
or tobacco use.
FAMILY HISTORY: The patient is not willing to communicate
her family history in detail. The patient's son reports
family history of diabetes mellitus.
PHYSICAL EXAMINATION: On admission, the patient is afebrile
with blood pressure 80/39, heart rate 100 and oxygen
saturation 100% in room air. She is cachectic, ill
appearing, in pain and moaning. Neck examination
demonstrates no jugular venous distention, no bruits, no
lymphadenopathy. The heart is regular rate and rhythm, S1
and S2, no murmurs noted. The chest is clear to auscultation
anteriorly. The abdomen demonstrates a firm protrusion in
the right side just lateral to the umbilicus with significant
tenderness to moderate palpation. No rebound, no guarding
and no gross ascites, guaiac negative with very little stool
in her vault. Extremity examination is significant for 4+
pitting edema from her inguinal region to her distal foot in
the right leg.
HOSPITAL COURSE: The patient was admitted to general floor
for treatment of her hypokalemia, however, she continued to
refuse medications, blood transfusions and several blood
draws. She continued to have nonbloody diarrhea as she was
having the week before admission. Urinalysis demonstrated
bacteruria on [**2130-9-28**], which was treated with Flagyl and
Ceftriaxone.
The patient eventually agreed to transfusion of two units of
packed red blood cells for hematocrit of 23.6 on [**2130-9-29**],
and her hematocrit subsequently increased to 32.0.
The patient decided to make her son her held care proxy but
stood firm in her decision to remain a full code. The
patient continued to be treated for hypokalemia. During her
admission, we were unable to place a central line for her
intravenous antibiotics and surgery attempted and was
unsuccessful. The patient continued to refuse medications.
The patient continued to develop erythema on the right side
of her abdominal wall which ruptured on [**2130-10-1**], with
discharge of yellow [**Doctor Last Name 352**] material which was cultured as
pansensitive pseudomonas. The patient's antibiotics were
changed to Levofloxacin and Flagyl for full coverage of the
flora of the abscess.
On [**2130-10-6**], the patient began to seize and underwent
ventricular fibrillation arrest for which she received CPR
two shocks and was intubated and sent to the Medical
Intensive Care Unit. In the Medical Intensive Care Unit, the
patient ruled out for myocardial infarction, had a negative
echocardiogram, no events on telemetry and was quickly
extubated, loaded with Depakote and transferred back to the
floor.
On the floor, the patient was then maintained on Valproate
which was adjusted by levels for therapeutic levels. The
patient continued to have discharge from her abscess wound
but maintained her blood pressure, did not have elevated
white blood cell count, and was afebrile during her
hospitalization.
On [**2130-10-13**], a family meeting was held with the patient, her
son [**Name (NI) **], her sister [**Name (NI) **], and various members of her health
care team. The patient decided that she wanted to remain
full code.
The patient had had a femoral line placed during her code
which was used to adjust her intravenous medications. The
patient developed anasarca with weeping of her skin from her
intravenous sites, and her wounds over the next few days.
The patient's pain was well controlled with Morphine and then
Dilaudid.
On [**2130-10-18**], it was decided to discontinue her antibiotics as
she had received a full course of Levofloxacin, Flagyl and
Vancomycin (Vancomycin had been started secondary to a
positive sputum culture for Methicillin resistant
Staphylococcus aureus during the hospitalization.
The patient had discussion with her primary care physician,
[**Name10 (NameIs) **], Dr. [**Last Name (STitle) **], and her son [**Name (NI) **], on [**2130-10-17**], and it
was decided to change her code status to DNR/DNI.
MEDICATIONS ON DISCHARGE:
1. Dilaudid 0.5 to 2 mg q4-6hours p.r.n.
2. Morphine Sulfate 1 mg intravenously q1hour p.r.n. pain.
3. Compazine 5 mg intravenously q8hours nausea p.r.n.
4. Valproate 300 mg intravenously b.i.d.
5. Nystatin Powder to groin b.i.d.
6. Protonix 40 mg intravenously q.d.
7. Lovenox 40 mg subcutaneous b.i.d.
8. Desitin/Lidocaine/A&D Ointment topically p.r.n.
9. Nystatin swab 5 to 15 mg p.o. q4-6hours p.r.n.
10. Intravenous fluids D5 one half normal saline with 40 meq
of potassium at 40 cc/hour.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 17014**], M.D. [**MD Number(1) 17015**]
Dictated By:[**Last Name (NamePattern1) 19727**]
MEDQUIST36
D: [**2130-10-18**] 16:25
T: [**2130-10-18**] 19:12
JOB#: [**Job Number **]
|
[
"197.7",
"427.41",
"197.8",
"682.2",
"V10.05",
"780.39",
"198.2",
"276.8",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2134, 2271
|
6075, 6858
|
1459, 1997
|
3060, 6049
|
2294, 3042
|
153, 783
|
805, 1433
|
2014, 2117
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,656
| 120,271
|
7210
|
Discharge summary
|
report
|
Admission Date: [**2174-5-3**] Discharge Date: [**2174-5-5**]
Date of Birth: [**2093-9-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain/pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 26720**] is an 80 yo s/p tissue AVR [**2174-4-27**] with Dr.
[**Last Name (STitle) **]. His post op course was complicated by
confusion/delerium thought to be due to anaesthesia/narcotics
and gradually improved. He also had atrial fibrillation, which
was not new, and he was started on amiodarone. On the day of
admission, approximately 1730 he was eating and developed [**2173-8-12**]
L sided chest pain/pressure with no radiation or associated
symptoms, no diaphoresis, nausea or vomiting. Per patient the
pain was relieved with 1 sublingual nitro, however his blood
pressure dropped to SBP 80s. He was transfered for further
evaluation.
Past Medical History:
Dyslipidemia
Hypertension
PTCA/PCI to RCA in [**2164**]
tachy-brady syndrome s/p PPM [**2169**] **Guidant PPM Model# 1283
Serial# [**Serial Number **]**
Atrial fibrillation
CVA in [**2154**], residual left-sided weakness, uses cane, brace on
left leg
OSA, not using CPAP for past couple years [**3-9**] discomfort after
SCC removal
Benign Prostatic Hypertrophy
Benign thyroid nodule
carotid artery stenosis s/p left CEA 4 years ago with
100% occlusion on the right - Chronic R internal carotid artery
occlusion. <40% carotid stenosis on left
Mohs resection of an invasive squamous cell carcinoma
Social History:
Lives with:wife
Occupation:retired. photo engraver
Tobacco:quit smoking 20 yrs ago, previously 1 small pack cigars
for 2 years
ETOH:occasionally drinks [**2-6**] glasses wine per evening
Family History:
Mother died of MI at 70-75yo. Father died of MI at 80yo. His
family history is significant for Alzheimer's disease. His
sister also has a heart murmur.
Physical Exam:
Pulse: 130 Resp:25 O2 sat: 96 BP Right: 103/66 Left:
General: Elderly male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs decreased bilateral bases with scattered wheezes
Heart: RRR [] Irregular [x] Murmur no audible murmur
Abdomen: Softly distended [x] non-tender [x] bowel sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema 1+
Neuro: Grossly intact L sided dificit as noted above, orientedx2
Pulses:
DP Right:2+ Left:[**2-6**]+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Sternal incision: clean, no drainage, no erythema, sternum
stable
Pertinent Results:
[**2174-5-2**] WBC-5.4 RBC-3.27* Hgb-10.3* Hct-29.6* Plt Ct-139*
[**2174-5-3**] WBC-6.3 RBC-3.29* Hgb-10.3* Hct-30.3* Plt Ct-171
[**2174-5-4**] WBC-6.1 RBC-3.21* Hgb-10.1* Hct-29.5* Plt Ct-170
[**2174-5-5**] WBC-6.2 RBC-3.29* Hgb-9.9* Hct-30.4* Plt Ct-198
[**2174-5-2**] PT-15.7* INR(PT)-1.4*
[**2174-5-3**] PT-19.4* PTT-26.6 INR(PT)-1.8*
[**2174-5-4**] PT-20.5* PTT-26.8 INR(PT)-1.9*
[**2174-5-5**] PT-27.6* PTT-30.9 INR(PT)-2.7*
[**2174-5-2**] Glucose-106* UreaN-25* Creat-0.9 Na-137 K-4.3 Cl-101
HCO3-29
[**2174-5-3**] Glucose-138* UreaN-27* Creat-0.9 Na-140 K-4.3 Cl-104
HCO3-29
[**2174-5-4**] Glucose-104* UreaN-24* Creat-0.9 Na-141 K-3.9 Cl-103
HCO3-29
[**2174-5-5**] Glucose-99 UreaN-20 Creat-0.8 Na-140 K-3.9 Cl-103
HCO3-30
[**2174-5-4**] ALT-34 AST-47* CK(CPK)-145 AlkPhos-82 Amylase-320*
TotBili-0.6
[**2174-5-5**] LD(LDH)-257* Amylase-306*
[**2174-5-4**] Lipase-706*
[**2174-5-5**] Lipase-626*
Brief Hospital Course:
Mr. [**Known lastname 26720**] was readmitted back to the cardiac surgical
service with rapid atrial fibrillation. Amiodarone was bolused
in the emergency department. Due to hypotension, he was
initially observed in the CVICU and started on Neosynephrine. He
ruled out for acute coronary syndrome by electrocardiogram and
biochemistries. Within 24 hours of readmission, he converted
back to a normal sinus rhythm and hemodynamics improved.
Neosynephrine was weaned and he transferred to the SDU. He
tolerated beta blockade. No further episodes of atrial
fibrillation were noted. Warfarin was continued and dosed for a
goal INR between 2.0 to 2.5. Amylase and lipase levels were
noted to be elevated. Abdominal exam remained benign and he
tolerated heart, healthy diet. By discharge, amylase and lipase
levels remained elevated but were improving. The remainder of
his hospital course was uneventful and he was discharged back to
[**Last Name (un) 1687**] House Rehab in [**Location (un) 745**].
Medications on Admission:
1. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
2. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation every four (4) hours
as needed for shortness of breath or wheezing.
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
please take 200mg twice a day for 7 days then decrease to 200 mg
daily .
6. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
10. niacin 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO BID (2 times a day).
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. fluticasone 50 mcg/Actuation Spray, (1) Spray Nasal [**Hospital1 **] (2
times a day).
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
15. warfarin 4 mg Tablet Sig: One (1) Tablet PO once [**5-3**]: INR
to be drawn [**5-4**] for further dosing .
Discharge Medications:
1. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for HR < 55 or SBP < 90 .
5. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO BID (2 times a day).
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed. Daily dose may vary according to INR. Adjust
warfarin for goal INR between 2.0 to 2.5.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Atrial Fibrillation
s/p Aortic Valve Replacement [**2174-4-27**]
Dyslipidemia
Hypertension
Prior Pacemaker Implantation
Cerebrovascular Disease
Elevated Amylase and Lipase
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisions:
Sternal - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2.0 to 2.5
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease to twice a week if dose stable. Rehab
physician to dose coumadin will at rehab. Please arrange for
coumadin follow up when discharged from rehab with PCP office
thank you
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are [**Telephone/Fax (1) 1988**] for the following appointments:
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2174-5-19**] 2:00
Cardiologist: Dr [**Last Name (STitle) **] office will contact you with appt
PCP: [**Name10 (NameIs) **] [**Name (NI) **] [**Telephone/Fax (1) 250**] [**2174-5-19**] at 920 am
These are appts that were already booked
[**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern1) 13280**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2174-8-22**]
1:45
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2174-5-5**]
|
[
"V42.2",
"V45.01",
"272.4",
"728.89",
"427.31",
"401.9",
"438.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7175, 7253
|
3670, 4666
|
328, 335
|
7469, 7589
|
2741, 3647
|
8768, 9485
|
1875, 2028
|
6070, 7152
|
7274, 7448
|
4692, 6047
|
7613, 8745
|
2043, 2722
|
269, 290
|
363, 1032
|
1054, 1653
|
1669, 1859
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,149
| 144,128
|
50370
|
Discharge summary
|
report
|
Admission Date: [**2141-3-17**] Discharge Date: [**2141-3-31**]
Service: MEDICINE
Allergies:
Quinidine / Propranolol
Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
Drop in HCT and elevated creatinine at rehab
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
Mr. [**Known firstname **] [**Initial (NamePattern1) **]. [**Known lastname **] is a very nice 87 year-old gentleman with
HTN, diastolic CHF (EF 65% 1/10), AFib not on Coumadin, and mild
AS, Stage IV CKD who comes with a "drop" in his HCT and elevated
creatinine and weight. He has had multiple admissions recently
for acute diastolic heart failure and was discharged to Rehab.
At rehab patient was eating well a "no salt added" food and
feeling well, but nurses noted he was gaining weight (up to 13
pounds as of yesterday). His torsemide was increased to 60 mg
twice a day, but he continued to gain weight. He uses his
regular [**3-3**] pillows, denies any shortness of breath, fever,
chills, rigors. He uses his TEDs in both legs religiously and
has noted mild to moderate swelling of his ankles. His activity
is not impaired and he has good apetite.
.
Patient also complaints of a productive cough with yellow sputum
over the last 1-2 days without SOB, fever, chills rigors,
rashes, joint pains. He reports that he feels fluid dripping in
the back of his trhought without any metal taste or preference
of time of the day. Food does not change it. There is no
rhinorrhea, increased lacrimation, odynophagia, sick contacts.
.
Patient denies any changes in his bowel movement, diarrhea,
constipation
.
Yesterday he had his hematocrit checked and per report it was
very low (unkown value) with guaiac positive stools. Per OSH
report he was very sleepy, but responded to verbal comands and
was oriented x3. In his labs, they also found a creatinine of 3
and Rehab considered that he was too complicated to be managed
there and sent him to the emergency room at [**Hospital1 **] [**Location (un) 620**], where he
had normal physical exam, stable VS and ECG showing RBBB and
atrial fibrillation without signs of ischemia.
.
In our emergency room the initial vital signs were: T 96.8 F,
HR 75 [**Doctor First Name **], BP 125/63 mmHg, RR 16 X', SpO2 99% on RA and FSG 74.
Patient look comfortable and well. His SBP fluctuated from
80-120 mmHg. His HCT was at his baseline at 23.5 (HCT on [**3-10**]
was 24), PLT 85, PTT of 35.3 with INR of 1.3 and BUN 103,
creatinine 3.0 and AP 317, Lipase 159. Patient refused NG lavage
and had guaiac positive stools. Given signs of GI bleeding
(guaiac) and borderline low BP patient received 1 unit of RBCs.
Pt was also administered pantoprazole IV. He is admitted to the
ICU for hemodynamic monitoring for possible GIB and hypotension.
His VS were T [**Age over 90 **] F, HR 69 X', BP 94/52 mmHg, RR 18 100%.
Past Medical History:
-Congestive heart failure with preserved LVEF (65% 1/10) --> per
DCS from [**2-8**], thought to have left HF leading to right HF
without primary pulm HTN
-Chronic Atrial fibrillation, not on warfarin given recent UGIB
([**2-8**])
-Mild aortic stenosis (peak 25 mmHg [**11-6**])
-Pulmonary artery hypertension (30mmHg + RA [**11-6**])
-Mild mitral regurgitation
-Moderate tricuspid regurgitation
-Mild aortic insufficiency
-Mild ascending aortic dilatation (3.7 cm)
-Left ventricular hypertrophy
-Prostate enlargement (followed by Dr. [**Last Name (STitle) **] [**Last Name (STitle) 79**])
-Hypertension
-Hypercholesterolemia
-Severe essential tremor, since [**2076**] (WWII)
-Venous stasis, followed by Dr. [**Last Name (STitle) **]
[**Name (STitle) 104985**] hernia repair
-Hemorrhoid repair
-History of MRSA cellulitis ([**2-7**])
-Chronic Renal Failure: Stage IV with eGFR of 24 ml/min (MDRD).
Recommend to check PTH every 3 months with target of 70-110
--History of MRSA cellulitis ([**2-7**])
.
RECENT HOSPITALIZATIONS:
[**2140-12-29**] to [**2141-1-4**]
-- for CHF exacerbation, given lasix ggt
-- left foot cellulitis/fluid collection managed medically with
Vanc/Cipro/Flagyl
-- AFib subtherapeutic on Coumadin so bridged with Heparin with
subsequent rectal bleeding, traumatic hematoma, oozing from
newly placed PICC line
-- incidentaloma seen in pancreas on RUQ u/s without further w/u
.
[**2141-1-31**] to [**2141-2-15**]
-- also for CHF exacerbation, given lasix ggt and metolazone
-- supratherapeutic INR on admission, complicated by epistaxis
and melena (GI followed but endoscopy was deferred)
-- C diff colitis treated with ? both Po flagyl and vancomycin,
course should have been completed [**2141-2-19**]
.
[**2141-3-7**] to [**2141-3-10**]
-- Unresponsive while sleeping after trazadone; negative
infectious work up
-- 16 beat run of VT
-- Decreased metoprolol from 12.5mg->6.25mg [**Hospital1 **]
-- Renal failure attributed to torsemide and pre-renal
Social History:
Usually lives with wife, married for >50yrs, currently at [**Hospital 100**]
Rehab. 3 children. No tobacco, EtOH, IVDU. Retired, formerly
worked manufacturing and distributing batteries. He smoked
cigars for 2-3 years and quit >45 years ago. He has not smoked
cigarettes. He does not drink alcohol on a regular basis. Denies
IV, illicit, or herbal drug use.
Family History:
Parents are both deceased. Father (73 years; "heart" disease);
Mother (48 years; stomach cancer). He has 2 siblings (80- breast
cancer, brother with ? abdominal cancer). He has 3 children (55,
53, 49 years; all well). A son [**Doctor Last Name **] has atrial fibrillation.
Physical Exam:
VITAL SIGNS - Temp 94.5 F, BP 142/121 mmHg, HR 67 BPM, RR 14 X',
O2-sat 100% RA
<br>
GENERAL - well-appearing man in NAD, comfortable, appropriate,
not jaundiced (skin, mouth, conjuntiva)
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP 10-12 cm, no carotid bruits
LUNGS - Mild right crackles at the base, no r/rh/wh, good air
movement, resp unlabored, no accessory muscle use
HEART - PMI displaced to the left, nl S1-S2, S3 intermittently
present, harsh SEM in RUSB [**3-4**] radiating towards neck; SEM [**3-4**]
in LLSB without radiation, 2/6 systolic murmur on apex radiating
towards axila and very mild [**1-2**] diastolic murmur in apex
ABDOMEN - NABS, mildly tense/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, weak peripheral pulses (radials,
DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-3**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact. Pt with baseline [**3-3**] HZ
tremors (intention tremors as well as rest)
DISCHARGE EXAM:
T95.1F, BP 90/56 (baseline for patient), HR 56, RR 18, Sat 98%RA
Heart: irreg irreg, occasionally bradycardic; 3/6 systolic
murmur
Lungs: decreased breath sounds at bases bilaterally, but
otherwise clear
Abd: soft, non-distended, + bowel sounds
+ scrotal edema
+ trace lower extremity edema to knees, 2+ pitting edema in
thighs bilaterally
Stage II Coccyx ulcer
Multiple venous stasis ulcers on lower extremities
Pertinent Results:
[**2141-3-17**] 06:48PM GLUCOSE-58* UREA N-103* CREAT-3.0* SODIUM-141
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18
[**2141-3-17**] 06:48PM estGFR-Using this
[**2141-3-17**] 06:48PM ALT(SGPT)-23 AST(SGOT)-42* LD(LDH)-243 ALK
PHOS-317* AMYLASE-284* TOT BILI-0.7
[**2141-3-17**] 06:48PM LIPASE-159* GGT-154*
[**2141-3-17**] 06:48PM TOT PROT-6.1* ALBUMIN-3.6 GLOBULIN-2.5
CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-2.7*
[**2141-3-17**] 06:48PM VIT B12-1729* FOLATE-15.5
[**2141-3-17**] 06:48PM WBC-6.4# RBC-2.66* HGB-7.7* HCT-23.5* MCV-88
MCH-29.1 MCHC-32.9 RDW-19.3*
[**2141-3-17**] 06:48PM NEUTS-88.8* LYMPHS-7.5* MONOS-2.9 EOS-0.5
BASOS-0.3
[**2141-3-17**] 06:48PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-1+
OVALOCYT-1+ TARGET-1+ SCHISTOCY-1+ ACANTHOCY-1+
[**2141-3-17**] 06:48PM PLT SMR-LOW PLT COUNT-85*
[**2141-3-17**] 06:48PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2141-3-17**] 06:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
CXR [**2141-3-17**]: FINDINGS: PA and lateral views of the chest are
obtained. There is marked cardiomegaly with no overt CHF. There
may be a small left pleural effusion. No definite signs of
pneumonia. Mediastinal contour is grossly stable. No
pneumothorax is present. Bony structures remain intact with a
dextroscoliosis of the T-spine again noted.
CXR [**2141-3-30**]: IMPRESSION: Persistent bilateral effusions. Improved
left basilar atelectasis.
[**2141-3-19**] 11:14 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2141-3-20**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-3-20**]):
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] @ 10:05 [**2141-3-20**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
URINE CULTURE (Final [**2141-3-25**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
Mr. [**Known firstname **] [**Initial (NamePattern1) **]. [**Known lastname **] is a very nice 87 year-old gentleman with
HTN, diastolic CHF (EF 65% 1/10), AFib not on Coumadin, and mild
AS, Stage IV CKD who comes with a "drop" in his HCT and elevated
creatinine and weight.
.
# C. difficile colitis: Patient with h/o C. diff here with
hypotension, diarrhea, in the absence of fever or leukocytosis,
found to be C. diff positive by stool culture. He was treated
with IV Flagyl & PO Vancomycin on HD4. Given that this is the
patients THIRD episode of cdiff colitis this year, he will need
a prolonged course of tapered antibiotic therapy. IV Flagyl was
discontinued and he was continued on po vanc with plans for
continued taper. His diarrhea improved. Schedule for taper
provided to rehab.
.
#. Anemia / GIB? - Pt with HCT of 23, normocytic (88),
normochromic (32) with RDW of 19. His ferritin is 349, TIBC 298,
TRF 229, Iron 97 with Iron/TIBC of 32% on [**2141-3-8**]. His B12 1340
and folate >assay in [**2139-12-31**]. Furthermore, pt has CKD stage IV
and is not on EPO. He was on coumadin until last month when he
had a presumed UGIB and nosebleed and required 1 unit or RBCs.
At that point his coumadin was stopped. Currently he has PLT of
80, INR of 1.3 and PTT of 35. The patient's HCT was trended and
noted to be stable at ~24-26. GI was consulted and given the
patient's baseline functional status, deferred EGD/[**Last Name (un) **] for
outpatient setting if at all.
.
#. Hypotension - Patient with persistent hypotension to the 70's
systolic, likely [**1-31**] to infection & cardiac disease that was
response to gentle IVF boluses & pRBC's. He was monitored
closely and improved to baseline (systolic values 90-100).
.
#. Acute on Chronic Diastolic Heart failure - Patient with EF of
65% gaining weight according to rehab (13 pounds), despite
higher torsemide dose. He does not report any dietary changes
and has been on "no salt added" diet. He takes his medications
as prescribed and no signs of infections. No clear precipitant,
however he is slowly gaining weight. Given IV Lasix 100 x1 on
admission, which resulted in a transient decrease in the
patient's blood pressure to the 70s SBP. As a result, the
patient's home torsemide was held. His hypotension persisted,
however, thought to be [**1-31**] to his diastolic dysfunction. Dr.
[**Last Name (STitle) **], his outpatient cardiologist, saw him and recommended
continued treatment with torsemide, to which the patient
diuresed well. He should continue diuresis with torsemide 40mg
[**Hospital1 **], with daily weights; if the patient's weight increases >
160, torsemide dosing should increase to 80mg in AM and 40mg in
PM. If weight decreases < 145, torsemide dosing should decrease
to 40mg daily. Daily potassium levels should be checked, and
potassium repletion (powder) provided. Spironolactone was
started on [**3-30**], and improved diuresis should be expected in the
next few days. He should also require less potassium
supplementation.
.
#. Thrombocytopenia - Pt has had multiple PLT counts in the
130-140 range in various occasions. However, since the last
admission they have been decreasing up to the point of 80,000
today. Furthermore, patient has been on heparin during all this
time. Given a concern for HIT, antibody was checked and was
positive, but the serotonin assay was negative (not likely HIT).
However, all heparin products were avoided during the
hospitalization.
.
# Positive blood culture. 1/4 bottles growing probably
Micrococcus; all other subsequent cultures negative. Thought
contaminant.
.
#Urinary tract infection: Empirically started on ceftriaxone;
culture grew Proteus. He completed a 7 day course of
ceftriaxone.
.
# Pancytopenia: Secondary to infection. Improved over course of
admission.
.
#. Increased AP and GGT with elevated lipase and an abnormality
on ultrasound suggestive of a pancreatic mass. GI was consulted
and recommended an outpatient MRCP.
.
#. Chronic atrial fibrillation - Patient with CHADS2 of 2 who is
on low-dose aspirin and had his coumadin recently stopped given
GIB. He is rate-controlled with metoprolol. TSH 3.9 in [**2141-2-27**].
Given tenuous SBP, patient's home metoprolol was initially held,
as was his ASA in setting of GIB; however, both were restarted
through the admission.
.
#. Chronic renal failure - Patient with creatinine of 3 at the
time of admission; improved to 2.0 at the time of discharge.
.
#. Hypercholesterolemia - his last lipid profile included LDL
62, HDL 85, Chol 156 and TG of 43 in [**2139-9-30**]. Continued
simvastatin.
.
#. Vitamin D deficiency - pt with VD of 17. He is currently on
maintainance therapy. He was continued on vitamin D at his home
dose.
.
#. Code - DNR/DNI, confirmed with patient and family.
Medications on Admission:
PhosLo 667 mg 2 Capsules QID
Cholecalciferol 1,000 PO daily
Omeprazole 40 mg PO BID
Metoprolol 25 mg 0.25 tab [**Hospital1 **]
Simvastatin 40 mg PO Daily
Aspirin 81 mg PO Daily
Tylenol 325 mg PO PRN
Ipratropium Bromide 17 mcg HFA 2 puff q4 hrs PRN
Amonium lactate 12% topical cream [**Hospital1 **]
Preparation H 1% PRN
Torsemide 60 [**Hospital1 **]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Please taper:
[**Date range (1) 1813**] 125mg Q6H;
[**Date range (1) 104987**] 125mg Q12H;
[**Date range (1) 22379**] 125mg daily;
[**Date range (1) 47784**] 125mg; every other day
[**Date range (1) 104988**] 125mg; every third day;
then stop.
3. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
4. Ipratropium Bromide 0.02 % Solution Sig: [**12-31**] Neb Inhalation
Q6H (every 6 hours) as needed for SOB / Wheezing.
5. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): If weight > 165lbs, increase to 80mg in the morning and
40mg at night; if weight < 145lbs, decrease torsemide to 40mg
daily.
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain / fever.
12. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-8**]
MLs PO Q6H (every 6 hours) as needed for cough.
14. Potassium Chloride 20 mEq Packet Sig: [**1-2**] packets PO once a
day as needed for hypokalemia: According to scale:
3.6-3.8 give 2 packets;
3.3-3.5 give 3 packets;
3.1-3.2 give 4 packets;
3.0 or less, contact MD.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
1) C. diff colitis
2) Congestive heart failure
3) Urinary tract infection
4) Acute on chronic kidney failure
5) Pancytopenia
Discharge Condition:
Ambulatory: able to walk ~20 feet with rolling walker
Mid assist, difficulty with balance
Mental status: A&O x 3, hard of hearing
Discharge Instructions:
You were admitted for lethargy and diarrhea. You were found to
have C. Difficile colitis and were started on antibiotics. Your
hospital course was complicated by low blood pressures, a
urinary tract infection, and decompensated heart failure. You
have improved dramatically and are much closer to your goal
weight of 145 pounds. You will continue to take
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up as follows:
Department: CARDIAC SERVICES
When: THURSDAY [**2141-6-1**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.4",
"333.1",
"458.9",
"427.31",
"285.9",
"459.81",
"428.33",
"600.00",
"518.0",
"041.6",
"584.9",
"284.1",
"272.0",
"008.45",
"403.90",
"287.5",
"707.03",
"428.0",
"599.0",
"707.12",
"416.8",
"707.22",
"268.9",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16963, 17057
|
10023, 14798
|
276, 292
|
17225, 17315
|
7145, 10000
|
17849, 18201
|
5252, 5527
|
15199, 16940
|
17078, 17204
|
14824, 15176
|
17380, 17826
|
5542, 6696
|
6712, 7126
|
192, 238
|
320, 2865
|
17330, 17356
|
2887, 4860
|
4876, 5236
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,720
| 123,004
|
49950
|
Discharge summary
|
report
|
Admission Date: [**2173-7-1**] Discharge Date: [**2173-7-3**]
Date of Birth: [**2127-3-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Tetracyclines
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46y/o male w/ MMP, in his USOH until last nite, when he put on 4
patches of fentanyl, reports takes [**12-31**] patches usually at home.
He was brought to the ED after being found in his home
unresponsive. Patient difficult to arouse, opened his eyes to
voice orders, responded to pain. PEERLA.After 0.25mg of narcan,
woke up, states that he had 4 fentanyl patches today but we did
not see any of those on him. Denies used of any other drug. No
alcohol.Denies any headache, visual changes, chest pain,
shortness of breath, abdominal complaints, dysuria or
constipation.
..
Of note, he was recently admitted on [**5-23**] and d/c on [**6-2**] for
mental status changes which were presumed at that time to be
partially secondary to drug use and hypotension. During that
admission he was briefly intubated, had a negative LP and
negative MRI. Ultimately it was determined that his methadone
dose was too high, it was then titrated and he was discharged on
100 mg methdone daily.
Past Medical History:
- HIV, last CD4 292, VL >100K in [**5-2**], OI: PCP, [**Name Initial (NameIs) 11395**]. Followed
br Dr. [**Last Name (STitle) **].
- Hepatitis C. grade [**11-29**] liver fibrosis.
- Alcohol abuse. h/o withdrawl seizures, shakes
- ETOH pancreatitis
- HIV nephropathy
- Polysubstance abuse.
- History of Tylenol overdose.
- Peripheral neuropathy and neurogenic bladder.
- CAD s/p stent LCx
- UGI bleed, no EGD done
Social History:
Patient has a history of heavy alcohol and heroin abuse. Denies
drinking now, used heroin yesterday. Is current smoker. Lives
independently in affiliation with an HIV case management group,
on disability. Formerly in methadone clinic, "walked off"
shortly prior to admission.
Family History:
N/C
Physical Exam:
IN ED:
PE: 97.8 HR 78 BP 89/38 RR 17 Sats 100%
Upon arrival to [**Hospital Unit Name 153**]:
P 77 BP 88/46 R 14 O2 100% on 2L
Pupiles reactive to light.symmetric, red conjuctiva
Breath sounds clear
Sis2 normal no murmurs
Abdomen soft, BS + non tender no distended
Neuro: patient sommnolent, no apparent motor deficit.
DTR ++/++++ bilaterally.
Pertinent Results:
5.7 > 10.8/32.2 < 103 MCV-83
N:54.5 L:32.0 M:3.9 E:9.2 Bas:0.3 Microcy: 1+
.
137 / 110 / 44
---------------< 81
4.6 / 16 / 2.8
.
U/A: mod bld, Tr pro, few bact
.
ABG 7.18/45/100 HCO3 18
.
Tox Screen:
Serum: Tricyc Pos. ASA, EtOH, Acetmnphn, Benzo, and Barb all
Negative
Urine: Benzos, Opiates, and Cocaine Pos. Barbs, Amphet, and
Mthdne all Negative
..
Ct scan Head:
FINDINGS: There is no evidence of acute intracranial hemorrhage.
No mass effect is seen. No shift of normally midline structures
is noted. The [**Doctor Last Name 352**]-white matter differentiations are preserved.
The surrounding soft tissue and osseous structures are
unremarkable.
IMPRESSION: No acute intracranial pathology, including no
evidence of acute intracranial hemorrhage.
..
Brief Hospital Course:
# Unresponsiveness/Mental status changes were felt to be due to
fentanyl overdose and interaction with benzodiazepines. In the
ED the patient woke up to 0.5 mg narcan for 20 mins and needed
repeated narcan 4 x. The negative head CT, normal WBC count,
lack of fever and signs of menigismus and quick response to
narcan were in support of overdose as the cause for MS changes.
In addition, urine tests were positive for benzos, opiates, and
cocaine. Patient was continued on narcan drip overnite and
weaned without diffuculty. At discharge he was alert and
oriented x3. He was not discharged on methadone and will follow
up with PCP and possibly restart methadone maintenance at [**Location (un) 27561**] after discharge. He was discharged with a new Duragesic
patch and an Rx for one more patch. He will follow up with his
PCP for further pain management.
..
# Non gap metabolic acidosis/resp acidosis - ?diarrhea vs RTA vs
rapid acidosis from NS + decreased resp drive from drug overdose
-recheck ABG if pt allows
-f/u gap in chem 7
..
#Acute renal failure - Patient's initial creatinine was 2.8 with
a baseline of 1.1-1.2. This ARF was most likely due to
dehydration/poor PO intake. Lisinopril was held, he was
rehydrated with NS and his creatinine returned to baseline.
..
#CAD/Hypotension - Antihypertensives were held at admission and
he received 2L NS in the ED which increased his SBP of 80-90 to
SBP 110s. Restarted outpatient cardiac meds on discharge as BP
returned to 130's/70's.
..
#Anemia - Patient's baseline hct is 33-37, on admission was
noted to be 32.2. Most likely anemia of chronic disease. Plan
to follow up as outpatient.
..
#Etoh history- Patient was place on CIWA scale for withdrawal
monitoring and given a given a banana bag for vitamin repletion.
He was also started on thiamine and folate daily.
..
#HIV - Not currently on HAART due to noncompliance. Would
reconsider once patient is stabilized and ready to commit to
treatment
..
#FEN - Advanced diet as tolerated, electrolytes repleted to
maintain levels within normal ranges.
..
#PPX - Patient is eating, hep sc
..
#Dispo - To home, with follow up in next week with Dr. [**Last Name (STitle) **]
..
#Code: DNR/DNI
Medications on Admission:
Meds at d/c from last hosp:
Amitriptyline 100 HS
Atorvastatin Calcium 20 qd
Atenolol 100 qd
Clonazepam 1 tid
Gabapentin 800 [**Hospital1 **]
Fentanyl 25 mcg/hr Patch 72HR
Lisinopril 20 qd
**Not on HAART MEDS due to non-compliance
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Transdermal every
seventy-two (72) hours for 1 doses.
Disp:*1 patch* Refills:*0*
4. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Klonopin 1 mg Tablet Sig: One (1) Tablet PO three times a
day.
7. Amitriptyline 100 mg Tablet Sig: One (1) Tablet PO at
bedtime.
8. Neurontin 800 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Narcotic overdose
Cocaine abuse
Discharge Condition:
Stable vital signs and mentating well
Discharge Instructions:
if you experience increasing dizinesss, chest pain, chest
tightness, shortness of breath, or feeling as if you are going
to faint you should call your doctor and if no doctor is
available you should go back to the emergency room.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2393**] in the next 5
days for post hospitalization follow-up and to decide what your
new medication regimen will be.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2173-7-3**]
|
[
"305.60",
"584.9",
"276.2",
"E850.2",
"414.01",
"401.9",
"965.09",
"571.5",
"285.29",
"042",
"070.54",
"V45.82",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6375, 6381
|
3254, 5467
|
324, 330
|
6457, 6496
|
2468, 3231
|
6774, 7131
|
2085, 2090
|
5747, 6352
|
6402, 6436
|
5493, 5724
|
6520, 6751
|
2105, 2449
|
268, 286
|
358, 1338
|
1360, 1776
|
1792, 2069
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,264
| 122,102
|
25296
|
Discharge summary
|
report
|
Admission Date: [**2131-11-8**] Discharge Date: [**2131-11-20**]
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
L groin/abdominal pain
Major Surgical or Invasive Procedure:
[**Doctor Last Name 3379**] and diverting colostomy, Left sartorius and rotation
flaps to Left groin
History of Present Illness:
88F with complaints of L grroin sweeling/pain for 1 week. Had
been living independentally & is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Scientist. About
two weeks PTA admission found to have fallen at home and had
difficulty getting around. 1 week PTA taken to the [**Doctor First Name **]
Scientist Benevolent Association house but has been c/o Left
leg/groin pain. Now has a new tender buldge in L groin. Also
with constipation; last BM 4-5days ago. +flatus today. Decreased
PO intake with intermittent nausea. No emesis.
Past Medical History:
none
Social History:
No tobacco/EtOH
Physical Exam:
998, 85, 144/59, 12 92% RA
AOx3
PERRLA, EOMI, anicteric
neck supple, NT
chest CTA B/L
RRR - m/r/g
Abd soft: L groin enderness, buldge with bowel sounds
Rectal refused
Ext WWP, no edema
Pertinent Results:
[**2131-11-8**] 04:30PM BLOOD WBC-20.6* RBC-3.73* Hgb-10.9* Hct-32.4*
MCV-87 MCH-29.3 MCHC-33.8 RDW-12.5 Plt Ct-365
[**2131-11-8**] 04:30PM BLOOD Neuts-90.6* Bands-0 Lymphs-6.4* Monos-2.8
Eos-0.2 Baso-0.1
[**2131-11-8**] 04:30PM BLOOD Glucose-131* UreaN-18 Creat-0.8 Na-134
K-4.0 Cl-96 HCO3-27 AnGap-15
[**2131-11-9**] 02:16AM BLOOD Calcium-6.8* Phos-3.8 Mg-1.4*
[**2131-11-19**] 07:10AM BLOOD WBC-8.6 RBC-3.38* Hgb-9.6* Hct-29.4*
MCV-87 MCH-28.4 MCHC-32.7 RDW-14.3 Plt Ct-378
[**2131-11-17**] 07:25AM BLOOD Glucose-114* UreaN-10 Creat-1.0 Na-136
K-4.0 Cl-100 HCO3-30 AnGap-10
[**2131-11-8**] 11:20 pm SWAB LEFT INGUNAL REGION.
**FINAL REPORT [**2131-11-15**]**
GRAM STAIN (Final [**2131-11-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2131-11-11**]):
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). RARE GROWTH.
GRAM POSITIVE RODS. SPARSE GROWTH. UNABLE TO IDENTIFY
FURTHER.
ANAEROBIC CULTURE (Final [**2131-11-15**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE. OF TWO COLONIAL MORPHOLOGIES.
Brief Hospital Course:
The patient was emergently taken to the operating room on
[**2131-11-8**] by general surgery
with a diagnosis of incarcerated left inguinal hernia for repair
and possible bowel resection. In the operating room the
following was performed: exploration of the left groin;
Evacuation of copious amounts or purulence; Radical debridement
of left groin for necrotizing fasciitis; Exploratory laparotomy;
Sigmoid colectomy with Hartmann's and colostomy and Bogata bag
placement. A gross perforation was found, the final pathology
showed no evidence of malignancy. At this point, she was
critically ill. She was being covered broadly with antibiotics
- Vanco and meropenem. A Bogata bag was sutured to the skin.
The groin was packed and then an Ioban dressing was placed over
this as well as over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**] [**Last Name (NamePattern1) 1662**] drain. She is being left
intubated and taken to the Intensive Care Unit in critical
condition.
[**2131-11-9**] The patient was hemodynamically stable and was taken
back to the OR for closure. The following was performed: Left
groin exploration and washout, abdominal
wall closure and colostomy maturation. The left groin wound was
packed open. The patient was again taken to the ICU from the OR.
She was extubated later this day. Infectious disease consulted
for Antibiotic management.
Over the next few days the patient recoved, began mobilizing
fluid, her NGT was removed, her groin wound remained clean, and
gas was seen in the ostomy bag. Plastic surgery was consulted
for closure of the groin wound.
[**2131-11-12**]: Transfered to the floor from the ICU. Clear diet was
started, and advanced slowly. OT/PT were consulted.
[**2131-11-14**]: The patient was taken to the OR by plastic surgery for
Debridement of left open groin wound with closure sartorius
muscle flap transfer and TFL fasciocutaneous rotational flap
closure. There were no complications, and the patient was
transfered to the floor from the PACU. Diet was restarted.
[**2131-11-17**]: The patient was tolerating a regular diet had good
pain control with PO pain meds and was working with PT/OT. She
was ready for discharge to rehab once placement is available.
[**2131-11-18**]: Foley placed secondary to incontinence and desire to
keep the wounds clean as possible.
[**2131-11-20**]: The pt did well and the case manager found a
rehabilitation bed for her. She is being transferred today in
good condition with 2 more days of antibiotics (meropenem and
vancomycin) per ID as well as Keflex 500mg qid x 14 days with
f/u in plastics clinic in 1 1/2 weeks.
Medications on Admission:
none
Discharge Medications:
1. Keflex 500 mg Tablet Sig: One (1) Tablet PO four times a day
for 14 days.
2. Meropenem 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q12H (every 12 hours) for 2 days.
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
10. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 2 days.
11. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q4H (every
4 hours) as needed for pain.
12. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for n/v.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
perforated sigmoid diverticulum.
Discharge Condition:
stable
Discharge Instructions:
Diet as tolerated. You may resume activity as tolerated.
Vancomycin and Meropenem to be given through final doses on
[**2131-11-22**].
You may shower, then pat-dry incision. Do not rub incision. No
tub baths or swimming for 3-4 weeks.
You may leave the incision uncovered or use a light dressing for
comfort.
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Inability to pass gas or stool from ostomy
* Swelling/erythema at incisions
* Other symptoms concerning to you
Followup Instructions:
Call Dr. [**First Name (STitle) **] Lee's office for a follow-up appointment in [**1-28**]
weeks.
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22796**] office for a follow-up in 2 weeks
([**Telephone/Fax (1) 6347**]
Call the plastic surgery clinic at [**Telephone/Fax (1) 4652**] to make an
appointment in 1 1/2 weeks at the cosmetic clinic (the clinic is
held on Friday, [**11-30**]).
|
[
"550.10",
"728.86",
"567.9",
"569.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.11",
"86.74",
"54.3",
"45.76",
"54.62",
"54.25"
] |
icd9pcs
|
[
[
[]
]
] |
6388, 6461
|
2507, 5143
|
286, 389
|
6538, 6547
|
1248, 2484
|
7099, 7514
|
5198, 6365
|
6482, 6517
|
5169, 5175
|
6571, 7076
|
1043, 1229
|
223, 247
|
417, 967
|
989, 995
|
1011, 1028
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,843
| 176,643
|
51145+59314+59315+59316
|
Discharge summary
|
report+addendum+addendum+addendum
|
Admission Date: [**2108-8-9**] Discharge Date: [**2108-8-11**]
Date of Birth: [**2052-9-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Cephalosporins / Bactrim / Ceftazidime / Mold/Yeast/Dust / Sulfa
(Sulfonamide Antibiotics) / Iodine / Hayfever / contrast dye
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
L fronto-parietal lesion
Major Surgical or Invasive Procedure:
L craniotomy for resection of cystic mass
History of Present Illness:
Patient is an elective admit for resection of L cystic lesion
Past Medical History:
T11-T12 disc herniation, hypothyroid, arthritis
Social History:
tobacco free >12 months, prior heavy ETOH use
Family History:
NC
Physical Exam:
On Discharge: the patient's motor sensory exam was intact and we
has amulating well
Pertinent Results:
[**2108-8-9**] CT Head
FINDINGS: The patient is status post left parietal craniotomy
with an
expected small amount of subcutaneous gas seen adjacent to the
craniotomy site as well as a small volume of pneumocephalus. The
left cystic lesion has now been resected and note is made of
edema within the resection bed in the left parietal and frontal
lobes. There is no acute intracranial hemorrhage or vascular
territorial infarction. Aside from the surgical bed, ventricles
and sulci are normal in size and in configuration.
[**2108-8-10**] MRI Brain with and without contrast
IMPRESSION: Status post resection of left parietal mass. There
is no
definite residual nodular enhancement seen, but meningeal
enhancement is
identified in the region. Blood products and expected
post-surgical changes are seen.
Brief Hospital Course:
55 y/o M with L fronto-parietal cystic lesion presents
electively for L craniotomy for resection of lesion. He was
taken to the OR on [**8-9**]. OR course was uncomplicated and patient
was transferred to the ICU for further monitoring. POstop CT
head demonstrated moderate pneumocephalus and expected postop
changes, no hemorrhage.
POD1 [**8-10**] he underwent postop MRI that demonstrated and he was
transferred to the regular floor.
POD2 [**8-11**] he was ambulating well and was cleared to go home by
physical therapy.
Medications on Admission:
ATENOLOL - 25 mg qday, ASTELIN 137 mcg Aerosol, Spray - 2
sprays each nostril 1 hour QHS, CELEBREX 200 mg [**Hospital1 **],
FEXOFENADINE 60 mg Tablet - 1 QHS FEXOFENADINE-PSEUDOEPHEDRINE -
60 mg-120 mg 1 qday,GABAPENTIN 300 mg [**Hospital1 **], HCTZ - 25 mg ',
LEVOTHYROXINE 175 mcg Tablet - 1 qday ,NASONEX 50 mcg Spray,
Non-Aerosol - 2 sprays [**Hospital1 **], SIMVASTATIN - 20 mg '
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain .
Disp:*90 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) as needed for constipation.
Disp:*90 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Cystic Mass at Left Fronto-Parietal
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you
should stay off until follow up.
?????? 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-15**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. 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.
??????You have an appointment in the Brain [**Hospital 341**] Clinic in four
weeks. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain with/ or without
gadolinium contrast. If you are required to have a MRI, you may
also require a blood test to measure your BUN and Cr within 30
days of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **]
please make sure to have these results with you, when you come
in for your appointment.
Name: [**Known lastname 17292**],[**Known firstname 5398**] P. Unit No: [**Numeric Identifier 17293**]
Admission Date: [**2108-8-9**] Discharge Date: [**2108-8-11**]
Date of Birth: [**2052-9-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Cephalosporins / Bactrim / Ceftazidime / Mold/Yeast/Dust / Sulfa
(Sulfonamide Antibiotics) / Iodine / Hayfever / contrast dye
Attending:[**First Name3 (LF) 599**]
Addendum:
5. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO every twelve
(12) hours: Take 2 tablets q12 hrs starting [**8-12**] for two days. On
the third day take one tablet q12 hrs until seen in brain tumor
clinic. .
Disp:*120 Tablet(s)* Refills:*2*
Discharge Medications:
5. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO every twelve
(12) hours: Take 2 tablets q12 hrs starting [**8-12**] for two days. On
the third day take one tablet q12 hrs until seen in brain tumor
clinic. .
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2108-8-11**] Name: [**Known lastname 17292**],[**Known firstname 5398**] P. Unit No: [**Numeric Identifier 17293**]
Admission Date: [**2108-8-9**] Discharge Date: [**2108-8-11**]
Date of Birth: [**2052-9-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Cephalosporins / Bactrim / Ceftazidime / Mold/Yeast/Dust / Sulfa
(Sulfonamide Antibiotics) / Iodine / Hayfever / contrast dye
Attending:[**First Name3 (LF) 599**]
Addendum:
famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day:
while taking dexamethasone taper. Disp:*60 Tablet(s)*
Refills:*2*
Discharge Medications:
famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day:
while taking dexamethasone taper. Disp:*60 Tablet(s)*
Refills:*2*
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2108-8-11**] Name: [**Known lastname 17292**],[**Known firstname 5398**] P. Unit No: [**Numeric Identifier 17293**]
Admission Date: [**2108-8-9**] Discharge Date: [**2108-8-11**]
Date of Birth: [**2052-9-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Cephalosporins / Bactrim / Ceftazidime / Mold/Yeast/Dust / Sulfa
(Sulfonamide Antibiotics) / Iodine / Hayfever / contrast dye
Attending:[**First Name3 (LF) 599**]
Addendum:
Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
6. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2108-8-11**]
|
[
"724.2",
"401.9",
"237.5",
"244.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
9205, 9348
|
1650, 2176
|
413, 457
|
3073, 3073
|
822, 1627
|
5292, 7170
|
699, 703
|
9089, 9182
|
3014, 3052
|
2202, 2589
|
3224, 5269
|
718, 718
|
732, 803
|
349, 375
|
485, 548
|
3088, 3200
|
570, 619
|
635, 683
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,981
| 174,389
|
16215
|
Discharge summary
|
report
|
Admission Date: [**2156-2-3**] Discharge Date: [**2156-2-6**]
Date of Birth: [**2106-2-17**] Sex: M
Service: CCU
HISTORY OF THE PRESENT ILLNESS: This is a 44-year-old male
with hypertension and hyperlipidemia who complained of chest
pain radiating to his bilateral shoulders. He also
complained of clamminess. He denied nausea, vomiting,
shortness of breath, palpitations, or syncope. His chest
pain was [**11-4**]. He was taken to [**Hospital3 4527**] where he
was noted to have [**Street Address(2) 2051**] elevations. He was transferred to
[**Hospital1 18**].
He had right-sided leads demonstrating 1 mm elevations.
Catheterization revealed proximal LAD 60%, ostial proximal
occlusion. During the pass at the RCA, initial reperfusion,
he had bradycardia and hypotension. He was treated with
thrombectomy and stent. He had an episode of ventricular
fibrillation and was cardioverted. Hemodynamics: Wedge
pressure 23, RA 16, PA 30/20. He was transferred to the CCU
for further monitoring.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Rectal polyps.
4. Occasional GERD with a questionable ulcer.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Lipitor 20 q.d.
2. Aspirin 81 mg p.o. q.d.
3. V vitamins.
No over the counter medicines.
FAMILY HISTORY: His father had a heart attack at age 66.
His mother had breast cancer. He is a 9-1-1 dispatcher.
Positive tobacco use. He has two grown children.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.7, pulse 86, blood pressure 121/73, respiratory rate 20,
98% on room air. He is a pleasant male in no acute distress.
His pupils are equally round and reactive to light and
accommodation. The mucous membranes were moist. He had a
regular rate and rhythm with distant heart sounds. No
murmurs, rubs, or gallops. No JVD appreciated. Lungs:
Clear to auscultation anteriorly. Extremities: He had no
clubbing, cyanosis or edema. He had positive dorsalis pedis
pulses.
LABORATORY DATA: White count 22.2, hematocrit 43.4,
platelets 375,000. Sodium 142, potassium 3.8, chloride 110,
bicarbonate 24, BUN 18, creatinine 1.0, glucose 95. Initial
CK 112, troponin 0.8, albumin 3.6, calcium 7.5, phosphate
3.0, magnesium 1.4.
HOSPITAL COURSE: He was monitored in the CCU overnight. He
initially had a lot of ectopy on telemetry including
nonsustained V tach which decreased in frequency once his
electrolytes were repleted. He was started on a beta
blocker; however, his blood pressure would not tolerate the
addition of an ACE inhibitor. His enzymes peaked with a CK
peak of 3,213, troponin greater than 50. His triglycerides
were 193, LDL 86, HDL 43.
He was started on Plavix after his stent was placed. His
hospital course was fairly unremarkable. However, one day
prior to admission it was noted that his hematocrit had
trended down slightly from his admission to a hematocrit of
39.6 to 35. He had thin and Guaiac positive stool which was
dark and tarry. He was made n.p.o. and started on IV
Protonix b.i.d. He had no further episodes of this dark
tarry stool. His following hematocrit was stable. He had
two days of stable hematocrit despite the episode of melena.
He was seen by GI who felt that a scope was needed; however,
in the peri MI period, it was determined that this would not
be appropriate and would be of high risk.
Because he had no further episodes of GI bleed and the
hematocrit remained stable, he was sent home on b.i.d.
Protonix with warning signs that if dark tarry stools or
melena were to recur or he became lightheaded he was to call
his primary care physician or go to the Emergency Room for
evaluation.
He was discharged home in good condition.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg once a day.
2. Plavix 75 mg once a day.
3. Atorvostatin 40 mg once a day.
4. Pantoprazole 40 mg b.i.d.
5. Metoprolol 25 mg b.i.d.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 7389**] and to
have light rest until then.
DISCHARGE INSTRUCTIONS: Low activity for one to two weeks
and also if dark tarry stools or lightheadedness occur to
call PCP or go to the Emergency Room.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 20150**]
MEDQUIST36
D: [**2156-2-6**] 11:40
T: [**2156-2-6**] 14:06
JOB#: [**Job Number 46262**]
|
[
"578.1",
"410.41",
"305.1",
"414.01",
"272.0",
"427.41",
"426.10",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"88.56",
"99.62",
"36.01",
"36.06",
"99.20",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
1338, 1508
|
3769, 4037
|
2297, 3746
|
4062, 4449
|
1224, 1321
|
1523, 2279
|
1042, 1201
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,952
| 173,773
|
22155
|
Discharge summary
|
report
|
Admission Date: [**2116-4-27**] Discharge Date: [**2116-4-30**]
Date of Birth: [**2062-9-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Demerol
Attending:[**First Name3 (LF) 7616**]
Chief Complaint:
fever, abdominal pain, N/V
Major Surgical or Invasive Procedure:
Midline placement in left arm
ERCP with stent placement
History of Present Illness:
53yo F with alcoholic cirrhosis s/p OLT on immunopsuppression,
h/o CM (EF 15%-->50%), atrial fibrillation, DM2, HTN,
hypothyroidism, who was admitted from liver clinic with fever,
vomiting and diarrhea since Saturday. Her fever was 104.7 at
11pm on Sunday morning, and 102 on day of admission.
.
Patient's sx started with the "worst headache of her life" with
associated nausea, vomiting, and watery diarrhea. Patient also
noted lower abdominal cramping, RUQ pain and tenderness, which
is similar to past episodes of anastomatic biliary stricture
relieved by biliary stent placement, last placed in [**2116-2-9**]
and due to be exchanged in [**Month (only) 547**].
.
Past Medical History:
1. s/p OLT- [**1-11**], for EtOH cirrhosis, c/b postop CHD stricture
s/p multiple stents last placed in [**2116-2-9**].
a. c/b portal HTN, thrombocytopenia, slowly increasing alk phos
b. s/p ERCP and new biliary stent on [**2115-6-21**]: anatstamotic
stricture 3 mm c/w post-op stricture, 6 mm stone in lower [**2-11**] of
CBD, extracted adn 9 cm and 7 cm stent in common hepatic duct
2. idiopathic cardiomyopathy- EF <20% in [**5-13**], EF 50% in [**9-12**],
followed by Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**], s/p AICD/VVI ppm
3. DM2- on Lantus
4. Hypothyroidism
5. h/o UGIB
6. RV perf after R heart bx s/p drain
7. AF with RVR
8. hyperkalemia s/p aldactone
9. pulmonary infiltrate on chest CT
10. hypertension
11. h/o UGIB and LGIB in [**2111**] with EGD with varicies, ? banded
12. h/o low back pain
13. s/p tubal ligation in [**2093**]
Social History:
Social History:
Lives with husband at home.
Tobacco ?????? [**3-14**] cigarettes/day.
EtOH ?????? Stopped drinking on [**3-14**],
previously [**4-11**] vodka drinks per day for 30 years.
No IVDA
Family History:
Strong hx of alcohol abuse and cirrhosis. Father died from MI at
53. Mother died at 57 from alcohol abuse, brother died in the
last two years from alcohol abuse
Physical Exam:
VS: T98.9 BP 125/76 HR 98 RR 20 O2sat 100% RA BS 277
Gen: fatigued and chronically ill appearing female
Skin: Multiple ecchymoses over arms
HEENT: MMM. PERRL. Sclera anicteric.
Neck: Supple. Full ROM. No cervical LAD.
Hrt: Tachycardic. Regular rhythm. No murmurs, rubs, or gallops.
Lungs: Equal breath sounds throughout. No rales rhonchi or
wheezes
Abd: S/ND. Tenderness to deep palpation over RUQ with guarding.
No organomegaly. Cholecystectomy scar.
Ext: WWP. No CCE
Neuro: CN2-12 intact. Alert and oriented x3. [**6-12**] strenght
throughout. Limited ROM with flexion/extension in right
shoulder. Minimal erythema and swelling over shoulder. 2+DTRs.
[**Name (NI) **] asterixis.
Pertinent Results:
[**2116-4-27**] ALT(SGPT)-146* AST(SGOT)-109* LD(LDH)-298* CK(CPK)-103
ALK PHOS-297* AMYLASE-32 TOT BILI-0.5
[**2116-4-27**] LIPASE-8
[**2116-4-27**] CK-MB-2 cTropnT-<0.01
[**2116-4-27**] PT-31.6* PTT-41.1* INR(PT)-3.4*
[**2116-4-27**] LACTATE-3.6*
[**2116-4-30**] INR 1.1, ALT 57, AST 18, ALK PHOS 161, AMYLASE 12,
LIPASE 13, TBILI 0.4
.
Rapamycin levels - 15.1, 8.1, 11.2, 7.1 for [**Date range (3) 57856**]
.
[**2116-4-27**] 12:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2116-4-27**] 12:40PM URINE RBC-21-50* WBC-[**7-18**]* BACTERIA-MOD
YEAST-MOD EPI-[**12-28**] TRANS EPI-[**4-12**]
[**2116-4-27**] URINE HOURS-RANDOM UREA N-404 CREAT-124 SODIUM-65
.
URINE CULTURE (Final [**2116-4-29**]): NO GROWTH.
.
FECAL CULTURE (Final [**2116-4-29**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2116-4-29**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2116-4-28**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2116-4-29**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
CMV Viral Load (Final [**2116-4-30**]): CMV DNA not detected.
.
[**2116-4-27**] 12:50 pm BLOOD CULTURE
AEROBIC BOTTLE (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 8 R
CEFTAZIDIME----------- PND
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 32 I
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
ERCP REPORT:
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: 2 plastic stents placed in the biliary duct were
found in the major papilla. Evidence of a previous
sphincterotomy was noted in the major papilla.
Cannulation: Cannulation of the biliary duct was successful and
deep with a balloon catheter using a free-hand technique.
Contrast medium was injected resulting in complete
opacification. The procedure was not difficult. Cannulation of
the pancreatic duct was not attempted.
Biliary Tree: A single irregular stricture of benign appearance
was seen at the middle third of the common bile duct. There was
no post-obstructive dilation. These findings are compatible with
anastomotic stricture.
Procedures: Both plastic stents were removed from the common
bile duct. Small amount of soft sludge came out on stent
extraction.
Two 10F Cotton [**Doctor Last Name **] biliary stents (7cm and 8cm) were placed
successfully in the common bile duct.
Impression: 2 Stents in the major papilla - evidence of prior
sphincterotomy
Residual anastomotic stricture
Two new stents replaced
.
GALLBLADDER/LIVER U/S WITH DOPPLER:
The hepatic veins are patent with appropriate directionality of
flow and normal-appearing waveforms. The portal veins are
patent with hepatopetal flow. The left hepatic artery is patent
with a resistive index of 0.41-0.46. There appears to be a good
systolic upstroke of the waveform. The right hepatic artery is
patent with a resistive index of 0.4 with good systolic
upstroke. The main hepatic artery is patent with resistive
index of 0.48-0.51. Biliary stents appear to be in place. No
intrahepatic biliary ductal dilatation is appreciated.
IMPRESSION: Patent hepatic vasculature with resistive indices
as above. No intrahepatic biliary ductal dilatation is
appreciated.
.
CXR ON ADMISSION: An ICD remains in place with the lead in the
right ventricle. The heart size is normal. The lungs
demonstrate scarring at the right lung base adjacent to the
hemidiaphragm. There are no focal areas of consolidation and no
pleural effusions are evident. Deformity of a lower thoracic
vertebral body and mild compression of an upper lumbar vertebral
body are without interval change. With regard to the right
basilar scarring, it is located at a site of a pre-existing more
confluent area of opacity. IMPRESSION: 1) No evidence of
pneumonia. 2) Linear scarring right lower lobe.
.
NON-CONTRAST HEAD CT SCAN: There is no evidence of acute
intracranial hemorrhage or shift of the normally midline
structures. The ventricles and cisterns are normal. The density
values of the brain parenchyma are normal, with preservation of
the [**Doctor Last Name 352**]-white matter differentiation. The visualized paranasal
sinuses and mastoid air cells are clear. Osseous and soft tissue
structures are unremarkable. IMPRESSION: No evidence of acute
intracranial hemorrhage. No change from [**2115-11-9**]
.
ECG [**2116-4-27**]: Sinus tachycardia and frequent atrial ectopy.
Diffuse low voltage. Prior myocardial infarction. Prior
anteroseptal myocardial infarction. Compared to the previous
tracing of [**2115-9-14**] the rate has increased and frequent atrial
ectopy has appeared as well as ventricular ectopy. Followup and
clinical correlation are suggested.
.
ECG [**2116-4-28**]: Sinus rhythm with slowing of the rate as compared
to the previous tracing of [**2116-4-27**]. Low limb lead voltage.
Prior anteroseptal myocardial infarction. No diagnostic interim
change.
.
PICC PLACEMENT: The right upper arm was prepped in a sterile
fashion. Since no suitable superficial vein was visible,
ultrasound was used for localization of a suitable vein. The
basilic vein was entered under ultrasonographic guidance with a
21-gauge needle. Hard copies of ultrasound images were obtained,
documenting patent vein before and after establishing access. A
0.018 guidewire was advanced under fluoroscopy into the superior
vena cava. Based on the markers on the guidewire, it was
determined that a length of 30 cm would be suitable. The PICC
line was trimmed to length and advanced over a 4-French
introducer sheath under fluoroscopic guidance into the
brachiocephalic vein. The sheath was removed. The catheter was
flushed. A final chest x-ray was obtained demonstrating the tip
in the brachiocephalic vein as ordered as a midline PICC. The
line is ready for use. A Statlock was applied and the line was
hep-locked. IMPRESSION: Successful placement of a 30-cm total
length PICC line with the tip in the brachiocephalic vein, ready
for use.
.
ECHO: The left atrium is dilated. The right atrium is moderately
dilated. There is symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Right ventricular
chamber size is mildly dilated and free wall motion is normal.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a small Pericardial effusion.
There are no echocardiographic signs of tamponade. No vegetation
seen (cannot exclude). Compared to the prior study of [**9-/2115**],
there is no significant change.
.
Brief Hospital Course:
## Cholangitis secondary to biliary stricture with biliary
sepsis -- Patient presented with fever to 104, RUQ, cholestatic
picture on LFTs, and history of recurrent biliary strictures
with stent placements. She was transferred to the MICU for
hypotension (BP 78/54), fever, elevated lactate 3.6, and
concerns for ascending cholangitis, as well as acute renal
failure and coagulopathy. Patient was oliguric as well, with
20cc of urine over 1.5 hours. She was given IVF and empirically
covered with vancomycin and meropenem, and given stress dose
steroids. She was also given vitamin K and FFP to reverse her
coagulopathy. Patient was then taken to ERCP, where biliary
stents were placed, relieving the obstruction. Her LFTs trended
downwards and amylase and lipase were WNL. She was continued on
the meropenem for panresistant E. coli from blood culture. A
midline was placed for home antibiotic administration. TTE was
negative for vegetations. Stress-dose steroids were weaned and
blood sugar control was tightened. She will need a repeat ERCP
in [**5-13**] weeks and may need surgery for biliary duct dilatation
for permanent relief of strictures.
.
## Headache -- Her headache persisted after ERCP. She did not
have any meningeal signs but did complain of some photophobia.
She was given Dilaudid, Sudafed, and Percocet with good effect
and headache had resolved by time of discharge.
.
## ARF -- Cr 1.9 from baseline 0.9, decreased to 0.8 with IVF,
FeNa nondiagnostic in context of furosemide but FeUrea 2.84%,
consistent with prerenal failure. Patient's medications were
renally dosed while in acute renal failure.
.
## s/p OLT -- Rapamune, mycophenolate mofetil, and prednisone
were continued. Rapamune levels were monitored daily and dosed
accordingly. Bactrim was continued for PCP [**Name Initial (PRE) 1102**]. She was
discharged home on rapamune 2 mg po qd, to be followed up in
clinic.
.
## Post-transplant diabetes -- She was controlled with insulin
glargine 16 units at night and regular insulin with tightened
sliding scale in the context of stress-dose steroids.
.
## Atrial fibrillation -- Coumadin was held for ERCP and
restarted after procedure on home dose. INR subtherapeutic on
discharge (1.1).
.
## Dilated cardiomyopathy -- Echo this admission showed EF
55-60%, no evidence of vegetations. Digoxin, hydralazine,
lasix, and imdur were held for hypotension. Carvedilol was
maintained. She will need her antihypertensives readded at an
outpatient visit when her blood pressures have stabilized.
.
## Urinary tract infection -- Patient also had positive
urinalysis, with fecal contamination on urine culture. Repeat
urine culture was negative.
.
## Diarrhea -- Patient noted diarrhea, nonbloody and nonmucousy.
C. diff negative x 2. Stool culture was negative for
salmonella, shigella, campylobacter.
.
## Brachial plexus injury -- From past PICC placement in [**2115**].
Neurontin was continued at renal dosage.
.
## Hypothyroidism -- Stable. She was kept on home-dose
levothyroxine.
.
## PPx -- Patient was on coumadin and given a PPI. She was seen
by PT and OT.
.
## Code: She remained FULL code. Patient was discharged home
with services.
Medications on Admission:
Outpatient meds:
Sirolimus 3mg qd
Mycophenolate mofetil 1000mg [**Hospital1 **]
Prednisone 5mg qd
Bactrim DS 1 tab qd
Coumadin 6mg qhs
Carvedilol 6.25mg qd
Digoxin 0.125mg qd
Hydralazine 50mg tid
Furosemide 20mg qd
Imdur 60mg qd
Levothyroxine 100mcg qd
Lantus 12U qhs
RISS
Neurontin 300mg qam/noon, 600mg qhs
Celexa 10mg qd
Xanax 0.5mg prn anxiety
Caltrate 1200mg qhs
Perocet 1-2tabs q6h prn pain
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
7. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. 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*
12. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
14. Midline care
Midline care per protocol
15. Insulin Glargine 100 unit/mL Cartridge Sig: Sixteen (16)
units Subcutaneous at bedtime.
16. Meropenem 1 g Recon Soln Sig: One (1) Intravenous three
times a day for 10 days.
Disp:*30 * Refills:*0*
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for headache. Tablet(s)
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Sliding
Scale Subcutaneous with meals.
19. Prednisone 20 mg Tablet Sig: As below. Tablet PO once a day
for 4 days: Please take two tablets on Friday (40 mg total), one
and a half tablets on Saturday (30 mg total), one tablet on
Sunday, and half a tablet next Monday. You should restart your
5 mg tablet as usual after that.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapy
Discharge Diagnosis:
1. Cholangitis
2. Biliary stricture
3. Biliary sepsis from obstruction
4. Headache
5. ARF
6. s/p OLT
7. Post-transplant diabetes
8. Atrial fibrillation
9. Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed.
.
Please follow up with appointments as listed below.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
Please contact your health care provider or come the emergency
room if you develop high fever, shaking chills, night sweats,
worsening headache, or abdominal pain.
.
Do not take your digoxin, hydralazine, imdur, or furosemide
until you see Dr. [**Last Name (STitle) 497**] and your blood pressure is found to be
stable. **
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2116-5-6**] 10:40
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2116-5-12**] 2:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2116-5-12**] 2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 7619**]
|
[
"397.0",
"427.31",
"576.2",
"785.52",
"995.92",
"425.4",
"250.00",
"584.9",
"038.42",
"V42.7",
"244.9",
"401.9",
"576.1",
"E878.2",
"997.4",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.05",
"38.93",
"51.10",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
16198, 16265
|
10659, 13843
|
304, 362
|
16479, 16488
|
3069, 6987
|
17064, 17530
|
2189, 2352
|
14291, 16175
|
16286, 16458
|
13869, 14268
|
16512, 17041
|
2367, 3050
|
238, 266
|
390, 1058
|
7001, 10636
|
1080, 1960
|
1992, 2173
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,932
| 106,260
|
7273
|
Discharge summary
|
report
|
Admission Date: [**2184-9-25**] Discharge Date: [**2184-10-18**]
Date of Birth: [**2105-12-15**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin / Bactrim / Phenergan / Reglan
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Right arterial line placement [**9-26**]
Intubation [**9-27**], [**9-29**]
Central line placement (right IJ) [**9-27**]
Cardiac cath [**9-29**]
Left arterial line placement [**10-2**]
Cardiac cath and bare metal stent placement to RCA [**10-3**]
Tunneled Dialysis Line placement [**10-12**]
History of Present Illness:
78F PMH of type I DM complicated by nephropathy, neuropathy, and
retinopathy, osteoporosis, CKD (baseline Cr 2.0) and recent
NSTEMI in [**6-/2184**] who is presenting with recurrent syncope [**1-29**] to
short episdoes of asystole since this AM.
.
Patient has h/o of gastroparesis and chronic nausea and
abdominal dyscomfort. She was at her baseline state of health
until this morning. At noon after taking 2 bites of her
sandwiched, she developed sudden nausea and had wretching X1,
immediately there after she syncopized per her husband with some
irregular limb movements w/o incontinence or tongue bite.
Husband caught her she did not fall on the floor and did not hit
her head. She reacovered after 30 seconds and came to quickly.
She recalls feeling faint but otherwise denies any preceeding
palpitaions, chest pain or other symptoms except nausea and
wretching. After ~ 10 minutes she had another identical episode
at which point her husband call EMS. En route EMS noted episode
of 6s of asystole and patient becoming unresponsive.
.
Upon arrival to the ED VS: 98.2 59 140/53 17 100%RA,
transcutaneous pacer pads were placed on patient. During
observation in ED patient bradyed down to the 40's, then had
about 10 second pause with syncope which ended with junctional
beat then sinus took over in the 50's. Half a milligram of
atropine was given with HR increasing only to the 60's. Initial
Glu 100, but 50 on repeat for which she recieved IV D50% 50cc.
EKG showed new T-wave inversions in the inferior leads
Trop = 0.08 X1
WBC 3.8, Hct 26, PLT 105 all at recent baseline, cr/BUN 2.3/70
at baseline
CXR: (my read), AP film hyperinflation, prominent hili and
increased mildly interstitial markings which are not
significantly changed from prior.
.
Of note patient's recent history includes admission [**2097-7-17**] for
NSTEMI, at the time presented with chest pain new ST depressions
and positive biomarkers and had MIBI showing a moderate fixed
inferior wall defect without reversible defects. Echocardiogram
showed new inferior wall motion (compared to [**2178**] prior) with
LVEF 45%, mild left ventricular hypertrophy, mild mitral
regurgitation, and mod PHTN (PASP 52 mm Hg above RA pressure).
Given concern for her renal functions and no reversible defects
on MIBI she was medically managed with ASA 325mg, [**Year (4 digits) **] 300,
atorvastatin 80 and metoprolol tartrate PO. More recently she
was admitted [**2087-9-9**] for worsening peripheral tingling which
after neg head CT was attributed to natural progression of her
peripheral neuropathy. On this admission was also noted to be
hypertensive to the 200's and was started on amlodipine which
she had been taking in the evenings intermitently only if her
SBP's > 130. She has otherwise been stable at home, no other
recent med changes. No new complaints beyond fatigue and ongoing
chronic complaints as per ROS below.
.
REVIEW OF SYSTEMS
On review of systems:
+ for chronic dizziness, lightheadedness, word finding
difficulties. Also had several recent mechanical falls.
- denies cough, hemoptysis, black stools or red stools. denies
recent fevers, chills or rigors. No prior h/o syncope.
.
Denies chest pain since NSTEMI 2 months ago, denies paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations.
Past Medical History:
- Type 1 diabetes with renal insufficiency (Dr. [**Last Name (STitle) 978**] and Dr.
[**First Name (STitle) 10083**] at [**Last Name (un) **]), peripheral neuropathy, gastroparesis
- Anemia (~29-30), on Procrit BIW
- Prepatellar bursitis
- Bilateral foot drop
- Osteoporosis
- Hypothyroidism
- Hyperhomocysteinemia
- Likely acute interstitial nephritis from cephalexin/bactrim
[**11/2182**]
- Osteoarthritis
- Cholelithiasis without cholecystitis per RUQ US [**2182**].
- CAD: s/p NSTEMI [**6-/2184**] (presented with chest pain, inferior ST
depression, positive enzymes, MIBI showed non reversible perf
defects, managed medically, no revascularization procedure
undertaken.)
- Ischemic cardiomyopathy with inf wall hypokinesis and LVEF 45%
per echo [**6-/2184**] post NSTEMI, NYHA class I-II.
Social History:
Patient lives with husband. She denies use of tobacco, alcohol,
recreational drugs, or herbal medications. She use bilateral
foot braces for neuropathy and foot drop. She reports being
independent in ADLs but is having increasing difficulty with
ambulation without assistive device.
Family History:
Mother died at age [**Age over 90 **] of old age. Sister died of ovarian CA in
her 50's. Sister still alive at age [**Age over 90 **]. No family history of
stomach or esophageal cancer.
Physical Exam:
Admission exam:
GENERAL: thin, NAD. Oriented x3. Mood, affect appropriate.
HEENT: mild pallor, PERRL, EOMI. No jaundice
NECK: Supple with JVD to ear lobes. There's radiating murmur
over bil carotids but no bruits.
CARDIAC: RRR, distant heart sounds with faint SM at apex and LSB
heard best over carotids. No r/g. No S3 or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: blacked based ulcer on palmar aspect of lateral
left foot unstagable but not deep. stage I-II ulcers on medial
left ankle and plantar right mid foot. Abrasion left knee. No
ROM limitation, pain or bony tenderness along BLE. No signs of
cellulitis or discharge. No c/c/e. Peripheral pulses are
palpable but faint. Also has OSA changes in fingers.
SKIN: ulcers and abrasion as above, no rash
Neuro: reduced sensory preception socks and gloves distribution,
mild bil intention tremor, A+O X3, very mild word finding
difficulty. otherwise grossly intact.
.
Discharge exam:
98.2 124/50 89 93%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric there is an ocular hemorrhage noted in
the left eye near the lateral canthus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest: she has right tunneled dialysis line which is c/d/i
without induration
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
Pertinent Results:
Initial labs:
[**2184-9-25**] 02:00PM BLOOD WBC-3.8* RBC-2.66* Hgb-8.7* Hct-26.0*
MCV-98 MCH-32.7* MCHC-33.5 RDW-13.4 Plt Ct-105*
[**2184-9-25**] 02:00PM BLOOD Neuts-69.8 Lymphs-19.1 Monos-6.3 Eos-4.5*
Baso-0.3
[**2184-9-25**] 02:00PM BLOOD PT-11.9 PTT-30.2 INR(PT)-1.1
[**2184-9-25**] 02:00PM BLOOD Glucose-101* UreaN-70* Creat-2.3* Na-140
K-4.8 Cl-105 HCO3-29 AnGap-11
[**2184-9-25**] 02:00PM BLOOD ALT-25 AST-28 CK(CPK)-49 TotBili-0.4
[**2184-9-25**] 02:00PM BLOOD Lipase-19
[**2184-9-25**] 02:00PM BLOOD CK-MB-3
[**2184-9-25**] 02:00PM BLOOD cTropnT-0.08*
[**2184-9-25**] 09:30PM BLOOD CK-MB-3 cTropnT-0.06*
[**2184-9-25**] 02:00PM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2
[**2184-9-25**] 02:00PM BLOOD TSH-11*
[**2184-9-25**] 09:30PM BLOOD Free T4-1.3
.
Pertinant labs:
[**2184-10-18**] 06:15AM BLOOD WBC-4.7 RBC-2.35* Hgb-7.5* Hct-23.2*
MCV-99* MCH-31.9 MCHC-32.3 RDW-18.4* Plt Ct-117*
[**2184-10-8**] 07:05AM BLOOD PT-10.9 PTT-47.1* INR(PT)-1.0
[**2184-10-18**] 06:15AM BLOOD Glucose-413* UreaN-32* Creat-2.5* Na-132*
K-4.2 Cl-95* HCO3-31 AnGap-10
[**2184-9-29**] 05:09AM BLOOD CK-MB-20* MB Indx-6.1* cTropnT-2.06*
[**2184-9-29**] 10:30AM BLOOD CK-MB-22* MB Indx-7.5* cTropnT-2.71*
[**2184-9-29**] 04:10PM BLOOD CK-MB-39* MB Indx-8.9* cTropnT-3.89*
[**2184-9-29**] 10:38PM BLOOD CK-MB-45* MB Indx-11.8* cTropnT-3.78*
[**2184-9-30**] 05:58AM BLOOD CK-MB-42* MB Indx-13.9* cTropnT-3.41*
[**2184-10-18**] 06:15AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.9
[**2184-10-14**] 06:20AM BLOOD calTIBC-222* Ferritn-641* TRF-171*
[**2184-9-25**] 02:00PM BLOOD TSH-11*
[**2184-10-14**] 06:20AM BLOOD PTH-50
[**2184-10-14**] 06:20AM BLOOD 25VitD-23*
[**2184-9-29**] 08:00AM BLOOD Cortsol-40.1*
[**2184-10-13**] 06:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
.
Imaging:
CXR [**2184-9-25**]: mild bibasilar atelectasis
.
MR of head, MRA of head and neck, [**2184-9-28**]
FINDINGS: There is no evidence of infarct or hemorrhage. There
are scattered T2/FLAIR hyperintensities in the subcortical and
periventricular white matter, which are nonspecific but could be
seen as the sequelae of chronic microangiopathy. There is
prominence of the ventricles and extra-axial CSF spaces, stable
since the prior examination. There is no mass, midline shift, or
hydrocephalus. There is mucosal thickening of the frontal,
ethmoidal, sphenoid, and maxillary sinuses. A small amount of
fluid is visualized in the mastoid air cells.
.
MRA BRAIN: There is irregularity of the cavernous internal
carotid arteries due to atheromatous disease. The right A1
segment is smaller, probably hypoplastic. The anterior cerebral
arteries are otherwise patent with normal branching pattern. The
left M1 and bilateral M2 segments exhibit narrowing and
irregularity likely atheromatous disease.
There is narrowing of the V4 segment of the right vertebral
artery. The
basilar artery appears patent. The posterior cerebral arteries
are patent with normal branching pattern. There is no evidence
of aneurysm, or arteriovenous malformation.
.
MRA NECK: The origin of the common carotid and vertebral
arteries is not
included in the field of view. The cervical vertebral arteries
are patent. There is mild narrowing of the proximal right
internal carotid artery. Otherwise, both internal carotid
arteries are patent. The diameter of the proximal carotid
arteries is larger than the distal diameter, therefore, there is
no stenosis by NASCET criteria.
IMPRESSION:
1. No evidence of infarction or hemorrhage.
2. Mild narrowing of the cavernous carotid arteries, likely
related to atherosclerotic disease. No aneurysm or arteriovenous
malformation.
3. Unremarkable MRA of the neck.
.
ECHO [**2184-9-29**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
focal hypokinesis of the inferior wall, basal to mid
inferolateral wall, distal septal wall, and apex. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with moderate global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve leaflets are mildly thickened. There
is severe mitral annular calcification. There is moderate
functional mitral stenosis (mean gradient 8 mmHg) due to mitral
annular calcification. No mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild left ventricular
hypertrophy. Focal regional left ventricular systolic
dysfunction consistent with multivessel CAD. Right ventricular
dilation and dysfunction. Moderate pulmonary artery
hypertension. Moderate functional [**Last Name (un) 22837**] stenosis from MAC.
Compared with the prior study (images reviewed) of [**2184-7-19**],
more extensive regional dysfunction is present with a decline in
ejection fraction. Right ventricular systolic dysfunction is now
present. There is a gradient across the mitral valve consistent
with functional mitral stenosis.
.
Cardiac Cath [**2184-9-29**]:
Assessment & Recommendations
1. Severe diffuse three vessel coronary artery disease with
subtotal occlusion of heavily calcified diffusely diseased RCA
2. Moderate pulmonary arterial hypertension with severe right
ventricular diastolic heart failure on pressor.
3. Moderate left ventricular diastolic heart failure.
4. Cardiogenic shock with SBP ranging from 60 mm Hg off pressor
to 180 mm Hg (with excellent cardiac index) on
pressor(norepinephrine)
5. Monitoring PA line left in place. As this is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 26900**], [**First Name3 (LF) **] NOT
advanced to PCW position or inflate balloon without fluoroscopic
guidance.
6. CCU team to evaluate the benefits and risks of RCA rotational
atherectomy and stenting given echocardiographic and hemodynamic
evidence of RV failure, but heavily calcified and diffusely
diseased RCA.
.
Renal US [**10-2**]:
IMPRESSION:
1. Findings consistent with bilateral abnormal renal arterial
circulation. No evidence of venous thrombosis. No stones or
hydronephrosis.
2. Right pleural effusion.
.
Cardiac Cath [**10-3**]:
Interventional details
Change for [**Doctor Last Name **]-0.75. Crossed with a ChoICE PT XS wire. Serial
dilations with 01.25 mm, 2.0 mm. 2.5 mm. 2.75 mm balloons.
Deployed a 2.5 x 18 mm Integriti stent and postdilated to 3.0
mm.
Used the 2.75 mm balloon to dilate the mid RCA. Final
angiography revealed normal flow, no dissection and 30% residual
ostial stent recoil in the RCA and 30% residual stenosis in the
mid vessel RCA. The distal RCA had diffuse unchanged disease.
Assessment & Recommendations
1.ASA 81 mg PO QD indefinitely
2.[**Doctor Last Name **] 75 mg PO QD x 30 days uninterrupted and preferably x 12
months.
3.Secondary prevention CAD.
.
VENOUS DUPLEX UPPER EXTREMITY [**2184-10-6**]
Duplex evaluation was performed of both upper extremities. Both
subclavian veins are patent and phasic. Thrombus is identified
in the right cephalic and the antecubital fossa as well as the
left cephalic vein. Left basilic vein is patent. Both brachial
and radial arteries are patent with calcifications.
IMPRESSION: Thrombus in both cephalic veins and antecubital
fossa on the
right. For diameters of patent veins as well as brachial and
radial arteries evaluate scan worksheet.
Brief Hospital Course:
78F PMH of type I DM (complicated by nephropathy, neuropathy,
and retinopathy), CKD (baseline Cr 2.0) and recent inferior
NSTEMI in [**6-/2184**] who presentd with recurrent syncope [**1-29**] to
short episdoes of asystole.
.
Acute issues:
# Bradycardia/Asystole/Syncope: Patient admitted following
multiple syncopal episodes preceded by nausea and retching. In
ambulance, noted to have 6 second asystolic pause. Had
additional 10 second pause in the ED and was given 0.5mg of
atropine. After admission to CCU, continued to have episodes of
bradycardia to the 30s-40s with associated hypotension. These
were often but not exclusively related to nausea and vomiting.
Concern for recurrent inferior MI but troponins and CK-MB
initially stable. Initially thought to be most likely secondary
to elevated vagal tone, but patient had progressive hypotension
and bradycardia as hospitalization progressed (see below
NSTEMI). Episodes of syncope resolved later in hospitalization,
with no events of significant symptomatic pauses noted on tele.
She did have several episodes of bradycardia to the 30s but was
asymptomatic during these events.
.
# Hypotention/Shock: Shock appeared cardiogenic in nature on
cath study but sepsis was highly considered given low SVR. On
day 2 of admission, patient became hypotensive to the 60s-80s
systolic, associated with bradycardia. She was started on
dopamine with good response. Patient also developed intermittant
fevers, so concern for sepsis. UA dirty, urine cultures were
negative to date except for one sample with staph aureus coag +,
pansensitive. [**12-31**] blood cultures grew gram positive cocci on
[**8-26**]. Patient given 1 dose vanc/zosyn, then switched to
vanc/cefepime. Cefepime was discontinued when urine culture
returned with staph and not GNR. Lactate 3.1 on [**9-27**], likely due
to hypoperfusion with low blood pressures, and eventually
normalized below 2 on repeat measurements. Patient with low
temperature and restarted on zosyn. Hemodynamically, pt required
pressor support on Hospital Day 8, pt remained on levophed gtt
with labile SBPs ranging from 90s to 150s intermittently. On
[**2184-10-3**] vanc and zosyn were discontinued as blood cultures were
no growth to date, and ID consulting team also recommended
discontinuing antibiotics. Patient was on lasix gtt to decrease
preload for cardiogenic shock and this was discontinued when CVP
goal of [**10-8**] was reached. Patient was weaned from pressors on
[**10-5**] and remained off pressors for remainder of hospital
course.
.
# Mental status changes: Patient with intermittant episodes of
unresponsiveness associated with hypotension, concerning for
seizure vs hypoperfusion. The first of these occurred following
dose of Phenergan and was associated with muscle rigidity,
attributed to medication reaction. However, patient continued to
have similar episodes throughout the day on [**9-27**]. After one
unresponsive episode, had sensation of falling. Also had periods
of hallucinations, picking at bedclothes, confusion more
consistent with acute delirium. Neurology consulted. MRI and MRA
of head/neck showed no infarct, just atherosclerotic disease in
cavernous carotid arteries. EEG showed no seizure activity.
Concern for encephalitis given low grade fevers, so LP done
which was unremarkable and viral PCR negative. The patient was
electively intubated to preform procedures and get imaging. She
remained intubated for some time given on pressors and going to
cath lab (see below). She was successfully extubated on [**10-5**].
After which her mental status was improved.
.
# Anuric Acute on Chronic Kidney Disease: Urine output decreased
to <10cc/hr on second day of admission. Cr increased from 2.2 on
admission to 3.4 the morning of [**9-27**]. FENa <1%, but no
improvement in UOP with fluid boluses or initiation of pressors.
Urine sediment suggestive of early ATN. Pt also with anion gap
metabolic acidosis which was most likely related to uremia and
lactic acidosis. In addition, delta/delta revealed underlying
non gap metabolic acidosis which could be related to RTA
secondary to diabetes. Renal consult suggested renal U/S, urine
lytes and urine eosinophils. Renal u/s showed R renal artery
parvus tardus suggestive of renal artery stenosis and poor
diastolic flow bilaterally. Cath study on [**10-3**] did not show
impressive stenosis of renal arteries and no interventions were
done. Urine lytes were consistent with ATN and urine eosinophils
were negative and thus made interstitial nephritis related to
cephalosporins (history of allergy) less likely. Following PCI
on [**10-3**], Cr continued to trend up with declining bicarb which
felt to be related to contrast induced injury. The patient's Cr
continued to increase and UOP only with diuretics. Per renal
recs home Epo was restarted, low phose diet, nephrocaps, and
sevelameer 800mg TID with meals started on [**10-12**]. Renal was
following and tunneled HD line was placed on [**10-13**]. Patient
underwent dialysis initiation once transferred to the floor and
will undergo MWF dialysis once discharged. She is largely
anuric at this point.
.
# CAD: Initially inferior wall STD + TWI similar to ECG changes
at the time of NSTEMI 2 months ago, but cardiac enzymes stable,
no chest pain. Continued home aspirin, [**Month/Year (2) 4532**], statin.
Metoprolol initially held due to bradycardia, hypotension,
pauses. Pt had troponinemia on [**9-29**] that peaked at 3.89 and
cath study showed 3VD - this was concluded to be demand NSTEMI
presentation. CAD was later intervened on [**10-3**] with high risk
PCI (after multiple family meetings regarding goals of care)
where the RCA was stented with BMS. Patient was restarted on
increased dose of metoprolol on [**10-7**].
.
# Nausea/Vomiting: most likely [**1-29**] to her chronic diabetic
gastroparesis but could also be manifestation of inferior
myocardial ischemia. Obstructive biliary issue is also on the
ddx given RUQ US showed cholelithiasis. LFTs on admission were
unremarkable and lipase negative. On day of demand NSTEMI LFTs
trended up slightly ALT 41, AST 64, AlkP 229, GGT 98, and TBili
normal. The patient continued to have nausea and emesis
intermitently throughout course. Low dose ativan was used to
control nausea given reactions to other medications as above.
This resolved by discharge, at which time the patient was
tolerating PO.
.
# Nutrition: Patient with poor PO intake on admission. Tube
feeds were initiated on [**10-2**] but rate could not be advanced
given high residual volume due to gastroparesis. A post-pyloric
tube was placed on [**10-5**] and tube feeds were resumed. The
patient continued to recieve tube feeds until she pulled out
tube on [**10-8**]. She resumed oral feeding on [**10-9**].
.
# ischemic cardiomyopathy: post NSTEMI echo in [**6-/2184**] showed inf
wall hypokinesis and LVEF 45%. No ACE-I were started given CKD.
NYHA class I-II. ECHO on this admission showed decreased LVEF to
35-40% likely secondary to additional cardiac insult this
admission. The patient was diuresed intermittently during
hospital course. Initially with IV lasix bolus. She was then
started on torsemide and metolazone with good response.
Diuretics were stopped on [**10-11**] secondary to low BPs and dry
volume status. Isordil was started for afterload reduction.
.
# Pancytopenia: this is long standing, unknown if worked up in
the past. Pt's thrombocytopenia worsened throughout course but
with normal coagulation panel which was not consistent with
DIC/TTP. Most likely this could be related to bone marrow
suppression related to stress/sepsis/shock/antibiotics.
Additionally patient on Epo at home, restarted on [**10-13**].
.
# Hypothyroidism: TSH elevated on presentation but with normal
FT4. Pt's home Synthroid was continued throughout course.
.
Transitional issues:
# Dialysis follow-up
# Cardiology follow-up
# Renal follow-up
# Patient's goal hematcrit should be >30% given her NSTEMI
during this admission. Patient recieved one unit of pRBC on the
day of discharge and total of 4unit pRBC during her hospital
stay.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 50 mcg PO DAILY Start: In am
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY Start: In am
8. Calcium Carbonate 500 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY Start: In am
10. Fish Oil (Omega 3) 1000 mg PO DAILY Start: In am
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Vitamin D 800 UNIT PO BID
13. Amlodipine 2.5 mg PO DAILY
patient has been taking this at home QHS:PRN SBP > 130.
14. Epoetin Alfa 0 UNIT IV ONCE Duration: 1 Doses Start: HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Vitamin D 800 UNIT PO BID
9. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
10. Isosorbide Dinitrate 10 mg PO TID
RX *isosorbide dinitrate 10 mg 1 tablet(s) by mouth Every 8
hours Disp #*90 Tablet Refills:*0
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
Every 8 hours Disp #*90 Tablet Refills:*0
12. Omeprazole 20 mg PO DAILY
13. Fish Oil (Omega 3) 1000 mg PO DAILY
14. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0
15. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
16. Glargine 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital1 8**]
Discharge Diagnosis:
Syncope
Non ST Elevation Myocardial Infarction
Renal Failure
Cardiogenic Shock
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 26898**],
It was a pleasure taking care of you during your recent
admission to [**Hospital1 18**]. You were admitted with fainting spells.
These were felt to be due to vasovagal episodes. These episodes
resolved and no pace maker was placed. However, your hospital
course was complicated by a heart attack which resulted in organ
damage and required you to be supported by a breathing machine
and medications to improve your blood pressure. A stent was
place in the site of the heart blockage. Unfortunately, the
heart attack resulted in significant damage to your kidneys. As
a result, you were started on dialysis. You improved once
dialysis was started and you were discharged to rehab. The
following changes were made to your medications.
STOP
Amlodipine
Iron Supplement
START
Nephrocaps
Multivitamin
Sevelamer
Folate
Isosorbide Dinitrate
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2184-11-2**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**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:[**2184-10-18**]
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6,891
| 145,953
|
51061
|
Discharge summary
|
report
|
Admission Date: [**2146-7-8**] Discharge Date: [**2146-7-11**]
Date of Birth: [**2087-9-10**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Vancomycin / Gentamicin / ceftriaxone
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
fevers, leukopenia, rash, transaminitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 yo female with PMH of bioprosthetic AVR and MVR ([**5-10**]) who
was admitted to CCU on [**2146-6-15**] with fevers. Blood cultures grew
Gemella. TTE revealed and unremarkable prosthetic aortic valve.
However, transvalvular gradient consistent with severe
bioprosthetic mitral stenosis and focal thickening on atrial
aspect of mitral bioprosthesis. CT [**Doctor First Name **] was consulted but opted
for nonoperative management. She is vanco/pen/sulfa/gent
allergic, so was started on linezolid in the CCU. This was
transitioned to dapto and eventually to Ceftriaxone 2g q24h +
Gentamicin 90 q12h per ID recs once cultures and sensitivities
returned for gemella on [**2146-6-21**] after desensitization. She was
seen in the outpatient [**Hospital **] clinic today for f/u care. Over the
last week, her labs have shown a progressive decline in WBC (5.5
[[**6-28**]]> 3.4 [[**7-4**]], 2.9 [[**7-7**]]) with developing transaminitis AST
up to 38 and ALT up to 45 (previously normal). She reports
ongoing low grade fevers with max of 100.4 over the last week
and has developed a new prickly livedoid rash on the bilateral
upper extremities and back. She currently has no complaints
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, [**Known lastname **]
stools or red stools. S/he denies recent chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
No DM, HTN, HLD
s/p C-section
Bioprosthetic AVR and MVR ([**5-10**]) [**1-6**] bicuspid AV with regurg and
bileaflet MV with prolapse
Social History:
She is married with 2 children.
-Tobacco history: Previous smoker; Originally quit 15 years ago,
but recently relapsed [**8-16**] as a coping mechanism for life
stressors. Quit again [**3-17**].
-ETOH: Occasional
-Illicit drugs: Denies
Family History:
She is adopted - states that her biological grandparents had
some type of heart disease, but that they died young so she is
not sure exactly what.
Physical Exam:
ADMISSION:
98.9 118/83 73 19 99 RA
GENERAL- NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. MMM
NECK- Supple, with JVP at clavicle at 45 degrees
CARDIAC- RRR, prominent heart sounds consistent with prosthetic
valve. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits. Livedoid rash with
sandpaper characteristic over extremities. No stigmata of
endocarditis
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
DISCHARGE:
VS: 97.9 98/53 - 109/61 49-50 16 100% RA
GENERAL- NAD. Oriented x3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. MMM
NECK- Supple, with JVP at clavicle at 45 degrees
CARDIAC- RRR, prominent heart sounds consistent with prosthetic
valve. No m/r/g. No thrills, lifts. No S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits. Livedoid rash with
sandpaper characteristic over extremities. No stigmata of
endocarditis
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION:
[**2146-7-8**] 05:00PM BLOOD WBC-2.5*# RBC-3.89* Hgb-12.1 Hct-35.8*
MCV-92 MCH-31.0 MCHC-33.7 RDW-12.7 Plt Ct-121*
[**2146-7-8**] 05:00PM BLOOD Neuts-55.4 Lymphs-31.9 Monos-10.3 Eos-1.7
Baso-0.8
[**2146-7-9**] 06:33AM BLOOD ESR-11
[**2146-7-8**] 05:00PM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-139
K-4.1 Cl-103 HCO3-27 AnGap-13
[**2146-7-8**] 05:00PM BLOOD ALT-45* AST-35 AlkPhos-79 TotBili-0.4
[**2146-7-8**] 05:00PM BLOOD Calcium-9.5 Phos-3.4 Mg-2.1
[**2146-7-9**] 06:33AM BLOOD CRP-7.0*
DISCHARGE:
[**2146-7-11**] 05:34AM BLOOD WBC-2.7* RBC-3.53* Hgb-10.8* Hct-32.4*
MCV-92 MCH-30.6 MCHC-33.4 RDW-12.6 Plt Ct-149*
[**2146-7-11**] 05:34AM BLOOD Neuts-29* Bands-0 Lymphs-61* Monos-4
Eos-1 Baso-1 Atyps-4* Metas-0 Myelos-0
[**2146-7-11**] 05:34AM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-140
K-4.0 Cl-104 HCO3-29 AnGap-11
[**2146-7-11**] 05:34AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.1
[**2146-7-10**] 06:09PM BLOOD Vanco-14.4
[**2146-7-9**] 11:00PM BLOOD Genta-5.0
[**2146-7-10**] 06:04AM BLOOD Genta-0.9*
Urine Culture: Negative
Blood Cultures: NTD
CXR:
No acute cardiopulmonary process
TTE:
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. A
bioprosthetic aortic valve prosthesis is present. The prosthetic
aortic valve leaflets are thickened. The transaortic gradient is
normal for this prosthesis. No masses or vegetations are seen on
the aortic valve. Trace aortic regurgitation is seen. A
bioprosthetic mitral valve prosthesis is present. The prosthetic
mitral valve leaflets are thickened. The gradients are higher
than expected for this type of prosthesis (6 mmHg at 54 bpm),
consistent with severe functional mitral stenosis. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No valvular vegetations seen (cannot exclude with a
transthoracic study). Mildly degenerated aortic valve
bioprosthesis with normal gradients and trace regurgitation.
Markedly degenerated mitral valve bioprosthesis with severe
functional stenosis and mild regurgitation. Normal global
biventricular systolic function.
Compared with the prior study (images reviewed) of [**2146-6-14**],
findings are similar.
Brief Hospital Course:
58 yo female with PMH of bioprosthetic AVR and MVR ([**5-10**]) s/p
recent admission to CCU with suspected Gemella endocarditis, now
with continued fevers despite outpatient IV abx with CTX and
Gent.
.
ACUTE
# Presumed Gamella Endocarditis: During last admission, TTE/TEE
was unable to rule out endocarditis during hospitalization. No
other source of bacteremia noted during that admission. Was
started on linezolid, transition to dapto, and then to
ceftriaxone and Gentomycin after desensitization in the CCU.
Fevers resolved at that time. Surveillance cultures were
negative. On discharge she was doing well, but developed low
grade fevers over the last week. It was thought that these were
due to drug reaction vs recurrent/worsening endocarditis. ESR
was nl. CRP was mildly elevated. Repeat cultures from PICC and
peripheral were negative. Her gentamicin dose was decreased to
80 mg IV BID. Ceftriaxone was stopped. She was desensitized to
vancomycin in the CCU per protocol. TTE showed no endocarditis.
It was felt by cards and ID that we could forgo repeat TEE as
her blood cultures were negative and she had been afebrile since
admission. She was sent home on
.
# Fevers: Differential included progressive valvular infection
vs. drug reaction vs. line-related infection. Patient was
afebrile since admission. PICC and peripheral cultures were
negative. CXR was negative. UA and culture was negative. Very
low grade at the moment and afebrile on admission. Ceftriaxone
was stopped. She was desensitized to vancomycin per protocol in
the CCU and sent home with continued IV vanc and gent till [**8-4**].
.
# Rash/Leukopenia/transaminitis: It was suspected that this was
a side-effect from the ceftriaxone. Her gentamicin dose was
reduced on admission, ceftriaxone was discontinued, and she was
desensitized to vancomycin in the CCU. LFTs trended down, rash
resolved, and she remained afebrile.
.
# Anxiety: Very anxious regarding hospitalization. Responded
well to xanax. Social work was consulted and alternative
measures including yoga were suggested.
.
TRANSITIONAL
# f/u vanc trough, gent trough, biweekly lytes, weekly CBC
# f/u with ID and Cardiology
Medications on Admission:
1. Aspirin EC 81 mg PO DAILY
2. Amoxicillin 500 mg PO PREOP
Take 4 pills prior to dental procedures
3. CeftriaXONE 2 gm IV Q24H
4. Gentamicin 90 mg IV Q12H
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Gentamicin 80 mg IV Q12H
until [**2146-8-4**]
RX *gentamicin 40 mg/mL 80 mg twice a day Disp #*4160 Milligram
Refills:*0
3. Vancomycin 1250 mg IV Q 12H
until [**2146-8-4**] Disp #*30 Tablet Refills:*0
RX *vancomycin 500 mg 1250 mg twice a day Disp #*65 Gram
Refills:*0
4. Outpatient Lab Work
[**2146-7-13**] Lab Work
ICD-9 424.90 Endocarditis
Please draw AM CBC with Differential, Vanc trough, BMP,
Gentamicin trough and LFTs
All laboratory results should be faxed to the Infectious Disease
at ([**Telephone/Fax (1) 4591**].
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Primary: recurrent fever
Secondary: rash, leukopenia, elevated LFTs
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 4887**],
It was a pleasure taking care of you during your recent
admission to [**Hospital1 18**]. You were admitted because you had low grade
fevers, low white count, rash, and elevated liver function
tests in the setting of continued treatment for your Gemella
endocarditis. On admission, we decreased your dose of
gentamicin, stopped your ceftriaxone, and desensitized you to
vancomycin while you were in the ICU. You had no problems with
the vancomycin. Repeat echocardiogram did not show a vegetation
on your valve. Your cardiologist and infectious disease doctors
[**Name5 (PTitle) 2985**] that a repeat transesophageal echo was not necessary. The
infectious disease doctors recommended that [**Name5 (PTitle) **] continue the
vancomyinc and gentamicin. Please follow up with cardiology and
infectious disease for your scheduled appointments.
Regarding your medications. Continue all as previously
described, except:
Start
Vancomycin 1250 IV q12 hrs
Stop
Ceftriaxone
Change
Gentamicin 80 IV q12 hrs
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2146-8-1**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2146-8-4**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2146-8-11**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"790.4",
"E930.5",
"693.0",
"288.50",
"780.60",
"E878.0",
"996.61"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9825, 9870
|
6850, 9037
|
395, 401
|
9981, 9981
|
4382, 6827
|
11193, 12084
|
2601, 2750
|
9244, 9802
|
9891, 9960
|
9063, 9221
|
10131, 11170
|
2765, 4363
|
316, 357
|
429, 2171
|
9996, 10107
|
2193, 2329
|
2345, 2585
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,418
| 104,676
|
52468
|
Discharge summary
|
report
|
Admission Date: [**2111-10-21**] Discharge Date: [**2111-10-27**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
s/p fall, unresponsiveness, SDH
Major Surgical or Invasive Procedure:
right craniotomy for evacuation of subdural hematoma
History of Present Illness:
86yo man with PMH significant for labile BP w/ HTN and
orthostatic hypotension presents after a fall and
unresponsiveness. He has had significant orthostasis with
multiple admissions and ED visits for fractures, and notes that
he has fallen perhaps 10 times over the past 2 weeks. He was
last admitted one month ago, at which time he had a normal HCT
and medication alteration. History per his son, he has had two
falls recently that he knows of, once yesterday and then again
today. Yesterday he refused to go to the ED after his fall. His
neighbors called him today and did not get an answer by phone,
and on arrival found him on the ground unresponsive, then
disoriented. He was brought to the ED. Here he had a HCT which
showed a large subdural hematoma with midline shift (see below).
Review of systems is notable for falls, increased drowsiness x 1
week, and some difficulty concentrating. He has also had a
headache x 2 weeks. He has no change in vision or diplopia, no
nausea, vomiting, dysphagia. His son says his neighbors have
noticed occasional strange behavior recently; for example, he
has lost weight and his pants have been falling down without him
noticing. His son is concerned about his safety at home (he
lives by himself).
Past Medical History:
autonomic instability w/ HTN to 220s but orthostatic hypotension
w/ tilt testing showing BP ddrop from 156/83 to 76/44 with tilt
s/p pacemaker placement for bradycardia and syncope [**5-/2110**]
atrial flutter s/p ablation
spinal stenosis
chronic renal insufficiency
depression
s/p cataract surgery
Social History:
lives alone, son is an endocrinologist (see below). h/o tobacco
use, no EtOH
Family History:
not elicited
Physical Exam:
Admission exam:
PE: VS: T99.6, HR 72, BP 220/104->181/94, then SBP 150s, RR 20,
SaO2 96%/RA, pain [**4-3**]
Genl: NAD, comfortable lying in bed
HEENT: cervical collar in place, MMM, OP clear
CV: RRR, nl S1, S2
Chest: CTA bilaterally anteriolaterally
Abd: soft, NTND, BS+
Ext: cool, multiple small lacerations
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says [**Doctor Last Name 1841**]
backwards. Speech is fluent with normal comprehension and
repetition; naming intact, no dysarthria. No right left
confusion. No evidence of neglect.
Cranial Nerves:
Pupils postsurgical, equally reactive to light, 2 to 1mm
bilaterally. Visual fields are full to confrontation.
Extraocular movements intact bilaterally, no nystagmus.
Sensation intact V1-V3. Facial movement symmetric. Hearing
intact to finger rub bilaterally. Palate elevation symmetrical.
Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact.
Motor: Normal bulk bilaterally. Tone normal. No observed
myoclonus, asterixis, or tremor. No pronator drift.
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF
R 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch throughout, decreased
bilaterally to vibration and proprioception. No extinction to
DSS.
Reflexes: 2+ and symmetric in BUE, 1+ in B patellae, absent
achilles. Toes downgoing bilaterally.
Coordination: finger-nose-finger normal, RAMs normal.
Discharge examination: stable, as above
Pertinent Results:
[**2111-10-26**] 04:00PM BLOOD WBC-6.3 RBC-3.76* Hgb-12.0* Hct-35.1*
MCV-93 MCH-32.0 MCHC-34.3 RDW-13.1 Plt Ct-315#
[**2111-10-24**] 07:50AM BLOOD WBC-7.6 RBC-3.44* Hgb-11.2* Hct-32.1*
MCV-94 MCH-32.5* MCHC-34.8 RDW-13.2 Plt Ct-192
[**2111-10-24**] 04:06AM BLOOD WBC-7.5 RBC-3.29* Hgb-10.6* Hct-30.6*
MCV-93 MCH-32.1* MCHC-34.6 RDW-13.2 Plt Ct-198
[**2111-10-23**] 03:25AM BLOOD WBC-8.0 RBC-3.27* Hgb-10.7* Hct-31.1*
MCV-95 MCH-32.8* MCHC-34.5 RDW-13.2 Plt Ct-219
[**2111-10-21**] 11:27AM BLOOD Neuts-80.6* Lymphs-13.2* Monos-4.7
Eos-1.3 Baso-0.1
[**2111-10-26**] 04:00PM BLOOD Plt Ct-315#
[**2111-10-26**] 04:00PM BLOOD PT-11.7 PTT-25.8 INR(PT)-1.0
[**2111-10-26**] 04:00PM BLOOD Glucose-101 UreaN-24* Creat-1.3* Na-136
K-4.9 Cl-100 HCO3-28 AnGap-13
[**2111-10-24**] 07:50AM BLOOD Glucose-107* UreaN-18 Creat-1.1 K-3.9
Cl-102 HCO3-23
[**2111-10-21**] 11:27AM BLOOD CK(CPK)-181*
[**2111-10-26**] 04:00PM BLOOD Calcium-9.0 Phos-3.5 Mg-2.3
[**2111-10-24**] 07:50AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.1
[**2111-10-26**] 04:00PM BLOOD Phenyto-7.3*
[**2111-10-24**] 07:50AM BLOOD Phenyto-4.1*
[**2111-10-22**] 02:15PM BLOOD Type-ART pO2-93 pCO2-42 pH-7.36
calTCO2-25 Base XS--1
[**2111-10-22**] 02:15PM BLOOD Glucose-163* Lactate-1.6
[**2111-10-21**] 02:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
.
.
CT HEAD W/O CONTRAST [**2111-10-21**] 11:56 AM
IMPRESSION: Heterogeneous but relatively low-attenuation
extraaxial collection, layering over the right cerebral
convexity, likely representing a subacute subdural hematoma (or
reflecting underlying profound anemia), with possible small foci
of acute hemorrhage, anteriorly. There is significant mass
effect and associated shift of the midline structures, as
described, with subfalcine and probable early uncal herniation.
No other hemorrhage is identified and there is no acute skull
fracture.
.
.
CT HEAD W/O CONTRAST [**2111-10-23**] 10:43 AM
IMPRESSION: Status post evacuation of the right frontoparietal
subdural hematoma. A small right frontal chronic collection
remains. There is moderate amount of pneumocephalus. A very
small amount of acute blood is seen just deep to the
post-surgical site as well as layering along the tentorium, the
subdural location. Continued followup is needed to document
stability of these tiny amounts of acute blood.
.
.
CT HEAD W/O CONTRAST [**2111-10-24**] 4:46 PM
IMPRESSION: Stable post-surgical changes within the right
cerebral hemisphere from evacuation of subdural hematoma. No new
foci of intracranial hemorrhage are identified.
Brief Hospital Course:
This patient was admitted on [**10-21**] to the neurosurgery service
for his procedure, done on [**10-22**]. He was prepared and consented
as per standard. His procedure (right craniotomy for evacuation
of subdural hematoma) had no intra-operative complications. The
patient tolerated the procedure well, and no drain was left in
place. His skin was closed with staples (to be removed 10 days
from the date of his surgery).
Postoperatively, the patient had difficulty with blood pressure
control (history of severe orthostatic hypotension). His blood
pressures were initially very labile while in the unit. When he
was transfered to the neuro stepdown unit, he remained mainly
hypertensive despite having started his normal antihypertensive
medications. His average SBP ranged from 170-180. Despite his
pressures, his neurological function began to improve post-op
and he was tolerating a regular diet, ambulating and had
adequate pain control. He had no new neurological issues.
On [**10-27**], he was doing well and had no further issues. His Hct
was 35. His dilantin level was therapeutic (around 10 corrected
for a low albumin), and he was discharged to rehab. He should
have his sutures removed [**11-1**] and follow up in neurology clinic
in [**4-30**] weeks with a HCT.
His antihypertensives should not be adjusted without speaking
with Dr. [**Last Name (STitle) **], his primary cardiologist: ([**Telephone/Fax (1) 15500**].
Medications on Admission:
ASA 81mg daily
metoprolol 25mg [**Hospital1 **]
lisinopril 5mg qhs
zoloft 25mg daily
midodrine 2.5mg [**Hospital1 **]
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: asdir
Injection ASDIR (AS DIRECTED): 2u for FS121-160,
4u for FS161-200,
6u for FS201-240,
8u for FS241-280,
10u for FS281-320,
12u for FS>320 and notify MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Subdural hematoma
Status post right craniotomy
Discharge Condition:
Stable
Discharge Instructions:
Take medications as prescribed.
Please follow up with Dr. [**First Name (STitle) **] in several weeks and Dr.
[**Last Name (STitle) 739**] in [**4-30**] weeks. You will need to have your sutures
removed in 10 days.
Call your doctor or go to the emergency room if you have any:
- redness, swelling, or drainage of your wound
- fever or chills
- difficulty thinking, speaking, or swallowing
- loss of consciousness
- chest pain or difficulty breathing
- weakness or tingling of your extremities
- any other concerning symptoms
Followup Instructions:
You need to have your sutures removed [**11-1**]. This can be done in
the neurosurgery clinic [**Telephone/Fax (1) 1669**]. You will need to follow up
with Dr. [**Last Name (STitle) 739**] in [**4-30**] weeks with a head CT prior to the
appointment; the office will call you with an appointment.
Previously scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2111-12-1**] 2:30
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Date/Time:[**2112-5-13**] 11:45
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
|
[
"337.9",
"427.32",
"852.26",
"401.9",
"V45.01",
"E888.9",
"585.9",
"458.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
9074, 9219
|
6349, 7786
|
301, 355
|
9310, 9319
|
3737, 6326
|
9893, 10690
|
2065, 2080
|
7954, 9051
|
9240, 9289
|
7812, 7931
|
9343, 9870
|
2095, 2405
|
229, 263
|
383, 1631
|
2746, 3718
|
2444, 2730
|
2429, 2429
|
1653, 1954
|
1970, 2049
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,799
| 184,917
|
1564
|
Discharge summary
|
report
|
Admission Date: [**2114-5-16**] Discharge Date: [**2114-6-5**]
Date of Birth: [**2052-2-16**] Sex: M
Service: SURGERY
Allergies:
Roxicet
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Colonic polyp found on screening colonoscopy
Major Surgical or Invasive Procedure:
single-port laparoscopic ileocecectomy
ex-lap and repair of anastamosis
IR guided aspiraiton and drain placement x 2
History of Present Illness:
Mr. [**Known lastname 9086**] is a 62 year old man with history of hypertension,
hyperlipidemia, anxiety, and GERD, who was initially admitted on
[**5-16**] for elective ileocecectomy for a sessile polyp in the
cecum. He had a cecal polyp discovered on a screening
colonoscopy in [**2111**], followed by 4 colonoscopies with removal.
Pathology returned only adenoma, but each time the polyp
recurred. His gastroenterologist recommended surgical removal.
He was referred to Dr. [**Last Name (STitle) 1120**], who offered him a laparoscopic
right colectomy.
Past Medical History:
- Hypertension
- Hyperlipidemia
- GERD
- Anxiety
- Hemorrhoids
- s/p knee arthroscopy
Social History:
He discontinued smoking cigarettes in about [**2084**]. He is married,
works as a lawyer, and drinks alcohol socially.
Family History:
His family history includes a mother who died of lung cancer.
She was a smoker who died at age 76. He has no family history of
colorectal cancer or inflammatory bowel disease.
Physical Exam:
HEENT: PERRL, EOMI, MMM, no oral ulcers
Neck: supple, no LAD
Respiratory: Decreased BS @ bases b/l
Cardiovascular: RRR no M/R/G
Back: No midline tenderness
Gastrointestinal: Soft, ND, no TTP, midline incision opened and
mid incisioin and packed , RUQ drain insterion site- without
erythema, RUQ drain with serosanguinous fluid/debirs- only a few
ccs
Musculoskeletal: No C/C/E
Skin: No rashes
Neurological: Grossly itnact
Other: LUE PIV- without erythema
Pertinent Results:
[**Hospital Unit Name 153**] admission labs:
[**2114-5-16**] 01:23PM BLOOD Hct-42.4
[**2114-5-17**] 08:00AM BLOOD Glucose-127* UreaN-11 Creat-1.0 Na-138
K-4.4 Cl-103 HCO3-28 AnGap-11
[**2114-5-17**] 08:00AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.2
[**2114-5-18**] 07:57PM BLOOD Glucose-140* Lactate-3.4* Na-137 K-3.3*
Cl-100 calHCO3-29
[**2114-5-18**] 07:57PM BLOOD Hgb-11.4* calcHCT-34
.
Most recent ABG:
[**2114-5-22**] 10:06PM BLOOD Type-ART Temp-38 pO2-129* pCO2-40
pH-7.50* calTCO2-32* Base XS-7 Intubat-NOT INTUBA
.
Labs on transfer:
[**2114-5-24**] 03:32AM BLOOD WBC-10.8 RBC-3.17* Hgb-10.0* Hct-28.1*
MCV-89 MCH-31.6 MCHC-35.5* RDW-14.9 Plt Ct-108*
[**2114-5-24**] 03:32AM BLOOD Neuts-90 Bands-0 Lymphs-7 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2114-5-24**] 03:32AM BLOOD PT-14.0* PTT-30.4 INR(PT)-1.2*
[**2114-5-24**] 03:32AM BLOOD Glucose-135* UreaN-23* Creat-0.8 Na-141
K-3.4 Cl-107 HCO3-25 AnGap-12
[**2114-5-24**] 03:32AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7
.
Microbiology:
Blood Culture, Routine (Final [**2114-5-21**]):
ESCHERICHIA COLI
.
Remaining blood cultures negative.
.
C. Diff negative X 4.
.
URINE CULTURE (Final [**2114-5-20**]): NO GROWTH
.
Imaging:
Most recent CXR: PA and lateral chest radiographs show bilateral
low lung volumes. Pleural fluid is bilateral, similar in
magnitude since [**5-25**]. There is associated mild bibasilar
atelectasis and the lungs are otherwise clear. Otherwise, the
visualized portions of the cardiomediastinal silhouette are
unremarkable. Visualized osseous structures are unremarkable.
Scattered air-filled loops of small bowel are partially
visualized.
.
Most recent CT:
1. Interval placement of a pigtail catheter in the right
subhepatic fluid
collection with interval decrease in size. The fluid collection
in the right paracolic gutter has slightly decreased in size.
2. Unchanged large midline pelvic fluid collection posterior to
the bladder.
3. Slight worsening of bibasilar lower lobe collapse and small
bilateral
pleural effusion.
.
[**2114-5-29**] CT OF THE PELVIS WITH IV CONTRAST: There is a 6.3 x
5.4-cm well-defined fluid collection posterior to the bladder
appears relatively unchanged compared to the prior study. The
rectum, sigmoid colon, urinary bladder, distal ureters,
prostate, seminal vesicles appear normal.
.
Pathology:
Ileum and right colon, partial ileocolectomy:
1. Residual sessile adenoma (up to 4.0 cm in greatest
dimension, located 2.5 cm from distal colonic resection margin)
with foci of high grade dysplasia; no invasive adenocarcinoma
identified. Resection margins are free of dysplasia.
2. Associated fibrosis, mild architectural distortion and mural
anthracotic pigment deposition, consistent with prior
polypectomy and ink tattooing.
3. Additional incidental adenoma (0.1 cm).
4. Ileal segment with no diagnosis abnormalities recognized.
5. Appendix with no diagnostic abnormalities recognized.
6. No intrinsic colonic mucosal abnormalities otherwise
recognized.
7. Thirteen regional lymph nodes with no carcinoma seen (0/13).
8. Multiple levels are examined (blocks D - I, K).
Ileocolonic anastamosis:
1. Colonic perforation with surrounding coagulative-type
necrosis of muscularis propria and transmural acute
inflammation.
2. Severely active colitis with ulceration surrounding
perforation site.
3. Ileocolonic anastomosis intact.
4. Colonic and ileal resection margins unremarkable.
Brief Hospital Course:
Mr. [**Known lastname 9086**] is a 62 year-old man with history of hypertension,
hyperlipidemia, GERD, and anxiety, admitted for ileocectomy for
removal of a sessile polyp found on screening colonoscopy.
.
He underwent an ileocecectomy on [**5-16**] for removal of the polyp.
He was subsequently recovering uneventfully on the surgical
service. On the morning of [**5-18**] he was tolerating a clear liquid
diet. He was on heparin for DVT prophylaxis.
.
On the afternoon of [**5-18**], the patient developed fever,
tachycardia, and hypoxia with O2 Sat 85% on RA, improving to 95%
on 3L. Labs revealed leukopenia (2.9K, decreased from 10k the
day prior) with 34% bands. CXR was notable for
pneumonperitoneum. He was taken back to the operating room and
underwent exploratory laparoscopy. A bowel leak was discovered,
thought to be secondary to a thermal injury, with gross stool in
the peritoneal cavity. He underwent open lapartotomy with
revision. Estimated blood loss was 1.5 L. He was extubated
without event.
.
In the PACU, he was noted to be hypotensive (80's-90's systolic)
and tachycardic to the 120's. He was given a total of 8 L IVF.
His urine output was reportedly good. Hematocrits were 42.4
preop on [**5-16**].7 immediately preop, and 32.4 on recheck. In
addition, he was on 6L face mask satting 94% and mildly
tachypneic (RR 20). He was febrile to 102. He received a dose of
ciprofloxacin, metronidazole, and fluconazole after surgery.
.
He was transferred to the MICU and found to have a pansensitive
E. coli bacteremia and was treated with Flagyl/Vanco/Cipro.
Respiratory distress likely [**1-22**] ARDS from sepsis/surgical
stress, as well as from restrictive physiology [**1-22**]
pain/distention in the abdomen given low lung volumes. Required
intubation, on time of transfer extubated and stable on 4 L NC.
Required pressors, off pressors > 48 hours prior to transfer.
Diuresed with lasix 20 mg IV daily, goal -2 L a day. Patient
with diarrhea, C. Diff times three negative. CXR demonstrates
atelectasis. Patient continued to have fevers ranging to 101F at
the time of transfer to the floor.
.
Anemia: HCT 22 to 28.6 this am following 2 Units pRBC
.
Anxiety: Patient become very anxious at night requiring prn
haldol. Improved once patient started home dose Celexa (every
other day) and Xanax q6hr.
.
Pain: No longer requires dilaudid PCA. Tolerating clears at time
of transfer. Co-managed with surgery throughout stay.
.
Thrombocytopenia: Unclear etiology. Ranged from 88-166. Started
to decrease Day 2 hospital course therefore unlikely HIT. Most
likely secondary to sepsis. Improved to 108 at time of transfer.
.
He was transferred to the floor on [**5-24**] with improving
oxygentation, decreased fever curve but never afebrile. His
leukocytosis peaked at 21 on [**5-27**] but has since decreased to
13.9.
.
A CT abd/pelvis on [**5-25**] revealed right upper quadrant fluid
collection with multiple smaller additional right
retroperitoneal fluid pockets which may be in continuity with
the largest right upper quadrant collection as well as a large
midline pelvic fluid collection. On [**5-25**] he had IR guided
aspiraiton of both collecitons with RUQ collection growing
enterococcus and pelvic colleciton with GNR. A drain was left in
the RUQ collection.
.
On [**5-30**], repeat CT showed that the subhepatic fluid collection
extends in the paracolic gutters and has slightly decreased in
size compared to the prior study now measuring maximally 4.7 x
2.4 cm. The fluid collection in the anterior pararenal space has
also decreased in size now measuring maximally 5.6 x 1.7 cm. No
free intra-abdominal air is noted.
.
The patient's HCT trended down from 25-23 resulting in
transfusion on packed red blood cells with a good effect, HCT
increased to 28. Stools were quaiac negative. Patient c/o of
multiple loose stools, c-diff was negative and imodium was
started with good effect. A PICC line was placed for long term
antibiotics.
.
Per ID the patient was d/c'd on Tigecycline 50 mg IV Q12H. [**Location (un) **] home therapies provided teaching regarding antibiotic
administration and will assit the patient and family at home.
The patient was also provided teaching regarding drain care and
wound care. The VNA will also assist with this. The patient's
staples were removed and steri strips were applied.
.
All d/c paperwork was reviewed with patient and family and all
questions were answered. Patient was encouraged to call with
questions or concerns. He will follow up with Dr. [**Last Name (STitle) 1120**] in [**12-22**]
weeks.
Medications on Admission:
- Atorvastatin 40mg daily
- Esomeprazole 40mg daily
- Aspirin 81mg daily,
- Acetaminophen
- Valsartan 80mg daily
- Citalopram 10mg QOD
- Amitriptyline 10mg daily
- Alprazolam 0.25mg PRN
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever, pain for 2 weeks: Please do not take
more than 4000mg in 24 hrs. .
7. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO Q6H PRN ()
as needed for anxiety.
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Normal Saline Flush 0.9 % Syringe Sig: Eight (8) Injection
once a day for 1 months: Please flush both drains daily with
10cc and withdraw until clear. .
Disp:*120 syringes* Refills:*2*
11. Outpatient Lab Work
Weekly lab work
Creat, bun, CBC w/diff, LFT's
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**]
12. Tigecycline 50 mg Recon Soln Sig: One (1) Intravenous twice
a day for 2 weeks.
Disp:*28 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Recurrent cecal polyp
Post op Hypotension/Tachycardia/hypoxia
Post op colonic perforation
Two intraabdominal abscesses
Post op anemia
.
- hypertension
- hyperlipidemia
- gastroesophageal reflux disease
- anxiety
Discharge Condition:
- stable
- tolerating a regular diet
- pain controlled on oral medication
Discharge Instructions:
General Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
- Your steri-strips will fall off on their own. Please remove
any remaining strips 7-10 days after surgery.
- You may shower, and wash surgical incisions.
- Avoid swimming and baths until your follow-up appointment.
- Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Wound care:
-Mid line incision - Pack open areas with duoderm gel moistened
2x2 gauze. Apply dry gauze on top.
-Please change this daily
.
Drains:
-Please flush drain with 10cc of normal saline and withdraw back
until clear.
-You have been using about 4 10cc syringes in the hopsital.
-Please empty and record drain output daily.
-Please change dressing daily and clean drain site with 1/2
peroxide and normal saline.
.
PICC:
-[**Location (un) 511**] home therapies will assist you with antibiotic
administration.
-This dressing will be changed by the VNA every week.
-You may shower, but the PICC must not get wet. Please cover.
-The VNA will draw weekly labs off your PICC and fax them to
infectious disease.
Followup Instructions:
1. Please call Dr. [**Last Name (STitle) 1120**] to make a follow up appointment in [**1-23**]
weeks, call [**Telephone/Fax (1) 160**] for appointment.
2. Please call your PCP, [**Name10 (NameIs) 7726**],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7728**], to make a
follow up appointment in [**12-22**] weeks or as needed.
Completed by:[**2114-6-6**]
|
[
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"518.0",
"300.00",
"518.5",
"293.0",
"785.52",
"567.22",
"285.1",
"998.32",
"287.4",
"E878.2",
"272.4",
"998.59",
"455.6",
"569.83",
"530.81",
"995.92",
"401.9",
"211.3",
"038.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"45.79",
"00.14",
"17.33",
"54.91",
"38.93",
"45.62",
"46.21"
] |
icd9pcs
|
[
[
[]
]
] |
11561, 11619
|
5402, 9966
|
311, 430
|
11884, 11960
|
1946, 1975
|
14225, 14612
|
1278, 1456
|
10202, 11538
|
11640, 11863
|
9992, 10179
|
11984, 13147
|
13162, 13489
|
1471, 1927
|
227, 273
|
13501, 14202
|
458, 1015
|
1991, 5379
|
1037, 1126
|
1142, 1262
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,694
| 187,507
|
6793+6794
|
Discharge summary
|
report+report
|
Admission Date: [**2104-4-26**] Discharge Date:
Date of Birth: [**2049-1-24**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: THis is a 55 year-old male
patient with known coronary artery disease, alcohol abuse,
bipolar disorder who was admitted to [**Hospital1 190**] on [**2104-6-26**] after approximately three day
history of chest pain. The patient lives in a group home.
He had previously been sober for fourteen months, however,
recently began drinking again. Approximately four days prior
to admission the patient entered a detox facility.
PAST MEDICAL HISTORY: Significant for coronary artery
disease as previously mentioned. He is status post stent to
his left circumflex in [**2103-6-29**]. He has documented
ejection fraction of 50%. The patient is positive for a
myocardial infarction eight years ago. He has a history of
bipolar disorder and alcohol abuse.
MEDICATIONS ON ADMISSION: Lithium 300 mg po q.a.m., 600 mg
po q.h.s., Trazodone 300 mg po q.d., Wellbutrin SR 150 mg po
q.a.m., Lipitor unknown dose, enteric coated aspirin 325 mg
po q.d., Atenolol unknown dose, Seraquel 100 mg po q.d.
HOSPITAL COURSE: The patient was taken to the Cardiac
Catheterization Laboratory on [**2104-4-28**], which revealed
three vessel coronary artery disease including a 50% left
main as well as a left ventricular ejection fraction of 45%.
The patient was taken to the Operating Room on [**2104-4-29**]
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] where the patient underwent a coronary
artery bypass graft times four. Postoperatively, the patient
extubated himself on the night of surgery and was quite
agitated upon waking from anesthesia. Psychiatry Service has
been following him since his admission to the hospital. They
recommended utilizing Haldol for sedation and recommended
holding other sedating medications as well as psychiatric
medications at that time. On [**4-30**] postoperative day one
the patient was on neo-synephrine for some hypotension,
Propofol intravenous drip was converted to __________. The
patient had been reintubated. He did not tolerate his self
extubation on the night of surgery due to respiratory
distress. The patient was placed on _________, however, that
did not sedate the patient adequately and he was placed back
on Propofol. He received increasing doses of Haldol,
however, wound up with a prolonged QTC, therefore his Haldol
was converted to Ativan and a morphine intravenous drip.
Again on postoperative day two the patient extubated himself
and did not tolerate it and was reintubated a second time.
The patient also discontinued his central intravenous line
and a new stick right IJ triple lumen catheter was placed.
The patient spiked a fever and was fully cultured at that
time. He remained on neo-synephrine for some hypotension and
also remained on morphine and Ativan drips for sedation. On
[**5-2**] the patient had a pulmonary artery catheter replaced
due to fever and hypotension. However, his cardiac numbers
were adequate. His tube feeds were resumed. He was placed
on Levaquin and Vancomycin secondary to fever to 102,
although his white blood cell count was between 10 and [**Numeric Identifier 890**]
and he was fully cultured. The following day all of the
psychiatric medications were discontinued at the
recommendation of the Psychiatry Service. There had been
worsening agitation and restlessness and it was their thought
that these drugs could be contributing to them. It was there
recommendation also to continue just Haldol and follow his
electrocardiogram daily to check his QT intervals.
Over the next couple of days the patient's pulmonary artery
catheter was discontinued. He remained extremely agitated
thrashing in the bed requiring large doses of sedation.
Morphine and Ativan drips were continued. It was still the
recommendation of the Psychiatry Service to not resume the
rest of his psychiatric medication. Infectious Disease
consultation was obtained on [**2104-5-5**] and it was their
recommendation to discontinue all of his antibiotics. The
Vancomycin was discontinued at that time, but the
Levofloxacin was continued at the discretion of the Cardiac
Surgery Service due to large amounts of sputum production.
The patient underwent bronchoscopy on the [**5-6**] for
increased secretions. On [**5-7**] the patient was continued
to progress with decreasing doses of neo-synephrine. Over
the next few days the Infectious Disease Consult Service had
signed off the case. On the [**5-8**] the patient
underwent percutaneous tracheostomy and percutaneous
endoscopic gastrostomy tube placed at the bedside by Dr.
[**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**]. The patient tolerated this procedure well.
On [**2104-5-9**] the patient was transferred from the
Cardiothoracic Surgery Service to the Surgical Intensive Care
Unit/Critical Care Service due to continued need for
intensive care support. Over the next few days the patient
remained febrile. Infectious Disease Service was reconsulted
on the [**5-10**]. It was their recommendation to
discontinue the Levofloxacin and to check for C-difficile in
his stool, which was ultimately negative. The patient at
that time had gram positive coxae in his blood, although it
was not yet speciated and he was started on Vancomycin due to
the findings. This was subsequently discontinued on the [**5-12**] since it was a line that was positive and not
actually blood cultures at that time. The patient was
started over the next few days on a Clonidine patch. His
morphine and Ativan were slowly being weaned and he was begun
on diuretics. The patient was also maintained on a Propofol
intravenous drip for sedating purposes. On the [**5-14**]
it was noted that the patient had Enterobacter in his sputum.
This was sensitive to Levofloxacin so he was resumed on that.
Vancomycin was also restarted due to gram positive coxae in
his blood.
Over the next few days the patient continued with slow
pressure support ventilation wean. The patient underwent
another bronchoscopy on [**5-17**] for thick copious
secretions. The patient underwent CAT scans of his chest,
abdomen and pelvis on the [**5-18**] due to continued
fevers without a definitive source and this revealed a left
lower lobe pneumonia as well as no abdominal fever source.
The patient began to wake up over the next few days and
became more alert and less agitated. It was also ascertained
around the [**5-18**] that the patient had Methacillin
resistant staph aureus in his sputum and was on Vancomycin at
that time. It was the recommendation of the Infectious
Disease Service to continue a fourteen day course of
Vancomycin, which was started on [**2104-5-15**] for MRSA
pneumonia. Over the next few days the Propofol was weaned to
off and discontinued on [**2104-5-20**]. His intravenous
Ativan was converted to intermittent dosing and ultimately
weaned off over the next few days. On [**5-21**] the
Infectious Disease Service signed off. It was their
recommendation to continue a fourteen day course of
Vancomycin as previously noted and to continue Levofloxacin
for his Enterobacter in his sputum.
Repeat sputum culture, however, on [**5-26**], revealed that
the Enterobacter in his sputum is intermittently resistant to
Levofloxacin and this was changed to Imipenem. On [**5-23**]
the patient was converted from his pressure support
ventilation to a trach mask and he has remained off the
ventilator since that time. He has tolerated a Passy-Muir
valve at times for speaking purposes. Physical therapy and
Occupational Therapy consultations were obtained and they
continued to follow the patient for treatment. The patient
also underwent a swallow evaluation, which he failed. It was
the recommendation of the Speech Therapy service to maintain
a strict NPO status and to continue tube feeds through his
percutaneous endoscopic gastrostomy until he was able to
swallow safely. The patient, however, has been witnessed to
get himself up to the sink and drink water on his own. The
patient continued to tolerate his tube feeds well through his
percutaneous endoscopic gastrostomy tube.
The patient remains hemodynamically stable and he is able to
be transferred to rehabilitation facility at this time. Most
recent cultures revealed resistant Enterobacter in the sputum
as well as MRSA in the sputum from [**5-23**]. The patient is
on Vancomycin, which is to continue through [**5-29**] to give him
a fourteen day course and Imipenem, which is starting today
[**5-26**] and that is to continue through [**6-8**] for a
fourteen day course both for pneumonia. Two sets of blood
cultures on [**5-18**] as well as two sets of blood cultures on
[**5-16**] were all negative. Stool for C-difficile was
negative on [**5-17**]. Right subclavian triple lumen catheter
tip on [**5-16**] was negative as was a urine culture on [**5-15**].
The patient's condition today [**2104-5-26**] is as follows:
temperature 98. Pulse 86. Normal sinus rhythm. Respiratory
rate 19. Blood pressure 135/60. Oxygen saturation on 35%
oxygen via tracheostomy mask is 98%. The patient remains
incontinent of large amounts of urine. Generally the patient
is awake and alert and responds appropriately to stimuli. He
is agitated at times, but tempting to get up and ambulate on
his own. Cardiovascular examination is regular rate and
rhythm. His breath sounds are coarse rhonchi bilaterally.
His abdomen is soft. His extremities are warm and well
perfuse.
Most recent laboratory values are from today [**2104-5-26**],
which revealed a white blood cell count of 17.[**2102**], this is
down from 24,000 on [**5-24**]. Hematocrit 33.2, platelet
count 295,000, sodium 138, potassium 4.0, chloride 98, CO2
31, BUN 26, creatinine 0.6, glucose 179.
MEDICATIONS: Aspirin 325 mg one per G tube q.d., Albuterol
meter dose inhaler four puffs q 4 hours and prn, Atrovent
four puffs q four hours and prn via trach. Heparin 5000
units subcutaneously q 8 hours, multi vitamins one po q.d.,
Clonidine patch 0.3 mg q Monday, Nystatin 5 milliliters swish
and swallow t.i.d., Colace 100 mg per G tube b.i.d., Imipenem
dose to be determined, Tylenol 650 mg per G tube q 6 hours
prn, Glucotrol 5 mg per G tube q.d., Nicotine patch 14 mg
q.d., Vancomycin 1 gram intravenous q 12 hours through [**2104-5-29**], Lopresor 50 mg q 6 hours per G tube, Trazodone 100 mg
q.h.s. per G tube, Ativan 2 mg q.h.s. prn, Ativan 0.25 mg q 8
hours around the clock per G tube, Haldol 40 mg q 6 hours per
G tube. The patient's current tube feeding, which he is
tolerating well is ProMod with fiber at his goal rate of 75
cc per hour.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass graft.
2. Postoperative delirium/aggitation.
3. Bipolar disorder.
4. Alcohol abuse.
5. Respiratory failure status post cardiac surgery.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2104-5-26**] 10:08
T: [**2104-5-26**] 09:10
JOB#: [**Job Number 25761**]
Admission Date: [**2104-4-26**] Discharge Date: [**2104-5-30**]
Date of Birth: [**2049-1-24**] Sex: M
Service: CARDIAC SURGERY
HOSPITAL COURSE: The patient has remained in the Intensive
Care Unit for continued pulmonary toilet. On [**5-26**] the
patient was fitted with Passy-Muir valve and instructed in
its use. The patient tolerated this well. Psychiatry
continued to follow the patient. On [**5-26**] decreased his
Haldol, discontinued his Ativan and started his Seraquel.
The patient's confusion continued to improve. The patient
had moderate amount of secretions, which she was coughing to
the end of his tracheostomy tube. Sputum culture from
[**2104-5-23**] showed MRSA and Enterobacter. The MRSA was thought
to be a colonization and for the Enterobacter the patient was
started on Imipenem. On [**2104-5-27**] the patient underwent
modified barium swallow, which showed mild to moderate
impairment of the oropharyngeal swallowing phase. It was
positive for aspiration only with thin liquids.
Recommendations were for small amounts of pureed foods with
aspiration precautions to continue tube feeds via the
percutaneous endoscopic gastrostomy and to reevaluate the
swallowing in one to two weeks.
The patient was ambulating with the aid of staff with walking
greater then 500 feet unassisted. The patient's delirium was
resolving and was much more appropriate. On [**5-28**] Vancomycin
was discontinued. The patient remained on Imipenem for the
Enterobacter in his sputum. The patient's Seraquel was
increased by psychiatry. They also advised to continue to
hold the Lithium until the delerium was completely resolved.
The patient was weaned off oxygen to a humidified nebulizer
with oxygen saturation greater then 94%. The patient
continued to hve moderate amount of secretions and able to
clear them to the end of his tracheostomy tube. The patient
tolerating Passy-Muir valve during the day on room air.
For nutrition, tube feeds were changed to cycle from 2:00
p.m. to 8:00 a.m., ProMod with fiber at 100 cc an hour. The
patient's secretions began to decrease. On [**2104-5-29**] the
patient's Seraquel was increased to 100 mg per psychiatry and
the daytime Haldol was discontinued. The patient had
decreased secretions, improved mental status and was cleared
for discharge to a rehabilitation facility on [**2104-5-30**]. On
[**2104-5-30**] the patient's tracheostomy tube was changed from a
#8 to a #6 Shiley cuffed. The patient tolerated the
procedure well. The patient was cleared for discharge to
rehab.
MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg po q.d. 2.
Atrovent MDI four puffs q 4 hours and prn. 3. Albuterol MDI
four puffs q 4 hours and prn. 4. Multi vitamin one per G
tube q day. 5. Clonidine patch 0.3 mg q Monday. 6. Colace
elixir 100 mg per G tube b.i.d. 7. Nicotine patch 14 mg
transdermal q day. 8. Metoprolol50 mg per G tube q day. 9.
Imipenem 500 mg intravenous q 6 hours via PICC line. Last
dose is on [**2104-6-8**]. 10. Trazodone 100 mg po q.h.s.
11. Haldol 40 mg po q.h.s. 12. Glucotrol 5 mg per G tube
per day. 13. Tylenol 650 mg per G tube per rectum q 6 hours
prn. 14. Seraquel 100 mg per G tube q.h.s. 15. Regular
insulin sliding scale for blood sugar 150 to 200 give 3 units
subQ, for blood sugar 201 to 250 give 6 units subQ, for blood
sugar 251 to 300 give 9 unties subQ, for blood sugar 301 to
350 give 12 units subQ. All medications are to be given via
the G tube.
The patient is to be on aspiration precautions. Diet is
ProMod with fiber via PEG tube at 100 cc an hour from 2:00
p.m. to 8:00 a.m. The patient may not have any thin liquids
until swelling is reevaluated. The patient may have a pureed
dysphagia diet with supervision. The patient is to hve a
Passy-Muir valve place as needed with the tracheostomy tube
cuff deflated. When the Passy-Muir valve is not on the
patient is to have humidified air via the trach. The patient
is to have blood sugars checked q.i.d. and to be treated with
a regular insulin sliding scale. The patient is to have
percutaneous endoscopic gastrostomy and tracheostomy care per
protocol. The patient is to follow up with Dr. [**Last Name (STitle) 70**]
upon discharge from rehab. The patient is to follow up with
his primary care physician upon discharge from rehab.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2104-5-30**] 12:10
T: [**2104-5-30**] 12:55
JOB#: [**Job Number 25762**]
|
[
"482.83",
"788.30",
"414.01",
"482.41",
"296.7",
"787.2",
"996.62",
"518.82",
"305.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"99.20",
"33.24",
"31.1",
"36.13",
"39.61",
"36.15",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10743, 11383
|
13830, 15875
|
939, 1150
|
11401, 13803
|
159, 583
|
606, 912
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,084
| 170,736
|
34354
|
Discharge summary
|
report
|
Admission Date: [**2198-4-14**] [**Month/Day/Year **] Date: [**2198-4-23**]
Date of Birth: [**2143-12-26**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Hypotension.
Major Surgical or Invasive Procedure:
IVC filter placement
Right IJ central line placement and removal
RUE PICC placement
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 33754**] is a 54-year-old woman with history of CNS
lymphoma who presents with increasing seizures and hypotension.
She is bedbound at baseline, with chronic indwelling Foley, and
lives with her husband who cares for her. For the past 9
months, she has been having intermittent "attacks" consisting of
eyes rolling back in her head and losing consciousness for
approximately 30 seconds up to 5 minutes that consistently
happen in association with positional changes. These have been
happening more frequently recently, about 1 to 2 times per day,
recently. Also, for the past 3 weeks, she has been "not
herself," more confused compared to her baseline (which is
oriented and coherent but with some word finding difficulties).
For the past week, she has been feeling generally not well, been
more anorexic than usual, and had several episodes of nausea
with nonbilious vomitting. Of note, Foley was last changed 4
weeks ago.
Review of systems was negative for recent fevers (had some
fevers in [**2198-2-21**] and was treated as an outpatietn for UTI,
none since). There was no change in urine output or appearance
of urine. She had no cough, shortness of breath, chest pain.
She also did not have change in bowel movements or blood in
bowel movements.
In the ED, initial blood pressure was 87/29, pulse 140, and
oxygen saturation was 96% in room air. She received 4 liters of
normal saline, was put in trendelenberg, and had a right IJ
placed. She additionally received 1 unit of packed RBC and was
started on Levophed. She was noted to have a positive
urinalysis. Cultures of blood and urine were sent, and CXR was
done. CT chest/abdomen with contrast was negative for PE but
did show right thigh hematoma. She received 1 g vancomycin IV x
1 and Zosyn 4.5 g IV x 1. She also received 10 mg IV Decadron x
1.
Past Medical History:
- CNS Lymphoma, diagnosed by brain biopsy [**2197-6-2**] (path
demonstrated large B-cell lymphoma); s/p 4 induction cycle of
high-dose methotrexate ([**2197-6-5**]); she developed progressive
disease that required the addition of rituximab to high-dose
methotrexate but she progressed further; she later had whole
brain cranial irradiation to 3,600 cGy completed on [**2197-7-27**];
she had a near total response on repeat head MRI on [**2197-7-26**].
Her treatment was followed by adjuvant temozolomide monthly.
- Right upper extremity DVT (PICC-related) in [**2197-6-23**]
- Pulmonary embolism in [**2197-9-23**]
- Hypertension
- Hyperlipidemia
- Oophorectomy at young age
Social History:
She lives with husband. She formerly worked as special
education teacher. She does not use tobacco, alcohol, or
illicit drugs.
Family History:
Her father is alive with diabetes and s/p coronary stent
placement. Her mother is alive with a stroke. She has a sister
who is healthy. She has 2 children but her daughter had
Streptococcus B at the time of birth.
Physical Exam:
Vital Signs: Temperature is 95.9 F, pulse 89, blood pressure
105/68, respiration 21, and oxygen saturation at 100% in room
air.
General: She appears well, sitting up, awake and alert
HEENT: Right IJ in place, clean and dry
Heart: Regular, no murmurs
Lungs: Clear bilaterally
Abdomen: Soft, nontender, nondistended, mild suprapubic
tenderness, no rebound or guarding
Back: No CVA tenderness
Extremities: They are warm, strong distal pulses, no tenderness
in thighs, 3+ LLE edema, no RLE edema, sensation intact
Neurological Examination: Her Karnofsky Performance Score is
50. She is asleep but arousable; she can follow simple
commands. She is oriented to self and hospital. Her language
is fluent with fair comprehension. Cranial Nerve Examination:
Her pupils are equal and reactive to light, 4 mm to 2 mm
bilaterally. Extraocular movements are full. Visual fields are
full to
threat. She has a right lower facial droop. Facial sensation
is intact bilaterally. Her hearing is grossly intact. Her
tongue is midline. Palate goes up in the midline.
Sternocleidomastoids and upper trapezius are strong. Motor
Examination: She has a drift in the right upper extremity. Her
muscle strengths are [**3-27**] in the left upper extremity, and 4-/5
in proximal left lower extremity and [**3-27**] in distal left lower
extremity. Her right upper extremity strength is about [**2-25**]
while it is [**1-25**] in proximal right lower extremity and 4+/5 in
distal right lower extremity. Her right toe is up while the
left is
down. Sensory examination is intact to pain bilaterally. She
cannot walk.
Pertinent Results:
Admission labs:
[**2198-4-14**] 05:40PM NEUTS-93.1* LYMPHS-5.0* MONOS-1.9* EOS-0.1
BASOS-0
[**2198-4-14**] 05:40PM WBC-13.2*# RBC-1.93* HGB-7.3* HCT-22.3*
MCV-116* MCH-38.1* MCHC-32.9 RDW-15.4
[**2198-4-14**] 05:40PM PT-16.3* PTT-36.1* INR(PT)-1.5*
[**2198-4-14**] 05:40PM GLUCOSE-231* UREA N-11 CREAT-0.9 SODIUM-136
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-17* ANION GAP-25*
[**2198-4-14**] 05:40PM ALT(SGPT)-35 AST(SGOT)-57* ALK PHOS-115 TOT
BILI-0.7
[**Hospital3 **]
[**2198-4-16**] 07:06AM BLOOD WBC-5.4 RBC-1.92* Hgb-6.9* Hct-19.9*
MCV-104* MCH-35.9* MCHC-34.7 RDW-22.5* Plt Ct-129*
[**2198-4-18**] 05:05AM BLOOD WBC-6.1 RBC-2.81* Hgb-9.6* Hct-27.9*
MCV-99* MCH-34.2* MCHC-34.5 RDW-21.3* Plt Ct-89*
[**2198-4-19**] 07:32AM BLOOD WBC-6.6 RBC-2.69* Hgb-9.4* Hct-27.3*
MCV-101* MCH-35.0* MCHC-34.6 RDW-21.2* Plt Ct-72*
[**2198-4-15**] 03:01PM BLOOD Plt Ct-167
[**2198-4-15**] 10:00PM BLOOD Plt Ct-149*
[**2198-4-17**] 07:13PM BLOOD Plt Ct-104*
[**2198-4-18**] 12:15PM BLOOD Plt Ct-83*
[**2198-4-19**] 12:00AM BLOOD Plt Ct-65*
[**2198-4-19**] 07:32AM BLOOD Plt Ct-72*
[**2198-4-19**] 12:00AM BLOOD Glucose-80 UreaN-5* Creat-0.4 Na-140
K-3.3 Cl-113* HCO3-22 AnGap-8
[**2198-4-19**] 12:00AM BLOOD ALT-35 AST-33 LD(LDH)-182 AlkPhos-139*
TotBili-0.4
[**2198-4-14**] 05:40PM BLOOD cTropnT-0.23*
[**2198-4-14**] 05:40PM BLOOD cTropnT-0.23*
[**2198-4-15**] 03:09AM BLOOD CK-MB-6 cTropnT-0.13*
[**2198-4-14**] 05:56PM BLOOD Lactate-8.0*
[**2198-4-15**] 04:22AM BLOOD Lactate-1.2
[**Month/Day/Year **] Labs
[**2198-4-23**] 01:36AM BLOOD WBC-4.8 RBC-2.26* Hgb-7.9* Hct-23.8*
MCV-105* MCH-35.1* MCHC-33.3 RDW-20.0* Plt Ct-41*
[**2198-4-23**] 01:36AM BLOOD Neuts-75.8* Lymphs-13.1* Monos-9.8
Eos-1.2 Baso-0.1
[**2198-4-23**] 01:36AM BLOOD PT-14.6* PTT-27.7 INR(PT)-1.3*
[**2198-4-23**] 01:36AM BLOOD Glucose-94 UreaN-6 Creat-0.4 Na-145 K-3.5
Cl-117* HCO3-25 AnGap-7*
[**2198-4-22**] 12:00AM BLOOD ALT-31 AST-41* LD(LDH)-229 CK(CPK)-13*
AlkPhos-152* TotBili-0.3
[**2198-4-15**] 03:09AM BLOOD CK-MB-6 cTropnT-0.13*
[**2198-4-23**] 01:36AM BLOOD Calcium-7.8* Phos-2.5* Mg-2.1
[**2198-4-15**] 04:22AM BLOOD Lactate-1.2
MICROBIOLOGY
Blood cx NGTD
Urine cx mixed bacterial flora; no growth
IMAGING
[**2198-4-14**] CT Head
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Stable post-radiation, post-surgical changes.
3. Known left basal ganglia lesion not well characterized on
this noncontrast study. MR recommended if there is need for
further evaluation.
4. Left mastoid air-cell opacification is stable.
[**2198-4-14**] CT Abdomen and Pelvis
IMPRESSION:
1. Probable hematoma in the right buttock and right obturator
externus muscle (medial right upper thigh). Recommend clinical
correlation for injury. Recommend follow-up as the right
obturator mass is incompletely
images/characterized.
2. Diffuse osteopenia with generalized body wall atrophy.
3. No pulmonary embolism.
4. New small-to-moderate left pleural effusion.
5. Fatty liver.
6. Small amount of free fluid in the pelvis.
7. Mild rectal wall thickening, ?? proctitis.
[**2198-4-16**] CT Pelvis
IMPRESSION:
1. Similar size to hematoma with increase in density upon
contrast
administration raising the possibility of active extravasation.
An underlying mass is not excluded and recommend followup
imaging study once treated.
2. Rectum not fully assessed in this study but prior suggestion
of proctitis not totally excluded. Clinical correlation
recommended.
3. Persistent small simple free fluid in the pelvis.
4. Significant increase in anasarca.
5. Diffuse demineralization.
6. Suboptimal bolus to assess for venous thrombosis but no
thrombus in
proximal common and superfical femoral veins.
[**2198-4-17**] Transesophageal Echocardiogram
IMPRESSION:
Normal global and regional biventricular systolic function. No
diastolic LV dysfunction, pulmonary hypertension, or
clinically-significant valvular disease seen. Normal estimated
intracardiac hemodynamics. Left pleural effusion
[**2198-4-17**] Lower Extremity Ultrasound
IMPRESSION:
Right mid and distal superficial femoral vein deep venous
thrombus. Bilateral edema.
[**2198-4-18**] Upper Extremity Ultrasound
IMPRESSION:
Chronic thrombus within the right cephalic vein. The bilateral
basilic veins were not well visualized. The remainder of the
vessels demonstrate no evidence for acute DVT.
[**2198-4-19**] Chest X-Ray
IMPRESSION:
Interval placement of right PICC with tip in the inferior right
atrium. Recommend retraction by 5 cm.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 33754**] is a 54-year-old right-handed woman with a history
of CNS lymphoma presents with hypotension.
(1) Hypotension: Differential included distributive (sepsis) vs
cardiac vs adrenal insufficiency versus volume depletion. There
was no hypoxia to suggest PE, and had a negative CTA in the ED.
CVP was zero argued against cardiogenic shock. She did recently
finish her steroid taper and could be adrenally insufficient.
Another possibility was volume depletion, possibly secondary to
blood loss into her thigh. Most likely possibility was thought
to be sepsis, possibly urosepsis given positive urinalysis in
the ED and chronic indwelling urinary catheter. Initial urine
culture was contaminated; subsequent cultures were negative but
sent after the start of antibiotics.
Her hypotension was very fluid responsive, and levophed was
weaned within hours of admission. Lactate was trended and fell
over the first day. She was treated for presumed sepsis with
aggressive fluid resuscitation to maintain MAP >65, although CVP
was persistently at 0. She was given empiric vancomycin and
pip/tazo. Blood cultures were persistently negative. Urine
culture from the ED was contaminated. Foley catheter was
changed. Given the potential for adrenal insufficiency,
Cortrosyn stimulation test was done and showed adequate adrenal
function.
When there was concern for Zosyn causing thrombocytopenia, this
was changed to meropenem. Vancomycin was discontinued when cx
were no growth. Meropenem was continued for 7 day course.
Hypotension was completely resolved on the floor for greater
than 5 days prior to [**Known lastname **] and she remained normotensive
with SBP 110's to 120's.
(2) Episodic Loss of Consciousness: This was attributed to
seizures by her husband and apparently by her neuro-oncologist,
who recently increased her Keppra dosing to control this. Also
possible, she was orthostatic (given that episodes are
reproducible with positional changes) and in the setting of
worsening baseline hypotension recently has become more
symptomatic. CT head negative for acute change. Neuro-oncology
followed and did not recommend EEG or other further testing.
Prophylactic Keppra was continued.
(3) Right Thigh Hematoma/Anemia: Right obturator hematoma
visualized on CT from the ED. This was concerning given that
she is currently on lovenox and hematocrit dropped. She
required 3 units pRBC over the first 48 hours to maintain her
Hct 22 to 24. Anticoagulation with lovenox was continued
initially given the small appearance of hematoma but stopped
after the first day because of unstable Hct. Repeat CT showed
stable 8 cm hematoma with a question of an underlying mass.
There were no signs of compartment syndrome. She was transfused
for symptoms and to maintain HCT >24. Last transfusion [**2198-4-23**]
for HCT 23.8. Goal HCT 25.
(4) History of DVT/PE: LLE DVT with PE was diagnosed in
[**2197-9-23**], with ongoing LLE edema. CT for PE negative in
the ED. Anticoagulation was held. LENIs were done, and she was
found to have a RLE superficial femoral clot. Given that
anticoagulation was stopped, she underwent placement of an IVC
filter which she tolerated.
(5) Anion Gap: AG was 21 on admission, improved to 14 after
fluids and resuscitation. Likely secondary to elevated lactate
(8.0). She later developed a non-gap acidosis, likely secondary
to normal saline, which was subsequently changed to lactated
Ringer.
(6) Elevated Troponin: She had flat CK, likely secondary to
demand and hypotension. EKG in the ED with ST depressions
laterally new since [**2197-9-23**]. Cardiac enzymes were trended
and decreased.
(7) Thrombocytopenia: Patient had thrombocytopenia which
trended down during admission, 41K on [**Year (4 digits) **], felt to be
consistent with timing of side effect from temodar. Hematology
was consulted and did not feel timing was consistent with HIT or
labs were consistent with DIC or TTP. She will resume Temodar
as determined by her outpatient neuro-oncologist but it has been
held during admission.
(8) CNS Lymphoma: She is currently being treated with adjuvant
Temodar after whole brain radiation, reportedly with good
response. Keppra and citalopram were continued. Neuro-oncology
followed her in house and will see her as an outpatient.
(9) Communication: With patient and husband [**Name (NI) **] [**Name (NI) 33754**]: Cell
phone [**Telephone/Fax (1) 79050**].
(10) Code: Full code.
Medications on Admission:
Citalopram 20 mg daily
Dexamethasone 0.5 mg QOD, recently decreased to 0.25 mg QOD and
then stopped [**2198-4-12**]
Enoxaparin 80 mg SubQ [**Hospital1 **]
Keppra 1000 mg [**Hospital1 **] (recently increased from 500 mg [**Hospital1 **])
Modafinil 200 mg daily
[**Hospital1 **] Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: Max 4 g tylenol per day.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush for 7 days.
6. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
7. Outpatient Lab Work
Please check CBC and electrolytes every other day and fax
results to Dr. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 724**] at [**Telephone/Fax (1) 14669**]
8. Intravenous fluids as directed D5 half normal saline
continuous IVF at 80 cc per hour. Continue based on fluid
status and PO intake.
[**Telephone/Fax (1) **] Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
[**Hospital3 **] Diagnosis:
Primary Diagnosis
Hypotension
CNS lymphoma
Deep venous Thrombosis
Obturator hematoma
Thrombocytopenia
[**Hospital3 **] Condition:
Hemodynamically stable, afebrile >1 week and off antibiotics
[**Hospital3 **] Instructions:
You were admitted to the hospital with low blood pressure. This
was felt to be from an infection or from bleeding into your hip.
We stopped your lovenox since this thins the blood and you had
a filter placed to prevent blood clots from going from your legs
to your lungs. You were also transfused blood for low blood
counts. We treated you with antibiotics for 1 week for a
possible urinary tract infection.
We made the following changes to your medications
1. We stopped your Lovenox
2. We stopped your modafanil
3. We added Percocet, Zofran, and Compazine as needed for pain
or nausea
Please return to the ER or call your primary care doctor if you
develop chest pain, shortness of breath, fever>101, chills,
dizziness, lightheadedness, headache or any other concerning
symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2198-5-17**]
1:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6781**], [**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2198-5-17**] 3:00
Please follow-up with Dr. [**Last Name (STitle) 724**] in 1 week. You have the following
appointment: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2198-5-3**] 11:30
|
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icd9cm
|
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[]
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[
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23,028
| 115,945
|
19034
|
Discharge summary
|
report
|
Admission Date: [**2144-3-20**] Discharge Date: [**2144-3-29**]
Date of Birth: [**2101-11-13**] Sex: F
Service: SURGERY
Allergies:
Codeine / Doxycycline / Aspartame / NSAIDS
Attending:[**First Name3 (LF) 3200**]
Chief Complaint:
incisional hernia
Major Surgical or Invasive Procedure:
laparoscopic incisional hernia repair with mesh, [**2144-3-20**]
History of Present Illness:
This was 42-year-old female with
multiple medical co-morbidities. She was having some
difficulty with a known ventral hernia that she had had for
quite some time, many, many months, but it recently has
become bothering her more. She claims that it was making it
difficult to do activities and having difficulty walking
around secondary to the weight, which she attributes to being
able to do that much because of discomfort from the hernia.
Past Medical History:
# HIV/AIDS
- Dx [**2130**]
- last CD4 423, nadir 43
- genotype [**10-21**]
NRTI / NtRTI mutations: 333E
NNRTI mutations: None
PI mutations: 63P
- prior OIs: PCP [**Last Name (NamePattern4) **] [**2132**]
- prior ARVs: Trizivir in [**2135**]
# HCV
- Genotype 2B
- Liver Bx [**5-22**] Grade1-2 inflammation, stage 3 fibrosis
Awaiting enrollment into psychiatric care and stabilization of
depression and substance abuse issues prior to initiation of
care.
# h/o HBV
- cAb positive, sAb positive
# h/o diverticulitis c/b colovaginal fistula [**2136**]
# DM2 on insulin, c/b diabetic neuropathy
# Peripheral neuropathy - thought to be [**2-19**] HIV, prior AZT,
exacerbated by DM
# GERD recent EGD showing esophogitis and OMR stating ? old PUD
# Bipolar/Anxiety
# s/p TAH/BSO
# HTN
# Genital HSV
# Substance abuse
# Chronic pain: on narcotics contract
# ASD on TTE [**12/2140**] w/ minimal shunting on CMR
# OSA - dx on recent sleep study, refuses BiPAP, uses home O2
at night
# Hypothyroidism
Social History:
The patient lives alone in [**Location (un) 14663**]. She is on disability, but
she has a PCA that comes in to help her. She smokes about a half
a pack a day of cigarettes. She occasionally visits her mother
who lives in a retirement home but otherwise has no social
support. Has no partner, no children. Has been married once. Her
last fiance in [**2127**] died two days prior to their wedding, which
was source of severe depression leading to hospitalization. She
has a history of bipolar and anxiety that she reports is severe.
She is not suicidal or homicidal at this time. She used to have
a psychiatrist but does not currently have one. History of drug
abuse most recently in [**Month (only) 404**] with cocaine positive in her
urine in addition to very poor social support.
Family History:
She is adopted but a history of cervical and breast cancer in
family members.
Physical Exam:
Vitals:=99.8,HR=61,BP=154/86,RR==18,sat= 96/4l
Gen:A+Ox3
HEENT;PERRL
CVS:N s1s2
Chest;CTABL
Abd;soft, mildly tender,mildly distended,no rebound/guarding
Ext:NO C/C/E
Wound:C/D/I
Pertinent Results:
[**2144-3-26**] 08:45AM BLOOD WBC-8.5 RBC-4.08* Hgb-12.5 Hct-36.4
MCV-89 MCH-30.6 MCHC-34.2 RDW-14.5 Plt Ct-240
[**2144-3-24**] 07:10AM BLOOD WBC-6.7 RBC-3.78* Hgb-11.1* Hct-35.7*
MCV-94 MCH-29.4 MCHC-31.2 RDW-14.2 Plt Ct-190
[**2144-3-22**] 06:30AM BLOOD WBC-6.7 RBC-3.82* Hgb-11.3* Hct-34.7*
MCV-91 MCH-29.7 MCHC-32.7 RDW-14.0 Plt Ct-181
[**2144-3-26**] 08:45AM BLOOD Neuts-76.3* Lymphs-10.8* Monos-4.0
Eos-8.4* Baso-0.6
[**2144-3-26**] 08:45AM BLOOD Glucose-161* UreaN-9 Creat-0.8 Na-137
K-4.4 Cl-96 HCO3-33* AnGap-12
[**2144-3-23**] 05:00AM BLOOD Glucose-104* UreaN-9 Creat-0.8 Na-142
K-4.8 Cl-101 HCO3-37* AnGap-9
[**2144-3-22**] 06:30AM BLOOD Glucose-195* UreaN-12 Creat-0.8 Na-139
K-4.4 Cl-101 HCO3-35* AnGap-7*
[**2144-3-25**] 06:30AM BLOOD ALT-19 AST-23 LD(LDH)-471* AlkPhos-86
TotBili-1.2
[**2144-3-25**] 06:30AM BLOOD VitB12-420 Folate-12.3
[**2144-3-25**] 06:30AM BLOOD TSH-34*
[**2144-3-26**] 07:15AM BLOOD T4-5.8 T3-92
Brief Hospital Course:
Ms. [**Known lastname 2808**] was taken to the operating room on [**2144-3-20**] for repair
of her incisional hernia. The operation proceeded without
complication. Please refer to Dr. [**Last Name (STitle) 51984**] operative note for
additional details. Her post-op course was dominated with pain
control issues, requiring initial stay in the PACU extending
through the night of POD 0 into POD 1 after which she was
transferred to the surgical ICU for pain management issues. She
was transferred to the floor on POD 3 where she remained for the
duration of her hospitalization.
Pertinents of her hospitalization, by systems:
Neurologically: Pain control continued to be an issue through
the initial portion of her hospital stay. She was followed
closely by the acute pain service - an epidural was placed and
she was started on her regimen of fentanyl
patch/methadone/neurontin. Her epidural was removed on POD 3
without incident and she was transitioned to a dilaudid PCA then
eventually oral dilaudid medication at a rate of [**2-25**] mg PO every
6 hours.
Psych: Ms. [**Known lastname 2808**] was seen by the psychiatry service to assess
for acute delirium on POD 4 after alleged refusal to take
medication and reported uncooperative behavior with her care.
She was deemed not to be delirious with no need for further
testing. She was largely cooperative with her care, without
incident, throughout the rest of her hospitalization.
Cardiovascular: no issues
Respiratory: The patient continued to require 3-4 liters oxygen
via nasal cannula throughout her hospital stay. When oxygen was
removed, her oxygen saturation would lie in the low-mid 90s but
desaturate further upon activity. Based on previous office
visits and per patient history, this was assessed to be baseline
for the patient who has arrangements for home oxygen therapy.
On POD 5, the patient was triggered for an O2 sat in the 70s
after activity on RA. CXR was unremarkable. Her oxygen was
re-continued and she remained without incident for the remainder
of her hospitalization.
GI: Ms. [**Known lastname 2808**] had return of bowel function relatively early in
her hospitalization and was advanced sequentially in diet to a
regular diet on POD 3. She tolerated all advances well without
issue.
GU: Foley cathether was removed at midnight after the epidural
was removed on POD 3. On POD 5, the patient complained of
symptoms of a UTI. UA was positive for UTI and she was started
on a 7 day course of ciprofloxacin.
Endo: Ms. [**Known lastname 51974**] fingersticks were found to be elevated on her
existing sliding scale. Followed by [**Last Name (un) **], they were consulted
on POD 4 for management of her [**Last Name (un) 6801**] and adjusted the scale
accordingly (can be found in the discharge medications).
Additionally, her TSH level was checked and found to be 34. She
reported that she had inadvertently stopped taking the synthroid
approximately a month prior to her admission. She was restarted
on synthroid during this hospitalization.
ID: Ms. [**Known lastname 51974**] antiretrovirals were restarted on POD 2.
Please see GU section re: UTI/ciprofloxacin.
On POD 8, Ms. [**Known lastname 2808**] was afebrile, tolerating oral intake and
was cleared by physical therapy for home with physical therapy
services. She was discharged home with instructions to followup
with Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) **], Dr. [**Last Name (STitle) 51969**] and the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**]
Center.
Medications on Admission:
abacavir-lamivudine 600-300', atazanavir 400', clonazepam 1'',
premarin, fluoxetine 80, gabapentin 900''', hydrocortizone 2.5%
cream rectally'', hydromorphone 2'', glargine 50units qam,
lactulose 12g/15ml - 15-30ml'', levothyroxine 150', metformin
1000'', methadone 20'', nystatin powder, promethazine 25 prh,
ranitidine 150'prn, asa 81', insulin ss
Discharge Medications:
1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for skin changes.
4. methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
8. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed for nausea.
9. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
10. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
11. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q6H (every 6
hours) as needed for pain for 5 days.
Disp:*60 Tablet(s)* Refills:*0*
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: [**2144-3-26**] - [**2144-4-1**].
Disp:*9 Tablet(s)* Refills:*0*
14. insulin lispro 100 unit/mL Solution Sig: One (1) see sliding
scale Subcutaneous see sliding scale: Insulin Sliding Scale as
follows:
Glargine 34 units with breakfast.
Sliding Scale (Humalog):
Breakfast Humalog Scale:
71-100: 4
101-150: 10
151-200: 13
201-250: 15
251-300: 17
301-350: 19
351-400: 22
Lunch Humalog Scale:
71-100: 4
101-150: 8
151-200:10
201-250:12
251-300:14
301-350:16
351-400:18
Dinner Humalog Scale:
71-100: 0
101-150: 4
151-200: 6
201-250: 8
251-300:10
301-350:12
351-400:14
Bedtime Humalog Scale:
71-100: 0
101-150: 0
151-200: 0
201-250: 3
251-300: 5
301-350: 6
351-400: 8
[**Name8 (MD) **] MD for >400.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Incisional hernia
HIV
Hepatitis B
Hepatitis C
Diverticulitis
History intravenous drug abuse
Bipolar disorder
Anxiety disorder
Gastroesophageal reflux disease
Peptic ulcer disease
Morbid obesity
Neuropathy
Thrush
Hypertension
Diabetes mellitus on insulin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a surgical operation called a laparoscopic
incisional hernia repair with mesh to repair your hernia. The
operation went well. You are proceeding well in your recovery.
You developed a urinary tract infection and are being treated
with an antibiotic called ciprofloxacin. Please take this
medication as described on your medication list.
Your oxygen levels were low while in the hospital. It is
important that you continue your existing home oxygen therapy
while at home and until reviewed by your primary care physician.
In the coming days, please be sure to be well rested but also be
sure to ambulate several times a day and be up and out of bed as
much as possible. It is recommended you take at least a short
walk every hour. No heavy lifting of items [**10-31**] pounds for 6
weeks. You may resume moderate exercise at your discretion but
no abdominal exercises.
Wound Care:
You may showerl; no tub baths or swimming. If there is clear
drainage from your incisions, cover with a clean, dry gauze.
Your steri-strips will fall off on their own.
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.
Your insulin sliding scale most recently adjusted by [**Last Name (un) **] is
here for your convenience:
Insulin Sliding Scale as follows:
Glargine 34 units with breakfast.
Sliding Scale (Humalog):
Breakfast Humalog Scale:
71-100: 4
101-150: 10
151-200: 13
201-250: 15
251-300: 17
301-350: 19
351-400: 22
Lunch Humalog Scale:
71-100: 4
101-150: 8
151-200:10
201-250:12
251-300:14
301-350:16
351-400:18
Dinner Humalog Scale:
71-100: 0
101-150: 4
151-200: 6
201-250: 8
251-300:10
301-350:12
351-400:14
Bedtime Humalog Scale:
71-100: 0
101-150: 0
151-200: 0
201-250: 3
251-300: 5
301-350: 6
351-400: 8
Followup Instructions:
You are scheduled to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
Wednesday, [**2144-4-1**] at 9:00 AM.
You are scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in his clinic on
Wednesday, [**2144-4-1**], at 1:00 PM. Phone:[**Telephone/Fax (1) 3201**]
Also, please follow up with Dr. [**Last Name (STitle) 51969**], your PCP, [**Name Initial (NameIs) 176**] 1 week
from your discharge.
Other appointments in the [**Hospital1 18**] system:
Provider: [**Name10 (NameIs) 2341**] [**Last Name (NamePattern4) 2342**], M.D. Phone:[**Telephone/Fax (1) 2343**]
Date/Time:[**2144-7-29**] 1:30
Completed by:[**2144-3-29**]
|
[
"296.80",
"530.81",
"250.60",
"070.70",
"568.0",
"552.21",
"V58.69",
"278.01",
"789.09",
"V85.41",
"042",
"599.0",
"300.00",
"355.8",
"304.03",
"244.9",
"357.2",
"305.1",
"112.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.51",
"53.62"
] |
icd9pcs
|
[
[
[]
]
] |
9766, 9815
|
3939, 7507
|
321, 388
|
10113, 10113
|
2982, 3916
|
12409, 13108
|
2690, 2769
|
7908, 9743
|
9836, 10092
|
7533, 7885
|
10264, 11164
|
2784, 2963
|
264, 283
|
11176, 12386
|
416, 861
|
10128, 10240
|
883, 1875
|
1891, 2674
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,350
| 134,943
|
12583
|
Discharge summary
|
report
|
Admission Date: [**2160-12-10**] Discharge Date: [**2160-12-11**]
Date of Birth: [**2096-12-22**] Sex: F
Service: MICU
CHIEF COMPLAINT: Altered mental status.
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old
woman with Stage III, grade 3 papillary serous ovarian cancer
(status post paclitaxel and carboplatin, Taxotere, Doxil,
monthly Taxol, gemcitabine, and Topotecan weekly x2 cycles),
who has been in the Bahamas in the past two months receiving
immuno-augmentive therapy. Per report, she did relatively
well until [**12-7**], when she developed nausea, vomiting,
diarrhea, and altered mental status, and subsequently fell.
She was ultimately flown back to [**Location (un) 86**] on the day of
admission, and was brought to [**Hospital1 18**] ED, where she was
confused and minimally responsive. She was hypotensive and
started on dopamine. She was hypoxic and intubated for
airway protection as well as hypoxia; she also reportedly had
periods of apnea. A right femoral line was placed.
Levofloxacin and metronidazole were given, CT scans were
obtained, and the patient was transferred to the Fenard
Intensive Care Unit for further management.
PAST MEDICAL HISTORY:
1. Ovarian cancer as above.
2. Hypertension.
3. Diabetes mellitus type 2.
4. Dyslipidemia.
5. Viral encephalitis.
6. Ovarian cystectomy in [**2130**].
7. D&C in [**2127**].
8. Appendectomy.
9. Neck lipoma excision.
ALLERGIES: The patient is allergic to codeine and Morphine.
MEDICATIONS ON ADMISSION: Unknown.
PHYSICAL EXAMINATION: On initial physical examination, the
patient's temperature is 95 degrees, heart rate 115, blood
pressure 71/50, respiratory rate 15, and oxygen saturation of
99% on mechanical ventilator. She was intubated. She had
conjunctival edema, reactive pupils bilaterally. Her heart
rate was tachycardic, there are normal S1, S2 heart sounds,
and there is a 2/6 systolic ejection murmur heard throughout
the precordium. She had bronchial breath sounds at the left
base, otherwise her lungs were clear to auscultation
bilaterally. Her abdomen was firm, distended, there were
hypoactive bowel sounds, and a fluid wave was palpable.
There was 2+ bilateral lower extremity pitting edema. The
extremities were cool and peripheral pulses were barely
palpable. She was moving her extremities purposely, and not
responding to verbal or tactile stimuli. Her skin was cool,
modeled, and clammy.
LABORATORIES: Initial laboratory evaluation demonstrated a
white blood cell count of 16.3 (69% neutrophils, 21% bands,
8% lymphocytes, and 2% monocytes), hematocrit 29.8, and
platelets of 224,000. PT was 17.2, PTT 33.7, and INR of 2.0.
Chemistries demonstrated a sodium of 128, potassium 3.4,
chloride 86, bicarbonate 15, BUN 46, creatinine 1.1, glucose
179, calcium 8.5, magnesium 2.3, and phosphorus 4.8. The
albumin was 2.6. LFTs were normal except for an AST of 63
and an alkaline phosphatase of 143. Urinalysis was negative
for UTI.
ABG on the ventilator was 7.46/28/213.
Diagnostic paracentesis was consistent with spontaneous
bacterial peritonitis; peritoneal fluid Gram stain
demonstrated 2+ polys, but no organisms.
Initial CT scan of the chest, abdomen, and pelvis
demonstrated a large left sided pleural effusion, moderate
right sided pleural effusion, bibasilar compressive
atelectasis, interval enlargement of left sided axillary
nodes, diffuse distention of multiple bowel loops, with the
majority of the small bowel dilated and fluid filled, right
sided colonic distention with air and fluid, ascites, and a
soft tissue mass in the mid-transverse colon leading to
relative decrease in the caliber of the remaining large bowel
with air in the left sided colon and rectum. Overall, there
was significant worsening of omental disease with scalloping
of the liver margin and falciform ligament as well as new
amorphous mass growing into the porta hepatis and compressing
the IVC and portal vein. The pancreas was also found to be
invaded by a large adjacent hypodense mass. Head CT
demonstrated no intracranial hemorrhage or mass effect.
HOSPITAL COURSE: As noted above, the patient was critically
ill at the time of admission. She was found to be in florid
septic shock. She was initially aggressively resuscitated
with multiple pressors to support her blood pressure as well
as broad-spectrum antibiotics for her peritonitis. Nearly
immediately following her transfer to the Intensive Care
Unit, it became clear that the patient's chances of surviving
her acute illness were essentially zero.
After waiting for the patient's close family members to
arrive at the bedside, supportive medical care was withdrawn
on the day following admission. Within 15 minutes of the
withdraw of pressors, the patient became hypotensive and
subsequently asystolic. She was pronounced dead at 8:20 p.m.
on [**2160-12-11**]. The case was declared as nonreportable
by the medical examiner, the admitting officer was notified,
and the death certificate was completed.
DEATH DIAGNOSES:
1. Septic shock.
2. Spontaneous bacterial peritonitis.
3. Hypoxic ventilatory failure.
4. Coagulopathy in the setting of sepsis and DIC.
5. Anemia of chronic inflammation.
6. Blood loss anemia.
7. Hyponatremia.
The remainder of the patient's past medical history as noted
above.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2161-3-13**] 13:42
T: [**2161-3-14**] 05:38
JOB#: [**Job Number 38934**]
|
[
"286.6",
"785.59",
"038.9",
"197.7",
"518.81",
"197.6",
"276.5",
"567.2",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"96.04",
"38.93",
"99.04",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
1509, 1519
|
4106, 5569
|
1542, 4088
|
154, 178
|
207, 1182
|
1204, 1482
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,752
| 198,252
|
24962
|
Discharge summary
|
report
|
Admission Date: [**2167-6-9**] Discharge Date: [**2167-6-11**]
Date of Birth: [**2081-12-18**] Sex: M
Service: MEDICINE
Allergies:
adhesive tape / Latex
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
Endotracheal intubation
ERCP
Right subclavian line placement
Left arterial line placement
History of Present Illness:
PCP: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) 275**] J.
Address: [**Street Address(2) 62723**], [**Hospital1 **],[**Numeric Identifier 27861**]
Phone: [**Telephone/Fax (1) 36175**]
Fax: [**Telephone/Fax (1) 62724**]
The history is obtained from review of OMR and OSH paperwork.
The patient is unable to give a history. I called the patient's
home number [**Telephone/Fax (1) 62725**] and did not get an answer. I was unable
to leave a message.
.
HPI:
85 yoM w/ a h/o aortic valve replacement, cirrhosis c/b varicies
and ascites ?secondary to ETOH use, and DM presented to [**Hospital 1562**]
hospital with rising LFTs. He was hospitalized last week at
[**Hospital 1562**] Hospital with cholangitis and found to have a biliary
obstruction. He was transferred to [**Hospital1 18**] for an ERCP with Dr.
[**Last Name (STitle) 58256**] where he was found to have multiple stones and sludge in
the CBD for which a sphincteroplasty was performed. A double
pigtail stent was placed. He was discharged back to [**Hospital 1562**]
Hospital and then d/c'ed to rehab a few days later. He was then
re-admitted to [**Hospital 1562**] Hospital initially for concerns about
non-dopplable lower extremity pulse but was eventually was
admitted with delirium. Notes document that on [**6-1**] he was A
and O x 3 and able to participate in giving a history. When he
re-presented on [**6-8**] he was unable to participate in giving
a history. He was treated for a UTI with ceftriaxone. He was
found to have a rising bilirubin (16 with dbili = 11) with
abnormal LFTs on [**2167-6-8**]. Per report MRCP there shows a CBD
stone. He is being treated with unasyn. He became more
lethargic and his lacate was 3.7 which was concerning for
sepsis. He is being transferred to [**Hospital1 18**] for repeat ERCP.
.
ROS:
He is able to state that he is in pain but cannot tell me where
or quantify the level.
Otherwise 12 point limited review of systems is negative
secondary to patient's mental status.
Past Medical History:
s/p AAA repair
s/p AV reaplacement
h/o ITP
DM
s/p hip replacement
BPH
Glaucoma
s/p appendectomy
s/p herniorraphy
previous hx of CCY and ERCP in [**2161**] with stent insertion
Social History:
SOCIAL HISTORY/ FUNCTIONAL STATUS:
Per [**Hospital1 1562**] records
After being discharged from [**Hospital 1562**] Hospital on [**6-6**] he was
at rehab. Prior to this admission he lived at home with his
wife with [**Name (NI) 269**] support.His wife was his primary caretaker as he
was blind and deaf. The patient was bedbound due to his severe
R hip pain and had previously transported himself with an
electric walker.
Family History:
The patient could not tell me this given his MS. I was unable to
contact any members of his family.
Physical Exam:
ADMISION PHYSICAL EXAM:
PAIN SCORE- could not be assessed given his mental status. He
states that the does have pain however
VS: T = 96.8, P = 97 BP = 144/81 RR = 26 O2Sat 98% on 2.5L
GENERAL: Elderly male laying in bed. He is tachypneic
Nourishment: OK
Grooming:OK
Mentation: He is somnolent but he does respond when I say his
name.
Eyes:NC/AT, R eye PERRL, L pupil is sluggish. EOMI without
nystagmus, + deep scleral icterus noted
Ears/Nose/Mouth/Throat: dry MM no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Decreased BS at L base
Cardiovascular: irregularly irregular, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
Rectal: Impacted with soft brown stool. Patient disempacted
Genitourinary: + scrotal edema
Skin: stage II decubitus present prior to admission
L foot healed ulcer.
B/l dusky discoloration of both feet
Extremities: 1+ radial, dopplable DP pulses b/l.
Presume R hip pain. He screams in agony when he is turned.
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 1. Unable to relate history
-cranial nerves: II-XII intact
Able to lift his arms and legs off of the bed in response to
commands.
Psychiatric: Delirious
Pertinent Results:
ADMISSION LABS
--------------
[**2167-6-9**] 11:27PM BLOOD WBC-11.4* RBC-4.59* Hgb-14.9 Hct-44.2
MCV-96 MCH-32.6* MCHC-33.8 RDW-17.7* Plt Ct-112*
[**2167-6-9**] 11:27PM BLOOD Neuts-87.8* Lymphs-4.6* Monos-7.3 Eos-0.1
Baso-0.2
[**2167-6-9**] 11:27PM BLOOD PT-19.4* PTT-37.1* INR(PT)-1.8*
[**2167-6-9**] 11:27PM BLOOD Glucose-120* UreaN-24* Creat-1.0 Na-142
K-4.1 Cl-108 HCO3-24 AnGap-14
[**2167-6-9**] 11:27PM BLOOD ALT-64* AST-146* AlkPhos-299* Amylase-24
TotBili-16.3*
[**2167-6-9**] 11:27PM BLOOD Lipase-12
[**2167-6-10**] 09:42AM BLOOD CK-MB-12* MB Indx-4.9 cTropnT-0.02*
[**2167-6-9**] 11:27PM BLOOD Calcium-10.4* Phos-2.2* Mg-2.3
[**2167-6-9**] 11:27PM BLOOD Digoxin-1.0
.
PERTINENT LABS
--------------
[**2167-6-11**] 09:17AM BLOOD PT-46.3* PTT-71.6* INR(PT)-4.9*
[**2167-6-11**] 09:17AM BLOOD Fibrino-81*
[**2167-6-11**] 09:17AM BLOOD FDP-10-40*[**2167-6-11**] 09:17AM BLOOD ALT-311*
AST-1169* LD(LDH)-1291* AlkPhos-247* TotBili-12.3* DirBili-9.4*
IndBili-2.9
[**2167-6-10**] 09:42AM BLOOD Acetmnp-NEG
[**2167-6-11**] 09:17AM BLOOD HCV Ab-NEGATIVE
[**2167-6-11**] 09:17AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE IgM
HAV-NEGATIVE
[**2167-6-11**] 02:52AM BLOOD Lactate-9.8*
[**2167-6-11**] 11:59AM BLOOD freeCa-0.97*
.
MICROBIOLOGY
------------
[**2167-6-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2167-6-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2167-6-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2167-6-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
.
[**2167-6-10**] 8:55 pm URINE Source: Catheter.
**FINAL REPORT [**2167-6-11**]**
URINE CULTURE (Final [**2167-6-11**]): NO GROWTH.
.
[**2167-6-10**] 2:47 pm URINE Source: Catheter.
**FINAL REPORT [**2167-6-12**]**
URINE CULTURE (Final [**2167-6-12**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
.
IMAGING
-------
Chest X-ray on admission:
Patient is currently in severe pulmonary edema associated with
bilateral
pleural effusions. Underlying infectious process cannot be
excluded, in
particular in the left lung. The patient is after replaced
valve, most likely aortic. Sternotomy wires are unremarkable.
Bilateral effusions are noted. No appreciable pneumothorax is
seen. ]
.
Liver/gallbladder ultrasound on admission:
IMPRESSION: Moderate ascites and right pleural effusion. Portal
vein is
patent and shows hepatopetal flow.
.
TTE [**2167-6-10**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. A bioprosthetic aortic valve prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
IMPRESSION: Small and hypertrophied left ventricle with normal
global systolic function. Normally-functionine aortic valve
bioprosthesis. Mild pulmonary hypertension.
Technically-difficult study.
.
Chest X-ray [**6-11**]:
FINDINGS: As compared to the previous radiograph, the patient
has been
intubated. The tip of the endotracheal tube projects 6.2 cm
above the carina. The patient also has received a right central
venous access line. The tip of the line projects over the mid
SVC. There is no evidence of complications, notably no
pneumothorax. Normal size of the cardiac silhouette. Presence of
small right pleural effusion cannot be excluded. On today's
image, the pre-existing parenchymal opacities already visible on
the previous image are predominating in the left and right lung
apices. Status post sternotomy.
Brief Hospital Course:
The patient is an 85 year old male with cirrhosis, s/p aortic
valve replacement, DM who was recently admitted with cholangitis
s/p ERCP with sphincterotomy, sludge removal, pigtail catether
placement now readmitted to OSH with delirium and elevated LFTs.
.
#. Multifactorial shock-like state: patient had cholangitis,
which progressed to florid septic shock following ERCP. He was
also profoundly hypovolemic with noted anion gap metabolic
acidosis. He required emergent intubation, aggressive fluid
resuscitation with central venous line placement, multiple
pressors, and broad-spectrum antibiotic therapy. Despite these
measures, patient continued to decline, progressing to DIC and
acute liver failure. After discussion with his family, he was
made DNR/DNI, and then focus was placed on comfort measures,
upon which he expired shortly after implementation.
.
# Toxic-metabolic encephalopathy: etiology was probably
multifactorial in etiology including infection and hepatic
encephalopathy, but could also have included medication effects,
hip pain, hospitalization, and constipation. Patient progressed
to septic shock and expired soon after being admitted to [**Hospital1 18**].
.
# Cholangitis/Elevated LFTS: patient presented with abnormal
LFTs, abdominal pain in the right upper quadrant and jaundice,
and was believed to have cholangitis. He was treated initially
with ampicillin/sulbactam, and then switched to broad spectrum
antibiotic therapy after progressing to septic shock. Patient
rapidly progressed to acute liver failure, and ultimately
expired due to the constellation of these findings.
# Atrial fibrillation: patient was continued on his home
digoxin, and a level was checked and found to be normal. His
metoprolol was held given his shock-like state.
.
# Diabetes mellitus: patient was maintained on sliding scale
insulin during his stay.
.
# S/p aortic valve replacement: patient presented without
anticoagulation treatment.
.
# Disposition: patient ultimately expired due to his shock-like
state
Medications on Admission:
Medications prior to admission:
Digoxin 0.125 mg po qod
Lantus 5 U qd
Lasix 20 mg po qd
Lidocaine patch to R hip
Omeprazole 20 mg po qd
Spironolactone 25 mg po qd
ASA 81 mg po qd
Celebrex 100 mg po qd prn pain
Doxycycline 100 mg po qd
Toprol 12.5 mg po qhs
Augmentin 875/125 mg po bid
Ultram 100 po tid
Medications on Transfer:
Spironolactone 25 mg q 10 am on hold
Dextrose 12.5 gm IV push as needed
Doxycycline 100 mg qd last given [**2167-6-9**] am
Lispro SSI
Lactulose 30 cc [**Hospital1 **] - not given due to loose stool.
Digoxin 0.125 mg qod
Lantus 5U daily ON HOLD
Lasxi 20 mg q 10 am ON HOLD
Lidoderm patch to R hip
Maalox 30 cc qid prn
Oxygen at 2.5 L
Ocean spray q hr as needed
Protonix 40 mg daily [**2167-6-9**] am
Albuterol nebs q 2 hrs prn
Artificial tears 2 drops q hour prn
Toprol 12.5 mg qhs - last given pm of [**2167-6-8**]
Ultram 100 mg tid
Unasyn 3 gm q 6 hours last given [**6-9**] at 1800
Vitamin K 10 mg today at 10:00 am
Zofran prn
Discharge Medications:
Patient expired during stay
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,707
| 175,050
|
40398
|
Discharge summary
|
report
|
Admission Date: [**2170-5-18**] Discharge Date: [**2170-5-30**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lasix / Diazoxide /
hydrochlorothiazide / tripranavir / Probenecid
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Fever and altered mental status
Major Surgical or Invasive Procedure:
Removal of right IJ line
History of Present Illness:
88 yo F with PAF, dementia, CHF, stage 4 sacral decub, IDDM, and
other medical issues went to OSH from nursing home with fever
and altered mental status today. She vomited 1x prior to
transfer to OSH, tachypneic with O2Sat down to 82% on 3L
(baseline 2L since [**Month (only) **]). It was thought she has a UTI and PNA
on CXR (bilateral increased reticular nodular interstitial
markings R>L). She became hypotensive with SBP in the 80s, but
there was no unit bed in the OSH. She was noted to fever up to
102.6F and tachycardia up to 130s. She received Zosyn and 2L
IVF with requirments of 4L O2 (on home oxygen). She was
transferred to [**Hospital1 18**].
.
Per HCP/son, patient has had 3 TIAs around [**Month (only) **] this year with
minimal residual deficit, although there is ? of left sided
weakness and swallowing problem. Since that time, a sacral
decubitus wound was noted and begin to get treated in [**Hospital **] rehab.
Her wound was debrided at [**Last Name (un) 27217**] in the beginning of [**Month (only) 958**]
with several days of ICU stay. Per family, she had + culture of
a very resistant bacteria that is not MRSA. She required 2 IV
antibiotics. Later, she was transferred to [**Hospital1 **] North for
long term care for her wound for a total of about 6 weeks. She
had wound vac and Foley catheter which is c/b frequent UTIs.
Later, she was transferred to Country Rehab, initially wound was
healing well, but found to have necrotic tissue, requiring
debridement again in [**Month (only) 116**]. Patient's mental status since [**Month (only) 116**] has
gradually deteriorated. She was able to meet with a lawyer to
work on her living will in the beginning of [**Month (only) 116**], but over the
last week, was confused about her name and her location.
.
On transfer, she got a 3rd L of IVF with improvement of SBP to
the 100s
.
In the ED, she was noted to be afebrile at 97.2, sinus
tachycardia up to 120s with BP 95/70, RR 30 on 94% 4L. Exam was
significant for sacral decubitus ulcer 10 cm with granulation
tissue on outer circumfirential segment with central necrotic
area. She was noted to have leukocytosis up to 32 and mildly
elevated LFTs. Coagulatons were normal. Lactate...after 3L
normalized. CXR suggests interstitial and alveolar process.
Per report, she received vancomycin and Flagyl, for concern of
C. diff given leukocytosis, diarrhea, and recent Abx. However,
only flagyl was noted on ED chart. SBP improved to 100 after 3L
IVF, but then dropped again to the 80s, so Levophed was started
through PIV first. She got RIJ CVL. CVP improved from 5-> [**7-27**]
after 4L, SvO2 90s. Prior to transfer, T 97.6 (temporal), 98
NSR, BP 102/62 (72), RR 27, O2Sat 97% 4L on 0.05 mcg/kg/min
norepinephrine.
.
On the floor, patient reports not feeling very well, threw up 1x
this morning and has been having diarrhea but could not tell
when it started. Denies pain currently.
Past Medical History:
- PAF
- IDDM
- dementia
- h/o TIAs/CVA [**1-/2170**] without deficit
- stage 4 sacral decub
- h/o cellulitis
- osteomyelitis- rx with ertapenem 1g IV qd and daptomycin 440
mg iv qd (to be complete on [**4-14**] per note from [**Hospital 27217**]
Hospital)
- hypothyroidism
- CAD
- HTN
- CHF, per report, normal EF 70% in [**Hospital3 **] ([**First Name8 (NamePattern2) **] [**Hospital 27217**]
Hospital note)
- spinal stenosis
- hypercholesterolemia
- osteoarthritis
- BPPV
- h/o duodenal ulcer with bleed [**1-/2170**]
- h/o gallstones
- h/o bile duct obstruction
- parotid gland mass
- s/p bilateral total hip replacements
- s/p TAH
Social History:
- lived independently prior to TIAs in 2/[**2169**]. Per report, was
working part-time and driving until then.
- never smoked
- rare EtOH
- no drugs
Family History:
- non-contributory
Physical Exam:
VITAL SIGNS - BP 128/65 mmHg, HR 92 BPM, RR 19, O2-sat 98% on 4L
GENERAL - lying on the right, appropriate, pale skin
HEENT - PERRLA, mucous membrane dry, OP clear
NECK - supple, no JVD, RIJ in place
LUNGS - dependent crackles on the right and diminished lung
sound, clearer on the left but + crackles, no wheeze or rhonchi,
no accessory muscle use
HEART - borderline tachycardia, unable to appreciate any m/r/g
ABDOMEN - soft, diminished bowel sound, non-distended, but
diffused tenderness, no mass, no HSM, no rebound
EXTREMITIES - warm, dry, no cyanosis/clubbing/edema, 2+ DP and
radial pulses bilaterally
SKIN - deep ulcerated area in the sacrum, tendon/bone are
visible, no purulent drainage
NEURO - alert, awake, oriented to [**Last Name (LF) 86**], [**2170-5-17**], CNs
II-XII grossly intact,
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation. Non
papilledema on fundoscopic exam. Extraocular movements intact
bilaterally, no nystagmus. Sensation intact V1- V3. Facial
movement symmetric. Hearing decreased to finger rub bilaterally,
L>R.
Palate elevation symmetrical. Sternocleidomastoid and trapezius
normal bilaterally. Tongue midline, movements intact.
Pertinent Results:
1. Labs on admission:
[**2170-5-18**] 08:43AM BLOOD WBC-32.0* RBC-4.81 Hgb-13.8 Hct-41.0
MCV-85 MCH-28.7 MCHC-33.7 RDW-16.4* Plt Ct-299
[**2170-5-18**] 08:43AM BLOOD Neuts-91* Bands-2 Lymphs-6* Monos-0 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2170-5-18**] 08:43AM BLOOD PT-12.4 PTT-27.2 INR(PT)-1.0
[**2170-5-18**] 08:43AM BLOOD Glucose-205* UreaN-32* Creat-0.8 Na-134
K-4.8 Cl-99 HCO3-21* AnGap-19
[**2170-5-18**] 08:43AM BLOOD ALT-32 AST-56* LD(LDH)-251* AlkPhos-131*
TotBili-0.4
[**2170-5-18**] 08:43AM BLOOD Lipase-17
[**2170-5-19**] 03:25AM BLOOD proBNP-[**2112**]*
[**2170-5-18**] 08:43AM BLOOD Albumin-2.4* Calcium-8.5 Phos-3.1 Mg-1.5*
[**2170-5-18**] 08:43AM BLOOD CRP-193.6*
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2170-5-30**] 06:25 9.0 3.86* 10.8* 32.7* 85 27.9 32.9 16.4* 369
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2170-5-30**] 06:25 [**Telephone/Fax (2) 88563**] 3.7 95* 38* 11
.
DIscharge labs:
**** MICROBIOLOGY ****
[**2170-5-22**] 3:14 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2170-5-25**]**
Respiratory Viral Culture (Final [**2170-5-25**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2170-5-23**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
.
[**2170-5-18**] 8:50 am BLOOD CULTURE SETS #1 and #2.
**FINAL REPORT [**2170-5-21**]**
Blood Culture, Routine (Final [**2170-5-21**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final [**2170-5-19**]):
Reported to and read back by DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2170-5-19**] AT
0520.
GRAM POSITIVE COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2170-5-19**]):
GRAM POSITIVE COCCI IN CLUSTERS.
.
MRSA screen positive ([**2170-5-18**])
Urine culture negative ([**2170-5-18**])
Blood cultures negative on [**2170-5-19**], NGTD on [**2170-5-20**]
Urine legionella negative ([**2170-5-18**])
C diff toxin negative ([**2170-5-21**])and [**2170-5-27**]
.
[**2170-5-20**] 6:46 pm SWAB Source: decubitus ulcer.
**FINAL REPORT [**2170-5-23**]**
GRAM STAIN (Final [**2170-5-21**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2170-5-23**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
.
**** IMAGING ****
CXR ([**2170-5-19**]): In comparison with the study of [**6-17**], there are
lower lung volumes. Continued enlargement of the cardiac
silhouette with pulmonary vascular congestion. The possibility
of supervening pneumonia in the right perihilar or the left
lower lung zone would have to be considered in the appropriate
clinical setting. Marked displacement of the lower cervical
trachea to the right wrist is consistent with a large thyroid
mass.
.
Abdomen plain film ([**2170-5-18**]): No previous images. Bowel gas
pattern is essentially within normal limits with no evidence of
obstruction. Ill-defined opacification in the left upper zone
could conceivably lie within the upper pole of the kidney. Of
incidental note are total hip arthroplasties bilaterally.
.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2170-5-21**] 1:13 PM
OSSEOUS STRUCTURES: The patient is status post bilateral total
hip
arthroplasties. No lytic or sclerotic focus concerning for
osseous malignant process is seen. Mild degenerative changes are
noted in the lumbar spine. Mild height loss is seen in the T9
vertebral body which is likely chronic, direct comparisons are
not available. Sacral decubitus ulcer is noted with loss of
tissue along the midline overlying the coccyx.
.
IMPRESSION:
1. Sacral decubitus ulcer with soft tissue thickening/fluid in
the presacral space.
2. Small hiatal hernia.
3. Diverticulosis without evidence of diverticulitis.
.
CT chest w/o contrast [**2170-5-21**]:
1. Cardiomegaly, with extensive coronary vascular calcification,
in conjunction with bilateral pleural effusions and diffuse
interstitial and bronchovascular thickening, all likely
reflecting congestive failure with hydrostatic edema. This
proces is asymmetrically worse on the right, which may reflect
asymmetric pulmonary edema or superimposed pneumonia. In the
absence of more remote radiographs or CT scans for comparison,
follow up radiographs are recommended to ensure resolution. If
this process fails to clear, dedicated HRCT may be helpful to
exclude progressive lung diseases such as chronic interstitial
fibrosis or lymphangitic carcinomatosis.
2. Numerous prominent mediastinal and hilar lymph nodes, most
likely reactive.
3. Large peripherally calcified hypoattenuating left thyroid
nodule.
.
TTE (Complete) Done [**2170-5-21**] at 2:32:50 PM
The left atrium is mildly 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%). 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. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is severe
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
.
MRI PELVIS W/O CONTRAST Study Date of [**2170-5-24**] 8:52 PM
MPRESSION:
1. Markedly limited evaluation secondary to patient motion.
2. Edema of the inferior sacrum and coccyx. Per discussion with
the
referring physician, [**Name10 (NameIs) **] ulcer probes to bone and the findings
are concerning for osteomyelitis. Unchanged large amount of
presacral edema.
.
CHEST (PORTABLE AP) Study Date of [**2170-5-24**] 11:20 AM
IMPRESSION: Marked improvement of congestive pattern, not
completely
eliminated, no new discrete pulmonary processes.
Brief Hospital Course:
88 yo F with diabetes, chronic stage 4 sacral decubitus,
osteomyelitis, dementia, CHF, and other medical issues found to
have fever and AMS, admitted to [**Hospital Unit Name 153**] for unstable hemodynamics.
.
#. Septic Shock, bacteremia: On admission, patient had high
fevers, hypotension (SBP 80s), tachycardia, and altered mental
status. Source was thought to be most likely sacral decubitus
wound [**Hospital Unit Name 2**] and pneumonia. UA was underwhelming. History of
diarrhea and high leukocytosis was concerning for C. Diff.
Patient initially treated with linezolid + meropenem (history of
VRE wound [**Hospital Unit Name 2**]) and IV flagyl + po vancomcyin. The latter
two were stopped after patient had no diarrhea, and C diff toxin
was negative. CXR was concerning for pulmonary edema but could
not exclude pneumonia. KUB negative for bowel obstruction.
Patient was on Levophed very transiently but then was
hemodynamically for the remainder of the ICU stay. Mental status
improved and was at baseline per family. After sepsis, she was
treated for pneumonia, bacteremia, and soft tissue [**Hospital Unit Name 2**]
with linezolid (given history of VRE) and meropenem. Linezolid
was later changed to vancomycin, given that VRE was not highly
suspected, and she remained stable on vancomycin and meropenem.
She should remain on these for AT LEAST of 14 days (not to be
stopped prior to ID appointment on [**2170-6-14**]), to treat presumed
deep soft tissue [**Date Range 2**]. Osteomyelitis could not be ruled in,
but she will be followed as an outpatient to determine whether a
longer course should be warranted.
.
#. Dyspnea, hypoxemia-acute diastolic heart failure- Per family,
patient did not have oxygen requirement prior to her stroke in
[**1-26**] and subsequent rehab/hospital stays. Initially on 4L but
weaned to 2-3 liters prior to transfer to floor. TTE from OSH
showed LVEF >70% (1+MR). However her chest imaging, including CT
was consistent with volume overload. TTE was repeated with
normal EF, but it was thought that she was in acute on chronic
diastolic heart failure. Her oxygen requirements improved during
diuresis. Pneumonia was also considered, but this was broadly
treated by her antibiotics above. She did not produce any sputum
for culture, and her respiratory viral culture and screen were
negative. Of note, there was some question that she may have
developing ILD, given that she had no O2 requirement prior to
her recent hospitalization and rehab months ago. CT showed no
evidence of ILD, but the proper study would be a HRCT. On
discharge her oxygen requirement was weaned to 2.2L. Her
clinical exam was consistent with improved but some residual
pulmonary edema plus likely dependent atelectasis, given
crackles only in lower midlungs. She was encouraged to use
incentive spirometry. Pt should continue diuresis with a goal of
-500 to 1L daily until oxygen is able to be titrated to off. Pt
diureses well to 20mg IV. Weight on discharge bed scale
145.4lbs.
.
#. Stage 4 decubitus wound, question of osteomyelitis: Tendon
and bone are visible by visual exam. Likely has chronic
osteomyelitis given depth of her wound and by history. Routine
wound care provided. Albumin low at 2.4 which inhibits wound
healing. Patient was advanced to soft diet once mental status
improved; nutritional supplements were added to promote wound
healing. Her sacral wound area was evaluated by both CT and MRI.
Both showed some soft tissue swelling, but no drainable fluid
collection. MRI showed marrow edema, which could be consistent
with osteomyelitis, but this was uninformative given previous
osteomyelitis. Bone biopsy was considered later in her
hospitalization, but it was thought that the risks of the
procedure did not outweight the diagnostic yield, given that she
was on antibiotics. Although our wound culture did not grow
much; we obtained outside hospital records when she first
presented, which showed abundant MRSA and abundant fecal flora.
See above for antibiotic regimen. She received pain control,
including tylenol and prn oxycodone. Near discharge, a wound
vacuum was initiated to improve healing. Further wound care can
be continued at rehab facility. ESR 89, CRP 27.1
.
#. Diabetes mellitus: Metformin was held and patient placed on
insulin sliding scale. Long-standing insulin was also started
for basal control. Pt may resume her home metformin therapy upon
discharge as well as continue glargine and insulin sliding scale
if needed.
.
#. Tachycardia: She had persistent sinus tachycardia following
her ICU stay. This improved and resolved.
.
#. Hypothyroidism: Continued on home levothyroxine.
.
#. Normocytic anemia was likely due to acute on chronic illness.
It was stable on monitoring, and her stools were guaiac
negative.
.
#. History of TIA with PAF: She was continued on aspirin. She
can consider restarting coumadin as outpt (was apparently d/c'd
in setting of hip surgery [**9-29**] y/a). She was started on
metoprolol 6.25mg [**Hospital1 **] to improve rate control and hopeful
improve diastolic heart failure.
.
#. History of GERD/PUD: Continued [**Hospital1 **] PPI.
.
#. HTN, benign: Her antihypertensives were held given her recent
septic episode. Given afib metoprolol 6.25mg [**Hospital1 **] was slowly
initiated. This can be further uptitrated as needed to ensure
good rate control. HR in 90's-100's during admission. BP
~systolic 100's.
.
#. CAD/HL: Unclear history. Continued asa/statin.
.
#INCIDENTAL RADIOGRAPHIC FINDINGS: PT WAS NOTED TO HAVE EVIDENCE
OF A POSSIBLE THYROID MASS ON CXR. THIS CAN BE FOLLOWED UP WITH
ULTRASOUND IN THE OUTPATIENT SETTING.
.
#CHEST CT SCAN-RECOMMENDS REPEAT EXAMINATION TO EVALUATE FOR
IMPROVEMENT IN ABOVE PROCESSES. ALSO HRCT SHOULD BE CONSIDERED
TO RULE OUT INTERSTITIAL LUNG DISEASE AND TO EVALUATE
LYMPHADENOPATHY.
.
.
Medications on Admission:
- Novolin R SS
- Aspirin 325 mg PO Daily
- Florastor 250 mg PO BID
- Simvastatin 20 mg PO Daily QHS
- MVI
- acidophilus 1 tab daily
- vitamin D 1000 units daily
- Tumbs 2 tabs daily
- Vitamin C 500 mg [**Hospital1 **]
- lansoprazole 30 mg [**Hospital1 **]
- metformin 500 mg [**Hospital1 **]
- heparin sq
- synthroid 112 daily
- fentanyl patch 25 mcg/hr patch q72 hr
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
5. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours): CONTINUE UNTIL INSTRUCTED TO
STOP BY ID. Until at least [**6-14**].
6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
13. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
15. insulin
10 units of glargine daily with humalog insulin sliding scale.
Please see attached.
16. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
17. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): CONTINUE UNTIL INSTRUCTED TO
STOP BY ID. Until at least [**6-14**].
18. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
19. furosemide 10 mg/mL Solution Sig: 20-40 mg Injection once a
day: to achieve daily fluid balance -500 to 1L.
20. Outpatient Lab Work
please check vancomycin trough on [**5-31**]. Please check weekly CBC,
LFTs, chemistries while on antibiotic therapy.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directedto the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
.
Daily chemistries while being diuresed
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
septic shock
hypoxia
stage 4 sacral decubitus ulcer
coagulase negative staphylococcus bacteremia
soft tissue [**Location (un) 2**]
acute on chronic diastolic heart failure
pneumonia
Discharge Condition:
Mental status: clear, coherent
Level of consciousness: alert, oriented to place, year, and
month
Activity status:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with fever and confusion and found to have
sepsis (a severe [**Location (un) 2**] in your blood). For this, you were
initially in the ICU, but then improved and were transferred to
the regular medical floor. You were given antibiotics for this
[**Location (un) 2**] and should continue this antibiotics until instructed
to stop by the infectious disease doctors. [**First Name (Titles) **] [**Last Name (Titles) 2**] was
likely due to your sacral wound.
In addition, you were noted to have heart failure (extra fluid
in your lungs). For this, you were given a "water pill" (lasix)
in order to remove extra fluid. You will continue his medication
while at rehab.
.
Medication changes:
1.Antibiotics-continue vancomycin and meropenem for AT LEAST a 2
week course. Do not stop until instructed by ID. Your
appointment is on [**2170-6-14**].
2.IV lasix 20-40mg daily to achieve -500 to 1L daily fluid
balance.
3.metoprolol started for heart rate.
.
Please talk to you doctors about the need for a thyroid
ultrasound and need for repeat chest ct scan.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 32949**] to
schedule a follow up appointment after discharge from your rehab
facility.
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2170-6-14**] at 1:30 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"427.89",
"428.0",
"272.4",
"V02.54",
"414.01",
"V12.54",
"285.29",
"486",
"707.24",
"730.18",
"995.92",
"428.33",
"786.09",
"530.81",
"250.00",
"780.97",
"273.8",
"427.31",
"707.03",
"038.12",
"785.52",
"V49.86",
"558.9",
"244.9",
"401.1",
"240.9",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
21459, 21533
|
13006, 18837
|
339, 365
|
21759, 21759
|
5454, 5462
|
23158, 23706
|
4162, 4182
|
19254, 21436
|
21554, 21738
|
18863, 19231
|
21974, 22656
|
6421, 12983
|
4197, 4997
|
22676, 23135
|
268, 301
|
393, 3320
|
5013, 5435
|
5476, 6404
|
21774, 21950
|
3342, 3979
|
3995, 4146
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,152
| 194,709
|
46935
|
Discharge summary
|
report
|
Admission Date: [**2167-11-8**] Discharge Date: [**2167-11-13**]
Date of Birth: Sex:
Service:
CHIEF COMPLAINT: Ventricular tachycardia.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old
female with a history of coronary artery disease, status post
questionable myocardial infarction five years ago; peripheral
vascular disease, status post right femoral, anterior tibial
and left femoral popliteal bypass on [**10-19**] and [**10-26**]
respectively here at [**Hospital1 69**].
She was transferred to a rehabilitation on [**2167-11-4**], where she
was noted to become unresponsive at hemodialysis
rehabilitation on Friday, [**2167-11-6**]. CPR was administered at
that time. There was a questionable rhythm and vitals. The
patient notes feeling sleepy when she had loss of
consciousness but no chest pain, shortness of breath or
diaphoresis.
Mental status returned to baseline after CPR and the patient
was taken to an outside hospital. An electrocardiogram was
normal. Troponin were negative. Hematocrit was 25. The
patient was transfused one unit of packed red blood cells.
Again today, on [**2167-11-8**], in the morning, the patient had one
episode of monomorphic ventricular tachycardia with no
symptoms, no light headedness, no loss of consciousness, no
chest pain, no shortness of breath. The patient was bolused
with Lidocaine and noted to have no further ectopy on
Lidocaine. The patient was transferred to [**Hospital1 346**] for close monitoring.
Here, the patient did not complain of any shortness of breath
or light headedness.
PAST MEDICAL HISTORY: Peripheral vascular disease. Status
post left femoral popliteal bypass, [**2167-10-26**]. Status post
right femoral proximal anterior tibial bypass, [**2167-10-19**],
complicated by Methicillin resistant Staphylococcus aureus,
gangrene and Clostridium difficile colitis. ESRD, secondary
to noninsulin dependent diabetes mellitus. She is status
post renal transplant in [**2160**] which failed and is back on
hemodialysis. Cerebrovascular accident and toxic
encephalopathy. History of upper gastrointestinal bleed,
lower gastrointestinal bleed. Asthma. Insulin dependent
diabetes mellitus. History of deep vein thrombosis with an
inferior vena cava filter. History of esophageal stricture,
status post dilatation. Positive Clostridium difficile.
Positive Methicillin resistant Staphylococcus aureus.
Glaucoma. Questionable myocardial infarction five years ago.
MEDICATIONS AT REHABILITATION:
Lanasalid 600 mg twice a day.
Flagyl 500 mg twice a day.
Levaquin 250 mg q.o.d.
Prednisone 7.5 q. day.
Neurontin 100 mg three times a day.
Nifedipine 30 q. day.
Lopressor 50 three times a day.
Protonic 40 q. day.
Lentis 12 units and regular insulin sliding scale.
Dilaudid prn.
ALLERGIES: Vancomycin, Enalapril or ace inhibitors and
Prazosin.
SOCIAL HISTORY: The patient lives with her husband in
[**Name (NI) **] Port. No tobacco, no alcohol, former R.N.
PHYSICAL EXAMINATION: On admission, the patient was
afebrile; blood pressure was 134/92; heart rate 82;
respiratory rate 16; saturating 95% on room air. In general,
she is well appearing, African-American female, with slight
anxiety. HEAD, EYES, EARS, NOSE AND THROAT: Pupils are
equal, round, and reactive to light and accommodation.
Oropharynx clear. Mucous membranes moist. Neck: Left
internal jugular TLC; site of CDI; no JVP. Chest: Clear to
auscultation anteriorly. Cardiovascular: S1 and S2 normal.
No murmurs, gallops or rubs. Regular rate. Abdomen: Soft,
nontender, nondistended, positive bowel sounds. Extremities:
Left lower extremity with staples clean, dry and intact.
Left toe amputated. Right lower extremity: Necrotic second
through fifth toes, no pulses. Neurology: Awake, alert and
oriented times three.
LABORATORY DATA: Potassium of 3.6; creatinine 3.1, baseline
being 2.9 to 3.3. Albumin was 2.1. CBC was stable.
Electrocardiogram showed sinus tachycardia at 102. Left
ventricular hypertrophy with a strained pattern and left axis
with Q's in 2, 3 and poor R progression.
HOSPITAL COURSE: 1.) Cardiovascular issues: Ventricular
tachycardia. The patient's enzymes were cycled times three
and were negative for any ischemic changes. The patient also
did not complain of any chest pain throughout this
hospitalization. The patient had a cardiac catheterization
during this admission for questionable ischemic cause of her
ventricular tachycardia which revealed two vessel coronary
artery disease with her proximal right coronary artery
diffusely diseased, mid right coronary artery 100% stenosed,
proximal left anterior descending 30%, distal circumflex
100%, obtuse marginal one 70%, with an elevated LVEDP of 16.
However, no intervention was performed, secondary to
difficulty of access for her right radial. Her groin was not
accessed secondary to her peripheral vascular disease and
recent femoral-popliteal and proximal anterior tibial
bypasses. However, it was felt that her coronary artery
disease was not responsible to cause her sustained
monomorphic VT episode at the outside hospital. EP
was consulted and they felt that optimally, they would prefer
an EP study and possible ventricular tachycardia ablation;
however, her present vascular access issues precluded any
studies. Therefore, the decision was made to start her on
Amiodarone 400 mg twice a day for seven days and then 400 q.
day for a month and then 200 mg q. day thereafter. The
patient will also be discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor
for daily transmission. Finally, the patient is to follow-up
with Dr. [**Last Name (STitle) 1911**] in one to three months.
Additionally, for cardiac issues, an echocardiogram was
performed in the hospital. Her ejection fraction was greater
than 65%. She showed patterns of hypertrophic non
obstructive cardiomyopathy with the left atrium mildly
dilated and severe symmetric left ventricular hypertrophy.
Additionally, the patient was initially placed on a Lidocaine
drip which was discontinued on hospital day number one. The
patient had a few episodes of non sustained monomorphic
ventricular tachycardia throughout the hospitalization,
without the Lidocaine drip. The patient again will be
closely followed by Dr. [**Last Name (STitle) 1911**] and with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts
monitor, with daily transmissions. The patient was continued
on aspirin, a statin, and increasing doses of her beta
blocker throughout this hospitalization.
2.) Peripheral vascular disease: The patient is status post
left femoral popliteal bypass and right femoral proximal
anterior tibial bypass. Vascular surgery was following her
throughout this hospitalization and recommended to continue
her antibiotics, including Linezolid, Flagyl and Levofloxacin
for two weeks. Levofloxacin was discontinued and Ceftriaxone
was started in place because of a risk of prolonged QT
interval, predisposing her to more ventricular tachycardia.
Therefore, on discharge, the patient has another seven days
of Linezolid, Flagyl and Keflex to finish. Vascular surgery
recommended not accessing any groin grafts at this time, due
to recent bypass surgery.
3.) Renal: The patient is status post failed renal
transplant on hemodialysis. The renal team was consulted and
the patient was dialyzed every Tuesday, Thursday and
Saturday. Additionally, Prednisone was continued 7.5 mg q.
day for failed renal transplant.
4.) Hematology: The patient has anemia of chronic disease.
The patient will be started on Erythropoietin three times a
week only during her dialysis sessions.
5.) Insulin dependent diabetes mellitus: The patient was
originally on Lentis 14 units q h.s. However, due to
increasing sugar levels, her Lentis was increased from 14 to
16, with adequate blood sugar levels. The patient will need
to be closely followed for insulin dependent diabetes
mellitus as an outpatient.
6.) Gastrointestinal: The patient has a history of
gastrointestinal bleeds. The patient had several hematocrits
throughout this hospitalization. Protonic was continued.
7.) Prophylaxis: The patient was kept on Methicillin
resistant Staphylococcus aureus and Clostridium difficile
precautions throughout this hospitalization. Additionally,
the patient was kept full code throughout this
hospitalization.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient will be discharged to
rehabilitation.
DISCHARGE DIAGNOSES:
Ventricular tachycardia.
Atherosclerosis.
Chronic renal failure.
Coronary artery disease.
DISCHARGE MEDICATIONS:
Aspirin 325 mg a day.
Lanasalid 600 mg every 12 hours for seven days.
Flagyl 500 mg p.o. twice a day for seven days.
Prednisone 7.5 mg p.o. q. day.
Gabapentin 100 mg p.o. three times a day.
Pantoprazole 40 mg p.o. q. day.
Tylenol 325 one to two tablets p.o. every four to six hours
prn.
Maalox prn.
Nephro-caps, one tablet p.o. q. day.
Ferrous gluconate 300 mg p.o. q. day.
Atorvistatin 10 mg p.o. q. day.
Metoprolol 100 mg p.o. twice a day.
Amiodarone 400 mg twice a day for one week; then 400 mg q.
day times one month and then 200 mg q. day.
Glargine 14 units q h.s.
Cephalexin 500 mg p.o. q. day times seven days.
Erythropoietin alpha 15,000 units three times a week, only
during dialysis.
FOLLOW-UP PLANS:
The patient is to follow-up with Dr. [**Last Name (STitle) 1911**] on [**2167-12-21**]
at 3:30 p.m.
The patient is also to follow-up with her primary care
physician within one to two weeks.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-932
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2167-11-12**] 02:28
T: [**2167-11-12**] 04:23
JOB#: [**Job Number 99561**]
|
[
"250.40",
"585",
"285.9",
"414.01",
"440.24",
"427.1",
"530.81",
"425.1",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"37.22",
"38.95",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8544, 8635
|
8658, 9354
|
4112, 8419
|
3002, 4094
|
9371, 9770
|
142, 168
|
197, 1591
|
1614, 2863
|
2880, 2979
|
8444, 8523
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,453
| 108,076
|
51266
|
Discharge summary
|
report
|
Admission Date: [**2104-6-22**] Discharge Date: [**2104-7-4**]
Date of Birth: [**2031-12-1**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Trileptal / Dilantin / Depakote / Soma
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
blood transfusions
History of Present Illness:
72 y/o female s/p recent elective cardiac cath on [**6-17**] where she
underwent stent to RCA. She was noted to have episodes of
bradycardia and hypotesion in the lab and was eventually
admitted to the CCU. She was discharged to Heb. Rehab and was
noted to have decreased Hct and hypotension in concert with dark
stools. She reportedly had a massive bowel movement and
developed hypotension. She currently denies chest pain, although
has some shortness of breath. She denies abdominal pain or
dysuria.
In the emergency room, noted to have a Hct of 22.3 (down from
30) was NG lavage negative and WBC of 31.9. She was also noted
to have ST depressions in 2,3,V4-V6 with a troponin of .13 (no
prior value)
Past Medical History:
1. COPD
2. Anxiety
3. Depression
4. Bilat carpal tunnel s/p release
5. seizure d/o
6. hiatal hernia
7. left radical mastectomy
8. D&C
9. GERD(?)
10. vertigo
11. TKR [**2104-6-9**]
12. ETT [**2100**] - negative
13. Dobutamine Echo [**5-/2104**] - normal augmentation, 2mm ST dep
Social History:
>30 pack year smoker
No etoh, illicit drug use.
Lives alone. has assistance with ADL's
Family History:
f: d. MI
s: d. lung ca
Physical Exam:
97.5 110-140/60-70, 134/72, 80-100, 88, 24, 100% 2L
general: sitting up in bed, alert, appropriate
heent: eomi, mmm
heart: rrr loud systolic murmur heard thru-out, loudest at LLHB
lungs: mild crackles throughout
abd: soft nontender nondistended
Ext: trace pitting edema, DP/PT 2 bilaterally, left knee with
healing surgical incision, staples now removed
neuro: non focal
OB positive stool
Pertinent Results:
[**2104-6-22**] 11:00PM CK-MB-NotDone cTropnT-0.13*
[**2104-6-22**] 04:04PM WBC-31.9* RBC-2.48*# HGB-7.8* HCT-22.3*#
MCV-90 MCH-31.5 MCHC-35.0 RDW-14.6
[**2104-6-22**] 04:04PM PT-12.6 PTT-28.7 INR(PT)-1.1
Brief Hospital Course:
GI: Ms. [**Known lastname 106373**] had intermittent bleeding from a duodenal ulcer.
She was placed on telemetry and on [**Hospital1 **] protonix and her
hematocrit was followed several times per day. She underwent 3
endoscopies in an effort to secure hemostasis. However, her
ulcer was so large and had an adherent clot, that it was not
possible to properly determine what was under the clot or to
cauterize it. Her vitals remained stable despite having
continued bleeding evidenced by several OB positive stools and
hematocrits that fell to 25. Although she was transfused 6 units
over a 3 day period, it was felt that her [**Hospital1 4532**] and aspirin
could not be discontinued in light of her recent placement of
bare metal stent. When she developed subjective lightheadedness
and her pressures fell to systolic 90's she was transferred to
the MICU.
In the MICU she underwent a procedure with interventional
radiology to sclerose the bleeding duodenal vessel. Upon
transfer to the MICU, her [**Hospital1 4532**] and aspirin was stopped and she
was transfused more PRBCs to maintain her hematocrit above 30.
Pt then transfered to [**Hospital Unit Name 196**]. Her HCT was stable in the low 30s.
[**Hospital Unit Name **] and [**Hospital Unit Name **] resumed. Sulfacrate and high dose PPI resumed.
Musculoskeletal: She had a total knee replacement 2 weeks prior
to admission and was prophylaxed with lovenox which was
discontinued shortly before this hospitalization.
Pulmonary: Ms. [**Known lastname 106373**] has COPD and was admitted to this service
on oxygen via nasal cannula. She underwent a brief steroid
taper. Her dyspnea resolved with fluticase and albuterol
inhalers and nebulizer treatments. Her oxygen was weaned to room
air, which she tolerated well.
Upon [**Hospital Unit Name 196**] transfer, she had two episodes of SOB which responded
to both albuterol/atrovent as well as diuresis. She was
subsequently weaned off O2.
Cardiology: Ms. [**Known lastname 106373**] has CAD s/p stent placement which was
medically managed with [**Last Name (LF) 4532**], [**First Name3 (LF) **], statin, BB, and captopril.
Her BB and captopril were discontinued during her acute bleeds
and then restarted once she was stable.
Medications on Admission:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
7. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Haloperidol 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed.
9. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Paroxetine HCl 10 mg Tablet Sig: 0.5 Tablet PO QOD (every
other day).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
13. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*0*
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*2*
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
7. Haloperidol 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Paroxetine HCl 10 mg Tablet Sig: 0.5 Tablet PO QOD (every
other day).
Disp:*30 Tablet(s)* Refills:*2*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. Salmeterol Xinafoate 50 mcg/DOSE Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
Disp:*1 Disk with Device(s)* Refills:*2*
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
HS (at bedtime).
Disp:*q/s 1 mo 1* Refills:*2*
19. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
GI bleed
total knee replacement
CAD
hypertension
hypercholesterolemia
depression
Discharge Condition:
good
Discharge Instructions:
Call your doctor if you feel dizzy, weak, notice black stools,
have bright red blood in your stool. You should also call if you
have chest pain, shortness of breath, or have leg swelling.
Followup Instructions:
On [**2104-7-7**], at the rehab facility, have the doctors [**Name5 (PTitle) 4169**] your
[**Name5 (PTitle) **], potassium, and hematocrit.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Where: [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2104-7-16**] 12:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2104-8-29**] 12:30
|
[
"V45.82",
"496",
"532.40",
"458.9",
"780.39",
"285.1",
"V43.65",
"428.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.30",
"99.29",
"45.13",
"44.44"
] |
icd9pcs
|
[
[
[]
]
] |
7866, 7951
|
2181, 4418
|
322, 343
|
8076, 8082
|
1946, 2158
|
8318, 8940
|
1497, 1521
|
5624, 7843
|
7972, 8055
|
4444, 5601
|
8106, 8295
|
1536, 1927
|
279, 284
|
371, 1075
|
1097, 1377
|
1393, 1481
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,806
| 152,378
|
6240
|
Discharge summary
|
report
|
Admission Date: [**2173-10-27**] Discharge Date: [**2173-10-29**]
Date of Birth: [**2119-7-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Brain Lesion
Major Surgical or Invasive Procedure:
[**2173-10-27**] Brain Biopsy
History of Present Illness:
Ms. [**Known lastname 24298**] is a 54yo F w/hx of unresectable pancreatic cancer
who presented to the ED with 2 episodes of RUE numbness. The
numbness started in fingers and spread up right arm and she
reports that her arm felt like a dead weight. The first episode
was at 9am while she was watching TV and the second at 1pm, each
lasting 5-10 minutes in total. She called her oncologist who
recommended that she come to the ED. She denies loss of
consciousness, headache, weakness, difficulty speaking or
swallowing, changes in vision, or urine incontinence. CT
scan showed hyperdensity in left posterior frontal lobe. She
was seen by neurology who recommended admission to OMED for
further workup and MRI of brain. Neurosurgery was not consulted.
Past Medical History:
1. Pancreatic Adenocarcinoma
2. Postoperative sepsis after Whipple's
3. Bipolar disorder, psychiatric hospitalizations
4. Asthma
5. Hypertension, currently off medications
6. Chronic resting tremor since [**2168**]
7. Cholecystectomy
Social History:
Worked as a clerk for an engineering firm; has been unemployed
since [**2164**]. Lives alone in [**Location (un) **]. She has friends and family
nearby for support. She ever smoking. She used to drink 4
alcoholic drinks/ night but quit in [**2164**]. She denies illicit
drug use.
Family History:
Grandmother with stroke at age 57
Mother with rheumatic heart disease, CAD, Colon cancer (in
20s-resected)
Father with AML
Uncle on mother's side with stomach cancer
Physical Exam:
PE on Admission:
Physical Exam:
VS: T: 97.4, BP:114/72, P: 58, RR: 18, 98% on RA
GEN: friendly, well-appearing, obese middle aged female in NAD
HEENT: PERRL, MMM, no LAD, no JVD, no thyromegaly
CV: rrr, normal S1, S2, no m/r/g
PULM: CTAB, no dullness to percussion
ABD: obese, BS+, soft, NT, NT, no masses, no HSM, no LAD
EXT: warm, trace edema, DP, PT 2+ bilaterally
NEURO: CNII-XII intact, sensation intact to light touch,
strength 5/5 in U/L extremities.
On Discharge: As above. Incision clean, dry and intact.
Pertinent Results:
ADMISSION LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2173-10-28**] 05:14 4.4 3.71* 11.2* 33.5* 90 30.1 33.4 18.1*
203
IMAGING:
MRI Head [**10-27**]:
IMPRESSION: No significant short-interval change in the focus of
abnormal
linear enhancement in the left precentral sulcus. In this
setting, the
differential diagnosis still favors leptomeningeal metastatic
disease.
[**2173-10-28**] CT Head:
IMPRESSION:
1. Status post parasagittal vertex craniotomy and brain biopsy
with trace
faint hyperdensity and pneumocephalus at the biopsy site and
moderate
bifrontal pneumocephalus, likely post-surgical changes.
2. Paranasal sinus disease.
3. No acute process in remainder of the brain.
Brief Hospital Course:
Electively presented for Brain Biopsy. Surgery was without
complication and the patient tolerated it well. She was admitted
for close neurological observation and pain control. SHe
remained in the PACU overnight, and on the morning of POD #1 she
was transferred to the floor. It was here where she ambulated
independently, had good pain control, and tolerated a general
diet. She was discharged to home on [**2173-10-29**] with
instructions to follow up in 10 days for a suture removal.
Medications on Admission:
1. Bupropion SR 150 mg PO BID
3. Citalopram Hydrobromide 80 mg PO DAILY
4. Lithium carbonate 600 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Risperidone Long Acting Injection 37.5 mg IM Q2W (WE)
7. Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
8. Lorazepam 1 mg IV PRN seizure
9. Levetiracetam 500 mhg po bid
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
5. citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
6. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Brain Lesion - Final pathology pending
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? If 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-10**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. 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 (617)[**Telephone/Fax (1) 24299**] to schedule an appointment wtih Dr.
[**Last Name (STitle) **] to be seen in 4 weeks.
??????You will not need an MRI of the brain
Completed by:[**2173-10-29**]
|
[
"296.80",
"401.9",
"157.9",
"493.90",
"348.89",
"V45.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
4820, 4826
|
3172, 3662
|
319, 351
|
4909, 4909
|
2428, 2428
|
6517, 7135
|
1711, 1878
|
4027, 4797
|
4847, 4888
|
3688, 4004
|
5060, 6494
|
1925, 2352
|
2366, 2409
|
267, 281
|
379, 1138
|
2860, 3149
|
2444, 2851
|
1910, 1910
|
4924, 5036
|
1160, 1396
|
1412, 1695
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,107
| 112,277
|
24816
|
Discharge summary
|
report
|
Admission Date: [**2130-8-29**] Discharge Date: [**2130-9-7**]
Date of Birth: [**2055-1-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Ace Inhibitors / Lidoderm / Codeine
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2130-8-31**] Mitral valve replacement utilizing [**Street Address(2) 11599**]. [**Male First Name (un) 923**]
porcine valve. Maze procedure utilizing radio frequency
ablation. Ligation of left atrial appendage.
History of Present Illness:
This is a 75 year old female with history of non-ischemic
cardiomyopathy and atrial flutter. She was recently admitted to
[**Hospital3 35813**] Center on [**2130-8-14**] with congestive heart failure
and hypotension. Workup revealed severe mitral regurgitation and
severely depressed left ventricular function with an ejection
fraction of 30%. Her coronary arteries were angiographically
normal. Based on the above results, she was subsequently
transferred to [**Hospital1 18**] for operative care.
Past Medical History:
Non-ischemic cardiomyopathy, Hypertension, Atrial flutter with
history of failed ablation, s/p PPM/AICD placement, Chronic
anemia, Osteoporosis with multiple lumbar compression fractures,
History of non-Hodgkins lymphoma, Spinal stenosis with chronic
low back pain, History of seizures, History of herpetic
neuralgia, s/p chole, s/p appendectomy
Social History:
No history of tobacco or ETOH. Lives with sister-in-law.
Family History:
Son diagnosed with coronary artery disease in his 40's.
Physical Exam:
Vitals: Temp 99.2, BP 106/50, HR 65 AV paced, R 18, SAT 99% RA
General: Elderly female in no acute distress
HEENT: oropharynx benign, PERRL, sclera anicteric
Neck: suppple, no JVD, no carotid bruits
Chest: lungs clear bilaterally
Heart: regular rate, s1s2, [**2-19**] holosystolic murmur
Abdomen: benign
Ext: warm, no pedal edema
Pulses: palpable distal pulses, no femoral bruits
Neuro: nonfocal
Pertinent Results:
[**2130-9-5**] 04:04AM BLOOD WBC-11.8* RBC-3.64*# Hgb-10.6*#
Hct-31.5*# MCV-87 MCH-29.2 MCHC-33.7 RDW-16.8* Plt Ct-112*
[**2130-9-7**] 04:12AM BLOOD PT-15.8* INR(PT)-1.7
[**2130-9-7**] 04:12AM BLOOD K-4.4
[**2130-9-5**] 04:04AM BLOOD Glucose-83 UreaN-16 Creat-0.5 Na-137
K-4.1 Cl-100 HCO3-28 AnGap-13
Brief Hospital Course:
Patient was admitted and underwent further preoperative
evaluation which included a repeat echocardiogram. This was
notable for 3+ mitral regurgitation with moderate to severe
tricuspid regurgitation. The overall left ventricular systolic
function was mildly depressed but compared to previous studies,
her ejection fraction had improved to 50%. There was moderate
pulmonary artery systolic hypertension. Her left atrium was
dilated. She had a normal aortic root and her aortic valves were
mildly thickened with only 1+ aortic insufficiency. Workup was
otherwise unremarkable and she was eventually cleared for
surgery. She remained stable on medical therapy. Antibiotics
were started for her preoperative urinary tract infection -
cutlture grew out E. coli sensitive to Bactrim and Ancef.
On [**8-31**], Dr. [**Last Name (STitle) **] performed a mitral valve
replacement([**Street Address(2) 11599**]. [**Male First Name (un) 923**] porcine valve) and MAZE procedure.
Surgery was uneventful. The intraoperative TEE showed no mitral
regurgitation with an ejection fraction around 35-40%. After the
operation, she was brought to the CSRU in stable condition. She
initially required multiple blood products for an anemia and a
postoperative coagulopathy. She concomitantly experienced a
transient increasing pressor requirement which prompted a TEE
which found no evidence of cardiac tamponade. Over the next 48
hours, she successfully weaned from inotropic support and was
extubated without difficulty. Amiodarone was eventually started
given her history of atrial fibrillation/flutter as well as
Warfarin for her porcine mitral valve replacement. She
maintained stable hemodynamcis and adequate urine output. She
was intermittently transfused with additional packed red blood
cells to maintain hematocrit near 30%.
Postop, she continued to experience a persistent leukocystosis.
All lines were changed and pan cultures were obtained. Her white
count peaked to 25K on POD#3. All cultures remained negative. On
POD#4, she transferred to the SDU. There medical therapy was
optimized. She required additional diuresis. By discharge, chest
x-ray was notable for improving pleural effusions. Amiodarone
was titrated and Warfarin was dosed for a goal INR between 2.0 -
2.5. By discharge, her white count improved to 11K. She remained
afebrile. At discharge, she was tolerating 1L nasal cannula with
oxygen saturations of 95%.
Medications on Admission:
Warfarin - stopped PTA, ASA 325 qd, Coreg 6.25 [**Hospital1 **], Digoxin
0.125 qd, Cozaar 25 qd, Sotalol 160 [**Hospital1 **], Protonix 40 qd,
Spironolactone 12.5 qd, Tegretol 100 [**Hospital1 **], lasix 40 qd, Lexapro
10 qd, Colace, Senna, Oxycodone
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily): [**9-4**] 2 mg
[**9-5**] 3 mg
[**9-6**] 3 mg INR 1.2
[**9-7**] INR 1.7
goal INR [**1-19**].
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
8. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg Qd x 1 week then 200 mg QD.
10. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
12. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name 62491**]Rehabilitation
Discharge Diagnosis:
Congestive Heart Failure, Mitral regurgitation, Non-ischemic
cardiomyopathy - s/p porcine MVR and MAZE, Hypertension, History
of Atrial flutter with history of failed ablation, s/p PPM/AICD
placement, Chronic anemia, Osteoporosis with multiple lumbar
compression fractures, History of non-Hodgkins lymphoma, Spinal
stenosis with chronic low back pain, History of seizures,
History of herpetic neuralgia, s/p chole, s/p appendectomy,
Postoperative leukocytosis, Preoperative UTI, Plueral effusions
Discharge Condition:
Good
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
No lifting more than 10 lbs for at least 10 weeks.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 62492**] on [**2130-9-21**] @ 2PM
Local cardiologist in 2 weeks
Local PCP [**Last Name (NamePattern4) **] 2 weeks
Completed by:[**2130-9-7**]
|
[
"511.9",
"V53.32",
"599.0",
"401.9",
"733.00",
"281.9",
"V10.79",
"427.31",
"286.9",
"424.0",
"425.4",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"35.23",
"37.33",
"88.72",
"96.71",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6275, 6344
|
2351, 4774
|
335, 550
|
6885, 6892
|
2026, 2328
|
7145, 7393
|
1537, 1594
|
5075, 6252
|
6365, 6864
|
4800, 5052
|
6916, 7122
|
1609, 2007
|
276, 297
|
578, 1078
|
1100, 1447
|
1463, 1521
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,195
| 173,359
|
46911
|
Discharge summary
|
report
|
Admission Date: [**2104-9-12**] Discharge Date: [**2104-9-24**]
Date of Birth: [**2037-8-2**] Sex: M
Service: [**Hospital 11212**] [**Hospital6 733**] Firm
CHIEF COMPLAINT: Bilateral lower extremity rash and pain and
cough.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
white male with an extensive past medical history including
metastatic non-small-cell lung cancer with metastases to the
skull, status post radiation therapy times 18, and metastases
to right iliac crest.
The patient was initially diagnosed with non-small-cell lung
cancer after banging his head in [**2104-5-7**]. The incident
led to a hematoma which was drained and found to have
metastatic non-small cells which were later to be found from
a lung primary. The patient underwent 18 rounds of radiation
therapy to the skull as well as one round of chemotherapy
with gemcitabine and carboplatin on [**2104-9-2**].
Shortly after chemotherapy, the patient developed bilateral
lower extremity pain and an erythematous rash. The rash was
nonpruritic. It was tender to the touch. There was some
relief with Tylenol. The rash is isolated to shins and
ankles and is unchanged in size and distribution over the
last few days prior to admission. However, the patient notes
an increase in the erythema of the rash.
REVIEW OF SYSTEMS: On review of systems the patient also
complains of a productive cough with yellow sputum times
several weeks. He has a history of significant chronic
obstructive pulmonary disease with multiple flares and is
currently on a number of inhalers at home. He denies
associated shortness of breath, fevers, chills, chest pain,
nausea, or vomiting. He endorses increased fatigue and
general malaise since chemotherapy was initiated.
In the Emergency Department, he was given one dose of
[**Year (4 digits) **] for a low-grade fever; and in addition to the rash,
thought possible cellulitis.
The patient was initially admitted to the Internal Medicine
Service on the [**Hospital Ward Name **]. During the first four days of
hospitalization, the patient developed progressive azotemia,
urinary retention, and hypotension with systolic blood
pressures reaching the middle 70s. The patient was also
noted to have a deterioration of mental status over this time
period. On hospital day four, he was transferred to the
Intensive Care Unit.
His Intensive Care Unit course was unremarkable, and his
hypotension and urinary retention resolved with intravenous
fluid administration.
After three days in the Intensive Care Unit, he was
transferred to the [**Hospital6 733**] Internal Medicine
Service.
Specific occurring in the Intensive Care Unit and previous
Medicine Service will be discussed in more detail below.
PAST MEDICAL HISTORY:
1. Rheumatic heart disease; status post aortic valve
replacement.
2. Congestive heart failure with an echocardiogram in [**2102**]
showing an ejection fraction of 20% to 30%.
3. Chronic atrial fibrillation.
4. Ablation for atrial fibrillation with pacemaker placed
in [**2098**].
5. Chronic obstructive pulmonary disease.
6. Diabetes.
7. Hypertension.
8. Gastroesophageal reflux disease.
9. Low back pain; status post L4-L5 laminectomy.
10. Bilateral cataracts.
11. Sleep apnea.
12. History of gastrointestinal bleed.
13. Degenerative joint disease; status post cartilage tear.
14. History of prostatitis.
15. History of melanoma diagnosed in the [**2062**].
16. Ventral hernia times two.
17. Status post open cholecystectomy.
18. Bilateral hearing deficit.
19. Cervical spine radiculopathy.
20. History of carpal tunnel syndrome.
21. History of rectal fissures.
SOCIAL HISTORY: The patient has a 30-pack-year smoking
history but denies alcohol or other drug use.
ALLERGIES: Allergy to PROCAINAMIDE and SULFA DRUGS which
cause thrombocytopenia.
MEDICATIONS ON ADMISSION:
1. Coumadin 10 mg p.o. q.d.
2. Digoxin 0.125 mg p.o. q.d.
3. Neurontin 900 mg p.o. t.i.d.
4. Flomax 0.4 mg p.o. b.i.d.
5. Proscar 5 mg p.o. q.d.
6. Klonopin 1 mg p.o. b.i.d.
7. Glyburide 5 mg p.o. q.a.m. and 2 mg p.o. q.p.m.
8. NPH insulin 6 to 8 units q.d.
9. Regular insulin sliding-scale.
10. Zestril 40 mg p.o. q.d.
11. Spironolactone 12.5 mg p.o. q.d.
12. Flovent.
13. Serevent.
14. Atrovent/albuterol.
15. Lasix 40 mg p.o. q.d.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission to the Emergency Department revealed vital signs
with a temperature of 100.7, blood pressure was 112/72, heart
rate was 100, respiratory rate was 24. On physical
examination the patient was in mild discomfort, in no
apparent respiratory distress. He was alert and oriented
times three. His scalp was notable for frontal prominence
with cavitation. His pupils were equal, round, and reactive
to light. His extraocular muscles were intact. His
oropharynx was clear. His mucous membranes were moist, and
his neck was supple. His lungs were clear to auscultation
bilaterally. His heart was regular in rate with occasional
periods of irregularity with a 3/6 systolic ejection murmur
at the left sternal border. He had a normal first heart
sound with a loud metallic second heart sound. His abdomen
was soft and nontender, with a large ventral hernia and two
well-healed surgical scars. He had 2+ dorsalis pedis and
posterior tibialis pulses, and 2+ pitting edema in the
bilateral left extremities. His bilateral shins were notable
for an erythematous maculopapular rash with shiny skin.
There were scattered petechiae in the area. The rash was
blanching. Both legs were more tender and warm. He had a
scar on his left chest from prior melanoma excision which was
atrophic with telangiectasia and a pigmented border.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 4.9, hematocrit
was 30.3, and platelets were 64. INR was 2.7. Sodium was
134, potassium was 4, chloride was 99, bicarbonate was 28,
blood urea nitrogen was 31, creatinine was 1, blood glucose
was 123. Urinalysis was within normal limits without any
hematuria.
PERTINENT STUDIES DURING THIS ADMISSION: Bilaterally lower
extremity Doppler studies revealed no evidence of deep venous
thrombosis.
A chest x-ray on [**2104-9-12**] (on admission) showed
increased opacity in the region of the right hilum consistent
with known right lung mass. Focal consolidation in the
region could not be excluded.
A CT of the chest on [**2104-9-16**] showed interval
enlargement of obstruction in the right lower lobe lung mass
with a collapse of superior segment as well as interval
increase in bulk in right hilar and mediastinal
lymphadenopathy. Low attenuation fossae in the liver which
could represent metastatic disease.
A CT of the head on [**2104-9-17**] was normal.
A CT of the cervical spine, and lumbar spine, and thoracic
spine on [**2104-9-17**] was without evidence of
metastatic involvement of the spinal canal or stenosis.
Plain films of the bilateral left extremities showed no
evidence of hypertrophic osteoarthropathy.
IMPRESSION: This is a 67-year-old male with non-small-cell
lung cancer diagnosed in [**2104-5-7**] with metastases to skull
and possibly the liver; status post aortic valve replacement
secondary to rheumatic heart disease, on Coumadin, congestive
heart failure with an ejection fraction of 20%, and a history
of gastrointestinal bleed presenting with cough times two
weeks as well as lower extremity rash and pain following
chemotherapy treatment on [**2104-9-2**].
HOSPITAL COURSE:
1. PULMONARY: The patient with newly diagnosed
non-small-cell lung carcinoma in [**Month (only) 116**] of this year with
metastases to the skull, right iliac, and possibly to the
liver. During this hospitalization, an interval increase in
the size of mass was noted by both a CT of the chest as well
as increase in hilar and mediastinal lymphadenopathy.
Although the patient complained of a frequent cough, he had
no respiratory distress on admission. He was started on
[**Month (only) **] for possible postobstructive pneumonia. A
bronchoscopy was performed on [**2104-9-19**] which
demonstrated complete obstruction of the superior segment of
the right lower lobe. No bronchial washings were performed.
Although the patient was admitted with oxygen saturations of
98% on room air, he developed a oxygen requirement which
began just prior to Intensive Care Unit admission. At the
time of discharge, he was still requiring supplemental oxygen
as well as albuterol and Atrovent nebulizer treatments three
to four times per day. The exact etiology for his increased
oxygen requirement was not known; however, it was thought to
be related either to interval obstruction by lung cancer or
decompensation from heart failure.
Radiology/Oncology was consulted after the patient left the
Intensive Care Unit for a possible radiation therapy to open
the right lower lobe obstruction. Options were discussed,
and it was thought that there was little chance that any
radiation therapy would prolong the patient's life, and no
further therapy was recommended.
2. LOWER EXTREMITY RASH: The patient's main complaint on
presentation was a painful, erythematous, petechial rash in
the bilateral shins; status post chemotherapy with
gemcitabine and carboplatin approximately one to two weeks
prior to admission.
Dermatology was consulted and felt that the rash was likely
drug-related with underlying stasis-related changes. A
biopsy was performed which confirmed stasis changes. A
topical steroid was recommended, and the patient had good
resolution of the lower extremity rash midway through his
hospitalization.
Lower extremity Doppler studies were performed which were
found to be negative.
Although the rash had scattered petechiae, there were no
ecchymosis or purpura. After resolution of rash, chronic
venous stasis changes persisted.
3. INFECTIOUS DISEASE: The patient with a low-grade fever
on admission and was started on [**Year (4 digits) **]. With evidence of
postobstructive pneumonia by chest x-ray and CT scan,
additional antibiotics including clindamycin, Flagyl, and
vancomycin were used intermittently. The patient spiked
through antibiotics, and it was thought that part of his
fever was cancer-related. No significant culture
abnormalities were found with negative blood culture, sputum
culture (which was contaminated), and a negative urine
culture.
At the time of discharge, the patient was to continue an
additional seven days of [**Last Name (LF) **], [**First Name3 (LF) **] Infectious Disease
recommendations.
4. NEUROLOGY: On admission, the patient was alert and
oriented times three. However, by hospital day two, his
mental status began to deteriorate. Although first in the
setting of hypotension and acute renal failure, it was
thought that altered mental status was secondary to metabolic
etiologies.
Throughout his Intensive Care Unit admission, however,
altered mental status persisted despite resolution of
hypotension and acute renal failure.
A Neurology consultation was obtained secondary to altered
mental status, as well as new onset urinary retention, and
lower extremity weakness. A CT scan of the cervical spine,
thoracic spine, and lumbar spine was obtained and was found
to have no evidence metastatic involvement or spinal
stenosis.
A unifying diagnosis of carcinomatous meningitis was
proposed; however, they diagnosis could not be fully
assessed, as a magnetic resonance imaging could not be
performed secondary to hardware from pacemaker in aortic
valve.
A lumbar puncture was attempted on [**2104-9-17**];
however, the patient refused, and due to the patient's body
habitus, history of lumbar surgery, and increased INR,
another attempt was not considered.
During his Intensive Care Unit stay, the patient had an
episode of agitation coinciding with the administration of
Fentanyl which was relieved with Risperdal. Although it was
not completely clear, Fentanyl and morphine were used
sparingly throughout the remainder of his hospitalization.
At the time of discharge, the patient continued to be
encephalopathic, and a clear etiology was not known. It was
thought that metabolic factors were contributing in part, as
well as the possibility of carcinomatous meningitis, as well
as a viral etiology. However, none of the diagnoses could be
fully assessed.
5. CARDIOVASCULAR: During his hospitalization, the patient
had a repeat echocardiogram which showed an ejection fraction
of 25% to 35% with 3+ tricuspid regurgitation and 2+ mitral
regurgitation. He has a history of congestive heart failure
as well as atrial fibrillation, and aortic valve replacement
status post rheumatic heart disease.
A contributing factor for his hypotension necessitating
Intensive Care Unit stay was most likely congestive heart
failure. Cardiac enzymes were cycled during his admission
which were negative times three. An adrenal insufficiency
workup was started secondary to the hypotension and was found
to be negative with a random cortisol level of 18.
6. RENAL: A few days after admission, the patient developed
progressive azotemia and urinary retention. There was some
concern for spinal metastasis; which were ruled out by a CT
of the spine.
The patient's hypotension led to acute tubular necrosis which
developed into acute renal failure with a creatinine reaching
a high of 2. With intravenous fluid resuscitation, the
patient's creatinine trended back to baseline and was 0.9 at
the time of discharge; reconfirming that the patient's acute
renal failure was secondary to prerenal causes. A FENa was
calculated to be less than 1%.
During his hospitalization, the patient had one episode of
self-discontinuing Foley catheter which led to bloody urine,
which subsequently was flushed and cleared. At the time of
discharge, the patient's urine output was appropriate and
clear of gross blood.
7. HEMATOLOGY: The patient was guaiac-negative during his
hospitalization, but has a history of rectal fissures as well
as a slow gastrointestinal bleed though related to
chemotherapy. He had been followed with serial hematocrits
prior to hospitalization with hematocrit dropping as low
as 27. He was transfused a total of 2 units during his
hospitalization.
The patient was additionally thrombocytopenic on admission
with platelets around 60,000 with unknown etiology, but
suspected to be related to chemotherapeutic agents. By the
time of discharge, the patient's platelets had rebounded to
700,000.
The patient was anticoagulated with Coumadin secondary to
aortic valve replacement. His INR reached as high as 6 and
tended to stay between 4 and 5 during the majority of his
hospitalization. At the time of discharge, INR had returned
to 2.5 after holding Coumadin. Coumadin was restarted at a
lower dose of 5 mg p.o. q.h.s. with plans to titrate up for
an INR goal of 2.5 to 3.5.
8. CODE STATUS: At the time of admission, a discussion of
do not resuscitate/do not intubate was had with both the
patient and family. On numerous other occasions, code status
was readdressed, and by the middle of his Intensive Care Unit
the patient had expressed wishes to return home for hospice
care.
The family initially did not accept that decision; however,
by [**2104-9-21**] the family had made the decision to
change the patient's code status to do not resuscitate/do not
intubate, and home hospice option was pursued. The patient
was discharged to home hospice on [**2104-9-24**].
DISCHARGE DIAGNOSES:
1. Encephalopathy; possibly carcinomatous meningitis.
2. Non-small-cell lung carcinoma obstructing the right lower
lobe.
3. Postobstructive pneumonia.
4. Congestive heart failure.
5. Chronic obstructive pulmonary disease.
6. Acute renal failure; acute tubular necrosis.
7. Drug-induced rash.
MEDICATIONS ON DISCHARGE:
1. Hospice medication regimen including Roxanol, Ativan,
Levsin, ABHR gel.
2. Risperdal.
3. Insulin sliding-scale.
4. Finasteride 5 mg p.o. q.d.
5. [**Year (4 digits) **] 500 mg p.o. q.d. (day one of seven).
6. Protonix 40 mg p.o. q.d.
7. Albuterol and Atrovent nebulizers q.4-6h. as needed.
8. Flovent 110 mcg 2 puffs b.i.d.
9. Serevent 2 puffs b.i.d.
10. Nystatin swish-and-swallow 5 cc p.o. q.i.d.
11. Coumadin 5 mg p.o. q.d. (with titration to a goal INR
of 2.5 to 3.5).
12. Klonopin 1 mg p.o. b.i.d.
13. Lasix 40 mg p.o. q.d.
DISCHARGE FOLLOWUP: The patient's care will continue to be
provided by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**], the patient's primary care
physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**], M.D. [**MD Number(1) 13930**]
Dictated By:[**Last Name (NamePattern1) 6240**]
MEDQUIST36
D: [**2104-9-25**] 21:57
T: [**2104-10-1**] 11:01
JOB#: [**Job Number 99510**]
|
[
"287.5",
"486",
"197.7",
"496",
"198.5",
"428.0",
"584.9",
"162.5",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
15552, 15852
|
15879, 16432
|
3878, 7545
|
7563, 15531
|
1337, 2749
|
191, 243
|
16454, 16898
|
272, 1316
|
2772, 3665
|
3682, 3851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,933
| 128,813
|
35770+58033
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-10-5**] Discharge Date: [**2178-10-8**]
Date of Birth: [**2134-1-12**] Sex: M
Service: MEDICINE
Allergies:
Depakote / Keppra / Oxycodone / Paxil / Sulfacetamide / Zoloft /
Bactrim / Seroquel
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 44yo male with DM, bipolar disorder, possible seizure
disorder vs pseudoseizures, recent cholecystectomy/appendectomy,
who presents with persistent hypoglycemia. This started 1 week
ago with blood glucose in the 40s and multiple syncopal
episodes. He stopped his inuslin use 5 days ago, although an OMR
note mentions he took 4 units humalog on [**10-2**]. He has been
eating and drinking normally, with sugars transiently increasing
to 330, 130, but has otherwise remained hypoglycemic until
presentation. Has had nausea, subjective fevers, and sweats.
Also, he fell 2 days ago onto his right side, and has since had
RUQ pain at the site of his recent cholecystectomy.
.
Upon arrival to the ED, his vital signs were: 97.6 153/94 138 24
100%. He was given 4 amps of D50 and 3L of D5 1/2 NS. His sugars
have transiently improved to ~70-120s, but between glucose
boluses have fallen back to the 40s. In the ED, he had a
possible pseudoseizure x1-2min with stable vitals and FS 128.
Imaging including CXR and CT abdomen were unremarkable. His WBC
count is elevated, but labs were otherwise normal. He was given
2mg hydromorphone for abdominal pain. He also received
octreotide for his persistent hypoglycemia and is being admitted
to the ICU for close blood sugar monitoring. His most recent
vital signs are: 157/92 95 20 100%,2L FS 128.
.
Review of systems is positive for nausea/vomiting 2 days ago,
diaphoresis usually in context of low blood sugars, abdominal
pain extending from hypogastrium around R side to the back that
is not new, chronic low back pain that is currently 9.5/10.
Negative for chest pain/pressure, SOB, rhinorrhea, diarrhea.
.
Past Medical History:
1. Hypertension
2. Type 2 Diabetes Mellitus - diagnosed at 40 years old, but
states that he was told for years that he had sugar in his urine
3. PTSD [**1-19**] work on [**Company 2318**] and seeing co-workers injured/killed
4. Bipolar disorder
5. History of alcohol abuse (sober since [**2175**])
6. Chronic pancreatitis--likely alcoholic
Recently, he has undergone multiple procedures for pancreatitis
summarized below:
[**2178-2-11**]: ERCP - pancreatic duct sphincterotomy, stone removal,
stent placement
[**2178-3-23**]: ERCP - pancreatic duct stone removal, dilatation of 5mm
genu stricture, stent replacement
[**2178-4-12**]: ERCP - stent removed due to persistent/increased
R-sided pain
7. Seizure disorder (although recent suggestion of
pseudoseizures).
8. Diabetic gastroparesis, resolved now spontaneously
9. History of LUE DVT
10. Chronic low back pain
11. Hyperlipidemia
12. History of electrocution 15 years prior.
13. Patient states he was stabbed on 14 different occasions in
multiple places on his body.
14. S/p cholecystectomy and appendectomy [**8-26**]
15. H/o apnea on depakote requiring intubation
Social History:
He lives with his wife and step son (24) in [**Location (un) 14840**] and is a
retired [**Company 2318**] worker. He has smoked 1 pack per day for over 30
years (current
smoker). States that he is not currently interested in quitting.
He is currently abstinent from alcohol since [**2175**]. He denies
IVDU.
Family History:
Mom - epilepsy, stroke, HTN, DM.
Physical Exam:
GENERAL: Pleasant, appears uncomfortable in bed, mildly
diaphoreticD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2
physiologically split. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally. No wheezes or
crackles
ABDOMEN: Appears mildly distended, soft, tender to palp in
hypogastrium to umbilicus extending to RUQ and R flank. NABS. No
HSM detected. Healing laparoscopy sites noted without erythema
or signs of infection.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. WWP.
SKIN: No rashes/lesions other than healing laparoscopy sites as
noted, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout, except R straight
leg raise limited by pain. Normal coordination, finger-nose
testing intact, sensation limited in upper extremities due to
h/o fractures/burns per pt, no asterixis, no pronator drift.
Gait assessment deferred
PSYCH: Listens and responds to questions appropriately,
pleasant. Appears anxious.
Brief Hospital Course:
44 year old man with DM type 2, bipolar disorder, seizure
disorder vs pseudoseizures, and recent cholecystectomy with
appendectomy who presented with multiple syncopal episodes,
diaphoresis, and persistent hypoglycemia and was initially
admitted to the ICU for close glycemic monitoring. The patient
had a history of DM Type 2 on Humulog 2 units [**Hospital1 **] (unusual
treatment of diabetes!). Potential etiologies included increased
exogenous administration of insulin or hypoglycemic medications
(self induced specially in light of history of pseudoseizures),
increased endogenous production of insulin, or impaired
gluconeogenesis. He stated that he had not taken insulin for [**3-22**]
days and had prescription only for Humalog (short-acting
insulin). Surreptitious administration remained a strong
possibility. CT scan and old MRCP did not reveal tumor such as
an insulinoma. INR and liver enzymes were normal, which argued
against impaired gluconeogenesis in the liver. Insulin,
C-peptide, BHB, and cortisol were sent. The insulin and
C-peptide were still pending at the time of discharge but his
cortisol stimulation test was completely normal. The patient was
discharge on Metformin [**Hospital1 **] to avoid hypoglycemia. He was
instructed not to take insulin and to follow up with [**Hospital **]
clinic for future management of his diabetes. The final
diagnosis depends on the C-peptide and Insulin levels but we
strongly suspected factitious disease. His fasting and
postprandial glucose remained normal or elevated during more
than 3 days monitoring on the hospital floor with out any
glucose supplementation. Total discharge time 45 minutes.
Discharge Medications:
1. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
11. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet
Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoglycemia
Discharge Condition:
Excellent
Discharge Instructions:
You had low blood sugars so please do not take any insulin
products. Please take Metformin to manage your diabetes. Please
follow up with [**Hospital **] clinic for future management of your
diabetes.
Followup Instructions:
[**Last Name (un) **] Follow Up. Please call if questions ([**Telephone/Fax (1) 4847**]:
[**2178-10-23**] - 2:00 PM - Eye exam
[**2178-10-23**] - 2:30 PM - Appointment with Dr. [**Last Name (STitle) 81354**]
[**2178-10-23**] - 3:30 PM - Appointment with Nurse educator.
Name: [**Known lastname 13043**],[**Known firstname 77**] C Unit No: [**Numeric Identifier 13044**]
Admission Date: [**2178-10-5**] Discharge Date: [**2178-10-8**]
Date of Birth: [**2134-1-12**] Sex: M
Service: MEDICINE
Allergies:
Depakote / Keppra / Oxycodone / Paxil / Sulfacetamide / Zoloft /
Bactrim / Seroquel
Attending:[**First Name3 (LF) 9498**]
Addendum:
Patient's C-peptide and Insulin levels were both low. Patients
with excess exogenous Insulin have elevated blood Insulin and
suppressed C-peptide levels when hypoglycemic. The cause of his
hypoglycemia remains unclear but could be related to either lack
of glucagon secretion from chronic pancreatitis or factitious
disease. Insulinoma resuls in elevated C-Peptide levels and is
unlikely (negative MRCP).
Discharge Disposition:
Home
[**First Name4 (NamePattern1) **] [**Name8 (MD) **] MD [**Last Name (un) 9499**]
Completed by:[**2178-10-12**]
|
[
"V45.89",
"296.80",
"338.29",
"305.03",
"250.82",
"577.1",
"309.81",
"345.90",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9058, 9204
|
4810, 6474
|
359, 365
|
7676, 7687
|
7936, 9035
|
3542, 3576
|
6497, 7591
|
7641, 7655
|
7711, 7913
|
3591, 4787
|
305, 321
|
393, 2052
|
2074, 3199
|
3215, 3526
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,988
| 191,860
|
36019
|
Discharge summary
|
report
|
Admission Date: [**2199-12-26**] [**Year/Month/Day **] Date: [**2199-12-30**]
Date of Birth: [**2119-1-27**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cephalosporins / Flagyl
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2199-12-27**] ORIF left intratrochanteric hip fracture
History of Present Illness:
80 y/o female s/p fall to floor from standing
Past Medical History:
Chronic anemia - receives transfusions monthly per patient (has
right portacath for chonic transfusions), recent dementia like
symptoms, Diverticulitis, Colitis, ? COPD
Social History:
Had recently been staying with family secondary to increasing
difficulty, her own home is a single story [**Last Name (un) **].
Family History:
Noncontributory
Physical Exam:
Upon admission:
O: T: BP: 132/41 HR:86 R16 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-27**] EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date (thought it was
[**2099**]).
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: poor effort on right not tested on leftSternocleidomastoid
and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Has left shoulder fx left grip , left hip fx is able to
wiggle toes. Right Bicep 4+ and Tricep 4+ grip 4+; Unable to
test
drift does not appear to drift on right
Sensation: Intact to light touch
CT/MRI: Small left sided occiptal subdural
Pertinent Results:
[**2199-12-26**] 10:50AM PT-13.8* PTT-27.0 INR(PT)-1.2*
[**2199-12-26**] 10:50AM PLT COUNT-232
[**2199-12-26**] 10:50AM WBC-13.6* RBC-3.40* HGB-10.1* HCT-28.8*
MCV-85 MCH-29.7 MCHC-35.0 RDW-21.8*
[**2199-12-26**] 10:50AM cTropnT-<0.01
[**2199-12-26**] 10:50AM CK(CPK)-19*
[**2199-12-26**] 10:50AM GLUCOSE-132* UREA N-16 CREAT-0.4 SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-31 ANION GAP-10
[**2199-12-26**] 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-NEG
[**2199-12-26**] 01:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2199-12-26**] 07:41PM WBC-11.1* RBC-3.33* HGB-9.9* HCT-27.8* MCV-84
MCH-29.8 MCHC-35.7* RDW-21.0*
[**2199-12-26**] 07:41PM PLT COUNT-227
Brief Hospital Course:
She was admitted to the Trauma Service and transferred to the
trauma ICU. On initial workup she was noted to have a left
chronic subdural hemorrhage with acute blood, a proximal humerus
fracture, right inferior ramus and acetabular fracture and a
left intratrochanteric fracture. She was evaluated by
Neurosurgery for the SDH which was nonoperative. It was
recommended that a repeat head CT be done which was stable. It
was initially thought there may be a fracture of her cervical
spine at C1-C2; an MRI was done and reviewed by Neurosurgery and
no fracture was noted, just degenerative changes. The cervical
collar was removed. She will follow up with Dr. [**First Name (STitle) **] in 4
weeks for a repeat head CT and will continue with the Keppra
until that time.
Orthopedics was consulted for the hip fracture; she was taken to
the operating room on [**2199-12-27**] for ORIF of the left hip.
Postoperatively she was transferred to the regular nursing unit.
It was recommended to start Lovenox for a total of 4 weeks. she
may weight bear as tolerated and will follow up with Dr.
[**Last Name (STitle) **] in 2 weeks. Her humeral fracture was managed non
operatively with a sling.
Given her history of chronic anemia and need for monthly blood
transfusions her hematocrits were monitored closely and remained
relatively stable given her hip surgery. Last hematocrit on [**12-30**]
was 23.4 (postop Hct was 23.5 on POD #1). She is followed by her
PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] in [**Hospital1 **], MA.
She was evaluated by Physical and Occupational therapy and has
been recommended for rehab after her acute hospital stay.
Medications on Admission:
Lasix 40 QD, Spironlactone 25mg
[**Last Name (LF) 244**], [**First Name3 (LF) **] 325 QD + prn, Combivent and Advair
[**First Name3 (LF) **] Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-27**]
Puffs Inhalation Q6H (every 6 hours) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) 30mg/0.3ml
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*qs 30mg/0.3ml* Refills:*0*
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime: hold
for loose stools.
10. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Zinc Sulfate 220 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
[**Location (un) **] Diagnosis:
s/p Fall
Subdural hemorrhage
Left proximal humerus fracture
Left acetabular fracture
Left intratrochanteric hip fracture
Pressure ulcer coccyx region (unstageable)
Right pelvic ring fracture
[**Location (un) **] Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
[**Location (un) **] Instructions:
DO NOT bear any weight on your left arm because of your
fracture. Continue to wear the sling for comfort.
Continue the Keppra until follow up with Neurosurgery.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **], Orthopedics in two weeks.
Please call [**Telephone/Fax (1) 1228**] to schedule an appointment.
Follow up with Dr. [**First Name (STitle) **], Neurosurgery in 4 weeks for a repeat
head CT scan. Call [**Telephone/Fax (1) 1669**] for an appointment. A follow up
MRI of your cervical spine is also being recommend at that time.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab regarding an incidental finding on MRI imaging of your
cervical spine (copy of report included in your [**Last Name (Titles) **]
summary). You or a family member will need to call for an
appointment.
Completed by:[**2200-1-1**]
|
[
"285.9",
"496",
"852.21",
"812.09",
"E885.9",
"808.0",
"808.49",
"707.25",
"707.03",
"294.8",
"820.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35"
] |
icd9pcs
|
[
[
[]
]
] |
2975, 4682
|
340, 400
|
2193, 2952
|
6695, 7408
|
829, 846
|
4708, 6003
|
861, 863
|
6162, 6355
|
292, 302
|
6387, 6468
|
6033, 6130
|
6505, 6670
|
428, 475
|
1433, 2174
|
878, 1119
|
1134, 1417
|
497, 668
|
684, 813
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,594
| 198,398
|
28357
|
Discharge summary
|
report
|
Admission Date: [**2185-3-29**] Discharge Date: [**2185-4-13**]
Date of Birth: [**2119-6-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain, dizziness
Major Surgical or Invasive Procedure:
[**2185-4-5**] Four Vessel Coronary Artery Bypass Grafting Surgery(left
internal mammary to first diagonal, saphenous vein grafts to
second diagonal, third obtuse marginal and posterior descending
artery)
[**2185-3-31**] Cardiac Catheterization
[**4-9**] Renal Biopsy
History of Present Illness:
Mr. [**Known lastname 14748**] is a 65 y/o man with PMH of DM2, hypertension, and
ESRD s/p renal transplant in [**2185-2-12**] who presented with chest
pain and dizziness. The patient went to the transplant clinic
for staple removal earlier today; he states that on his way
home, he noted several episodes of "almost passing out" which he
cannot describe further. States he had to "shake himself" to
"wake up." In that setting he says he realized that "something
wasn't right." He arrived home and took a sublingual
nitroglycerin which relieved his symptoms. He then contact[**Name (NI) **] the
transplant clinic where he was directed to return to the ED. He
also took a 325 mg aspirin prior to leaving the house. Of note,
the patient experienced a perioperative myocardial infarction
and also was noted to have elevation in cardiac enzymes in
setting of acute hypoxic event during recent admission [**2185-3-23**] -
[**2185-3-27**]. He declined treatment with heparin at that time but was
evaluated by the Cardiology consult team. He has an upcoming
appointment with outpatient Cardiology (Dr. [**Last Name (STitle) **] at [**Hospital1 18**]
later this week. Echocardiogram during admission for transplant
([**3-7**]) showed EF 45-50% with inferior and inferolateral
hypokinesis. Initial vitals in the ED were T 97.8, HR 59, BP
121/58, RR 16, O2 100% on 4L NC. In the ED, he complained of
slight ongoing chest pressure and was treated with sublingual
nitroglycerin X 1 and morphine 2 mg IV X 1, and the chest pain
resolved. Patient's troponin found to be elevated at 9, so was
started on heparin gtt without bolus after discussion with
Cardiology fellow. He was noted to be guaiac negative prior to
initiation of heparin.
Past Medical History:
1. Diabetes type II for 20 years.
2. Hypertension.
3. Dyslipidemia.
4. Myocardial infarction status post stent about five years ago,
repeat MI post renal transplant in [**2-/2185**] with new LBBB.
5. Malignant melanoma of the left upper chest status post
resection in [**2178**] with no apparent recurrence.
6. End-stage renal disease secondary to diabetic nephropathy,
on hemodialysis since [**2183-4-14**]; s/p DCD renal transplant on
[**2185-3-1**].
7. s/p Thyroidectomy
Social History:
He [**Date Range **] any tobacco, drug, or alcohol use. He worked as a
machinist as well as a bus driver. He is currently retired on
disability. Lives alone with two cats. Has sister in the area.
Family History:
Noncontributory
Physical Exam:
ADMIT EXAM
T: 98 BP: 130/55 HR: 61 RR: 18 O2 100% RA
Gen: Pleasant, well appearing male in no acute distress, sitting
up in bed
HEENT: No scleral icterus. MMM, OP clear. Poor dental hygeine.
NECK: supple, no lymphadenopathy
CV: RRR, no appreciable murmur, heart sounds distant
LUNGS: faint crackles bilateral bases, otherwise clear
ABD: soft, protuberant, surgical scar in RLQ covered with
steristrips and minimal erythema, normoactive bowel sounds
EXT: R>L lower extremity pitting edema (chronic per patient),
RUE fistula covered with dressing, DP pulses 2+ bilaterally
SKIN: Ecchymoses on left lower abdomen. Patches of dry skin on
hands, legs.
NEURO: A&O X 3. Speaking clearly and in full sentences. Moving
all extremities without difficulty. Face symmetric.
Pertinent Results:
[**2185-3-29**] 08:17PM BLOOD WBC-3.7* RBC-2.97* Hgb-9.5* Hct-28.5*
MCV-96 MCH-32.0 MCHC-33.4 RDW-17.2* Plt Ct-292#
[**2185-3-29**] 08:17PM BLOOD PT-13.8* PTT-27.3 INR(PT)-1.2*
[**2185-3-29**] 08:17PM BLOOD Glucose-136* UreaN-46* Creat-5.1* Na-141
K-3.9 Cl-99 HCO3-27 AnGap-19
[**2185-3-29**] 08:17PM BLOOD CK-MB-4 proBNP-[**Numeric Identifier **]*
[**2185-3-29**] 08:17PM BLOOD cTropnT-9.20*
[**2185-3-30**] 01:20PM BLOOD CK-MB-NotDone cTropnT-7.90*
[**2185-3-31**] 01:00PM BLOOD cTropnT-5.65*
[**2185-3-31**] 01:00PM BLOOD Albumin-3.1*
[**2185-3-31**] 01:00PM BLOOD %HbA1c-5.9
[**2185-3-31**] Cardiac Cath:
1. Coronary angiography of this right dominant system
demonstrated 3
vessel coronary artery disease. The LMCA had an eccentric
ostial 40%
stenosis. The LAD was heavily calcified with diffuse disease in
the
proximal segment to a 30% stenosis. The mid-LAD had a 60%
stenosis
between D1 and D2. The bifurcating D1 had a proximal 50%
stenosis. The
large D2 had an origin 80% stenosis. There were septal
collaterals to
the RCA. The LCx had mild diffuse plaquing proximally to
30-40%. There
was a 70% bifurcating stenosis involving 2 major limbs of the
OM2. The
distal AV groove LCx had collaterals to the RCA. The RCA had a
proximal
occlusion within the Gianturco-Roubin stent with faint distal
filling
via vasa and right-to-right collaterals.
2. Limited resting hemodynamics revealed elevated left sided
filling
pressure with a LVEDP of 22 mmHg. Systemic arterial pressure
was normal
at 131/46 mmHg. There was no transaortic valve gradient on
pullback of
the catheter from the LV to the aorta.
[**2185-4-4**] Carotid Ultrasound:
A 60-69% right ICA stenosis and a 40 to 59% left ICA stenosis.
[**2185-4-13**] 05:29AM BLOOD WBC-5.8 RBC-3.33* Hgb-10.5* Hct-30.5*
MCV-92 MCH-31.5 MCHC-34.5 RDW-17.5* Plt Ct-181
[**2185-4-12**] 05:15AM BLOOD PT-14.1* PTT-28.5 INR(PT)-1.2*
[**2185-4-13**] 05:29AM BLOOD Glucose-144* UreaN-29* Creat-3.7* Na-138
K-3.9 Cl-101 HCO3-28 AnGap-13
[**2185-4-12**] 05:15AM BLOOD Glucose-125* UreaN-24* Creat-3.4* Na-141
K-3.2* Cl-103 HCO3-30 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 14748**] was admitted under cardiology after ruling in for a
myocardial infarction. Troponins were elevated while CK and CKMB
remained flat. He remained stable on intravenous Heparin.
Hemodialysis was continued per schedule. It was decided to
proceed with cardiac catheterization on [**3-31**] which
revealed severe three vessel coronary artery disease and
moderate left ventricular diastolic dysfunction - see result
section for further details. Cardiac surgery was therefore
consulted and additional workup was performed. Preoperative
evaluation was notable for mild to moderate disease of the
internal carotid arteries. In preparation for cardiac surgical
intervention, Plavix was discontinued. Workup was otherwise
unremarkable and he was cleared for surgery.
On [**4-5**], Dr. [**Last Name (STitle) **] performed coronary artery bypass
grafting. For surgical details, please see separate dictated
operative note. Following the operation, he was brought to the
CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He
maintained stable hemodynamics and transferred to the SDU on
postoperative day one. He was followed closely by the renal
service and continued on hemodialysis throughout post-op course.
Chest tubes were removed on post-op day two and epicardial
pacing wires on post-op day three. Antibiotics were started for
UTI on post-op day three. But since yeast was grown in urine
culture, Fluconazole was started and he will needs a 14 day
course. He worked with physical therapy during post-op course
for strength and mobility. Over next several days he continued
to slowly recover receiving blood transfusions with dialysis and
remained anuric. On [**4-12**] he underwent a renal biopsy which is
initially negative for rejection.
He was ready for discharge home on
Medications on Admission:
prograf 2 mg [**Hospital1 **]
cellcept [**Pager number **] mg TID
valcyte 450 mg twice weekly (Tu/Fri)
Bactrim SS once daily
nystatin 5 mL four times daily
protonix 40 mg daily
unithroid 175 mcg daily
renagel 2400 mg TID with meals
nephrocaps 1 cap daily
carvedilol 25 mg [**Hospital1 **]
plavix 75 mg daily
finasteride 5 mc once daily
hydrocodone/acetaminophen 1-2 tabs every 4 hours as needed for
pain
aspirin 325 mg daily
lantus 10 U daily with breakfast
humalog sliding scale QACHS
lipitor 40 mg daily
lasix 40 mg once daily
procrit [**Numeric Identifier 961**] U once weekly
omeprazole 20 mg once daily
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
every twelve (12) hours.
Disp:*120 Tablet(s)* Refills:*0*
2. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*0*
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(WE,SA).
Disp:*60 Tablet(s)* Refills:*10*
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 ML(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. 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*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
12. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-20**]
hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
15. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 12 days.
Disp:*12 Tablet(s)* Refills:*0*
16. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*qs 1 month* Refills:*0*
17. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease - s/p CABG
Chronic Congestive Heart Failure(Mixed - Systolic, Diastolic)
Acute Myocardial Infarction
End Stage Renal Disease s/p Renal Transplant [**2185-2-12**]
Hypertension
Elevated Cholesterol
Type II Diabetes Mellitus
Carotid Disease
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in in [**3-19**] weeks, call for appt
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 53321**] ([**Telephone/Fax (1) 68829**] in [**1-16**] weeks, call for appt
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4334**] [**Telephone/Fax (1) 45347**] in [**1-16**] weeks, call for appt
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2185-4-18**] 1:20
Completed by:[**2185-4-13**]
|
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icd9cm
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[
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282, 305
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2879, 3076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,783
| 135,101
|
1348
|
Discharge summary
|
report
|
Admission Date: [**2136-2-7**] Discharge Date: [**2136-2-23**]
Date of Birth: [**2067-4-8**] Sex: M
Service: MEDICINE
Allergies:
Betadine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Dyspnea, found to have new ARF
Major Surgical or Invasive Procedure:
Cystoscopy
Bilateral percutaneous nephrostomy tube placement (with revision
on left)
IVC filter placement
Thoracentesis- diagnostic and therapeutic
PICC placement
History of Present Illness:
68 yo male with pmh of sCHF (EF 45%), DM, metastatic prostate
cancer, htn, urinary incontinence s/p artificial sphincter, and
chronic back pain s/p multiple surgeries presents with dsypnea
to the ED and found to have new ARF.
The patient states he has had worsening DOE for a few days as
well as wheezing. No cough, fevers, orthopnea, edema, PND;
sleeps with one pillow. Also states he has be forgetful for the
past few days; will forget what is said in the middle of a
conversation. Admits to sever pain in his back and decreased
motility. Used to use two canes to walk, now requires a walker
and has trouble standing. Of note, has been taking clonazepam a
few times over the past few days (more then usual) for anxiety.
Also admits to jerking movements of his arms which he can't
control. Admits to nausea and slight vomiting; no blood in his
vomit; as well as anorexia and itchiness.
In the ED, VS: T 96.1 BP 134/65 HR 54 RR 20 Sat 98% on RA.
Labs revealed a Cr of 8.3 and hyperkalemia to 6.3. Was given 1
gm IV calcium gluconate, D5/10 units of regular insulin,
kayexalate 30 gm x 1 and his K decreased to 5.0. Also given 2 L
NS and was transfused 1 unit of PRBCs. Became hypoglycemic and
was given an amp of D50.
Currently, he denies shortness of breath.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria. Admits to 10 lb weight loss
since the fall.
Past Medical History:
1. Metastatic prostate cancer (diagnosed in mid1-[**2117**]'s) to the
spine with history of cord compression, status-post radical
prostatectomy, radiation therapy, steroid therapy, and
chemotherapy with mitoxantrone.
2. Type 1 diabetes mellitus
3. Hypertension
4. H/o urinary incontinence s/p artificial sphincter
5. Herpes simplex virus stomatitis
6. Radiation esophagitis.
7. Colonic polyps
8. History of cervical spinal stenosis as well as chronic low
back pain and facet arthropathy; previously followed in the
[**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**] Clinic where cervical epidural steroid injections
last summer showed improvement but thoracic and lumbar
injections
exacerbated his pain.
9. S/p vertebroplasty at T10 to L1 for tumor invasion of the
vertebral bodies
10. History of upper GI bleed ([**2134**])
11. History of DVT previously on coumadin but stopped "a while
ago" after 6 months (per pt) due to difficulty controlling
levels
12. History of sCHF related to chemotherapy drugs
13. Status-post T8 kyphoplexy, [**11/2135**]
Social History:
Social history is significant for the absence of current tobacco
use. Pt quit smoking in [**2119**] wth a history of 45-pack-year.
There is no history of alcohol abuse.
The patient is a retired software engineer who lives in
[**Location 8242**] with his wife. His two sons and one daughter live
nearby.
Family History:
Uncle with prostate cancer. No family history of premature
coronary artery disease or sudden death.
Physical Exam:
Vitals - T: 94.7 po, 93.9 axillary BP: 140/70 HR: 116 RR: 20 02
sat: 97% on 2L
GENERAL: Elderly male sitting in bed in NAD, but very sleepy.
Slow to answer, eyes close frequently.
HEENT: Normocephalic, atraumatic. Conjunctival pallor present.
No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD.
CARDIAC: RRR. no MRG, no rub present
LUNG: Decreased breath sounds throughout. Patient breathing
comfortably, able to talk in full sentences.
ABDOMEN: + BS, soft, slight distension, nontender. Asterixis
present.
EXT: No edema prsent, wearing compression stockings.
NEURO: Sleepy, CN II- XII intact. 5/5 strength in his upper
and lower extremities, sensation to light touch intact
throughout. Frequent jerking of his arms. 2+ knee, achilles and
bicep reflexes. equivical babinskis
DERM: Bruises present over his extremities.
RECTAL: normal rectal tone, guaiac negative
Pertinent Results:
[**2136-2-7**] 08:30AM GLUCOSE-133* UREA N-97* CREAT-8.3*#
SODIUM-122* POTASSIUM-6.3* CHLORIDE-VERIFIED B TOTAL CO2-20*
[**2136-2-7**] 08:30AM CK(CPK)-249*
[**2136-2-7**] 08:30AM cTropnT-0.05*
[**2136-2-7**] 08:30AM CK-MB-14* MB INDX-5.6 proBNP-GREATER TH
[**2136-2-7**] 08:30AM WBC-5.8 RBC-2.57* HGB-8.2* HCT-23.9* MCV-93
MCH-32.0 MCHC-34.4 RDW-14.4
[**2136-2-7**] 08:30AM NEUTS-85.9* LYMPHS-7.1* MONOS-4.4 EOS-2.3
BASOS-0.3
[**2136-2-7**] 08:30AM PLT COUNT-309
[**2136-2-7**] 10:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2136-2-7**] 10:00AM URINE RBC-[**6-13**]* WBC-[**3-8**] BACTERIA-NONE
YEAST-NONE EPI-0
[**2136-2-7**] 11:35AM URINE HOURS-RANDOM UREA N-452 CREAT-61
SODIUM-29
[**2136-2-7**] 11:35AM URINE OSMOLAL-351
Pleural fluid cytology [**2-15**]: NEGATIVE FOR MALIGNANT CELLS.
Micro:
[**2136-2-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-2-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2136-2-19**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-2-19**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-2-15**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL;
ANAEROBIC CULTURE-FINAL INPATIENT
[**2136-2-13**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2136-2-12**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2136-2-11**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2136-2-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2136-2-10**] URINE,KIDNEY FLUID CULTURE-FINAL {ESCHERICHIA COLI}
INPATIENT
[**2136-2-10**] URINE,KIDNEY FLUID CULTURE-FINAL {ESCHERICHIA COLI}
INPATIENT
[**2136-2-10**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
INPATIENT
[**2136-2-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL INPATIENT
[**2136-2-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL INPATIENT
[**2136-2-8**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2136-2-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2136-2-7**] URINE URINE CULTURE-FINAL
Imaging:
CXR [**2-7**]: Cardiomegaly with left lower lobe airspace disease
likely
representing atelectasis and vascular crowding. However,
pneumonia cannot entirely be excluded.
Renal US [**2-7**]: Bilateral moderate hydronephrosis unchanged from
prior study.
Head CT ([**2-9**]): 1. Study limited by motion artifact. Within this
limitation, no acute hemorrhage, large vascular territory
infarction, or large mass seen.
2. Right Sylvian fissure hypodensity which may be volume
averaging; however, MRI is more sensitive for the detection of
small metastases or acute ischemia.
3. Probable chronic sinus disease.
Lower extrem US ([**2-9**]): Left peroneal, deep venous thrombosis,
likely acute.
CT abd/pelvis ([**2-9**]): 1. Progressive retroperitoneal
lymphadenopathy with vaguely defined soft tissue densities and
surrounding fat stranding, accounting for obstruction of each
ureter. The appearance is most suggestive of retroperitoneal
fibrosis associated with malignant lymphadenopathy and
infiltration.
2. Mostly stable appearance of bony metastatic disease noting
interval compression fractures apparently treated before with
vertebroplasty.
3. New pleural effusions with a small amount of ascites and
anasarca, a state of diffuse edema.
CTA ([**2-15**]):
1. No evidence of pulmonary embolism.
2. Findings consistent with congestive heart failure including
cardiomegaly, moderate dependent bilateral pleural effusions and
peribronchovascular and peripheral septal interstitial
thickening.
3. 5-mm left upper lobe pulmonary nodule partly obscured by the
left pleural effusion but appears new from [**2134-2-4**].
Three-month chest CT followup is recommended after diuresis to
distinguish nodular atelectasis from a true lung nodule.
4. Dependent atelectasis of both lower lobes, left worse than
right.
5. Extensive coronary artery calcifications.
6. Underlying mild-to-moderate centrilobular emphysema.
7. Numerous sclerotic lesions of the thoracic skeleton
compatible with known metastatic prostate cancer.
8. A large subcarinal lymph node and other mediastinal nodes at
the upper
limits of normal in size may be related to congestive failure.
These can be reassessed at the time of pulmonary nodule
followup.
CXR ([**2-19**]):
There is dense retrocardiac opacity with moderate left effusion
and
patchy alveolar infiltrates in the right lower lung and left mid
lung.
Compared to the film from four days ago, the infiltrates appear
slightly
worse. The right PICC line is unchanged with tip in the right
atrium.
Brief Hospital Course:
68 yo male with pmh of sCHF (EF 45%), DM, metastatic prostate
cancer, htn, urinary incontinence s/p artificial sphincter, and
chronic back pain s/p multiple surgeries presents with dsypnea
and found to have post-obstructive ARF which improved following
nephrostomy tube placement, complicated by acute LE DVT, GNR
bactermia, and HAP.
# Acute renal failure: Patient presented to the ED with many
symptoms consistent with uremia, and renal US showed b/l
hydronephrosis consistent with post-renal obstruction. FENA
3.2%. Foley initially was placed with urine flow and some
improvement in BUN & Cr. He was hyperkalemic on presentation
and treated in the ED. Renal and [**Month/Year (2) **] were consulted. On HD
#2, he became oliguric and hyperkalemic, and CT abd/pelvis w/o
contrast demonstrated retroperitoneal LA and metastatic
retroperitoneal fibrosis. [**Month/Year (2) 159**] took pt to OR to perform
cystoscopy, but was unable to place ureteral stents. Following
this, IR successfully placed bilaterally percutaneous
nephrostomy tubes. The right tube began putting out ample
urine, while the left tube was found to put out scant, bloody
urine. Two days after initial placement, IR repositioned the
left tube. Following PCN tube placement, the pt went through
post-obstructive diuresis with largely resolved ARF, during
which time his fluid deficit was replaced and electrolytes were
closely monitored and repleted PRN. His Cr decreased to 1.1 by
the time of discharge.
# GNR bacteremia: The patient was found mid-way through his
hospital course to have GNR in his urine from the left
nephrostomy tube and in also in his blood. Likely he developed
infection in his left kidney due to obstruction which caused the
bacteremia. He was initially covered with vanc/zosyn, which was
switched to Cipro following GNR speciation (E. coli) with
pan-sensitivity (this was changed back to vanc/zosyn after the
development of a HAP). Further BCx and UCx were without growth.
# Left LE acute DVT: The patient had swelling of his left LE
and was found to have an acute peroneal DVT. Anticoagulation
was deferred given the prcedures necessary to relieve his renal
obstruction and also a previous history of difficult to control
INR when on coumadin in the past. IVC filter was ultimately
placed by IR without complications.
# Hospital-acquired PNA: The patient developed low-grade fever
for which a CXR demonstrated a left lower lobe pneumonia on
[**2-19**]. He remained asymptomatic with no bump in his WBC count.
He was started on Vanc/Zosyn for hospital-acquired pneumonia and
Gram-negative coverage, given his hx of GNR bacteremia. The pt
remained afebrile following broad antibiotic coverage.
# Dyspnea: Patient originally presented with worsening dyspnea.
[**Month (only) 116**] be related to multiple factors including anemia, acute on
chronic heart failure, and volume overload. Dyspnea improved
following diuresis, but pt experienced an acute decompensation
on HD #8, during which time he was presumed to be in flash
pulmonary edema, given large IVF replacement with his
post-obstructive diuresis, or PE, given his known acute thrombus
despite IVC filter placement. He was placed on 15L O2 via face
mask, CXR demonstrated some perihilar fullness as well as small
L pleural effusion, and EKG demonstrated no acute changes. He
was given Lasix, Nitro, and ASA, and cardiac enzymes were sent,
which were unremarkable. Following CTA, he was transferred to
the ICU for closer management. Unremarkable CTA ruled out PE,
and he was presumed to be volume overloaded with pulmonary
edema. Following adequate diuresis, his respiratory status
returned close to baseline.
# Anemia: Patient with a Hct of 23.9 on admission, baseline Hct
ranges 26-30, likely due to decreased production given
metastatic prostate cancer. MCV 93. Received 1 unit of PRBC in
the ED. Coags remained essentially normal throughout course of
admission, and Hct remained stable at 23-24 following initial
transfusion. Following PCN tube placement, Hct dropped to 21.6,
for which 2 units PRBCs were given. There was no clinical
evidence of bleeding except from the left nephrostomy tube.
Following transfusion, Hct was stable around 23-28.
# Electrolyte abnormalities: Patient with an AG of 16 at
admission. Likely secondary to uremia due to his acute renal
failure. Also hyperkalemic, treated with kayexalate, and
hyponatremic, likely secondary to volume overload. Once renal
obstruction was relieved, pt underwent post-obstructive diuresis
during which time electrolytes were closely monitored and
repleted as necessary.
# Altered mental status: Patient was very sleepy and somewhat
confused during hospitalization, likely due to combination of
factors: uremia, hyponatremia, hypoglycemic episodes, and
increased serum concentrations of home benzos and pain meds
given compromised renal function. Benzos were avoided and
opioids minimized during admission. Head CT demonstrated no
evidence of hemorrhage or large mass, but did indicate small
hypodensity at Sylvian fissure, and met could not be completely
ruled out. Hypoglycemic episodes were minimized and drugs
renally-dosed to minimize iatrogenic contributions. As uremia,
electrolyte disturbances, and hypoglycemic episodes resolved,
patient's mental status improved.
# Acute on chronic systolic heart failure (non-ischemic):
Patient with an EF of 45% on his last TTE and a BNP on admission
of > 70,000. Pt continued on metoprolol, and lasix and ACEi
were held given compromised kidney function. He experienced an
acute decompensation as described above. However, following
resolution of volume overload, lasix and ACEi were re-started.
# Multi-focal atrial tachycardia: Over course of
hospitalization, pt developed persistent tachycardia that, on
EKG, demonstrated evidence of MAT vs. PACs. He endorsed some
SOB during tachycardic episodes, and episodes responded well to
5 mg IV lopressor pushes. Additionally, metoprolol regimen was
increased to 100 mg TID from 50 mg [**Hospital1 **], to which the pt
responded well with decreased episodes of tachycardia.
# DM: Patient is on insulin as an outpatient, however given his
hypoglycemic episode in the ED, his decreased PO intake due to
his anorexia, and his impaired renal function, his lantus and
sliding scale were diminished. Blood sugar was monitored with
qid fingersticks. Upon improving kidney function, patient
developed hyperglycemia during which time his insulin was
titrated back up towards his home dose.
# Metastatic prostate cancer: Followed by Dr. [**Last Name (STitle) **]. On
leupron as an outpatient. Last dose was about 1-1.5 months ago.
# Chronic back pain s/p multiple surgeries: Patient complains
of back pain currently. Given his altered mental status and ARF
on admission, his home pain regimen was decreased his chronic
home opiod regimen: morphine SR 60 mg tid (was on 100 mg tid)
and oxycodone 30 mg po q4h prn (was on 60 mg q4h prn).
Uptitrated his regimen back to his home regimen once his renal
failure improved.
# Pulmonary nodule: The patient was seen on CTA to have a 5 mm
pulmonary nodule of unknown significance. His primary doctor
and oncologist were informed of the finding and he will follow
up with them for continued care.
# Code: Full code, confirmed with the patient
Medications on Admission:
Clonazepam 0.5 mg po tid prn anxiety
Lasix 20 mg po daily
Glucagon prn hypoglycemia
Lantus 10 units qam
Lispro Sliding scale
Leuprolide q3 months
lisinopril 20 mg po daily
Lorazepam 0.5 - 1 mg qhs prn insomnia - is out of this
medication now
Metoprolol 100 mg po daily
Morphine SR 100 mg po tid
Oxycodone 60 mg po qid prn pain
Pantoprazole 40 mg po daily
ASA 81 mg daily
Biscodyl 2 tab daily prn
Colace 100 mg po daily
senna 1 tab daily prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
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. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Three (3)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 10 days: Last day is
[**3-3**].
13. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours) for 10 days: Last
day is [**3-3**].
14. Oxycodone 30 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for pain.
15. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) Units
Subcutaneous qAM.
16. Insulin Lispro 100 unit/mL Solution Sig: 1-15 Units
Subcutaneous ss.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary:
-Acute renal failure secondary to obstruction from malignant
peritoneal fibrosis
-Deep venous thrombosis
-E coli UTI and bacteremia
-Hospital-acquired pneumonia
-Acute on chronic systolic heart failure
Secondary:
-Diabetes
-Hypertension
-Chronic back pain
-Metastatic prostate cancer
Discharge Condition:
Stable
Discharge Instructions:
You were seen in the hospital with acute renal failure due to
obstruction of your ureters (the tubes that run from your
kidneys to your bladder). In order to relieve this obstruction,
tubes were placed directly into both of your kidneys, and your
acute renal failure has resolved following this procedure.
Also while you were in the hospital, you were noted to have a
deep venous thrombosis, or blood clot, in a vein in your left
calf. A filter was placed in a large vein, called the inferior
vena cava (IVC), to prevent the blood clot from dislodging and
ending up in a place such as your lungs. You were not placed on
anticoagulation given the on going bleeding from the nephrostomy
tubes.
Finally, you were found to have a rapid heart rate occasionally,
known as tachycardia, for which the doses on some of your home
medications were adjusted. You also had a period of congestive
heart failure with fluid on your lungs due to this rapid heart
rate as well as fluid overload. This resolved with medications
intended to pull the extra fluid off of your lungs.
Also while you were in the hospital, bacteria was found both in
your blood and in your urine for which you were started on an
antibiotic. After starting this medication, your blood and
urine have no shown any evidence of bacteria. Finally, you were
found on chest x-ray to have pneumonia in your left lung, for
which we are treating you with two antibiotics given IV through
your PICC line.
Medication changes:
1. Your metoprolol was increased to 100 mg three times a day
from your previous dose of 100 mg once each day.
2. Your lisinopril was decreased to 5 mg each day from your
previous dose of 20 mg each day.
3. Your clonazepam and lorazepam were discontinued during your
hospitalization. Please be in touch with your primary care
provider regarding restarting these medications if you feel the
need to do so.
Please contact your doctor or return to the emergency department
in the case of: chest pain, shortness of breath,
lightheadedness, decreased urine output from your nephrostomy
tubes, confusion or feeling "foggy", or any concerns you may
have.
Please be sure to empty your bladder 3 times a day by
decompressing your artificial urethral sphincter.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1200mL
Followup Instructions:
You will need to follow-up in the [**Hospital 159**] clinic:
We have scheduled an appt for you with Dr. [**Last Name (STitle) 770**] in [**Last Name (STitle) 159**]
for [**2136-3-7**] at 10AM in the [**Hospital 159**] clinic on the [**Location (un) 470**]
of the [**Hospital Ward Name 23**] Building at [**Hospital1 18**].
If you need to change the appointment, please call
[**Telephone/Fax (1) 8243**].Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**]
Date/Time:[**2136-3-7**] 10:00
You will need to followup with Interventional Radiology for
replacement of your nephrostomy tubes in approximately 3 montsh.
An appointment was made for you:
This is scheduled for 8:30 am on [**2136-5-16**]. Please do not eat from
midnight the night before. You should report to the Day Care
Center on the [**Location (un) 448**] of the [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 517**]
[**Hospital1 18**]. You will need a ride home. If you have questions or
problems, please page the Interventional Radiologist on call
anytime at pager [**Numeric Identifier 5603**].
Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**]
Date/Time:[**2136-5-16**] 10:00
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2136-2-23**]
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27,362
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33059
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Discharge summary
|
report
|
Admission Date: [**2179-1-20**] Discharge Date: [**2179-2-2**]
Date of Birth: [**2158-5-11**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Hypertensive Emergency
Major Surgical or Invasive Procedure:
Hemodialysis.
Renal biopsy.
History of Present Illness:
HPI: 20-year-old female with MPGN s/p renal transplant ([**7-13**])
and recurrent MPGN who was recently transferred from [**Hospital1 336**] to
[**Hospital1 18**] from [**Date range (3) 76868**] with acute renal failure. During her
hospitalization, her blood pressure was difficult to control and
her medications were titrated up (hydralazine was added and
nifedipine was added as a prn with instructions to check bp at
home). She was having headaches which may have been related to
this. There was a question of whether she may be hemolyzing from
hypertension and hematology was consulted for this. Hematology
reviewed records from [**Hospital1 336**] where she had a similar presentation
and the therapy focused on controlling her bp. She was started
on [**Hospital1 **] for the MPGN. She underwent embolization of an AV
fistula to the upper pole of her grafted kidney with the hope
that this might help restore some renal function unfortunately,
her creatinine increased from 4's->6.3. This remained stable,
however, for several days and slowly started decreasing, the
rest of her electrolytes remained stable. She also underwent a
couple of blood transfusions for low hematocrit.
.
Given that her creatinine remained stable and her blood pressure
had stabilized on the modified anti-hypertensive regimen, she
was discharged on [**1-19**]. On [**1-20**], pt was seen by her primary care
physician complaining of headache, nausea, vomiting and eyelid
bruising, right eye blurriness. Her blood pressure in the [**Hospital 3782**]
clinic was 220 systolic. She was sent to [**Hospital1 18**] ED.
.
ED: Initial VS 98.5 77 [**Telephone/Fax (2) 76869**]0% RA. Head CT: no acute
changes. Given labetalol 260mg IV, enalapril IV, clonidine
patch, and hydralazine IV, morphine, and zofran. Ophthalmology
consulted in ED, found severe hypertensive retinopathy,
periorbital ecchymosis also likely related to HTN, no emergent
intervention recommended. Was seen by renal fellow, recs
nitroprusside gtt if BP >180/100, change clonidine patch if BP
control, increase hydralazine to 50mg TID otherwise condinuing
other home BP and other meds, 1/2 NS for hypernatremia, chem 10
in am.
.
The patient reports a history of migraines, stating that they
occur qmonthly with her periods and are associated with nausea
and vomiting. They are improved with tylenol and percocet. She
will have HA associated with HTN, but it is difficult for her to
differentiate which comes first. This HA was similar in nature
to her migraines however not occuring with her period. She
started vomiting yesterday at midnight, reports vomiting Q
30minutes throughout the day. States that her vision hadn't been
a problem in the past. No recent illness or sick contacts. [**Name (NI) **]
recent travel. No cough, SOB, fevers, chills, diarrhea,
constipation, dysuria, hematuria or decrease in UOP. Endorses
medication compliance. States that her HA improved with
"something I got in the ED." Currently no N/V, "I'm tired."
.
The patient was transferred to the ICU for continued BP
monitoring. In ICU BP 150s on nitroglycerine gtt. Pt continued
on home BP meds.
Past Medical History:
1)MPGN: diagnosed age 9 by bx s/p LRRT age 18 complicated by
worsening renal function age 20. Biopsy late [**2177**] showed
recurrent MPGN in transplant kidney.
2)Peripheral edema [**1-9**] steroids.
3)HTN [**1-9**] steroids and renal disease.
4)Menstrual migranes.
Social History:
Lives at home with [**Month/Day (2) **], brother and sister, college student
at [**Name (NI) 498**] [**Name (NI) 86**] in the health sciences. Denies ETOH, illicit
drugs, tobacco.
Family History:
No history of kidney disease, malignancy, heart disease, or
diabetes.
Physical Exam:
VS: Temp: BP:157/90 HR:89 RR:10 O2sat 93%
GEN: young woman, lying in bed, eyes closed, pale
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions, righy
eyelid ecchymoses.
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, 2/6 systolic ejection murmur at base,
does not radiate.
CHEST: no CVA tenderness, right tunneled catheter line in place
(per pt placed in [**10-15**])
ABD: nd, +b/s, soft, nt, no hepatosplenomegaly, transplanted
kidney on RLQ, non-tender, no bruit or erythema. + ecchymoses
over scar c/w site of prior coil embolization.
EXT: warm, good pulses, trace pedal edema.
SKIN: no rashes/no jaundice, pale with delayed capillary refill.
NEURO: AAOx3. No focal deficits. No meningismus.
Pertinent Results:
[**2179-1-20**]:CT HEAD: FINDINGS: There is no evidence of acute
intracranial hemorrhage, shift of midline structures, or
hydrocephalus. [**Doctor Last Name **]-white matter differentiation is grossly
preserved. Visualized paranasal sinuses are normally aerated.
IMPRESSION: No evidence of acute intracranial hemorrhage. Lumbar
puncture would be necessary to exclude microscopic quantities of
blood or meningitis.
[**2179-1-21**]: CXR: 1. Left basilar opacity, most likely due to
atelectasis and perhaps with an effusion, although the
possibility of infection cannot be excluded in the appropriate
clinical setting. If infection is suspected, PA and lateral
views could be helpful to evaluate further.
2. Mild cardiomegaly.
[**2179-1-21**]: TTE The left atrium is normal in size. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 70%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is a small pericardial effusion. The effusion appears
circumferential. No right ventricular diastolic collapse is
seen. There is brief right atrial diastolic invagination. There
is significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling.
Impression: small pericardial effusion with evidence of somewhat
impaired ventricular filling.
.
CHEST (PA & LAT) Study Date of [**2179-1-22**] 9:07 PM
FINDINGS:
There is a central venous catheter in situ. Position is
unchanged compared to prior radiograph. The cardiac shadow is
markedly enlarged. There has been an increase in apparent
cardiac size compared to radiograph yesterday. This acute
change is worrisome for the development of a pericardial
effusion. Note is also made of mild increase in perihilar
vascular markings compared to prior study. There is no evidence
of pleural effusion. There is left basal atelectasis
correlating with the finding demonstrated on previous chest
radiograph. There is no significant pleural effusion.
IMPRESSION: Cardiomegaly which has progressed from previous
chest radiograph one day earlier suggesting the interval
development of a pericardial effusion. Echocardiogram is
recommended.
.
Portable TTE (Focused views) Done [**2179-1-23**] at 12:33:05 PM
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/ lobal systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
PERICARDIUM: Small to moderate pericardial effusion. Effusion
ircumferential. No echocardiographic signs of tamponade.
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a small (0.7cm inferior and inferolateral to the LV;
1.1cm around the right atrium; 0.5cm anterior to the right
ventricle and around the apex) echolucent circumferential
pericardial effusion without echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of [**2179-1-21**], the
findings are similar.
[**2179-1-19**] 05:45AM BLOOD WBC-6.0 RBC-2.63* Hgb-7.3* Hct-22.9*
MCV-87 MCH-27.7 MCHC-31.9 RDW-17.2* Plt Ct-162
[**2179-1-20**] 01:30PM BLOOD Neuts-84.5* Lymphs-8.2* Monos-5.6 Eos-1.5
Baso-0.1
[**2179-1-19**] 05:45AM BLOOD PT-13.1 PTT-29.3 INR(PT)-1.1
[**2179-1-19**] 05:45AM BLOOD Fibrino-174#
[**2179-1-19**] 05:45AM BLOOD Glucose-95 UreaN-57* Creat-6.3* Na-137
K-4.8 Cl-106 HCO3-23 AnGap-13
[**2179-1-19**] 05:45AM BLOOD ALT-4 AST-8 LD(LDH)-244 AlkPhos-21*
TotBili-0.5
[**2179-1-20**] 01:30PM BLOOD ALT-7 LD(LDH)-586* CK(CPK)-58 AlkPhos-33*
TotBili-0.8
[**2179-1-21**] 01:50AM BLOOD CK(CPK)-34
[**2179-1-20**] 01:30PM BLOOD CK-MB-3 cTropnT-<0.01
[**2179-1-21**] 01:50AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2179-1-19**] 05:45AM BLOOD Calcium-8.5 Phos-5.2*
[**2179-1-21**] 01:50AM BLOOD Calcium-8.5 Phos-5.5* Mg-1.4*
[**2179-1-20**] 01:30PM BLOOD Hapto-<20*
[**2179-1-20**] 01:30PM BLOOD HCG-<5
[**2179-1-19**] 05:45AM BLOOD FK506-4.5*
[**2179-1-21**] 01:50AM BLOOD FK506-2.3*
Brief Hospital Course:
Ms. [**Known lastname 76867**] is a 20-year-old female with a h/o MPGN-type I s/p
living donor renal transplant ([**7-13**]) now with allograft failure
[**1-9**] rejection or recurrence of MPGN, with recent admission for
acute renal failure and difficult to control HTN, returning 1
day after discharge ([**1-20**]) with severe hypertension, HA, N/V,
eye swelling and blurriness, called out of the MICU with
controlled BPs. Blood pressure improved with oral medications,
hemodialysis was initiated, and patient underwent diagnostic
renal biopsy.
.
#) Hypertension: Patient was recently admitted to the MICU at
[**Hospital1 336**] for malignant hypertension and required IV medications. She
then transferred her care to [**Hospital1 18**] and was admitted for acute on
chronic renal failure and elective plasmapheresis, she had
difficult to control blood pressures during her last admission.
This is likely [**1-9**] underlying renal issues and steroid use. She
has been previously worked up for secondary HTN. Patient's
long-standing renal issues and subsequent HTN have resulted in
retinopathy and impaired ventricular filling. BPs have been
better controlled on oral BP meds. Throughout her hospital stay,
she did continue to have elevated blood pressures (reaching
190-200s). Several changes to her medication regimen were made
during this hospitalization, including addition of labetalol,
captopril, increased dose of furosemide & hydralazine, and D/C
metoprolol & nifedipine. Antihypertensives were given earlier in
the morning in response to elevated BP right before receiving
her morning medications. Aldosterone results are still pending.
Per ophthalmology, she should follow-up as an outpatient for
retinopathy.
.
#) Acute renal failure/Type I MPGN: Patient has a h/o MPGN-type
I s/p renal transplant now with most likely recurrence in
transplanted kidney. She had nephrotic range proteinuria
(Protein:creatinine ratio=7.9) on admission. She was started on
hemodialysis to allow renal recovery and monitor creatinine
trend. Epoetin and sodium bicarb were given in dialysis.
Plasmapheresis was held during admission. Captopril was also
initially held given possible reaction with apheresis membrane
(also contraindicated given hyperkalemia initially), but then
readded. Creatinine range was 3.5-7.2. Patient was continued on
calcitriol, folic acid, renal diet, Kayexalate prn, and lasix. A
renal biopsy was done and patient respond well to it, with
minimal hematuria and moderate pain. Hemodialysis will be
continued as an outpatient in [**Hospital1 8**]. Calcium carbonate and
sodium bicarbonate was D/C'd per renal team and ferrous sulfate
PO will now be given in IV iron form at hemodialysis. Renal
biopsy showed recurrance of her MPGN in the transplanted kidney.
She will follow up with Dr. [**Last Name (STitle) **] and likely will undergo
surgical removal of her transplanted kidney in the near future.
.
#) Pericardial effusion: First TTE revealed a small
circumferential pericardial effusion with evidence of impaired
ventricular filling, no RV collapse. CXR on [**2179-1-22**] revealed
increase in pericardial shadow from previous. Repeat TTE on
[**2179-1-23**] showed similar findings of pericardial effusion as
previous TTE, no signs of cardiac tamponade. Pulsus paradoxes
were 5-8mmHg. Per cardiology, patient can follow-up with an
outpatient echo.
.
#)Anemia: Hematology was consulted during last admission, and
thought hemolysis was likely attributed to malignant
hypertension, and a possible component of medication side
effects from Prograf. LDH was elevated and haptoglobin low,
which is consistent with hemolysis. Per renal fellow, she had
negative Coombs antibody test on during the last admission.
Initially, hct was monitored [**Hospital1 **], she had a drop to 20 and was
transfused 1unit pRBCs. Her hematocrit stabilized to 24-26, and
she remained hemodynamically stable throughout the rest of her
hospital stay. IV iron and epoetin will now be given while in
dialysis.
.
#) Immunosuppression: Renal biopsy showed recurrence of MPGN in
her transplanted kidney. She was discharged on Prednisone,
CellCept and Prograf.
.
#) Headache: Patient denied migraine symptoms (photophobia) but
did report some nausea. This is likely related to hypertensive
urgency/emergency. Head CT performed and showed no acute
changes. Not suspicious for meningitis as no leukocytosis,
fevers, meningismus, sick contacts. She did report several
headaches while on the floor, not all associated with elevated
BP. Tylenol and Percocet prn controlled her pain.
.
#)Contact: [**Name (NI) 6961**]:
Next of [**Doctor First Name **]: [**Name (NI) **],[**First Name3 (LF) **]
Relationship: MOTHER
Phone: [**Telephone/Fax (1) 76870**]
[**Name2 (NI) **] Phone: [**Telephone/Fax (1) 76871**]
W [**Telephone/Fax (1) 76872**]
Next of [**Doctor First Name **]: [**Known lastname **],[**First Name3 (LF) **]
Phone: [**Telephone/Fax (1) 76873**]
Other Phone: [**Telephone/Fax (1) 76874**]
Medications on Admission:
Losartan 50 mg Tablet Sig: 1.5 Tablets PO BID
Clonidine 0.4 mg/24 hr Patches qWed
Furosemide 20 mg PO BID
Metoprolol Tartrate 100 mg PO BID
Isradipine 15 mg PO BID
Hydralazine 25 mg PO TID
Nifedipine 10 mg PO Q6H prn SBP>160.
Prednisone 5 mg Tablet PO EVERY OTHER DAY
Mycophenolate Mofetil 250 mg PO BID
Tacrolimus 4 mg PO Q12H
Calcitriol 0.25 mcg PO DAILY
Folic Acid 1 mg PO DAILY
Ferrous Sulfate 325 mg PO TID
Calcium Carbonate 1000 mg PO DAILY
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H prn
Sodium Bicarbonate 1300 mg PO qAM, 650 mg Po QPM
Epoetin Alfa 10,000 UNITS Injection QMOWEFR
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
Disp:*4 Patch Weekly(s)* Refills:*2*
3. Losartan 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
4. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours: Please check your blood pressure before taking this
[**Last Name (LF) **], [**First Name3 (LF) **] not take if your blood pressure is less than 120.
Disp:*3 Tablet(s)* Refills:*2*
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
8. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day): please check your blood pressure before taking this
[**Last Name (LF) **], [**First Name3 (LF) **] not take if your blood pressure is less than 120.
Disp:*270 Tablet(s)* Refills:*2*
9. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO three times
a day.
Disp:*270 Capsule(s)* Refills:*2*
10. Tacrolimus 0.5 mg Capsule Sig: Five (5) Capsule PO Q12H
(every 12 hours).
Disp:*300 Capsule(s)* Refills:*2*
11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Hypertensive emergency
.
Secondary diagnosis:
1)MPGN: diagnosed age 9 by bx s/p LRRT age 18 complicated by
worsening renal function age 20. Biopsy late [**2177**] showed
recurrent MPGN in transplant kidney.
2)Peripheral edema [**1-9**] steroids.
3)HTN [**1-9**] steroids and renal disease.
4)Menstrual migranes.
Discharge Condition:
stable
BP 112/72 prior to discharge
Discharge Instructions:
You were admitted for a hypertensive emergency. While you were
in the hospital you were managed for severe hypertension and
many medication changes were made. Hemodialysis was also started
per the renal team in order to manage volume status and kidney
failure. A renal biopsy was done in order to figure out the
cause of the kidney failure.
You are being discharge discharged on several new blood pressure
medications. Please take as discussed with the kidney doctors.
Before taking captopril and hydralazine please check your blood
pressure, do not take these medications if your blood pressure
is less than 120.
You have been set up for dialysis monday wednesday and fridays
at the [**Hospital1 8**] dialysis center. Your first session is
tomorrow, please arrive at 11.
Please call your doctors [**Name5 (PTitle) **] return to the hospital if you
experience any concerning symptoms including blood pressure that
is too high >150 despite taking your medication or <100, severe
headache, confusion, fevers, or any other worrisome symptoms.
Followup Instructions:
Your dialysis has been arranged at [**Hospital1 8**] fro Monday,
Wednesday and Friday. They are expecting you for your first
session tomorrow, Wednesday [**2-3**], at 11:00.
.
You will be seeing Dr. [**Last Name (STitle) **] weekly for the next several
weeks to monitor your blood presssure.
Dr.[**Name (NI) 17254**] secretary is working on making you an
appointment for next week. Please call the office at
[**Telephone/Fax (1) 673**] tomorrow to find out the date and time of the
appointment. They are aware that you need an appointment on a
tuesday or thursday.
You have an appointment already scheduled for the following
week:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-2-18**] 10:00
.
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2179-2-8**] 2:40
.
Please follow-up with your PCP within one week after discharge
from the hospital.
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
[
"285.21",
"581.2",
"V42.0",
"784.0",
"585.6",
"584.9",
"V58.65",
"403.01",
"311",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.23",
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
16811, 16817
|
9596, 14583
|
354, 383
|
17192, 17230
|
4982, 4998
|
18324, 19403
|
4034, 4105
|
15229, 16788
|
16838, 16838
|
14609, 15206
|
17254, 18301
|
4120, 4963
|
292, 316
|
411, 2067
|
5007, 9573
|
16903, 17171
|
2076, 3531
|
16857, 16882
|
3553, 3821
|
3837, 4018
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,310
| 101,142
|
13639
|
Discharge summary
|
report
|
Admission Date: [**2124-4-6**] Discharge Date: [**2124-4-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonscopy
History of Present Illness:
86yo M with h/o gastric ulcers admitted with BRBPR. pt with hx
of gastric ulcers here with rectal bleeding starting today. Had
6 total episodes today. No chest pain, SOB, lightheadedness,
dizziness.
In the ED, initial vs were: T98.2 HR75 BP:129/70 RR:16
O2Sat:100RA. Gross blood on rectal exam. Underwent NG lavage
which came back bilious with no blood or clots. Was going to be
admitted to the floor, however, when he got up to use the
bedside commode he had a large (1L) bloody BM. He then got up
off the commode, felt weak and syncopized onto the bed(did not
hit his head) and was transiently not breathing and pulseless.
Responded within seconds and was then A&Ox3.
GI team saw him afterward in ED but did not feel comfortable
sending patient for tagged RBC scan in setting of slightly
unstable vital signs. Patient received 2 units uncrossmatched
pRBCS in ED and another 2units crossed matched cells on arrival
to MICU. General Surgery was consulted.
VS prior to transfer to MICU: BP 87/65 HR 65 O2Sat100% NRB.
On the floor, patient is feeling comfortable. No abdominal or
chest pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies cough or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
constipation, abdominal pain.
Past Medical History:
CKI (baseline creatinines over last year 1.1-1.3)
Gastric Ulcers s/p billroth procedure
GERD
Hypothyroidism
Celiac Disease
Social History:
The patient has never smoked tobacco. He does not drink any
alcohol. He has never done any drugs. He is sexually active
with his wife. [**Name (NI) **] originally from [**Country 2560**], usually lives
with his wife, but his wife is back in [**Country 2560**] right now for
another couple of weeks. His nephew was shot in the abdomen in
[**Country 2560**], so his wife went back to [**Country 2560**] to be with him.
Patient denies any history of smoking. He currently has a couple
of jobs, including selling Spanish newspaper on the street.
Lives [**First Name4 (NamePattern1) 41140**] [**Last Name (NamePattern1) **]. In [**Country 2560**], he used to be a politician.
Moved here about 10 years ago.
Family History:
His mother had lung cancer. His brother had
leukemia, and another brother had [**Name (NI) 2481**] disease.
Physical Exam:
Vitals: BP:128/75 P:75 R: 18 O2: 100
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2124-4-6**] 08:23PM HCT-35.8*
[**2124-4-6**] 06:25PM CK(CPK)-83
[**2124-4-6**] 06:25PM CK-MB-NotDone cTropnT-<0.01
[**2124-4-6**] 06:25PM HCT-39.8*
[**2124-4-6**] 02:11PM POTASSIUM-5.3*
[**2124-4-6**] 02:11PM CK(CPK)-82
[**2124-4-6**] 02:11PM CK-MB-NotDone cTropnT-<0.01
[**2124-4-6**] 02:11PM WBC-10.0 RBC-4.69 HGB-12.9* HCT-39.2* MCV-84
MCH-27.5 MCHC-32.9 RDW-16.0*
[**2124-4-6**] 02:11PM PLT COUNT-221
[**2124-4-6**] 11:50AM HGB-12.7* calcHCT-38
[**2124-4-6**] 10:15AM GLUCOSE-158* UREA N-28* CREAT-1.3* SODIUM-141
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-30 ANION GAP-15
[**2124-4-6**] 10:15AM WBC-9.6 RBC-4.51* HGB-12.5* HCT-37.9* MCV-84
MCH-27.7 MCHC-33.0 RDW-15.9*
[**2124-4-6**] 10:15AM NEUTS-69.8 LYMPHS-19.5 MONOS-5.1 EOS-4.8*
BASOS-0.6
[**2124-4-6**] 10:15AM PLT COUNT-282
[**2124-4-6**] 10:15AM PT-11.2 PTT-26.0 INR(PT)-0.9
EKG: New LBBB from prior on [**2123-12-12**] and also new from ED EKG.
colonoscopy: Polyps and diverticulosis. Will need repeat
colonoscopy in the future to remove polyps. No intervention.
Brief Hospital Course:
Mr. [**Known lastname 41141**] is an 86 y.o. Spanish speaking male with history of
PUD s/p Billroth II and celiac disease, admitted on [**2124-4-6**] to
MICU for BRBPR, s/p colonoscopy revealing diverticulosis.
# Lower GI Bleed:
Patient had a h/o gastric ulcers so initially it was thought
that he could have a very brisk UGIB, but with negative NG
lavage and rectal blood on exam, lower GI bleed felt more
probable. He received 4 units pRBCs, was prepped overnight and
then underwent colonoscopy which revealed diverticulosis and
several polyps but no active bleeding. The polyps were not
removed given recent bleed and the patient will need another
colonoscopy for removal as an outpatient. Hcts remained stable
and he was called out to the floor for observation. He passed
two more clots of old blood per rectum while on the floor, then
had no further bleeding for more than 24 hours. Patient was
discharged home but told to return if he had any further
bleeding or if he developed lightheadedness. He was told to
schedule a followup appointment with his PCP for as soon as
possible on Monday morning. Because of his history of PUD, he
was re-started on omeprazole 20mg daily; he states he does not
have any gastritis or reflux symptoms but will discuss whether
or not this medication is needed with his PCP.
# Hyperkalemia:
Patient has had this in the past in the setting of ARF; on
admission, his creatinine was slightly elevated which likely
contributed to hyperkalemia. There were no associated EKG
changes and the K trended down through the course of his ICU
stay.
# Acute Renal Failure:
His baseline creatinine 1.1-1.3 over the last 2 years and on
admission his creatinine was high-normal for him at 1.3. This
was thought likely [**1-4**] pre-renal azotemia. His medications were
renally dosed and the creatinine trended down during the course
of his ICU stay after transfusion.
# Left Bundle Branch Block:
Patient did not have a history of LBBB including on an EKG 5
months prior to admission. As he had a syncopal event in the ED,
which was thought likely vasovagal in setting of BRBPR, cardiac
enzymes were cycled to rule out cardiac event. Enzymes remained
negative. EKG remained unchanged although on telemetry patient
noted to have intermittent LBBB. It was thought likely this LBBB
was related to age-related degeneration of the cardiac
conduction system and less likely ACS so no further workup was
pursued. Repeat EKG showed persistent LBBB, not rate related.
Patient would benefit from Echocardiogram as an outpatient.
# Communication: Patient and Wife [**Doctor Last Name 2048**], currently in
[**Country 2560**]): [**Telephone/Fax (5) 41142**] [**Telephone/Fax (3) 41143**]
# Code: Full (discussed with patient)
Medications on Admission:
None
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diverticular bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 41141**],
You were admitted with bleeding in your GI tract. We performed
a CAT scan of your abdomen and a colonoscopy, and found that you
have a condition called "diverticulosis". Your bleeding stopped
on its own, and you now have a condition called "anemia" (low
blood counts from bleeding), which will impove with time as your
body recovers.
You should eat a high fiber diet (at least 25-30g per day) to
avoid further progression of divertiulosis. High fiber can be
found in whole wheat products, fruits and vegetables.
We also discovered that your blood sugar levels are slightly
elevated, which indicates that you may have a condition called
"diabetes". It is very important that you see Dr. [**Last Name (STitle) **] for
follow up to have this treated.
No changes have been made to your medications, but it appears
that you have previously been prescribed Omeprazole for reflux,
which you may continue to take if you would like. We will give
you a prescription which you may fill.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within 2 weeks to
have your blood counts monitored. We have also made you an
appointment to see Dr. [**Last Name (STitle) **] in gastroenterology (see below)
[**First Name9 (NamePattern2) 7289**] [**Known lastname 41141**],
Ud fue [**Hospital 41144**] [**Hospital **] hospital porque estaba [**Hospital 41145**] [**Doctor First Name **] colon.
Nos parace de [**Location 41146**] [**Location **] tiene Diverticulosis [**Doctor First Name **] colon.
Le observabamos, y ahora no [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 41145**]. Ahora tiene anemia,
[**Last Name (NamePattern1) **] dice [**Last Name (NamePattern1) **] el nivel de sus [**First Name9 (NamePattern2) 41147**] [**Doctor Last Name **] [**Female First Name (un) **] baja, [**Last Name (un) **] va a
mejorar en unas meses.
Debe Ud comer una dieta con mucha fibra [**Last Name (un) **] prevenir
empeoramiento de [**Doctor First Name **] diverticulosis. Se puede encontrar fibra en
vegetales y comida de [**Last Name (un) 41148**].
El nivel de azucar en [**Doctor First Name **] sangre estaba [**First Name9 (NamePattern2) 41149**] [**Last Name (un) 33761**] este
hospitalizacion, y es posible [**Last Name (un) **] tenga diabetes. Hay [**Last Name (un) **]
seguir con [**Doctor First Name **] doctor [**First Name (Titles) **] [**Last Name (Titles) 41150**].
No hemos cambiado sus medicamentos, [**Last Name (un) **] nos parece [**Last Name (un) **] estaba
tomando Omeprazole en el pasado [**Last Name (un) **] acidez, y puede Ud
continuar [**Female First Name (un) **] medicine si quiere. Vamos a darle una receta
[**Female First Name (un) **] [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 41151**].
Por favor, [**Last Name (un) **] una cita con [**Doctor First Name **] doctor [**First Name (Titles) 41152**] [**Last Name (Titles) **] 2 semanas
[**Last Name (Titles) **] chequear [**Doctor First Name **] hematocrito ([**First Name9 (NamePattern2) 41147**] [**Doctor Last Name **]) y mantenga [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
[**First Name9 (NamePattern2) **] [**Last Name (un) **] hemos hecho con el doctor [**First Name (Titles) **] [**Last Name (Titles) 41153**] (Dr.
[**Last Name (STitle) **].
Mucho gusto, y suerte con todo!
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2124-5-11**] 1:15
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] and make an appointment
within 1-2 weeks
|
[
"244.9",
"276.7",
"250.00",
"426.3",
"584.9",
"585.9",
"579.0",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
7260, 7266
|
4267, 7014
|
266, 278
|
7332, 7332
|
3185, 4244
|
10872, 11168
|
2532, 2643
|
7069, 7237
|
7287, 7311
|
7040, 7046
|
7483, 10849
|
2658, 3166
|
1420, 1645
|
221, 228
|
306, 1401
|
7347, 7459
|
1667, 1791
|
1807, 2516
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,917
| 106,510
|
3369
|
Discharge summary
|
report
|
Admission Date: [**2125-9-3**] Discharge Date: [**2125-9-6**]
Date of Birth: [**2046-3-14**] Sex: F
Service: MEDICINE
Allergies:
Senna / Iodine / Optiray 350
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
BiPap
History of Present Illness:
79 yo F with hx of DM2, HTN, Ao Stenosis s/p AVR and now has
bioprothetic AS and pacemaker (complete heart block w/100%
Vpacing) presenting on admission from wards floor with acute
respiratory distress and flash pulmonary edema. Patient was
found in resp distress by nursing; ABG demonstrated
7.30/55/68/28, and stat CXR showed interval changes with BL
pulmonary congestion.
.
According to history taken earlier today with Russian
interpreter, the patient was presented to ED [**2125-9-3**] by
ambulance after becoming unresponsive at elderly day care
facility. Patient was found by staff with LOC for unknown
duration. Prior to this episode she was having cold sweats,
shaking and nausea. No CP, SOB, loss of bowel or bladder
continence or post-ictal state. For the past week she has been
experiencing fatigue. Per ED report hypoglycemic BS 60 in field,
received OJ x 2 -> BS 101.In ED VS were 97, 72, 150/76, 19,
99%RA. She received fluids and missed PM doses of meds (inc
Lasix).
.
On floor at [**2144**], was feeling well, started having respiratory
distress. On exam appeared wet, 218/118 L arm, gave her hydral
10mg IV x1, 40mg IV lasix, NRB 80%, and transferred to CCU.
Past Medical History:
1. Complete Heart Block s/p DDDR pacemaker placement [**2120**]
2. CAD status post CABG x1 (SVG to PDA during AVR with porcine
valve) on [**2119-1-31**]. s/p cypher stent to LAD [**7-19**]
3. Diabetes mellitus type 2 on insulin and oral agents.
4. Hypertension.
5. Hypercholesterolemia.
6. Schwanomma T11 to T12 s/p resection ([**2-16**]).
7. PVD with bilateral sublavian stenosis
8. Depression
9. Left atrial thrombus noted on TEE at SEMC [**12-23**] now on
coumadin
Social History:
lives with husband
Former agriculture worker. Son is involved in her care ([**Doctor First Name **]).
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse
Family History:
Brother who died of an MI at the age of 65 and had CVA. Both
parents with CVA.
Physical Exam:
On admission:
VS: T=afebrile BP= R 106/doppler, L 207/57 HR=90 R=24O2 sat= 99%
GENERAL: Respiratory distress, on BiPAP. Oriented x3.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa
NECK: Supple with JVP elevation.
CARDIAC: RR, normal S1, S2. [**2-17**] RUSB systolic murmur radiating
to carotids, [**1-20**] Apical murmur. No thrills, lifts.
LUNGS: Resp were labored, on BiPAP. Anterior exam soft diffuse
crackles BL
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial +2, pedal +1/doplar
Left: Radial +2, pedal +1/doplar
On discharge:
VS: T=36.7 BP= L 136/40 HR=65 R=20 sat= 95% on RA
GENERAL: NAD,. Oriented x3. Russian speaking, with limited
English
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa
NECK: Supple with JVP elevation to 8cm.
CARDIAC: RR, normal S1, S2. [**2-17**] LUSB late peaking systolic
murmur radiating to carotids and [**1-20**] diastolic murmur at RUSB,
No thrills, lifts.
LUNGS: Resp were unlabored, on nasal canula. Crackles at bases
bilaterally, improved from yesterday
ABDOMEN: Soft, obese, NTND. No HSM or tenderness. +BS
EXTREMITIES: trace edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial +2, pedal +1/doplar
Left: Radial +2, pedal +1/doplar
Pertinent Results:
[**2125-9-3**] 11:38PM BLOOD Type-ART pO2-68* pCO2-55* pH-7.30*
calTCO2-28 Base XS-0
[**2125-9-4**] 12:51AM BLOOD Type-ART pO2-121* pCO2-44 pH-7.39
calTCO2-28 Base XS-1 Intubat-NOT INTUBA
[**2125-9-3**] 03:30PM BLOOD cTropnT-<0.01
[**2125-9-4**] 12:34AM BLOOD CK-MB-5 cTropnT-0.02*
[**2125-9-4**] 06:50AM BLOOD CK-MB-6 cTropnT-0.05*
[**2125-9-4**] 06:50AM BLOOD PT-30.6* PTT-28.2 INR(PT)-3.0*
[**2125-9-4**] 06:50AM BLOOD Plt Ct-191
[**2125-9-3**] 03:30PM BLOOD Neuts-82.4* Lymphs-11.5* Monos-4.4
Eos-1.1 Baso-0.5
[**2125-9-3**] 03:30PM BLOOD WBC-7.4 RBC-4.17* Hgb-11.6* Hct-33.8*
MCV-81* MCH-27.8 MCHC-34.3 RDW-14.3 Plt Ct-201
[**2125-9-4**] 06:50AM BLOOD WBC-7.1 RBC-4.23 Hgb-11.5* Hct-33.6*
MCV-80* MCH-27.1 MCHC-34.1 RDW-14.3 Plt Ct-191
.
CXR [**2125-9-3**]:
FINDINGS: There is a left-sided pacemaker with leads ending at
the right
atrium and right ventricle. There are intact sternal wires.
There is mild
cardiomegaly and mild pulmonary edema without evidence of large
pleural
effusions. There is calcification of the aortic arch and the
mitral annulus
as well as of the trachea. There is no pneumothorax or focal
consolidation.
.
IMPRESSION: Mild cardiomegaly and mild pulmonary edema.
.
CXR [**2125-9-4**]:
FINDINGS: There are low lung volumes. There is mild
cardiomegaly, stable. A dual-lead pacemaker is unchanged. There
has been interval improvement in pulmonary edema with minimal
interstitial opacities and blunting of the
costophrenic angles. Severely calcified mitral annulus is noted.
No focal
consolidation or pneumothorax.
.
IMPRESSION:
1. Interval improvement in pulmonary edema.
Brief Hospital Course:
79 yo F with hx of DM2, HTN, Aortic Stenosis s/p AVR and now has
bioprosthetic critical AS and pacemaker presenting on admission
from wards floor with acute respiratory distress and flash
pulmonary edema.
.
# Pulmonary Edema/diastolic CHF: Patient has a history of
multiple CHF exacerbation admissions in the past. On this
admission, patient reportedly missed PM medications (lasix) and
received some IVF when she was being admitted for episode of
hypoglycemia. She was found by nursing after transfer to the
wards floor to be in respiratory distress, and CXR showed BL
flash pulmonary edema, hypertensive to sBP200s, and ABG
7.30/55/63/28. She was placed on BiPAP, morphine, Hydralizine
IVx1, Lasix IV40mg, and transferred to the CCU. Troponins were
0.01->0.02->0.05. She was diuresed with IV lasix, then
transitioned to home Lasix, and her respiratory status improved
to baseline. On discharge, the patient was oxygenating well on
room air.
.
# Hypertension: On transfer to the CCU, patient was found to
have sBP in 200s. When remeasured, had L arm sBP 207 and R arm
sBP 106, however, history of BL subclavian stenosis (R-80%;
L-40%) therfore opted not to get CT to check for aortic
dissection; CXR did not show evidence of dissection/widened
mediastinum. She had received hydralizine 20mg IV prior to
transfer. Her home medications were reconciled with her
pharmacy, and she was placed on Valsartan 120mg [**Hospital1 **] and
Carvedilol 25mg [**Hospital1 **]. Her home nifidipine and hydralizine were
held since her BP was well controlled with a range of
106-135/40-53, and concern for afterload reduction in critical
AS.
.
# Ao Stenosis: patient has hx of critical bioprosthetic AS s/p
AVR [**2118**]. According to TTE of [**3-22**] and [**1-23**]: patient has high
transvalvular gradient and valve area of 0.7. No further ECHOS
have been done, per Dr. [**Last Name (STitle) **], as patient will not proceed
with any intervention anyway. Discussed with patient and
family, and confirmed that she would not like to pursue surgical
correction. Therefore, no ECHO or pre-operative evaluation was
performed on this admission.
.
# Diabetes: patient originally presented with low blood sugars
to the 60s and LOC. Typically on Lantus 35U at home, and Lispro.
In the hospital, she was started on Lantus 20U and insulin
sliding scale to estimate her insulin requirements. Her final
Lantus dose at discharge was titrated at 23U in addition to ISS.
She will be discharged on this regimen, in addition to Lispro
for extra mealtime coverage.
# CAD s/p CABG: Patient has known long-standing disease CAD.
CABG x 1 with SVG to PDA in [**2118**], PCI to LAD [**2119**]. Recent flash
pulmonary less concerning for possible ischemic event, CE normal
range and no associate CP. She was continued on ASA 81mg,
Carvedilol 25mg [**Hospital1 **], Simvastatin 40mg PO daily, and Zetia 10mg
during hospitalization, and at discharge.
# History of left atrial appendage thrombus: Patient was
started on Coumadin 5mg on admission, due to unknown home
amount. Coumadin was held for INR 3.1, and medication
reconcilation started on home dose of 4mg the following day. On
discharge, patient is on Coumadin 4mg with INR 1.9 (related to
held dose).
# Mild Dementia: per patient's son, she has mild dementia at
baseline. She was continued on Aricept 10mg daily. During
hospitalization, she appeared oriented and appropriate.
#FEN: she was continued on a heart healthy diabetic diet.
#Prophylaxis:
-DVT ppx with coumadin
-Pain management with tylenol
-Bowel regimen with colace, miralax (unknown allergy to senna)
Medications on Admission:
On transfer:
DONEPEZIL [ARICEPT]10mg daily
EZETIMIBE - 10 mg daily
FUROSEMIDE [LASIX] - 80 mg [**Hospital1 **]
INSULIN GLARGINE [LANTUS] 30 units SC once a day
INSULIN LISPRO - (- Dosage uncertain
IRBESARTAN [AVAPRO] - 150 mg daily
METOPROLOL SUCCINATE -- 100 mg SR 1.5 Tablet(s) daily (Total
150mg daily)
NIFEDIPINE - 60 mg Tablet XR daily
PANTOPRAZOLE - 40 mg Tablet (E.C) daily
POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. 1 Tab(s) [**Hospital1 **]
SERTRALINE - 100 mg Tablet - 1 Tablet(s) by mouth every morning
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth every morning
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth daily
TRAZODONE - 50 mg Tablet QHS for insomnia
WARFARIN - Dosage uncertain
.
ACETAMINOPHEN [TYLENOL] -
ASPIRIN [ASPERDRINK] 81mg PO
DOCUSATE SODIUM [COLACE] - 100 mg Capsule qday
FERROUS SULFATE - 325 mg ( Sustained Release) daily
OMEGA-3 FATTY ACIDS - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO QAM.
5. Lantus 100 unit/mL Solution Sig: Twenty Three (23)
Subcutaneous once a day.
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Valsartan 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. Furosemide 80 mg Tablet Sig: 1.5 Tablets PO QAM.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
19. Omega-3 Fatty Acids Oral
20. Acetaminophen Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Hypoglycemia
Acute exacerbation of chronic diastolic congestive heart failure
(EF 75%)
Hypertension
Aortic Stenosis
DM II - insulin dependent
CAD
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 because you were found to be
unresponse in your day home facility and had a very low blood
sugar level. You were taken to the hospital and given juice and
fluids to improve your blood sugar level. Because of these
symptoms you also missed your evening dose of lasix. Overnight
while in the hospital you had worsening symptoms of shortness of
breath and high blood pressure. This was believed to be an acute
exacerbation of you chronic known congestive heart failure. You
were admitted to the ICU to treat these symptoms. You were given
medications (IV lasix) to help remove excess fluid from your
lungs and also treated with a specially oxygen mask. Your
symptoms improved quickly with these treatments and you were
able to be discharged home.
.
The following changes were made to your medication:
- Please take Valsartan 120 mg twice daily
- Please take Furosemide (lasix) 120 mg in the morning and 80mg
in the evening. Please be sure to take this medication as
prescribed and to never miss a dose as it could result in sudden
worsening of your chronic congestive heart failure.
- Please start taking Carvedilol 25 mg twice daily
- Please decrease your lantus dose to 23units per day as your
previously higher dose may be contributing to your episodes of
hypoglycemia
- Please stop taking Nifedipine XL 60mg twice daily
- Please stop taking Toprol XL 50mg three times daily
- Please stop taking Hydralazine 10mg PO twice daily
- Please stop taking Irbesartan 150mg PO daily
Please continue to take your other home medications as
prescribed.
Please be sure to take all medications as prescribed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Please be sure to keep all follow-up appointments with your
doctors. (see below)
.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your
doctors.(See below)
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 4606**]
Appt: [**9-20**] at 2:45pm
Department: CARDIAC SERVICES
When: FRIDAY [**2125-10-12**] at 3:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PODIATRY
When: TUESDAY [**2125-9-18**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Psychiatry:
Department: HMFP
When: TUESDAY [**2125-9-25**] at 3:20 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 15631**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
.
Completed by:[**2125-9-6**]
|
[
"V45.81",
"428.33",
"V42.2",
"414.00",
"428.0",
"401.9",
"V45.01",
"518.82",
"272.0",
"V10.89",
"250.80"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11583, 11658
|
5401, 9001
|
307, 314
|
11848, 11848
|
3777, 5378
|
13933, 15293
|
2258, 2339
|
9995, 11560
|
11679, 11827
|
9027, 9972
|
12031, 13910
|
2354, 2354
|
3046, 3758
|
247, 269
|
342, 1523
|
2368, 3032
|
11863, 12007
|
1545, 2014
|
2030, 2242
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,142
| 143,735
|
4779
|
Discharge summary
|
report
|
Admission Date: [**2122-7-13**] Discharge Date: [**2122-7-18**]
Date of Birth: [**2058-8-3**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Shellfish Derived / Levaquin
Attending:[**Known firstname 3326**]
Chief Complaint:
fevers and sob x 5 days
Major Surgical or Invasive Procedure:
[**7-16**]: Bronchoscopy with bronchoalveolar lavage
History of Present Illness:
The patient is a 63 yo M with NSCLC and CLL who originally p/w 5
days of fever and SOB. The patient reports that until 5 days
ago he was feeling well. He initially went to [**Location (un) 620**] on [**7-8**] for symptoms of shortness of breath and was given a course
of levoquin. He reports that he developed a pruritic truncal
rash while on the levaquin (thus it was discontinued on initial
presentation to [**Hospital1 18**]). At home however, even while on the
levaquin, he continued to be SOB and was febrile to 100.5 x 3
days PTA. 2 days PTA, he coughed up 1/4 cup of blood. Prior to
that, cough was productive of moderate amounts of yellow sputum.
Hemoptysis and worsening "burning" rash is what prompted his
presentation to [**Hospital1 18**] ED.
.
On admission, CXR revealed b/l hazy opacities. He was initially
started on cefepime/vanco/flagyl/bactrim for pulomonary
infection unresponsive to levofloxacin. He was previously
requiring O2 via nasal cannula to max of 4L, but since yesterday
evening, has had increasing oxygen requirement overnight so that
he was placed on a NRB. Throughout the day, he has been
maintaining O2 sats on NRB in the mid to upper 90s, however,
with movement and with removal of mask he promptly desaturates
to the 80s. He has had multiple coughing fits with posttussive
emesis at which time he desaturates to the 80s. He continues to
bring up small amounts of blood in his sputum. A CT scan was
obtained today given his broad coverage, but persistent
respiratory decompensation which showed b/l consolidations and
ground glass opacities. ID was consulted and recommended adding
voriconazole to his above abx coverage and further recommended
bronchoscopy. They also felt that bactrim was not indicated
given low risk of PCP. [**Name10 (NameIs) 15250**] the day, he became
increasingly tachypneic to RR as high as 40s and although,
recent ABG revealed 7.44/37/141, he looked to be tiring with use
of accessory respiratory muscles and was transferred to the ICU
for further respiratory monitoring and out of concern for
possible need for intubation.
.
ROS: Denies chest pain, abdominal pain, blood in stool, urinary
symptoms. +25lb weight loss x1 year.
Past Medical History:
# Adenocarcinoma of the lung/ Large cell lung cancer - diagnosed
left [**2112**], right [**2118**], s/p wedge resection and RLL lobectomy.
previously treated with Taxol/Cisplatin, Tarceva, and now
Navelbine x8
# CLL
# CAD s/p 3v CABG [**11/2115**]
# COPD
# s/p inguinal hernia repair
Social History:
live swith wife. retired [**Name2 (NI) **]. smoking 30yrs x 1-1.5ppd;
quit [**2113-1-18**]; EtOH: rare; Illicits: none
Family History:
Mother died of breast cancer 66yrs, Brother w/ h/o CAD
Physical Exam:
Vitals: T 96.2 HR 104 BP 110/59 RR 37 O2sat 90-98% NRB
General: pale male, appears short of breath with NRB mask in
place using accessory neck and abdominal muscles to breath, is
however, able to complete full sentences, but appears tired.
HEENT: PERRL, OP clear, mildy dry MM
Neck: supple
CV: tachycardic, prominent heart sounds, no murmurs appreciated
Lungs: Decreased breath sounds throughout right lung,
specifically right base, Left lung w/ decreased BS apically and
with crackles from mid lung to base.
Abdomen: soft, NT/ND, +BS
Ext: 1+ b/l LE edema, feet cool w/ palpable DP/PT pulses
Neuro: CN 2-12, strength, sensation grossly intact
Pertinent Results:
Imaging:
[**2122-7-8**] CXR ([**Hospital1 **] [**Location (un) 620**]) - Increased density in the R lung
suspicous for PNA. There are extensive post surgical changes in
the chest. Persistent focal areas of increased density n the
lateral aspect of the lower right lung and in the left
perihiklar region may represent residual or current tumor.
These appear stable.
Micro:
[**2122-7-13**] Blood - pending
[**2122-7-15**] sputum - GPC in pairs and clusters
.
BAL [**2122-7-16**]: + malignant cells c/w NSCLC adenocarcinoma; no viral
agents, legionella, pcp, [**Name10 (NameIs) **] afb growth to date
.
[**2122-7-14**] Chest CT:
Interval progression of dense left perihilar and right posterior
lung consolidation with numerous new bilateral small areas of
consolidation and diffuse ground-glass opacity. As was
described in the past report, differential diagnosis for the
chronic consolidation would include bronchoalveolar carcinoma or
cryptogenic organizing pneumonia. The interval progression of
consolidation in these two areas could at least in part
represent progression of one of these processes with possible
superimposed infectious pneumonia. Primary considerations for
the multifocal new areas of consolidation also includes acute
infectious process. Other considerations that would account for
the diffuse ground-glass opacity would include hypersensitivity
pneumonitis, drug reaction, or hydrostatic pulmonary edema.
Brief Hospital Course:
The patient is a 63yo M with h/o NSCLC, CLL, and CAD p/w fevers
and shortness of breath x 5 days with worsening hypoxia despite
broad coverage antibiotics. Hospital course by problem is as
follows:
.
# Hypoxia: CT scan shows increased lung consolidation and
diffuse ground glass opacities. In review of most recent chest
CT in [**3-/2122**], appears to have worsening disease concerning for
progression of lung cancer. Ground glass opacities concerning
for superimposed infection and even postobstructive pneumonia
given progression of disease. Although, by cell counts, not
immunosuppressed, given CLL he is functionally immunosuppressed.
Additionally, WBC count difficult to follow as indicator of
infection due to CLL. Alimta is most recent therapeutic
oncologic [**Doctor Last Name 360**] and does not appear to have increased risk of
pneumonitis nor is there other clear medications cause of
pneumonitis. Despite ABG without significant derangements, had
increased WOB w/ accessory muscle use and tachypnea on transfer
concerning that the patient would tire. Had episode of desat to
80s with increased WOB secondary to likely mucus plugging as he
improved s/p expectoration of small amount of blood-tinged
sputum. Trial of 20mg IV lasix on [**7-17**] failed: pt dropped SBP to
80s from 100s with no improvement in O2 requirement.
Broad coverage antibiotics were continued with
cefepime/vancomycin/ flagyl/ and voriconazole as per ID recs
with azithromycin for atypical coverage. Bronchoalveolar lavage
samples were sent with cultures pending, as above.
Due to poor respiratory status the patient was intubated on
[**2122-7-17**].
.
# NSCLC: CT scan showed what appears to be progression of
disease with consolidation secondary to pneumonia. Unclear when
patient last received Alimta, but this appears to be his most
recent treatment. The team had been in touch with Dr. [**Last Name (STitle) 3274**]
(outpt oncologist) regarding rec's, and it was felt that there
were no further treatment options to treat his underlying
disease.
.
# Hemoptysis: Most likely secondary to underlying infective
process vs. progression of pulmonary oncologic process. Hct were
followed, which had been stable during admission.
.
# CLL: Again, status of disease was not entirely clear, but
certainly lung ca is more active issue currently given
advancement of disease.
.
# CAD: s/p CABG in [**2114**]. On statin alone, not on ASA (unclear
reason, but potentially while undergoing tx) nor BB ([**1-16**] to
hypotension in past). No active issues currently. The patient
was maintained on a statin, with ASA held given hemoptysis
.
# Anemia: baseline appears to fluctuate some but hct appears
mainly high 20s to mid 30s with nml MCV and elevated RDW.
Likely secondary to AOCD given oncologic processes. Hct was
followed. Stool was guaiac'ed regularly.
.
# Rash: likely drug rash; ? [**1-16**] to levoquin. Asymptomatic,
appears to be resolving.
This was monitored, with benadryl as needed for pruritus
.
# Hypothyroidism: Recently diagnosed with hypothyroidism. The
patient was maintained on thryroid hormone replacement
.
# FEN: The patient was kept NPO for intubation, and was
maintained on D51/2NS at 50cc/hr maintenance fluid.
.
# PPx: SC heparin, PPI were used.
.
On [**2122-7-18**] am pt had an episode of bradycardic arrest with loss
of pulse for 30-60seconds. pt received 1mg atropine given with
HR 40 --> 130 and restoration of BP. On ventilator, FiO2 changed
to 1.0 and peep reduced to 10. EKG showed RBBB with sinus
tachycardia in 140s. changes may be rate-related. Etiology was
unclear: perhaps vagal episode from ETT tube, but this appears
to be unlikely given proper placement on CXR. CXR not
suggestive of PTX. EKG not consistent with inferior infarct. The
family was notified and chose to pursue a DNR code status at
that time.
.
At ~3:30pm the patient became bradycardic again. The family was
called to the bedside. The patient continued to become
bradycardic with decrease in respiratory rate until
cardiopulmonary arrest. The family was at the bedside
throughout. Time of death = 3:52pm.
Medications on Admission:
Lipitor 10mg daily
Foradil inhaler 12mcg [**Hospital1 **]
Aranesp 400mcg 1x/2 weeks
B-12 1000mcg 1x/9weeks
Alimta 685mg 1x/3weels
Folic acid 400mg daily
Econpred Plus 1% drops/Left Eye daily
Levoquin x 5 days
Discharge Disposition:
Expired
Discharge Diagnosis:
nonsmall cell lung cancer
post-obstructive pneumonia
CLL
anemia
CAD
hypothyroidism
Discharge Condition:
expired
|
[
"496",
"518.81",
"786.3",
"485",
"693.0",
"244.9",
"V45.81",
"285.22",
"E930.8",
"162.8",
"204.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
9643, 9652
|
5276, 9383
|
322, 376
|
9778, 9788
|
3816, 5253
|
3072, 3128
|
9673, 9757
|
9409, 9620
|
3143, 3797
|
259, 284
|
404, 2610
|
2632, 2918
|
2934, 3056
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,393
| 121,834
|
4763
|
Discharge summary
|
report
|
Admission Date: [**2163-12-6**] Discharge Date: [**2163-12-13**]
Date of Birth: [**2096-9-8**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Rigid bronchoscopy
Cardiac catheterization
History of Present Illness:
67 y.o russian speaking female with histroy of metastatic renal
cancer, admitted afetr developing hypotension with ECG changes
during rigid bronchoscopy.
The patient was diagnosed with renal cell carcinoma in [**Month (only) **]
[**2160**]. Two to three months prior to the presentation, she
devolped slowly progressive dyspnea on exertion and cough,
thought to be due to metastatic mass compressing her left
bronchial tree. She presented to interventional pulmonary for
elective rigid bronchoscopy/tumor debulking/stent placement on
[**12-6**]. During debulking procedure she developed endobronchial
bleeding, followed by hypotension and ST elevations in multiple
leads. Bedside TTE showed global hypokinesis with EF 20-25% and
the patient was taken to emergent cardiac cath wich showed
normal systemic pressures and normal coronaries. She was
transfused with 2units of packed red cells for hematocrit of
23.3. Repeat echocardiogram showed improved left ventricular
function. The patient was extubated on [**12-7**] and transferred to
the general medical floor on [**2163-12-9**]
Past Medical History:
1. Renal cell carcinoma, clear cell, diagnosed [**1-27**], status post
left nephrectomy and left lower lobe resection
2. Status post TAH, uterine prolapse repair
3. Hyperlipidemia
Social History:
married, denies smoking or alcohol use
Family History:
non-contributory
Physical Exam:
VS: BP 138/72 HR 70 T 98.6 RR 20
Gen: NAD, A&O x 4
HEENT: PERRL. EOMI. MMM. OP clear. No LAD.
CV: RRR, soft SM @base
Pulm: Diminished BS 2/3 up L lung,+tympany. R lung diffuse
extrabronchial sounds
Abd: Soft, NT/ND x 4Q, no rebound/gaurding, BS not appreciable
Ext: No edema, cyanosis, clubbing.
Neuro: CN II-XII intact. 5/5 strength UE & LE bilat.
Pertinent Results:
[**2163-12-6**] 08:14PM TYPE-ART PO2-222* PCO2-43 PH-7.41 TOTAL
CO2-28 BASE XS-2
[**2163-12-6**] 08:14PM LACTATE-1.4
[**2163-12-6**] 07:43PM CK(CPK)-25*
[**2163-12-6**] 07:43PM CK-MB-NotDone cTropnT-0.33*
[**2163-12-6**] 07:43PM HCT-22.1*
[**2163-12-6**] 06:14PM CK(CPK)-23*
[**2163-12-6**] 06:14PM CK-MB-NotDone cTropnT-0.28*
[**2163-12-6**] 03:05PM TYPE-ART PO2-250* PCO2-42 PH-7.38 TOTAL
CO2-26 BASE XS-0
[**2163-12-6**] 03:05PM HGB-8.0* calcHCT-24 O2 SAT-98
[**2163-12-6**] 03:05PM freeCa-1.24
[**2163-12-6**] 03:00PM WBC-10.3 RBC-2.81* HGB-7.4* HCT-23.3* MCV-83
MCH-26.3* MCHC-31.8 RDW-15.8*
[**2163-12-6**] 03:00PM PLT COUNT-524*
Brief Hospital Course:
1. Lung mass: patients pulmonary status remained stable during
the remainder of her hospital stay. She was taken to repeat
bronchoscopy on[**2163-12-12**], wich showed 60% occlusion at the LUL
[**Female First Name (un) 5309**]. No intervention was done during the procedure. Pulmonary
recommended argon photocoagulation therapy as an outpatient.
2. Blood loss: she had no signs of hemoptysis, her hematocrit
remained stable.
3. CV: initial global hypokinesis with mild troponin elevation
were believed to be due to coronary artery spasm. Repeat
echocardiogram showed improved left ventricular function. She
remained tachycardic (low 100s) for rest of her hospital stay,
without any additional ECG changes.
4. Renal cell carcinoma: the plans were to continue Avastin as
outpatient. The patient will follow up with Dr. [**Last Name (STitle) **].
5. Yeast infection: the patient developed vaginal yeast
infection, affecting perineal region as well, she was treated
with Miconazole powder with only partial response. SHe was given
one dose of Diflucan, Monistat and Doxepin on the day od
discharge.
Medications on Admission:
Lipitor 10 mg po every night
Protonix 40 mg po daily
Avastin per onc schedule
Discharge Disposition:
Home
Discharge Diagnosis:
renal cell CA
coronary vasospasm
hypotension
airway obstruction
Discharge Condition:
stable
Discharge Instructions:
Take your medications as prescribed. Call your doctor or return
to the emergency room for chest pain, shortness of breath,
fever,blood in the sputum, lightheadedness or any other concerns
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-12-14**] 4:00
Provider: [**Name11 (NameIs) 5558**],[**Name12 (NameIs) 5557**] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2163-12-14**] 4:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19988**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-12-14**] 4:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"458.29",
"413.9",
"V10.52",
"519.1",
"518.5",
"E878.8",
"285.9",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.22",
"96.71",
"33.24",
"99.04",
"96.05",
"88.56",
"32.01"
] |
icd9pcs
|
[
[
[]
]
] |
4042, 4048
|
2814, 3911
|
278, 323
|
4156, 4164
|
2130, 2791
|
4401, 5091
|
1710, 1728
|
4069, 4135
|
3938, 4019
|
4188, 4378
|
1743, 2111
|
231, 240
|
351, 1434
|
1456, 1638
|
1654, 1694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,051
| 107,549
|
41037
|
Discharge summary
|
report
|
Admission Date: [**2127-10-14**] Discharge Date: [**2127-10-19**]
Date of Birth: [**2056-12-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2127-10-14**] - Coronary bypass grafting x3 with the left internal
mammary artery to left anterior descending artery and reverse
saphenous vein grafts to the distal right coronary artery and
the ramus intermedius artery.
History of Present Illness:
(History and review of systems obtained via Russian interpreter)
70 year old Russian male with type II diabetes and severe PVD
s/p urgent right fem/[**Doctor Last Name **] bypass surgery in [**2127-2-4**] and
known severe PVD on the left leg. In [**2112**], he had an acute MI
while in [**Country 532**]. He was treated medically and has not had a
catheterization. Since the heart attack, he has been
experiencing exertional angina when he first starts walking. His
symptoms resolve with nitroglycerin and he is able to continue
walking. He walks 1-2 hours several days per week. He has
recently taking nitroglycerin about 5 days per week. The patient
has been seen by Dr. [**Last Name (STitle) 171**] recently and had a stress test back
in [**Month (only) 958**] which was suggestive of possible left main or left main
equivalent multi-vessel disease. He was referred for cardiac
catheterization to further evaluate. He was
found to have three vessel disease upon cardiac catheterization
and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
diabetes type II
arthritis
severe PVD
severe LLE PVD
CAD s/p MI in [**2112**] in [**Country 532**]
dyslpidemia
hypertension
remote stomach ulcer; denies bleeding
remote cyst removed from coccyx
Social History:
Lives with:Wife
Occupation:retired electrical engineer
Cigarettes: Smoked no [] yes [x] quit [**12/2126**] 1 ppd x 30 years
Other Tobacco use:denies
ETOH: < 1 drink/week [] [**2-10**] drinks/week [x] >8 drinks/week []
Illicit drug use:denies
Family History:
Noncontributory
Physical Exam:
Pulse: 60 Resp:16 O2 sat:100/RA
B/P Right:130/76 Left:
Height:5'7" Weight:186 lbs
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] no Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] well healed incisions
both lower extremities
Edema [] trace
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+2
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2127-10-14**] ECHO
Prebypass
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild to moderate ([**1-5**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-5**]+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2127-10-14**] at 915 am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Mild mitral
regurgitation persists. Aorta is intact post decannulation.
cxr
PA and lateral upright chest radiographs were reviewed in
comparison to
[**2127-10-16**].
Right internal jugular line tip is at the level of mid SVC.
Heart size and
mediastinum are unremarkable. There is no evidence of pulmonary
edema or
focal consolidations to suggest infectious process. Small amount
of pleural
effusion is noted better on the lateral view as well as left
basal
atelectasis.
Sinus rhythm. Left anterior fascicular block. Right
bundle-branch block. Low voltage. Since the previous tracing of
[**2127-10-6**] the right bundle-branch block is new. Clinical
correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 140 142 414/456 33 -19 -14
[**2127-10-19**] 05:45AM BLOOD WBC-6.9 RBC-3.38* Hgb-10.9* Hct-31.2*
MCV-92 MCH-32.2* MCHC-34.9 RDW-12.9 Plt Ct-223#
[**2127-10-14**] 12:46PM BLOOD WBC-8.6 RBC-2.93*# Hgb-9.6*# Hct-26.7*#
MCV-91 MCH-32.8* MCHC-36.0* RDW-12.3 Plt Ct-137*
[**2127-10-19**] 05:45AM BLOOD Glucose-159* UreaN-18 Creat-1.0 Na-136
K-4.7 Cl-100 HCO3-28 AnGap-13
[**2127-10-14**] 12:46PM BLOOD UreaN-13 Creat-0.9 Na-139 K-3.9 Cl-110*
HCO3-23 AnGap-10
[**2127-10-19**] 05:45AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.3
Brief Hospital Course:
Mr. [**Known lastname 89496**] was admitted to the [**Hospital1 18**] on [**2127-10-14**] for surgical
managment of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. Within 24 hours, he awoke neurologically intact
and was extubated. He remained in the intensive care unit to
wean from his pressors. On postoperative day two, he was
transferred to the step down unit for further recovery. He was
gently diruesed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. Beta blockade, aspirin and
a statin were resumed. He continued to make steady progress and
was discharged to his home on postopertaive day five. All
follow-up appointments have been made for him.
Medications on Admission:
FAMOTIDINE 20 mg Tablet [**Hospital1 **]
GLARGINE [LANTUS] 100 unit/mL Solution - 18 units at bedtime
INSULIN LISPRO [HUMALOG] per Sliding scale
ISOSORBIDE MONONITRATE (Not Taking as Prescribed: pt states not
taking b/c concerned about BP dropping
LISINOPRIL 2.5 mg Daily
METFORMIN 1,000 mg [**Hospital1 **]
METOPROLOL TARTRATE 12.5mg [**Hospital1 **]
SIMVASTATIN 20 mg Daily
ASPIRIN 81 mg Daily
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*1*
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*qs qs* Refills:*0*
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
9. Insulin sliding scale
please resume your sliding scale that you were on prior to
surgery
Your lantus dose has been adjusted - please follow up with
[**Last Name (un) **]
10. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p cabg
Diabetes mellitus type II
Peripheral vascular disease
Dyslpidemia
Hypertension
Arthritis
Discharge Condition:
Alert and oriented x3 nonfocal - russian speaking
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage
Edema none
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
7) Please continue to monitor blood glucose, and follow up with
[**Last Name (un) **] for adjustments in insulin doses
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2127-11-20**] at 1:30
Cardiologist: Dr [**Last Name (STitle) 171**] [**Telephone/Fax (1) 62**] on [**2127-11-10**] at 12:40
Wound check - cardiac surgery office [**Telephone/Fax (1) 170**] on [**2127-10-28**]
10:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**4-8**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2127-10-19**]
|
[
"250.00",
"411.1",
"443.9",
"414.01",
"401.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7667, 7716
|
5053, 5992
|
324, 550
|
7882, 8120
|
2905, 5030
|
9127, 9768
|
2132, 2150
|
6439, 7644
|
7737, 7861
|
6018, 6416
|
8144, 9104
|
2165, 2886
|
274, 286
|
578, 1637
|
1659, 1855
|
1871, 2116
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,900
| 132,061
|
12786
|
Discharge summary
|
report
|
Admission Date: [**2124-6-18**] Discharge Date: [**2124-7-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Intubation
PEG Tube Placement
History of Present Illness:
87F with dementia, dm2, CRI, recent GI bleed who resides at
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] and was found to be minially responsive. Of note,
she was recently admitted to [**Hospital1 18**] from [**6-5**] - [**6-13**] for duodenal
ulcer requiring 5U pRBCs now s/p EGD with epi and cautery. The
patient was at [**Hospital3 1186**] and was noted to become SOB at
around 11:30am. She worsened to the point that she became
unresponsive and hypotensive with BP 60/20, bradycardiac with
pulse 36. EMS was called and intubated the patient on arrival.
She was given atropine with effect, then paced to 70s
transcutaneously. Central line was placed in ED, patient was
started on dopamine, levophed, and neosynephrine. Initial labs
revealed a K= 6.08 (though hemolyzed), lactate 6.8. There was
also concern for BB toxicity as a cause of the bradycardia. Pt
was given calcium, glucagon, vanc, cefepime for empiric abx
coverage. She was transcutaneously paced in the ED for a time,
then her native rate increased to 50s in SR. Code discussions
were held with the patient's daughter and the decision was made
for full code status. The patient was admitted to MICU for
further management. She received 1L of IVF in ED.
.
Past Medical History:
1. Dementia
2. NIDDM
3. Renal insufficiency (bl Cr 2.0)
4. Vitamin D deficiency
5. HTN
6. UGI bleed with admission [**Date range (1) 39419**] tx with 5Units PRBC,
EGD with epi and cautery.
7. Iron deficiency anemia
Social History:
Lived at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] recently, unknown tobacco or EtOH
history.
Family History:
NC
Physical Exam:
VS: T 94.1 117/48 66 11 1005 on vent
Vent: AC 550 x 14 0.7 5
General: Intubated, sedated
HEENT: surgical pupils, b/l cataracts
Neck: supple, no LAD
Chest: good air moving bilaterally
CV: RRR s1 s2 normal, [**2-1**] SM LUSB
Abd: soft, NT/ND, NABS
Ext: 1+ edema
Neuro: sedated
Pertinent Results:
Admission Labs:
[**2124-6-18**] 10:03PM TYPE-ART TEMP-36.1 PO2-135* PCO2-30* PH-7.39
TOTAL CO2-19* BASE XS--5 INTUBATED-INTUBATED
[**2124-6-18**] 10:03PM LACTATE-1.3
[**2124-6-18**] 09:33PM proBNP-[**Numeric Identifier 39420**]*
[**2124-6-18**] 09:33PM CORTISOL-29.8*
[**2124-6-18**] 04:45PM TYPE-ART PO2-105 PCO2-36 PH-7.32* TOTAL
CO2-19* BASE XS--6
[**2124-6-18**] 04:45PM LACTATE-2.6*
[**2124-6-18**] 04:45PM freeCa-1.34*
[**2124-6-18**] 04:25PM GLUCOSE-295* UREA N-82* CREAT-3.4* SODIUM-141
POTASSIUM-5.1 CHLORIDE-114* TOTAL CO2-17* ANION GAP-15
[**2124-6-18**] 04:25PM CK(CPK)-79
[**2124-6-18**] 04:25PM CK-MB-NotDone cTropnT-0.24*
[**2124-6-18**] 04:25PM CALCIUM-9.6 PHOSPHATE-5.2* MAGNESIUM-2.6
[**2124-6-18**] 04:25PM WBC-18.8* RBC-3.61*# HGB-10.4*# HCT-32.3*#
MCV-89 MCH-28.8 MCHC-32.2 RDW-17.2*
[**2124-6-18**] 04:25PM PLT COUNT-382
[**2124-6-18**] 01:38PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2124-6-18**] 01:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2124-6-18**] 01:24PM LACTATE-6.3*
[**2124-6-18**] 01:05PM CK(CPK)-75
[**2124-6-18**] 01:05PM cTropnT-0.25*
[**2124-6-18**] 01:05PM CK-MB-NotDone
[**2124-6-18**] 01:05PM PLT COUNT-325
[**2124-6-18**] 01:05PM PTT-26.0
.
Discharge Labs:
136 98 81
---------------<134
3.8 33 2.6
Ca: 9.1 Mg: 2.0 P: 3.3
.
7.6 >---< 227
26.3
PTT: 44.9
.
Imaging:
CHEST (PORTABLE AP) [**2124-6-28**] 10:39 AM
The cardiac silhouette is enlarged but unchanged. There is a
persistent left retrocardiac opacity and bilateral pleural
effusions, left side worse than right. There is minimal
pulmonary vascular congestion. Calcifications of the thoracic
aorta are seen. There is a left-sided PICC line with distal tip
in the mid SVC. Left IJ catheter has been removed. The
nasogastric tube has also been removed.
.
CT HEAD W/O CONTRAST [**2124-6-26**] 8:26 PM
FINDINGS: There is no evidence of intracranial hemorrhage, mass
effect, shift of normally midline structures, hydrocephalus, or
acute major vascular territorial infarct. Atherosclerotic
disease overall does not appear significantly changed as does
small vessel ischemicc changes. Additionally, previously
identified chronic appearing right-sided subdural collection
does not appear as prominent on today's examination. Paranasal
sinuses and mastoid air cells are well aerated. Soft tissues are
unremarkable. No acute fractures.
IMPRESSION:
No acute intracranial pathology. If concern for acute ischemia,
MRI would be more sensitive evaluation.
.
CT ABDOMEN W/O CONTRAST [**2124-6-26**] 8:27 PM
CT OF THE ABDOMEN WITHOUT IV CONTRAST: The lung bases
demonstrate bilateral pleural effusions and bibasilar airspace
consolidation. Limited evaluation of the solid organs due to
lack of IV contrast. The liver and spleen demonstrate punctate
calcifications. Gastrostomy tube is noted. The pancreas and
adrenal glands appear normal. Bilateral renal cysts. There is no
evidence of intra- abdominal bleeding. Severe calcification of
the aorta and its branches.
Limited evaluation of the loops of bowel due to lack of oral
contrast, however, no gross abnormality is detected.
CT OF THE PELVIS WITHOUT IV CONTRAST: The bladder, distal
ureters, rectum, and sigmoid appear unremarkable. Rectal tube is
noted.
BONE WINDOWS: Severe degenerative changes of the lumbar spine.
No suspicious lytic or sclerotic lesions.
IMPRESSION: Very limited study due to lack of contrast and
artifact from patient's arms. No evidence of retroperitoneal
bleed.
.
ECHO Study Date of [**2124-6-21**]
Conclusions:
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. The interatrial septum is
aneurysmal. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is 11-15mmHg. There
is moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with distal septal, inferior
and apical akinesis. EF 45-50%. No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There are
filamentous strands on the aortic leaflets consistent with
Lambl's excresences (probably a normal variant). There is mild
aortic valve stenosis (area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is mild functional mitral stenosis due to
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is
a small pericardial effusion. There are no echocardiographic
signs of
tamponade. Compared with the prior study (images reviewed) of
[**2124-6-18**], no definite change. If clinically indicated, a TEE
may better exclude a cardiac source of embolism.
.
MR L SPINE W/O CONTRAST [**2124-6-21**] 12:51 AM
MR L SPINE W/O CONTRAST; MR THORACIC SPINE W/O CONTRAST
CLINICAL INFORMATION: Patient with question of cauda equina
syndrome, for further evaluation.
THORACIC SPINE:
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial
images of the thoracic spine were obtained.
FINDINGS: There are mild multilevel degenerative changes seen in
the thoracic spine without spinal stenosis or extrinsic spinal
cord compression. The spinal cord demonstrates increased signal
from mid thoracic region to the conus level with slight
expansion of the cord. The axial images, which are slightly
limited by motion, demonstrate central increased signal within
the cord. The findings are suspicious for ischemia within the
cord.
IMPRESSION: Increased signal within the spinal cord from mid
thoracic region T6 level to the conus, predominantly in the
central portion of the cord. These findings are suspicious for
ischemia. No abnormal flow voids are seen surrounding the spinal
cord, suspicious for fistula. However, gadolinium- enhanced MRI
would help for further assessment if clinically indicated. There
is a large pleural effusion visualized on the right side.
LUMBAR SPINE:
FINDINGS: The distal spinal cord shows increased signal up to
the conus level suspicious for ischemia. Degenerative changes
are seen with mild spondylolisthesis of L4 over L5 and mild
spinal stenosis. Mild disc bulging is identified at L3-4 and
L5-S1 levels. There is moderate bilateral foraminal stenoses
seen at the L4-5 level and mild bilateral foraminal stenosis
seen at the L5-S1 level. The paraspinal soft tissue evaluation
demonstrates mild increased signal in the posterior muscles in
the lumbar region, which could be due to mild edema.
IMPRESSION: Increased signal within the distal spinal cord,
suspicious for ischemia to the spinal cord. Degenerative changes
in the lumbar region.
.
RENAL U.S. PORT [**2124-6-19**] 5:48 PM
IMPRESSION:
1. No evidence of hydronephrosis, bilaterally.
2. Bilateral renal cysts as noted above.
3. Increased echogenicity of renal parenchyma (right greater
than left) is suggestive of underlying "medical renal disease."
2. Moderate amount of ascites within the right upper quadrant.
.
BILAT LOWER EXT VEINS PORT [**2124-6-18**] 5:36 PM
IMPRESSION: No evidence of DVT involving the right or left lower
extremities.
.
MICRO
[**2124-6-18**] 1:05 pm BLOOD CULTURE
**FINAL REPORT [**2124-6-24**]**
AEROBIC BOTTLE (Final [**2124-6-24**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2124-6-22**]):
[**2124-6-20**] REPORTED BY PHONE TO YVEL [**Doctor Last Name 39421**] AT 3:40 AM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
[**2124-6-18**] 1:38 pm URINE Site: CATHETER
**FINAL REPORT [**2124-6-19**]**
URINE CULTURE (Final [**2124-6-19**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2124-6-18**] 2:45 pm BLOOD CULTURE
**FINAL REPORT [**2124-6-24**]**
AEROBIC BOTTLE (Final [**2124-6-24**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2124-6-24**]): NO GROWTH.
FECAL CULTURE (Final [**2124-6-22**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2124-6-22**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2124-6-21**]):
REPORTED BY PHONE TO [**Doctor First Name 156**] [**Doctor Last Name 157**] [**2124-6-21**] @ 10:25 AM.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2124-6-22**] 1:14 pm BLOOD CULTURE 1 OF 2.
**FINAL REPORT [**2124-6-28**]**
AEROBIC BOTTLE (Final [**2124-6-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2124-6-28**]): NO GROWTH.
[**2124-6-22**] 10:08 am URINE Source: Catheter.
**FINAL REPORT [**2124-6-23**]**
URINE CULTURE (Final [**2124-6-23**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
[**2124-6-22**] 1:13 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT [**2124-6-28**]**
AEROBIC BOTTLE (Final [**2124-6-28**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2124-6-28**]): NO GROWTH.
.
Brief Hospital Course:
87F c DM, HTN, CRI, who presented with hypotension, bradycardia
likely from neurogenic shock now resolved with new onset
bilateral lower extremity paraplegia, spinal cord infarct, RLE
ischemia also complicated by C. diff colitis.
.
#. Bilateral lower extremity weakness, neurogenic shock. Most
likely secondary to spinal infarct due to thrombus or possibly
prolonged hypotension. MRI did not show evidence of aortic
dissection. TTE with ?aortic valve vegetation that was felt by
cardiology to represent a normal variant of the aortic valve
rather than a true vegetation. .As the patient's neurologic
symptoms persist and the chance for recovery is poor per
neurology; she received 1 dose of Decadron and mannitol but
these were discontinued as the yield for recovery is low per the
Neurology consultants. Patient remains on IV heparin. The
decision of long term anticoagulation vs. bleeding risk remains
and this needs to be addressed with the family and long term
team regarding the need for ongoing anticoagulation.
.
# Right ischemic foot. Patient treated with low dose heparin
with goal PTT 40-60 given her chronic subdural hematoma.
Vascular surgery agreed with anticoagulation and would normally
recommend angioplasty. However, given her multiple
co-morbidities, the risk is high for this procedure. Therefore,
it was agreed that anticoagulation for now would be the best
management.
.
# C. difficile colitis. Positive C. diff toxin currently being
treated with oral Flagyl. Patient is due for another 7 day
course of treatment. She remains without a leukocytosis or
fever. Patients diarrhea has improved significantly with one
loose BM per day upon discharge.
.
# Sepsis. There was no clear evidence of sepsis in this patient.
She was originally started on vanc/zosyn on admission given her
hypotension and bradycardia. All initial culture data was
negative. Vanc/zosyn was discontinued. Patient was transiently
hypothermic in the ICU requiring a bear hugger however her
temperatures remained stable on the floor. Continue to monitor
for signs of sepsis, culture if hypothermic.
.
# Change in mental status. Patient has underlying dementia with
delirium in the hospital. Repeat head CT showed resolution of
chronic subdural hematoma, not concerning for acute bleed,
midline shift or intracranial masses. Patient now close to
baseline in terms of mental status however generally moans to
stimulation, moves upper extremities, at times can give one work
answers or repeat words. Otherwise, baseline mental status is
poor.
.
# Fluid overload/CHF. Patient with anasarca likely secondary to
fluid resuscitation, poor nutritional status. BNP was >[**Numeric Identifier 17952**]
however this was in the setting of acute renal failure. Patient
diuresed with IV lasix and IV hydrochlorothiazide which is
ongoing with a goal of negative 1 to 1.5 L daily. Patient
followed by nephrology with ongoing recommendations for
diuresis.
.
# NSTEMI. Troponin peaked at 1.24 on [**6-21**], CK peak 164. MB peak
of 50. No EKG changes. Continue ASA 325 mg, Lipitor; on heparin
gtt for ?arterial thrombosis.
Of note, on echo, the patient has apical AK (new from prior echo
which showed HK) which poses a risk for thrombus formation and
further emboli. Therefore, if goals of care to pursue aggressive
medical management as we doing, would recommend long-term
anticoagulation with heparin/coumadin bridge. Currently goal PTT
40-60 given co-morbidities of chronic subdural hematoma and
recent history of UGI bleed.
.
# HTN. Patient initially hypotensive. After resuscitation
patient was hypertensive ranging 120-150s. Her BP meds were
added including Labetalol and Nifedipine. Patient's BP meds are
to be staggered given her SBP drops when all meds are given
simultaneously. Patient's SBP has been 120-130 for the last
several days prior to discharge.
.
# Acute on Chronic Renal Failure. Likely due to ATN [**1-28**]
hypotension. Patient was evaluated and followed by Nephrology.
They did not recommend dialysis. Patient's Creatinine stabilized
at 3.0-3.5, currently 2.6. Continued IV lasix and chlorthiazide
with goal of running negative 1-2 L. All meds were dosed
renally. Continue to monitor I/Os, renal function and
electrolytes.
.
# Anemia with h/o GI bleed. Patient recently admitted and
treated in the MICU due to UGIB [**1-28**] duodenal ulcer. Patient had
an NG lavage that was negative and remained guaiac negative.
Given this history however she was maintained on IV heparin with
a narrow therapeutic index of PTT 40-60. Her hematocrit remained
low by stable in the upper 20's. She received a total of one
unit of pRBCs upon leaving the MICU and has not required further
transfusions.
.
# DM2. Patient maintained on long and short acting insulin. Her
finger sticks were difficult to control with FS >200s. She is
currently on a regimen on Glargine 4 units [**Hospital1 **] with a Humalog
sliding scale with better control.
.
# Nutrition: PEG tube placed by radiology on [**2124-6-26**]. Tolerating
tube feeds.
.
# Prophylaxis. ASA 81 mg, IV Heparin gtt, no bowel regimen.
.
# Access -PICC placed [**2125-6-27**].
.
# Code Status/Communication: Health care decisions have been
made by the patients daughter [**Name (NI) 1743**] who is the next of [**Doctor First Name **]. A
family meeting with ethics, social work and the medical team
regarding the patients wishes given her worsening medical
condition. The daughter felt strongly that the patient would
want aggressive medical measures even if she is unable to walk
or talk again. This discussion should be ongoing with the
daughter given that the patients chances for recovery are poor.
Daughter, [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **] (H) [**Telephone/Fax (1) 39422**]; (C) [**Telephone/Fax (1) 39423**]
Grandson [**Name (NI) 4882**] [**Name (NI) **] [**Telephone/Fax (1) 39424**]. Patient remains a FULL
CODE.
Medications on Admission:
1. [**Telephone/Fax (1) **] 100 mg [**Hospital1 **]
2. Labetolol 400 mg [**Hospital1 **]
3. Hydralazine 50 mg qid
4. Mirtazipine 15 mg qhs
5. Bisacodyl 10 mg pr qd prn
6. MOM prn
7. Tylenol prn
8. Clonidine 0.3 mg patch - 2 patches qWed
9. ASA 81 mg qd
10. Fe Sulfate 325 mg qd
11. MVI qd
12. Ranitidine 150 mg qd
13. Lantus 6 U qhs, Novalog SS
14. Nifedipine XL 90 mg qd
Discharge Medications:
1. Atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: [**12-28**] PO Q6H (every 6
hours) as needed for pain.
4. Nifedipine 10 mg Capsule [**Month/Day (2) **]: Three (3) Capsule PO Q8H (every
8 hours).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Labetalol 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day).
7. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
8. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Four (4) units
Subcutaneous twice a day.
9. Furosemide 200 mg IV BID
Please give 30 minutes after chlorthiazide
10. Chlorothiazide 1000 mg IV BID
please give 30 minutes prior to lasix administration
11. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
12. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
13. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
[**Last Name (STitle) **]: One (1) Intravenous ASDIR (AS DIRECTED): Goal PTT 40-60.
14. Humalog 100 unit/mL Cartridge [**Last Name (STitle) **]: per sliding scale
Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Primary:
1. Spinal Cord Infarction with bilateraly lower extremity
paralysis
2. Bradycardia Arrest s/p resucitation
3. C. Difficile Colitis
4. Diabetes
5. Dementia
6. Non ST Elevation Myocardial Infarction
7. Acute on Chronic Renal Failure
8. Right Ischemic Foot
.
Secondary:
Chronic subdural hematoma
HTN
Vitamin D deficiency
Iron deficiency anemia
Discharge Condition:
Guarded - patient is chronically ill, inabilty to move her lower
extremities, baseline severely demented
Discharge Instructions:
Please ensure that patient takes all of her medications as
directed.
.
Please follow up as listed below.
.
Please return to the emergency room with any fevers, chills, low
blood pressure or any other acute medical problems.
Followup Instructions:
Please ensure that you follow up with the doctor at your nursing
home facility. You were previously followed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. You were previously seen by a Dr. [**Last Name (STitle) 3315**] who may
continue to follow you at [**Hospital 671**] Rehab. If you do not find a
primary care physician of your choice then you can call Health
Care Providers for a new primary care doctor. The number there
is [**Telephone/Fax (1) 250**].
Completed by:[**2124-7-3**]
|
[
"427.89",
"427.5",
"336.1",
"428.0",
"280.9",
"344.1",
"250.00",
"785.50",
"268.9",
"458.9",
"584.9",
"294.8",
"410.71",
"112.2",
"518.81",
"585.9",
"440.20",
"432.1",
"403.90",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"43.11",
"37.78",
"38.91",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19745, 19819
|
11878, 17772
|
268, 300
|
20213, 20320
|
2285, 2285
|
20592, 21108
|
1970, 1974
|
18195, 19722
|
19840, 20192
|
17798, 18172
|
20344, 20569
|
3625, 11855
|
1989, 2266
|
222, 230
|
328, 1575
|
2301, 3609
|
1597, 1815
|
1831, 1954
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,911
| 168,536
|
44823
|
Discharge summary
|
report
|
Admission Date: [**2123-9-24**] Discharge Date: [**2123-9-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8367**]
Chief Complaint:
Sent for anemia
Major Surgical or Invasive Procedure:
Transfusion of 3 un pRBCs
History of Present Illness:
[**Age over 90 **] year old (Russian-speaking) male with history of severe CAD
s/p multiple PCI, chronic systolic and [**Age over 90 7216**] CHF, moderate
AS, and chronic GI bleeds presented to the ER with anemia. He
was referred in to the ED by his gastroenterologist for a blood
transfusion. The patient has a long history of chronic GI
bleeds which have been attributed to an undetected AVM that have
been bleeding due to the dual anti-platelet agents. He has been
previously thought too-high risk to undergo EGD or colonscopy
based on his coronary disease so complete diagnostic evaluation
for his source of bleeding has not occurred. He was last
admitted to [**Hospital1 18**] [**Date range (1) 95898**] for chest pain and ruled in for
NSTEMI that was exacerbated by his bleeding. During that
admission he had several melanotic stools, and his Hct nadir was
20% and peak Tnt was 0.2. He remained on his aspirin and
plavix. He was seen in [**Hospital **] clinic on [**2123-9-23**] at which time his
Hct was 28.6 which was down from 34.5 on [**2123-9-6**]. Per note in
OMR from his GI doctor, his aspirin was to decrease from 325 mg
to 81 mg daily.
.
Upon arrival to the ED his initial vitals signs were 98.1 71
114/53 12 96%RA. Within ~first hour of being in ED, his blood
pressure dropped to 89/palp with HR stable in 75. He received
1L of NS and 1 unit of PRBCs. He was found to have dark brown
guaiac + stool. He received protonix 40 mg IV x1. With his son
as interpreter, he was asymptomatic denying chest pain,
dizziness, or shortness of breath. He stated that he was feeling
weak but no other symptom.
Past Medical History:
--Coronary Artery Disease - s/p BMS to OM2, D1, LCX ([**2122-11-16**])
for unstable angina with TWI in V2-V4
- NSTEMI s/p cardiac cath and balloon angioplasty on [**2123-5-24**]
--CHF, systolic EF 40% and [**Date Range 7216**] dysfunction with sever LVH
--Valvular disease - moderate aortic stenosis, mild to moderate
aortic and mitral regurgitation, ?bicuspid congenital valves
--HTN
--COPD
--Gout
--DJD - bilateral knee pain
--h/o chronic pyelonephritis
--s/p bladder stone removal
--Colon cancer
Social History:
Social history is significant for occasional cigarrettes
socially 20 years ago. He drinks about 1 glass of wine or
alcoholic drink /week. He is from [**Country 532**] and worked as a
general surgeon in [**Location (un) 4551**]. He retired at age 63 due to his hand
tremor. He has been widowed for 8 years and lives alone in
[**Location (un) **]. He has children in the area who are helpful. Has an
aid who comes to clean the apt and bathe him.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
.
Physical Exam:
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), loud 3/6 systolic
murmur, JVD 9-10cm
Respiratory / Chest: difficult to assess [**2-13**] patient
non-compliance/language barrier
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: no C/C/E
Skin: intact, without rashes or jaundice
Neurologic: Attentive
Pertinent Results:
Lab Results:
[**2123-9-23**] 12:00PM BLOOD WBC-5.5 RBC-3.47* Hgb-8.8* Hct-28.6*
MCV-82 MCH-25.3* MCHC-30.8* RDW-20.5* Plt Ct-205
[**2123-9-24**] 04:15PM BLOOD WBC-5.4 RBC-3.14* Hgb-8.0* Hct-25.3*
MCV-81* MCH-25.4* MCHC-31.5 RDW-20.3* Plt Ct-201
[**2123-9-25**] 04:06AM BLOOD WBC-7.4 RBC-3.61* Hgb-9.6* Hct-29.3*
MCV-81* MCH-26.6* MCHC-32.8 RDW-19.2* Plt Ct-181
[**2123-9-26**] 03:49AM BLOOD WBC-11.5*# RBC-4.31* Hgb-11.4* Hct-35.9*
MCV-83 MCH-26.4* MCHC-31.6 RDW-18.1* Plt Ct-178
[**2123-9-26**] 10:50AM BLOOD WBC-8.8 RBC-4.22* Hgb-11.3* Hct-34.8*
MCV-82 MCH-26.9* MCHC-32.6 RDW-19.1* Plt Ct-166
.
[**2123-9-23**] 12:00PM BLOOD Neuts-63.8 Lymphs-27.0 Monos-6.2 Eos-2.7
Baso-0.3
[**2123-9-24**] 04:15PM BLOOD Neuts-52.7 Lymphs-35.6 Monos-6.0 Eos-5.1*
Baso-0.7
.
[**2123-9-24**] 04:15PM BLOOD Glucose-110* UreaN-38* Creat-1.3* Na-141
K-4.0 Cl-106 HCO3-26 AnGap-13
[**2123-9-25**] 04:06AM BLOOD Glucose-92 UreaN-33* Creat-1.1 Na-141
K-3.8 Cl-108 HCO3-25 AnGap-12
[**2123-9-25**] 07:35PM BLOOD Glucose-111* UreaN-33* Creat-1.2 Na-142
K-4.2 Cl-107 HCO3-27 AnGap-12
[**2123-9-26**] 03:49AM BLOOD Glucose-115* UreaN-32* Creat-0.9 Na-142
K-4.0 Cl-108 HCO3-26 AnGap-12
[**2123-9-26**] 10:50AM BLOOD Glucose-125* UreaN-30* Creat-1.0 Na-143
K-3.9 Cl-107 HCO3-29 AnGap-11
.
[**2123-9-24**] 04:15PM BLOOD Calcium-8.8 Phos-2.9
[**2123-9-25**] 04:06AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
[**2123-9-25**] 07:35PM BLOOD Mg-2.2
[**2123-9-26**] 03:49AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.2
[**2123-9-26**] 10:50AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.3
.
[**2123-9-26**] 11:48AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2123-9-26**] 11:48AM URINE Blood-SM Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2123-9-26**] 11:48AM URINE RBC-0-2 WBC-[**12-2**]* Bacteri-MOD Yeast-NONE
Epi-0
.
Urine Culture: Pending
.
EKG: sinus @65 with RBBB, LAFB, biventricular hypertrophy and
extensive lateral ST depressions (w/o significant change from
[**2123-9-5**])
TTE: [**2123-9-3**] - The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is 0-10mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. No masses or thrombi are seen in the
left ventricle. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-45 %) with infero-lateral
hypokinesis. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
are severely thickened/deformed. There is moderate aortic valve
stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
[**Age over 90 **] yo male with history of CAD s/p multiple PCI, systolic and
[**Age over 90 7216**] CHF, aortic stenosis and chronic GI bleeding admitted
for GI bleed and hypotension.
1. GI bleed: Patient's anemia appears to be likely related to a
slow and chronic GI bleed, which was thought related to an
undiagnosed AVM, however unable to get colonoscopy considering
CAD. Following admission to the MICU, his GIB bleed slowed.
His blood pressure rapidly normalized following 1L of saline and
1 unit of pRBCs. His bleeding likely exacerbated in the setting
of dual anti-platelet agents- plavix and ASA 325mg. Stopped
Plavix and switched to ASA 81mg, also treated with PPI IV bid,
then switched to PO PPI. Received three units of PRBC's on
admission, Hct improved significantly. H. pylori serologies
pending. Checked [**Hospital1 **] Hct. Maintained 2 peripheral IVs as
access in the event that the patient developed a more acute
bleed, however was not necessary. Continued iron supplements.
.
2. Coronary Artery Disease: No evidence of acute ischemia with
unchanged EKG, has ST depressions chronically in V2-V6, and no
elevation in cardiac enzymes, times three sets. Contact[**Name (NI) **]
primary cardiologist who agreed with stopping plavix. Restarted
BB prior to leaving the MICU but at a reduced dose of 12.5mg
[**Hospital1 **]. Patient remained chest pain free once sent to the floor.
Continued statin, beta blocker, nitro prn, aspirin while
inpatient. Plavix has been discontinued, as above, as stent was
placed greater than 6 months ago. Consulted cardiology for
further recommendations, want to reinitiate long acting
nitrates, Imdur 60mg QD. Will send patient home with this
regimen and have him follow up with his primary Cardiologist in
the next few weeks.
.
3. Chronic Systolic and [**Hospital1 **] Congestive Heart Failure:
euvolemic at this time. Continued beta blocker. Unclear why
patient is no longer on ACEI. He was previously taking
lisinopril 2.5mg as recently at 5/08, although this medication
is no longer on his list. Will have patient follow up with
outpatient cardiologist.
.
4. COPD: Currently asymptomatic. Continued nebs PRN.
.
5. Gout: stable, asymptomatic. Continued allopurinol and
colchicine
.
6. BPH: Stable. Continued tamsulosin
.
7. Leukocytosis: New during hospitalization. Found to have a
UTI. As patient has chronic UTI's, started ciprofloxacin 500mg
[**Hospital1 **] for a total of 7 days. Patient is to follow up with his
urologist as an outpatient.
.
FEN: heart-healthy diet, replete lytes prn
.
PPx: bowel regimen; holding DVT prophylaxis in setting of GI
bleed
.
CODE: FULL CODE
Medications on Admission:
Ipratropium Bromide Neb Q6H
Allopurinol 100 mg DAILY
Aspirin 325 mg DAILY
Atorvastatin 80 mg DAILY
Clopidogrel 75 mg DAILY
Docusate Sodium 100 mg [**Hospital1 **]
Isosorbide Mononitrate 60 mg daily
Polysaccharide Iron Complex 150 mg daily
Tamsulosin 0.4 mg qhs
Pantoprazole 40 mg Q12H
Metoprolol Tartrate 37.5 mg [**Hospital1 **]
Levalbuterol HCl Neb q4hrs:prn
Nitroglycerin 0.3 mg prn
Colchicine 0.6 mg [**Hospital1 **]:prn
Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
12. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed.
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: end date [**2123-10-3**].
Disp:*13 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Family Care
Discharge Diagnosis:
Primary Diagnoses:
Acute on Chronic anemia of chronic blood loss
Gastro-intestinal bleed
UTI
.
Secondary Diagnoses:
Coronary Artery Disease
Hypertension
CHF
COPD
Gout
DJD
colon cancer
Discharge Condition:
good
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of a low hematocrit
found at your GI physician's office. It was presumed that this
was a result of your chronic gastrointestinal bleeding. You
were transfused 3 units of blood and your counts appropriately
responded. Your GI bleeding and anemia resolved prior to
discharge. You also experienced chest pain while you were
hospitalized. Cardiology was consulted and added back Imdur to
your medication regimen. Please continue to weigh yourself
every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. You were also found to have a
urinary tract infection. You were started on ciprofloxacin, and
should continue this medication for the next 6 days.
.
These medications were added to your regimen, please continue to
take them as directed once you are discharged:
Imdur 60mg once a day
Ciprofloxacin 500mg twice a day for 6 more days
.
These medications were changed from your normal home regimen:
Metoprolol changed to 12.5mg twice a day, please continue this
dose until you discuss with your outpatient Cardiologist whether
or not to increase back to your original dose of 37.5.
Aspirin switched to 81mg from 325mg.
.
These medications were discontinued, please do not take them
when you are discharged:
Plavix (clopidogrel)
.
If you experience bright red blood per rectum, dark tarry
stools, vomiting blood, nausea, chest pain, shortness of breath
or any other worrisome symptoms please seek medical attention.
Followup Instructions:
Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
phone number ([**Telephone/Fax (1) 1921**], regarding your UTI and the urine
bacterial cultures.
.
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2123-10-4**] 2:00
.
Please follow up with your Cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2123-10-4**] 3:00, regarding your chest
pain and cardiac medications.
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 13545**]
Date/Time:[**2123-12-23**] 10:00
Completed by:[**2123-9-26**]
|
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icd9cm
|
[
[
[]
]
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[
"99.04"
] |
icd9pcs
|
[
[
[]
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|
6722, 9379
|
278, 305
|
11385, 11392
|
3517, 6699
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9405, 9831
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11416, 12920
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3069, 3498
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223, 240
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333, 1960
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1982, 2487
|
2503, 2953
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,461
| 143,887
|
43739
|
Discharge summary
|
report
|
Admission Date: [**2152-12-14**] Discharge Date: [**2153-1-2**]
Date of Birth: [**2087-1-2**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Nsaids / Ultram
/ Iodine-Iodine Containing
Attending:[**First Name3 (LF) 4611**]
Chief Complaint:
Neck swelling
Major Surgical or Invasive Procedure:
Laryngoscopy ([**2152-12-15**])
Ultrasound guided neck biopsy
Percutaneous enterogastric tube placement
History of Present Illness:
65 y/o presents with neck pain. Patient first noticed increased
hoarseness 1 week ago. Then started having sharp, right sided,
constant [**12-23**] neck pain 5 days ago. Additionally started having
hemoptysis 3 days ago. Patient explains she has a chronic cough
that is frothy and clear but hasn't had blood until 3 days ago.
Patient has also had occassional chills and mild SOB. She denied
fever, chills, night sweats. She notes that she sometimes she
choked on food in the last 2-3 days. Patient thas a 53 pack year
history of smoking (started smoking 1 PPD at age 13). Presented
to her PCP's office, where an large painful mass was noted in
her right neck. Urgent ultrasound demonstrated enlarged lymph
nodes and evidence of an underlying mass of unknown size. She
was referred to the ED for CT scan and further workup.
.
In the ED, initial VS were: T 97.4 HR 78 BP 181/56 RR 20 SpO2
99% RA.
Exam notable for hoarseness and tenderness to palpation of the
right neck. CT non contrast of neck demonstrated large
circumferential mass nearly occluding her airway. ENT was
consulted who performed direct laryngoscopy. Recs pending on
transfer. Admitted to ICU for monitoring given near airway
compromise, and for further workup of neck mass.
.
On arrival to the MICU, patient was hoarse and tolerating her
secretions well. Complains of neck pain but denies any
significant shortness of breath.
.
Review of systems:
+Weight loss
Past Medical History:
- schizophrenia
- severe depression
- COPD/Asthma
- hx of atypical chest pain
- Hypertension
- Chronic back pain, L4 radiculopathy
- Peripheral vascular disease
- psoriasis
- s/p TAH
- s/p cholecystectomy
- h/o narcotic abuse in past
- multiple previous UTI's
.
Social History:
Smokes a pack a day since age 16, >50 pack years
smoking. Denies alcohol use or other drug use. She lives
currently with her husband and twin sister. She is not currently
employed.
Family History:
father and sister with schizophrenia
Physical Exam:
Admission Physical Exam
Vitals: T: 98.8 BP:155/66 P:73 R: 16 O2: 97% 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
Neck: slightly erythemaous relatively firm painful spherical
mass
about 4.5cm x 4.5cm x 3.5 cm in the mid-sternocleidomastoid
region. Tender to palpation, not attached to skin, slightly
mobile but overall fixed. Mildly fluctuant on exam.
Lung: coarse exp rhonchi bilaterally all over the lung fields
bilaterally. no audible wheezes.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
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
DISCHARGE EXAM:
Vitals: 97.9, 100/58, 83, 20, 97RA
GEN: NAD.
HEENT: Sclerae non-icteric, o/p clear, moist oral membranes. dry
nares filled with crusted mucous.
Neck: Supple, firm painful mass about 4.5cm x 4.5cm x 3.5 cm in
the mid-sternocleidomastoid region. Tender to palpation, not
attached to skin, slightly mobile but overall fixed.
CV: S1S2, reg rate and rhythm,.
RESP: Distant breath sounds bilaterally, but comfortable
breathing.
ABD: Soft, non-tender, non-distended, + bowel sounds. PEG in
place
EXTR: No edema.
DERM: No rash.
Neuro: grossly non focal
Pertinent Results:
ADMISSION LABS:
[**2152-12-14**] 06:30PM BLOOD WBC-10.1# RBC-4.33 Hgb-11.9* Hct-37.3
MCV-86 MCH-27.6 MCHC-32.0 RDW-13.3 Plt Ct-431
[**2152-12-15**] 03:25AM BLOOD PT-12.9* PTT-26.6 INR(PT)-1.2*
[**2152-12-14**] 06:30PM BLOOD Glucose-134* UreaN-16 Creat-0.8 Na-140
K-4.3 Cl-100 HCO3-28 AnGap-16
.
DISCHARGE LABS:
[**2153-1-2**] 05:09AM BLOOD WBC-4.3# RBC-4.14* Hgb-11.0* Hct-34.3*
MCV-83 MCH-26.7* MCHC-32.2 RDW-14.2 Plt Ct-156
[**2153-1-1**] 06:00AM BLOOD Neuts-50 Bands-0 Lymphs-38 Monos-10 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2153-1-2**] 05:09AM BLOOD Glucose-103* UreaN-23* Creat-0.6 Na-132*
K-4.2 Cl-93* HCO3-32 AnGap-11
[**2153-1-2**] 05:09AM BLOOD Calcium-8.4 Phos-1.6* Mg-1.7
STUDIES:
CT Neck without contrast ([**2152-12-14**])
Severe circumferential narrowing of the airway by a soft tissue
mass that
extends from the epiglottis to the thyroid cartilage. Soft
tissue mass just deep to the right sternocleidomastoid
corresponds to lesion seen on
ultrasound; incompletely assessed without contrast. Consider MRI
for further assessment. Findings highly concerning for
malignancy, possibly squamous carcinoma.
-----------
CXR ([**2152-12-14**]): No significant interval change. No acute
cardiopulmonary
process.
-----------
Neck Soft tissue Ultrasound ([**2152-12-14**]): Palpable lump in the
lower right neck is an abnormal lymph node that measures 38 x 18
x 25 mm. It has some vascularity and shows marked irregularity.
It lies lateral to the internal jugular. Other abnormal lymph
nodes are present in this region, but are considerably smaller.
In the upper neck just inferior to the right submandibular
gland, a mass is seen with its broadest space at the right
trachea extending outwards into the more lateral aspect. This
measures approximately 4 x 3 cm in the transverse and is
associated with an enlarged lymph node in this region also. No
evidence of abnormality is seen on the left side. Lobes of the
thyroid appear normal. These appearances suggest a malignancy
arising out of the region of the trachea or vocal cords with
metastatic lymph nodes. Dr. [**Last Name (STitle) **] was informed and the
patient was instructed to go to the emergency room for further
evaluation.
-----------
CYTOLOGY: Lymph node (right neck), fine needle aspirate:
POSITIVE FOR MALIGNANT CELLS, consistent with squamous cell
carcinoma.
-----------
VIDEO OROPHARYNGEAL SWALLOW: Oral and pharyngeal swallowing
evaluation was
performed in conjunction with the speech and swallow service
using multiple consistencies of barium. There was premature
spillover with evidence of pharyngeal swallow delay.
Mild-to-moderate aspiration was observed with thin liquids and
in part due to hyperextended position of the head, but not
cleared with prompting. Aspiration of nectar thick liquids was
also noted related to extensive residua in the piriform sinuses.
Please see the full speech and swallow service report in OMR for
further details.
-----------
CT CHEST: New sub-4-mm right upper and lower lobe pulmonary
nodules should be evaluated with chest CT in one year. No
additional suspicious pulmonary lesions. Large right neck mass
not fully imaged; see neck CT from [**2152-12-14**] for additional
details.
----------
MRI HEAD/NECK:
FINDINGS: Head images demonstrate prominent ventricles and
sulci, likely age related and involutional in nature. On the
diffusion-weighted sequences, there is no evidence of acute
ischemic disease or acute infarctions.
The study of the neck demonstrates soft tissue laryngeal mass on
the left,
causing narrowing of the airway, the right neck mass is not
clearly identified in this examination, please consider
obtaining additional images under conscious sedation or under
anesthesia for further characterization.
-----------
CT NECK:
1. Irregular, heterogeneously enhancing, lobulated mass seems to
originate in the left piriform sinus and crosses midline to fill
the right superior
piriform sinus. It also fills the laryngeal ventricles, causing
significant narrowing of the airway, and also invades the
glottis, aryepiglottic folds, true vocal cords, with only subtle
extension to the false vocal cords.
2. Another right neck mass at the level of C4 anterior to
carotid artery and SCM muscle may be an extension of the
laryngeal mass or a nodal metastasis.
3. A third mass does not appear to be contiguous with the first
two, and lies behind the right SCM with possible invasion into
the muscle.
4. There is considerable compressive mass effect on the right
jugular vein
with complete encasement of the right external carotid artery.
The arterial system is patent.
-----------
MICROBIOLOGY:
URINE CULTURE (Final [**2152-12-16**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Ms. [**Known lastname 11753**] is a 65 y/o F with long smoking history who presented
with voice hoarseness and painful neck mass found to be
squameous cell carcinoma.
.
#. Squameous Cell Carcinoma: 65 year old female with long
smoking hx, right sided [**Doctor First Name **], and increased hoarseness. This
symptom cluster was concerning for malignancy with likely SCC
with unknown primary. Hoarseness [**2-16**] [**Doctor First Name **] and RLN involvement. CT
scan highly suspicious of malignancy and showed possible airway
compromise. Initially admitted to the MICU due to concern for
airway stability. ENT was consulted who performed laryngoscopy
and though patient most likely had supraglotic SCC with
bilateral metastatis. They did not think her airway was
compromised and recommended biopsy of the node for diagnosis.
She received Dexamethasone 10 mg IV to help with swelling of
neck mass and dysphagia. Transferred to the medical floor. On
the medical floor the patient underwent FNA of a lymph node
which showed SCC. A double lumen port was placed and she was
transfered to the oncology service and received Cis-platin,
taxotere and a 4 day infusion of 5-FU. The patient tolerated
her chemotherapy well and was scheduled for follow up with her
oncologist on [**2153-1-10**]. Was neutropenic for ~3 days - was given
neupogen once counts were noted to be down trending. Would
consider neupogen given day after chemo given neutropenia with
this cycle.
.
#. Nutrition: The patient described difficulty swallowing on
admission which was believed to be related to her large neck
mass. On the medical floor the patient underwent speech and
swallow evaluation which showed the patient to be at high
aspiration risk with food frequently being stuck in the
esophagus. A PEG tube was placed through which the patient
received nutrition and medications. Her nutrition requirment
was two cans of ensure (480 mL) TID with 100mL free water bolus
with each feeding. She was noted to have increased residuals at
times - if continues would consider running continuous tube
feeds at 65cc/hr.
.
#. Anxiety/pain: The patient was noted to have a significant and
appropriate amount of anxiety regarding SCC diagnosis. Seen by
SW who provided support. Also increased her home lorazepam
dosing from 0.5mg TID to 1mg TID. The patient received IV
morphine for pain control and olanzapine per home regimen and
additional PRN. She was highly fixated on these medications and
perseverative. These perseverations are a chronic issue as
discussed with her psychiatrist. She was able to be redirected
when explained she was not going to receive narcotics. Once it
was determined that the patinet was not having signficant pain
her morphine was discontinued and the patient continued to
recieve tylenol PRN. She was also started on oxycodone 2.5mg
q4hrs prn pain.
.
#. Shortness of breath: CT chest showed RLL consolidation and
with history of COPD and wheezing on exam, she was treated with
azithromycin IV 500 mg for 5 days for question CAP. She was
given IV dexamethasone for neck mass swelling and continued on
her home tiotropium and albuterol q4. The shortness in breath
improved after these interventions and the patient continued to
recieve albuterol nebulizers PRN and tiotropium Cap daily.
.
#. Hypertension: Home medications initially held as patient was
NPO. Restarted once NG tube was placed. Became hypertensive to
~150-160 systolic off medications. Patient had good BP control
on her home lisinopril 20 mg daily.
.
# Urinary Retention: Patient was initially treated for a UTI on
admission. She did not have any issues with urinating prior to
the transfer OMED service. While on OMED the patient was noted
to not be voiding a foley catheter was placed and drained in
excess of 1000 mL. Foley was removed and patient was still
retaining. The etiology of the retention was not clear, but
felt to be related to the patient's psychotic perseverant
behavior. An MR [**Name13 (STitle) 1093**] was attempted, but due to the patient's
extreme intolerance of the procedure as well as an aborted
attempt at fiberoptic intubation due to bleeding of the mass no
spinal cord imaging was possible. The patient was discharged
with a foley catheter in place and urology follow up.
.
#. Contrast Allergy: Patient had a documented contrast allergy
of unknown type or severity. The patient was unable to tolerate
neck MRI and therefore underwent CT neck with contrast for
characterization of her malignancy. Patient recieved
pretreatment with prednisone and benadryl without incident or
minor reaction.
.
#. Constipation: The patient developed constipation after being
transfered to the OMED service without a bowel movement for
greater than 9 days. She was treated with an aggressive bowel
regimen including magnesium citriate with ability to move
bowels.
.
#. Schizoaffective disorder: The patient appeared to be at her
baseline through out her admission per her family and primary
care doctor. She had significant perseverative behavior
including asking for pain medications and significant
psychomotor aggitation. As she had a history of severe
parkinsonian symptoms in the past zyprexa dosing was not changed
and patient was treated sparingly with zyprexa for behavior
control. her perseverative beahviors were felt to be the
etiology of both her constipation and urinary retention as she
was observed on the commode on several occasions unable to focus
on initiating a bowel movement or urinating.
.
#. Tobacconism: Patient had a chronic tobacco dependence on
admission with a pack a day habit. She was given nicotine
patches and lozanges PRN.
.
Transitional Issues:
- Port suture to be removed [**1-5**] by any physician
[**Name Initial (PRE) **] [**Name10 (NameIs) **] [**Name11 (NameIs) **]4-mm right upper and lower lobe pulmonary nodules
should be evaluated
with chest CT in one year.
- Patient is a high risk intubation even with fiberoptic
visulization due to friability of the lyrangal mass, would need
trach or cricotomy for emergent intubation.
- Patient should continue to be offered nicotine cessation by
her PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] should have tube feeding switched to 65 cc/hr
continuous if continues with high residuals
- Patient was discharged with a foley catheter in place
- Patinet was discharged with urology and oncology follow up
- Patient will need pshyciatry follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Name8 (MD) 94003**], MD, [**Location (un) **], MA [**Telephone/Fax (1) 94004**] after discharge
from Rehab
- Patient will need PCP follow up once discharged from Rehab
Medications on Admission:
Albuterol
Lisinopril 20mg QD
lorazepam 0.5mg TID
olanzapine 5mg QHS
omeprazole 40mg QD
spiriva
aspirin 81mg QD
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Telephone/Fax (1) **]:
One (1) Cap Inhalation DAILY (Daily).
2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
3. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
4. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for Agitation,
anxiety.
5. lorazepam 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
6. lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q4H (every 4 hours).
8. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2
times a day).
9. polyethylene glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: Seventeen
(17) gm PO DAILY (Daily).
10. nicotine 21 mg/24 hr Patch 24 hr [**Last Name (STitle) **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
11. nicotine (polacrilex) 2 mg Lozenge [**Last Name (STitle) **]: One (1) Lozenge
Buccal Q1H (every hour) as needed for tobacco withdrawl.
12. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) mg PO Q4H (every 4 hours) as needed for Pain.
13. sodium chloride 0.65 % Aerosol, Spray [**Age over 90 **]: [**1-16**] Sprays Nasal
QID (4 times a day) as needed for dry nares.
14. ondansetron 8 mg Tablet, Rapid Dissolve [**Month/Day (2) **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
15. senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. lactulose 10 gram/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
17. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) mL
Injection TID (3 times a day).
18. oxycodone 5 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
19. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (2) **]:
One (1) Topical once a day.
20. Ativan 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every four (4)
hours as needed for anxiety.
21. aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO once a day.
22. Vitamin B-12 1,000 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary: Laryngeal squamous cell carcinoma
Dysphagia/odynophagia
Schizoaffective disorder
Secondary: COPD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs [**Known lastname 11753**],
It was a pleasure taking care of you during your
hospitalization. You were admitted with a painful neck mass.
This was biopsied and unfortunately turned out to be a Squamous
Cell Cancer. You were unable to eat and had a feeding tube
placed through which you will receive your nutrition. You also
had a special type of IV called a Portacath placed to help give
your chemotherapy. You received your first cycle of
chemotherapy while in the hospital and tolerated it well. You
had a drop in your white blood cell counts after chemo and were
given medications to help improve your immune system. You also
had difficulty emptying your bladder and required intermittent
striaght catheterization, you have a follow up appointment
scheduled with urology on [**1-18**]. You will also need to
contact Dr. [**Last Name (STitle) **] about scheduling a follow up appointment and
coordinating your home services. You were noted to have
difficulty with your balance and were discharged to a rehab
facility to help regain your strength. You will need to follow
up with your pshyicatrist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 94003**] at
[**Telephone/Fax (1) 94004**] once you are discharged from Rehab. You will
need to have another several cycles of chemotherapy in the
coming months. You will have a follow up appointment with Dr.
[**Last Name (STitle) **] in her clinic on [**2153-1-10**] and then be readmitted to
the hospital after that for a second round of chemo.
We made the following changes to your medications:
-CONTINUE Albuterol nebulizer every 4 hours
-START Acetaminophen 325-650 mg every 4 hours as needed for pain
-START Docusate 100 mg twice daily
-START Heparin 5000 units sub-cutaneously three times a day
while at rehab.
-START Saline nasal spray 1 puff as needed for dry nose
-CONTINUE Lisinopril 20 mg daily
-START Lidocaine 5% patch daily
-START Lorazepam 1 mg three times a day
-START Lorazepam 0.5 mg every 4 hours as needed for anxiety
-START Nicotine patch 21 mg daily
-START Nicotine lozenge 2 mg every hour as needed for nictoine
craving
-START Zofran 8 mg every 8 hours as needed for nausea
-CONTINUE Zyprexa 5 mg every night before bed
-START Zyprexa 5 mg twice a day as needed for aggitation
-START Oxycodone 2.5 mg every 6 hours as needed for pain
-START Senna 1 tablet twice daily for constipation
-CONTINUE Tiotropium bromide 1 cap inhaled daily
-CONTINUE Aspirin 81 mg daily
-CONTINUE Vitamin B12 1 mg once a day
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2153-1-10**] at 9:30 AM
With: [**Last Name (LF) 3150**],[**Name8 (MD) **] MD [**Telephone/Fax (1) 11133**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
Specialty: Urology
When: WEDNESDAY [**2153-1-17**] at 2:00 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD
Specialty: Internal Medicine
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 250**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge. They
can call the number listed above to make the appointment.
|
[
"564.00",
"786.30",
"311",
"599.0",
"288.03",
"799.02",
"724.2",
"161.8",
"493.20",
"787.20",
"788.20",
"305.1",
"041.49",
"486",
"443.9",
"295.70",
"696.1",
"196.0",
"E933.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.07",
"43.11",
"31.42",
"40.11",
"99.25",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
18885, 18985
|
9412, 15066
|
365, 471
|
19136, 19136
|
3926, 3926
|
21891, 22995
|
2433, 2471
|
16251, 18862
|
19006, 19115
|
16115, 16228
|
19323, 20910
|
4237, 9389
|
2486, 3344
|
3360, 3907
|
15087, 16089
|
20939, 21868
|
1917, 1932
|
311, 327
|
499, 1898
|
3942, 4221
|
19151, 19299
|
1954, 2218
|
2234, 2417
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,907
| 121,310
|
25001
|
Discharge summary
|
report
|
Admission Date: [**2190-7-31**] Discharge Date: [**2190-8-3**]
Date of Birth: [**2167-3-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Found Unresponsive
Major Surgical or Invasive Procedure:
Intubation [**2190-7-31**]
History of Present Illness:
23 yo M with PMH significant for heroin abuse and oxycontin
abuse transferred from OSH with Heroin Overdose (snorted 6 bags
of heroin), LUL PNA and leukocytosis. Pt was intubated (06:30
on [**7-31**]) in [**Hospital1 18**] ED for hypoxia (100% NRB; O2 sat 90%) and
hypotension (SBP 84). ABG was 7.23/60/85. He was found to have a
left lower lobe pneumonia. He received Versed and Propofol for
sedation, 3 liters of normal saline, and 1 liter lactated
ringers solution. An A-line and NGT were placed. Remained
hemodynamically stable in the MICU and was extubated on [**2190-8-1**]
at 2:30am without difficulty.
Currently patient is tolerating a PO diet and satting 97% on 2L
NC, and is transferred to the floor for further treatment of PNA
and heroine abuse.
Past Medical History:
- heroin abuse
- Wisdom teeth removed [**2190-7-29**] on Amox
Social History:
Social hx:
Lives at home. Denies cocaine abuse, EtOH abuse, any IV drug use
(only snorts Heroin). Admits to ativan use prn. Prior Rehab for
for oxycontin use.
Family History:
Family Hx: Non-contributory
Physical Exam:
PE: T 98.5, 117-153/55-83, 20, on 2L NC 96% with recent ABG
7.43/41/93
Gen: Sitting in bed; NAD
HEENT: PERRLA, EMOI, anicteric 5 mm pupils
CV: RR, Nl S1S2, No MRG
Lungs: decreased BS in LUL, CTAB, no WRR
Abd: soft, ND, positive BS
Ext: no edema, strong DP/PT pulses. no IV tracks appreciated
.
Pertinent Results:
Admission Labs:
.
CBC with Diff:
[**2190-7-31**] 12:15AM WBC-23.1* RBC-4.61 HGB-14.0 HCT-40.6 MCV-88
MCH-30.3 MCHC-34.4 RDW-12.1
[**2190-7-31**] 12:15AM NEUTS-81* BANDS-2 LYMPHS-11* MONOS-3 EOS-0
BASOS-0 ATYPS-2* METAS-1* MYELOS-0
[**2190-7-31**] 12:15AM PLT SMR-NORMAL PLT COUNT-309
.
Chemistries:
[**2190-7-31**] 12:15AM GLUCOSE-139* UREA N-16 CREAT-0.9 SODIUM-140
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-23 ANION GAP-16
[**2190-7-31**] 12:27AM LACTATE-2.4*
[**2190-7-31**] 06:10AM CALCIUM-8.3* PHOSPHATE-3.1 MAGNESIUM-1.3*
[**2190-7-31**] 06:10AM ALT(SGPT)-11 AST(SGOT)-15 LD(LDH)-190 ALK
PHOS-52 TOT BILI-0.8
.
Tox Screen:
[**2190-7-31**] 12:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-8.6
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Admission ABG 7.23/60/85
.
Admission CXR: AP upright portable view of the chest. There is a
consolidation in the lingula, as well as less dense
consolidation in the left upper lobe. The right lung appears
clear. Mediastinal contours are normal. There is no pleural
effusion. The visualized osseous structures appear unremarkable.
.
IMPRESSION: Lingular and left upper lobe pneumonia.
.
Admission EKG [**7-30**]: ST 102, nl axis, nl intervals, TWI III, [**Last Name (un) 11181**]
in avF, nmo ST changes. early repol in V3.
.
Additional labs:
[**2190-8-1**] 04:10AM BLOOD WBC-12.1* RBC-3.97* Hgb-11.7* Hct-34.5*
MCV-87 MCH-29.5 MCHC-33.9 RDW-12.1 Plt Ct-211
[**2190-8-2**] 06:25AM BLOOD WBC-9.0 RBC-4.18* Hgb-12.3* Hct-35.2*
MCV-84 MCH-29.4 MCHC-35.0 RDW-11.9 Plt Ct-239
[**2190-7-31**] 06:10AM BLOOD Neuts-76* Bands-1 Lymphs-21 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2190-8-1**] 04:10AM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-141 K-3.4
Cl-106 HCO3-27 AnGap-11
[**2190-8-2**] 06:25AM BLOOD Glucose-101 UreaN-7 Creat-0.7 Na-141
K-3.9 Cl-105 HCO3-27 AnGap-13
[**2190-7-31**] 06:10AM BLOOD ALT-11 AST-15 LD(LDH)-190 AlkPhos-52
TotBili-0.8
Brief Hospital Course:
Hospital Course:
.
# Heroin Overdose: The patient was transferred from an OSH after
snorting 6 bags of heroin. He was intubated (06:30 on [**7-31**]) in
the [**Hospital1 18**] ED for hypoxia (100% NRB; O2 sat 90%) and hypotension
(SBP 84). The ABG was 7.23/60/85. He was found to have a left
upper lobe and lingular PNA. He received Versed and Propofol for
sedation, 3 liters of normal saline, and 1 liter lactated
ringers solution. An A-line and NGT were placed. He remained
hemodynamically stable in the MICU and was extubated on [**2190-8-1**]
at 2:30am without difficulty. He was transferred to the floor
on [**8-1**] and was satting at 97% on RA. His respiratory status
was stable throughout the rest of his stay. An addiction
consultation was obtained and the patient noted he wanted to
resolve his addiction problem. [**Name (NI) **] noted this was not a
suicide attempt so psychiatry was not consulted. His family was
aware of the situation and involved in his care. Case
management, social work and [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**] (psychiatric liason
nurse who works with patients with addiction) were involved in
placing the patient at an addiction rehab.
.
# Elevated tylenol level at admission: His tylenol level was
8.6 on admission. He denied an overdose and his LFTs were
normal. Abdominal exam was benign throughout his stay.
.
#Leukocytosis/aspiration PNA: The patient was found to have a
left upper lobe and lingular pneumonia. There was concern for
an aspiration pneumonia since he had decreased mental status
after his heroin overdose. He was started on clindamycin to
cover for aspiration and levofloxacin to cover for community
acquired pneumonia. His WBC trended down from 23 at admission
to 9 on [**8-2**]. He was afebrile on the floor and at discharge.
.
# Communication- [**Last Name (LF) 6961**], [**First Name3 (LF) **] and [**Doctor Last Name **], Home: [**Telephone/Fax (1) 62792**],
[**Doctor Last Name **] Cell: [**Telephone/Fax (1) 62793**], [**Doctor First Name **] Cell: [**Telephone/Fax (1) 62794**]
Medications on Admission:
Medications on admission: OTC Extra Strength Tylenol for pain
s/p Wisdom teeth removal
.
Medication on MICU transfer:
Clindamycin 600 mg IV Q8H, Azithromycin 250 mg PO Q24H, Senna 1
TAB PO BID, Docusate Sodium (Liquid) 100 mg PO BID, Ibuprofen
400 mg PO Q6H:PRN
Discharge Disposition:
Extended Care
Facility:
Bald [**Doctor Last Name **]
Discharge Diagnosis:
1. Heroin Overdose
2. Aspiration Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Your medications have been changed. Please take your
medications as prescribed.
Please return to ER or call your primary care doctor if you
develop increasing shortness of breath, chest pain, worsening
cough, fevers, chills, dizziness or lightheadedness.
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**Doctor Last Name 60171**] [**Name (STitle) **],
in [**12-6**] weeks. Her number is [**Telephone/Fax (1) 60170**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
[
"276.2",
"E980.0",
"518.81",
"305.50",
"314.01",
"507.0",
"965.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6098, 6153
|
3696, 3696
|
332, 360
|
6240, 6247
|
1788, 1788
|
6551, 6816
|
1429, 1458
|
6174, 6219
|
5837, 6075
|
3713, 5785
|
6271, 6528
|
1473, 1769
|
274, 294
|
388, 1150
|
1804, 3673
|
1172, 1236
|
1252, 1413
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,507
| 174,288
|
21914
|
Discharge summary
|
report
|
Admission Date: [**2113-12-27**] Discharge Date: [**2113-12-30**]
Date of Birth: [**2059-10-8**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Iodine
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
UGIB
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
54-year-old female with past medical history of UGIB secondary
[**Known firstname **] duodenal ulcer, on pantoprazole no presents with dark red
vomit and dark red bowel movement starting today.
.
The patient was in her usual state of health until the day of
admission. At that time the patient had emesis x1 which was dark
red in appearance. She also noted a dark red bowel movement. A
few hours later she became lightheaded. This reminded her of her
prior duodenal bleed so she presented [**Known firstname **] [**Hospital1 18**] EW for further
evaluation. The patient denies chest pain, palpitations,
diarrhea, constipation or other symptoms. She notes mild
epigastric discomfort. She has not taken her pantoprazole for
"some time". She denies aspirin or NSAID use.
.
In the EW, initial vitals were: T 98.2, HR 107, BP 85/61, RR 18,
SaO2 100% RA. The SBP nadired in mid 70s but responded without
treatment [**Known firstname **] SBP 100s. She was started on maintanance fluid for
a total of 1L. Guaiac positive with maroon stool. NGL with
coffee grounds that did not clear after 1L. She was started on
pantoprazole gtt. She has 18g x2 for access and was typed and
crossed for 2 units. GI was consulted. The patient was sent [**Known firstname **]
the MICU with vitals: HR 86, SBP 112, RR 13, SaO2 100% RA.
.
Currently, the patient notes discomfort from the NG tube. She
otherwise feels well.
.
ROS: Per HPI. Otherwise negative in 10 other systems.
Past Medical History:
1. Mild asthma
2. h/o anemia
3. h/o duodenal ulcer, s/p UGIB, s/p cauterization, H. Pylori
positive although no treatment (GI felt that treatment was not
warranted)
4. h/o low back pain
5. h/o shingles
6. h/o benign mass in soft palate
7. h/o anxiety
8. h/o gestational diabetes
9. h/o palpitations
Social History:
immunologist. Lifelong nonsmoker. She drinks alcohol about one
drink (glass of wine) per day. She does not use recreational
drugs.
Family History:
HTN, HLD, CVA. 5-healthy siblings.
Physical Exam:
Admission Exam:
VS: Temp: 97.7 BP: 112/71 HR: 98 RR: 13 O2sat: 100% RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, MMM, op without lesions, no supraclavicular or
cervical lymphadenopathy,
RESP: CTA b/l with good air movement throughout
CV: RR, nl rate, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, epigastric tenderness, no masses or
hepatosplenomegaly
EXT: warm, no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. CN II-XII grossly intact
RECTAL: per EW guaiac positive dark red stool
Discharge Exam:
Vitals: 98.7 98/62 60 16 97% RA
General: thin, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear [**Known firstname **] 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
Pertinent Results:
Admission Labs
[**2113-12-27**] 02:15PM BLOOD WBC-13.1*# RBC-4.06* Hgb-11.8* Hct-35.7*
MCV-88 MCH-29.0 MCHC-33.0 RDW-13.9 Plt Ct-268
[**2113-12-27**] 02:15PM BLOOD PT-12.5 PTT-27.5 INR(PT)-1.1
[**2113-12-27**] 02:15PM BLOOD Glucose-168* UreaN-40* Creat-0.8 Na-139
K-4.0 Cl-102 HCO3-27 AnGap-14
[**2113-12-27**] 02:15PM BLOOD ALT-16 AST-21 AlkPhos-55 TotBili-0.3
Serial HCTs
[**2113-12-27**] 05:10PM BLOOD Hct-29.5*
[**2113-12-27**] 10:44PM BLOOD Hct-25.6*
[**2113-12-28**] 03:22AM BLOOD Hct-27.9*
[**2113-12-28**] 10:20AM BLOOD Hct-30.7*
[**2113-12-29**] 05:10PM BLOOD Hct-33.9*
[**2113-12-30**] 06:25AM BLOOD WBC-5.7 RBC-3.71* Hgb-11.2* Hct-32.1*
MCV-87 MCH-30.1 MCHC-34.7 RDW-14.3 Plt Ct-196
Imaging:
CXR:
IMPRESSION: No acute cardiopulmonary process. No evidence of
free air
beneath the diaphragms.
EGD:
-Coffee grounds in the stomach
-A single 1cm ulcer was found in the proximal bulb.
-A small clot/pigmental material was present, which is
predictive of the likelihood of rebleeding.
-8 cc of Epinephrine 1/[**Numeric Identifier 961**] was injected circumferentially at
the base of the ulcer.
-A bipolar gold probe was applied [**Known firstname **] the area for coaptive
coagulation of the underlying vessel.
-Otherwise normal EGD [**Known firstname **] 2nd part of duodenum.
Brief Hospital Course:
54-year-old female with past medical history of UGIB secondary
[**Known firstname **] duodenal ulcer, on pantoprazole but not taking it regularly
presented with upper GI bleed.
.
# Upper GI bleed with acute blood loss anemia: Patient had
history of duodenal ulcer and GIB. There were no precipitating
triggers for this bleed, such as NSAID use, but patient had been
not taking pantoprazole consistently. NGL in ED with coffee
ground emesis, melena and increased BUN/Cr ratio. She was
started on PPI gtt and underwent EGD which revealed a 1cm ulcer
in the proximal bulb of the duodenum. This was treated with
epinephrine and coaptive coagulation. She received 2 units pRBCs
for HCT drop from 35 [**Known firstname **] 25 and had subsequent stable HCTs around
30. She was hypotensive overnight on initial evening of
admission with SBPs 80s but this improved with fluids and PRBCs.
The patient was transferred from the MICU [**Known firstname **] the floor and
remained stable. H pylori tested was deferred [**Known firstname **] outpatient. The
patient will followup with GI in two weeks; before this she will
have H.pylori testing with her PCP. [**Name10 (NameIs) **] was discharged with
strict instructions [**Known firstname **] continue taking pantoprazole 40 mg [**Hospital1 **].
.
# Leukocytosis: The patient presented with leukocytosis of
unclear etiology. She had no evidence of infection and CXR
without consolidation. Her WBC resolved [**Known firstname **] 5.7 on discharge.
Medications on Admission:
1. pantoprazole 40 mg PO BID
2. Calcium/Vit D 500/500 mg/iu PO BID
Discharge Medications:
1. 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*
2. Outpatient testing
Please perform urease breath test and H.pylori stool antigen.
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer with upper GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dr. [**Known lastname **],
You were admitted [**Known firstname **] the hospital for an upper GI bleed that was
found on endoscopy [**Known firstname **] be secondary [**Known firstname **] a duodenal ulcer. The
ulcer was cauterized and injected with epinephrine.
.
Your HCT was stable for two days before discharge. Please make
sure [**Known firstname **] return if you have any recurrent signs of bleeding,
including dark stool. You will need [**Known firstname **] followup with GI in 2
weeks; this appointment is listed below. Before then, you will
need [**Known firstname **] have testing for H.pylori with a urease breath test and
H.pylori stool antigen. We will write you a prescription for
this and notify your PCP. [**Name10 (NameIs) 357**] talk [**Known firstname **] your PCP and make sure
this testing is complete before your GI appointment.
.
You should take the followng medication every day:
Pantoprazole 40 mg by mouth twice daily.
.
We have made no other changes [**Known firstname **] your medications.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2114-1-4**] at 1:40 PM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**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: ENDO SUITES
When: FRIDAY [**2114-1-5**] at 1:30 PM
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2114-1-5**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],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) 3202**]
Campus: EAST Best Parking: Main Garage
Department: GASTROENTEROLOGY
When: THURSDAY [**2114-1-11**] at 10:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"493.90",
"300.00",
"285.1",
"276.52",
"532.40",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
6553, 6559
|
4661, 6147
|
318, 323
|
6638, 6638
|
3351, 4638
|
7834, 8946
|
2290, 2326
|
6265, 6530
|
6580, 6617
|
6173, 6242
|
6789, 7811
|
2341, 2843
|
2859, 3332
|
274, 280
|
351, 1803
|
6653, 6765
|
1825, 2126
|
2142, 2274
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,180
| 133,797
|
199
|
Discharge summary
|
report
|
Admission Date: [**2139-12-25**] Discharge Date: [**2139-12-31**]
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
Right subtrochanteric femur fracture
Major Surgical or Invasive Procedure:
[**2139-12-26**] - Trochanteric femoral nail for right subtrochanteric
femur fracture
History of Present Illness:
87F s/p fall this AM, transferred here from [**Hospital3 2005**]
for R subtrochanteric femoral fx. She states she currently
doesn't have any pain. She does not know how she fell. She was
found by her aid at home on the floor by her bed. She denies HA,
CP, neck pain. She was recently admitted to the MICU for CHF
exacerbation from [**2139-11-24**] to [**2139-12-4**]
Past Medical History:
1. Falls, multiple noted in OMR & D/C summaries
2. Pulmonary HTN, on 2L/nc @ home, PDA per echo [**2120-11-5**]
3. h/o exudative pleural effusion, treated with talc for
pleuredesis ([**2128-2-17**])
4. CHF per Echo ([**2136-3-26**]) - Grade I (mild) LV diastolic
dysfunction, LV inflow pattern suggests impaired relaxation, -
LVEF>55%
5. Mild (1+) AR, trivial MR, trivial TR (Echo [**2136-3-26**])
6. HTN
7. Chronic Renal Insufficiency, baseline creat 1.2 - 1.7
8. Type II DM, %HbA1c 6.3 ([**2136-2-3**])
9. Hyperlipidemia
10. Chronic low back pain,
12. Spinal stenosis, L3-4 & L4-5, per MRI ([**2134-2-27**])
13. Compression fracture of the T3-T4, per CT ([**2136-5-22**])
14. h/o Left knee medial meniscus [**Last Name (LF) 1994**], [**First Name3 (LF) **] MRI ([**2129-10-26**])
15. Obesity
16. Anemia (baseline ~ 26-30)
17. h/o Rectus sheath hematoma
18. h/o Hemorrhoids
19. h/o UGI Bleed
20. Urinary incontinence
21. Syncope
22. Gallstones, per CT ([**2136-4-4**])
23. Depression
.
<b>PSHx:</b>
- s/p IM nail right humerus ([**2134-3-2**]), secondary to fall
- s/p Open posterior treatment of cervical fractures at C3,
cervical laminectomy at C2-C4, posterior arthrodesis, C3-C4
([**2134-3-2**]), seconadary to fall
- s/p EGD([**2129**]) gastritis/duodenitis and HP, rx recommended but
no documentation of eradication
- s/p MVA ([**12/2127**])
- s/p Colonoscopy [**2124**] (two small adenomas) & [**8-28**] (2 sessile
sigmoid polyps, path: mucosal prolapse)
- s/p TAH for fibroids.
Social History:
Russian-speaking widow (husband [**Name (NI) 1995**] died of sudden cardiac
death [**10/2127**]) who
lives alone. Has lived in the United States since ~[**2116**]. She
worked as a bookkeeper in [**Country 532**]. Son [**First Name8 (NamePattern2) 1975**] [**Name (NI) **],
[**Telephone/Fax (1) 1958**]) in area & assists. Son is only relative as
daughter died ~[**2114**] of sarcoma. She does not drink or smoke.
Ambulates with rolling walker, housing has elevator/no steps.
VNA has been involved with HM/HHA [**Hospital1 **]: [**Hospital6 1952**]
Care, Inc. [Phone: ([**Telephone/Fax (1) 1996**]; Fax: ([**Telephone/Fax (1) 1997**]] & [**Hospital1 **]
Family & Children??????s Service [[**Telephone/Fax (1) 1998**]].
Denies tobacco use (ever). Denies ETOH use.
Family History:
Negative for diabetes, cardiac disease, hypertension and cancer
with the exception of her daughter who died of a sarcoma.
Family history is notable for longevity.
Physical Exam:
v/s: 97.8 62 98/50 18 100% 3L Nasal Cannula
A&O x 3
Calm and comfortable
HEENT: no facial trauma, no cspine tenderness
ext: RLE with swelling and firmness at anterior/lateral thigh,
no
laceration or bruising. 2+ DP and PT pulse. normal sensation of
big toe, medial and lateral calf and posterior thigh. normal
plantar and dorsiflexion of foot.
Pertinent Results:
[**2139-12-25**] 02:50PM WBC-8.4 RBC-2.74* HGB-7.9* HCT-25.7* MCV-94
MCH-28.9 MCHC-30.7* RDW-15.8*
[**2139-12-25**] 02:50PM NEUTS-84.5* LYMPHS-10.2* MONOS-5.1 EOS-0.1
BASOS-0.2
[**2139-12-25**] 02:50PM GLUCOSE-200* UREA N-39* CREAT-1.7* SODIUM-145
POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-39* ANION GAP-13
[**2139-12-25**] 02:50PM PLT COUNT-229
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Orthopedic service on [**2139-12-25**]
for a right subtrochanteric femur fracture after being evaluated
and treated with closed reduction in the emergency room. She was
noted to have a Hct=25.7, with a baseline of 30-32, so she was
given 2 units of packed red cells overnight. In addition, she
received one dose of kayexalate for hyperkalemia to 5.7 without
EKG changes. She underwent open reduction internal fixation of
the fracture without complication on [**2139-12-26**]. Please see
operative report for full details. She was extubated without
difficulty and transferred to the recovery room in stable
condition. In the early post-operative course Ms. [**Known lastname **]
developed anuria, with a creatinine bump above her baseline, and
she was transferred to the TSICU for further monitoring and
treatment of her volume status and worsening renal
insufficiency. During this time, she was transfused an
additional 2 units of packed red cells. She remained in the ICU
overnight and eventually showed improvement with good urine
output, and was transferred to the floor in stable condition.
On hospital day 3 she was transfused an additional 2 units of
packed red cells for post-operative anemia. On hospital day 5,
she received a visit from the Russian Cardiology Service who
recommended restarting her home Lasix, which was done.
She continued to make good urine had adequate pain management
and worked with physical therapy while in the hospital. The
remainder of her hospital course was uneventful and Ms.
[**Known lastname **] is being discharged to rehab in stable condition. She
will follow with both her Cardiologist and Orthopedic trauma
team in 4 and 2 weeks, respectively.
Medications on Admission:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
6. furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO twice a
day as needed for fever/pain.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
13. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
14. guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) as needed for sputum production/cough.
Disp:*200 cc* Refills:*0*
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for wheezing/shortness of breath.
Disp:*30 bullets* Refills:*0*
16. iron aspgly&ps-C-B12-FA-Ca-suc [**Medical Record Number 2001**]-1 mg-mg-mcg-mg
Capsule Sig: One (1) Capsule PO twice a day.
17. cholecalciferol (vitamin D3) 400 unit Capsule Sig: Two (2)
Capsule PO once a day.
18. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-28**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
19. diclofenac sodium 3 % Gel Sig: One (1) Topical twice
weekly.
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day for 2 weeks.
4. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain for 2 weeks.
5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
13. guaifenesin 100 mg/5 mL Syrup Sig: One Hundred (100) ML PO
Q4H (every 4 hours).
14. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once
a day for 4 weeks.
15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Start 2 weeks post-fracture: [**1-9**].
16. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
17. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
18. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Right subtrochanteric femur fracture
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Wound Care:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be partial weight bearing on your right leg
- You should not lift anything greater than 5 pounds.
- Elevate right leg to reduce swelling and pain.
Other Instructions
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You are being started on a Bisphosphonates to help prevent
fragility fractures. Take Alendronate weekly as prescribed. Take
first thing in the morning on an empty stomach. Take with at
least 8 ox of water. Remain upright for at least 30 minutes. Do
not eat, drink or take other medications for at least 30
minutes.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Physical Therapy:
Activity: Out of bed w/ assist tid
Pneumatic boots
Right lower extremity: Partial weight bearing
Treatments Frequency:
Wound care:
Site: Right Hip
Type: Surgical
Dressing: Gauze - dry
Change dressing: qd
Followup Instructions:
Please call the office of Dr. [**First Name (STitle) **] to schedule a follow-up
appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks at [**Telephone/Fax (1) 1228**].
Please call ([**Telephone/Fax (1) 1987**] to arrange follow-up with your
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] / NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 month.
Please follow-up with your primary care physician regarding this
admission.
|
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,423
| 187,400
|
44389
|
Discharge summary
|
report
|
Admission Date: [**2107-9-18**] Discharge Date: [**2107-9-25**]
Date of Birth: [**2026-6-13**] Sex: F
Service: MEDICINE
Allergies:
Metoclopramide
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Abdominal Pain with nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Name14 (STitle) 95166**] is an 81F with HTN, DMII (HbA1c 7.9%), hx of
CVA (Pontine) with residual right sided weakness and dysarthria,
vascular dementia (baseline AOx2), history of UTIs presenting
with LUQ pain with associated nasuea and vomiting. The morning
of admission she was noted to have LUQ pain and Non-Biliary
Non-Bloody emesis.
.
Of note the patient was admitted to [**Hospital1 18**] from [**Date range (1) 95167**] for
UTI and hypertensive urgency in the setting of nausea and
emesis. During that admission she was treated for a UTI (Mixed
Bacterial Flora on UCx) with Cipro, started back on her PO meds
and discharged back to Cooliage House.
.
Vitals by EMS with SBP 248/105, HR 102, vomitting, yellow-green.
.
Upon arrival to ED initial 97.7 [**Telephone/Fax (2) 95168**]00% RA sat. Pt
repored [**3-23**] Abdominal pain. Her ED exam was notable for her
being sleepy but arousable, AOX2, No JVD, 2/6 SEM, Clear lungs,
tender LUQ. Patient was given 1L NS. Peak SBP in ED of 237. 20G.
Pt with UA notable for + Nit, trace ketones. WBC 10.3, Hct 32.9
Cr 1.5. LFTs WNL. NSR 93 NANI TWI I, aVL, PRWP. No changes from
[**2106-4-18**]. The patient underwent a CXR, CT Head, CT Abdomen and
Pelvis. The pt received Cipro 400mg IV, Labetalol 10mg IVx3,
Zofran 4mg IV x2, Nitro gtt, Hydralazine 10mg IV, Lisinopril 5mg
POx1, Metoprolol 50mg PO, Regular Insulin 6 units. She received
1L of NS and put out 1L of UOP.
Past Medical History:
HTN
Type 2 DM
CVA '[**96**] with right sided weakness
Dementia
Hyperlipidemia
Dysphagia
Glaucoma
Chronic diastolic CHF
Social History:
Lives at [**Location **] NH
No tob/etoh/drugs
Family History:
NC
Physical Exam:
Vitals: T: Afebrile BP: 186/81 92 18 100%O2:
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Exam unchaged upon discharge
Pertinent Results:
On admission:
[**2107-9-18**] 02:05PM BLOOD WBC-10.3 RBC-4.00*# Hgb-11.0* Hct-32.9*#
MCV-82 MCH-27.6 MCHC-33.5 RDW-13.9 Plt Ct-349
[**2107-9-18**] 02:05PM BLOOD Neuts-89.6* Lymphs-8.0* Monos-1.3*
Eos-0.7 Baso-0.4
[**2107-9-18**] 02:05PM BLOOD PT-11.9 PTT-20.5* INR(PT)-1.0
[**2107-9-18**] 02:05PM BLOOD Glucose-328* UreaN-29* Creat-1.5* Na-137
K-4.4 Cl-99 HCO3-25 AnGap-17
[**2107-9-18**] 11:04PM BLOOD Calcium-9.6 Phos-3.2 Mg-2.3
[**2107-9-18**] 02:05PM BLOOD ALT-11 AST-20 AlkPhos-94 TotBili-0.3
[**2107-9-18**] 02:05PM BLOOD Lipase-48
[**2107-9-18**] 02:05PM BLOOD cTropnT-0.01
[**2107-9-18**] 11:04PM BLOOD cTropnT-<0.01
[**2107-9-18**] 11:04PM BLOOD %HbA1c-7.7* eAG-174*
On discharge:
[**2107-9-23**] 05:30AM BLOOD WBC-8.3 RBC-3.41* Hgb-9.6* Hct-28.1*
MCV-83 MCH-28.3 MCHC-34.3 RDW-14.5 Plt Ct-259
[**2107-9-23**] 05:30AM BLOOD Glucose-60* UreaN-23* Creat-1.9* Na-140
K-4.7 Cl-107 HCO3-21* AnGap-17
[**2107-9-23**] 05:30AM BLOOD TotProt-6.0* Calcium-8.8 Phos-4.3 Mg-2.0
Anemia evaluation:
[**2107-9-20**] 02:45AM BLOOD calTIBC-212* Hapto-103 Ferritn-79
TRF-163*
[**2107-9-23**] 05:30AM BLOOD TSH-1.3
[**2107-9-23**] 05:30AM BLOOD VitB12-843
[**2107-9-18**] 5:10 pm URINE CULTURE (Final [**2107-9-20**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
B12 843
TSH 1.3
SPEP: pending on DC
[**2107-9-18**] EKG: Sinus rhythm. Consider left atrial abnormality. Left
ventricular hypertrophy with ST-T wave abnormalities. Since
previous tracing of same date there is no significant change.
[**2107-9-18**] CXR: Low lung volumes, which accentuate the
bronchovascular markings. Given this, no acute cardiopulmonary
abnormality seen.
[**2107-9-18**] CT head: FINDINGS: No evidence of acute intracranial
hemorrhage, midline shift, mass effect, or acute large vascular
territorial infarction is seen. Prominent hypodensity of the
periventricular and subcortical white matter is again seen,
likely sequela of chronic small vessel ischemic change.
Hypodensity in the left basal ganglia/internal capsule is again
seen, likely lacunar infarct. Lacunar infarct may now also be
present in the left thalamic region, versus volume averaging.
Global prominence of the sulci and ventricles is consistent with
global atrophy. Subcentimeter ossific/calcific densities
adjacent to the inner table of the frontal bone bilaterally may
represent dystrophic dural ossification/calcification or
so-called "burnt out" meningioma. Visualized paranasal sinuses
and the mastoid air cells are clear. No acute fracture is seen.
IMPRESSION: No acute intracranial abnormality. Chronic changes,
as above.
[**2107-9-18**] CT abd/pelvis w/ contrast:
1. Cholelithiasis without definite CT evidence of acute
cholecystitis.
2. No evidence of bowel obstruction.
3. 8mm medial right lower lobe pulm nodule appears mildly
increased in size since [**2097**]. Although this is very slow growth,
***follow-up is recommended in 3 months in this patient with a
known primary malignancy.***
[**2107-9-20**] Renal ultrasound:
1. Echogenic kidneys consistent with medical renal disease. No
evidence of hydronephrosis.
2. Essentially nondiagnostic study to evaluate for renal artery
stenosis due to respiratory motion. Gross patency of renal
arteries is suggested by the presence of arterial waveforms
bilaterally.
***PENDING RESULTS AT TIME OF DISCHARGE***
- [**2107-9-18**] BLOOD CULTURES: No growth to date
- [**2107-9-23**] 05:30AM BLOOD SPEP
Brief Hospital Course:
81F with HTN, DMII (HbA1c 7.9%), hx of CVA (Pontine) with
residual right sided weakness and dysarthria, vascular dementia
(baseline AOx2), history of UTIs presenting with hypertensive
urgency in the setting of nausea/vomiting.
# Hypertensive Urgency: The patient was restarted on her home
meds as well as a nitro gtt. Her clonidine pills were changed
to a patch given special concern of rebound hypertension if not
able to take clonidine when nauseated. Her felodipine was
changed to amlodipine due to difficulty swallowing pills
(felodipine cannot be crushed). It was noted that the patient
had decreased urine output when her blood pressure dropped below
140 and did not respond to fluid boluses. Her BP meds were
titrated to keep her SBP higher to have better urine output,
goal SBP 150-180. A renal U/S was obtained which did not show
any evidence of renal artery stenosis. Lisinopril was held, and
metoprolol uptitrated. At time of discharge, patient's blood
pressure was controlled in the goal range on the following
antihypertensives: amlodipine, metoprolol, isosorbide
mononitrate, and clonidine patch. These can be uptitrated as
tolerated or lisinopril restarted when renal function returns to
baseline.
# Acute renal failure: Secondary to hypoperfusion in the setting
of blood pressure lowering and associated with oliguria. This
improved with liberalization of blood pressure parameters to SBP
150-180. Cr peaked at 2.1 and was ***1.8*** at time of
discharge. She should have her chem 7 rechecked on Wednesday
and thereafter as needed to monitor for continued improvement in
renal function.
# Tardive dyskinesia: Pt with constant chewing, thought d/t
tardive dyskinesia from chronic Reglan use for gastroparesis.
This medication was discontinued. Speech and swallow evaluated
her and thought she safely tolerated a thin liquids and moist
ground solids diet. She should take all liquids by straw with
crushed meds with purees. Recommended aspiration precautions
with 1:1 supervision for all po intake (pt must be fed) and TID
oral care. Aspiration precautions including:
# Nausea, Emesis: The patient did not have any emesis or nausea
while in the MICU or on the floor.
# Diabetes mellitus: Pt continued on home Lantus 22 units qhs
with humalog SS. Prior to discharge her BS were noted to be low
(39/47 asymptomatic) which is most likley secondary to impaired
renal function. Her Lantus dose was decreased to 18U. This can
be uptitrated as renal function improves. Glipizide was held due
to poor po intake initially but should be restarted as
outpatient as FSG tolerate.
# UTI: Patient grew out a pansensitive UTI. She will complete a
7-day course of ciprofloxacin with her last dose on [**2107-9-25**] at
2200.
# Normocytic anemia: Decline in Hct while in MICU but improved
without intervention; likely was hemodilutional. Hct at
baseline on discharge. Ferritin 79 nondiagnostic for iron
deficiency; guaiac negative stools. Hemolysis unlikely with
normal haptoglobin. B12 normal. SPEP pending on discharge.
# RUL lung nodule: Incidental finding on CT abd/pelvis.
Recommended for follow-up CT chest in 3 months.
# Pruritis: No localized rash seen, likely related to lying in
bed. Pt given Sarna prn. Would benefit from mobilization OOB
and PT and nursing home.
# Pending results: Bcx x 1 and SPEP.
Medications on Admission:
ASA 81mg PO Daily ([**9-17**] 10am)
Pravastatin 80mg (10am - [**9-17**])
Metoprolol 200mg SR Daily ([**9-17**] 10am)
Lisinopril 10mg PO Daily ([**9-17**] 10am)
Lisinopril 5mg PO QHS
Felodipine SR 10mg (9/4/10am)
Isosorbide Mono "ER" 30mg ([**9-17**] 10am)
Clonidine 0.3mg TID ([**9-18**] 6am)
Nitroglycerine -/3mg for SBP>180 ([**2107-9-18**] 9:50am)
Lantus 22 units QHS
Novolin SS
Glipizide 10mg [**Hospital1 **](5pm [**9-17**]/)
Colace 100mg [**Hospital1 **] ([**9-17**] 10pm)
Senna [**Hospital1 **] ([**9-17**] - 8pm)
Omeprazole 20mg (10am - [**9-17**])
Gas-X ([**9-18**] 6am)
Metoclopramide prior to meals 5m PO ([**9-17**] 430pm)
Tramadol 25mg PO BID ([**9-17**] 8pm)
Citalopram 10mg ([**9-17**] 10am)
Timolol Drops 0.25% ([**9-18**] 6am)
MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
2. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day:
Hold for SBP < 140 or MAP < 80.
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
Hold for SBP < 140 or MAP < 80.
5. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
6. Lantus 100 unit/mL Cartridge Sig: Twenty Two (22) units
Subcutaneous at bedtime.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. Humalog 100 unit/mL Cartridge Sig: Sliding scale
Subcutaneous three times a day: As directed.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Timolol 0.25 % Drops Sig: One (1) Ophthalmic once a day.
13. Simethicone 80 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for bloating.
14. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. Tramadol 50 mg Tablet Sig: Twenty Five (25) mg PO twice a
day as needed for pain: Hold for oversedation or RR<10.
16. Outpatient Lab Work
Please check Chem-7 (including BUN/Cr) on Monday, [**2107-9-26**] as
thereafter as needed to monitor for improving renal function.
17. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3
doses.
18. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Hypertensive Urgency
Acute Renal Failure
Urinary Tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted because you had a dangerously elevated blood
pressure. Your blood pressure was brought down using different
medicines. Your blood pressure came down; however, your kidneys
were used to such high blood pressure that you subsequently
developed kidney failure. This is gradually improving.
You were also noted to have a urinary tract infection. You were
started on ciprofloxacin.
The following changes were made to your medications:
Cipro to complete treatment for UTI
Change felodipine to amlodipine 10mg daily given difficulty
swallowing pill
Increase metoprolol to 125mg three times a day
Stop lisinopril for now due to acute renal failure
Change clonidine pills to clonidine patch 0.2 mg/24 hr 1 PTCH TD
QMON
Stop Reglan due to tardive dyskinesia
Restart Glipizide as tolerated when eating usual diet
Decrease Lantus to 18U, adjust as needed
Start Sarna lotion as needed for itching
Followup Instructions:
Follow up with your physician at [**Hospital3 2558**].
Completed by:[**2107-9-25**]
|
[
"698.9",
"574.20",
"333.85",
"438.89",
"285.9",
"401.0",
"E933.0",
"041.4",
"290.40",
"428.32",
"365.9",
"787.01",
"438.13",
"584.9",
"599.0",
"518.89",
"438.20",
"428.0",
"437.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12501, 12571
|
6655, 9997
|
314, 321
|
12680, 12680
|
2576, 2576
|
13784, 13870
|
1997, 2001
|
10795, 12478
|
12592, 12659
|
10023, 10772
|
12856, 13761
|
2016, 2557
|
3267, 4876
|
235, 276
|
349, 1774
|
4885, 6632
|
2590, 3253
|
12695, 12832
|
1796, 1917
|
1933, 1981
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,340
| 111,116
|
34795
|
Discharge summary
|
report
|
Admission Date: [**2124-5-14**] Discharge Date: [**2124-5-17**]
Date of Birth: [**2041-11-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is an 82 year old man with hx of T3, N0, M0 colon ca
s/p transverse colectomy in [**2122**] c/b incisional hernia,
dementia, T2DM, HTN presents with fever and lethargy.
.
Pt is a resident of [**Location 10059**] Nursing Centre. He had 3 days of
cold symptoms, 2 days of constipation and was noted to have
decreased appetite and overall depressed functioning compared to
baseline. Today he had a fever to 100.8 and vomited yellowish
(nonbloody) emesis x 2 and he was referred to the ED.
.
In the ED, initial vs were: T 106.1 P 111 BP 161/82 R 18 94%O2on
RA, Patient was given 1 g Vanc, 4.5 g Zosyn, Tylenol 1g and 2
litres of NS. Ice packs were placed to cool him and he was
afebrile on arrival to the floor. He had no complaints.
.
Review of sytems:
(+) Per HPI
(-) Denies cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied diarrhea, or abdominal pain.
Past Medical History:
DM II on insulin
Colon cancer T3N0M0, dx [**8-3**] (as part of GIB w/u) s/p transverse
colon resection [**2122**]->complicated by poor wound healing (finally
closed)
Ant abdominal wound->stage II ulceration, chronic since
colectomy
Advanced Dementia, A&OX1, has guardian
incisional hernia, large, asymptomatic
GIB [**8-3**], EGD with possible diulefoy
Anemia, Fe def
CKD III baseline 1.3 (on [**3-/2124**])
chronic dCHF on lasix
Hypertension
Hearing loss
Constipation
H/o delirium
Social History:
Lives at [**Hospital 10138**] nursing home in [**Location (un) 538**]. Married but
wife has been living in [**Name (NI) 760**] for past 18 yrs, still in
contact with pt per Mr. [**Last Name (Titles) 79682**].
<br>
Guardian: [**Name (NI) **] [**Last Name (NamePattern1) 79682**] Is the power of attorney.
-[**Telephone/Fax (2) 79683**]h
-[**Telephone/Fax (2) 70408**]w
-[**Telephone/Fax (2) 79684**]c
<br>
Elder Resources: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 79685**]
[**Telephone/Fax (2) 79686**]w
[**Telephone/Fax (2) 79687**]c
.
[**Hospital 10138**] nursing home
[**Telephone/Fax (1) 79688**]
Family History:
NC. None given by patient or known by power of attorney.
Physical Exam:
Vitals: T 98.7 BP 132/69 HR 86 RR 27 97%RA
General: Alert, oriented to person, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, dentures in
place
Neck: supple, JVP not elevated, no LAD
Lungs: Few scattered rhonchi, no wheezes or crackles. Otherwise
clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Large ventral hernia with clean dressing in placement.
soft, non-tender, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
on discharge
Vitals:97.1 137/75 77 18 100%RA
Pain: denies
Access: PIV
Gen: nad, calm and pleasant
HEENT: mm dry
CV: RRR, [**4-1**] SM all over
Resp: CTAB with slight basilar crackles, no wheezing
Abd; soft, obese, nontender, large ventral hernia, +BS
Ext; no edema
Neuro: A&OX1 at baseline, otw nonfocal
Skin: ant abdominal wound with stage II ulceration (present on
admission) well healing
psych: pleasant, calm
.
Pertinent Results:
WBC 5.6->4s
hgb 12->10s (after fluids)
HCT 31->28.9
Plt 160s ->225
Creat 1.6-->1.2 stable X2 days (baseline 1.3)
lactate 1.3
.
U/A [**5-14**]: >50 WBCs, +bacteria, +RBCs, <1 epis
UCx [**5-14**] >100K enterobacter cloacae, pansensitive
Blood cx X2 [**5-14**] NTD
.
.
.
.
Imaging/results:
CXR [**5-14**]: No acute process
.
CXR [**5-15**]: low lung volumes, mild pulm edema, no consolidation,
mild CM
.
Brief Hospital Course:
Briefly, Mr. [**Known lastname **] is an 82 year old man with h/o DM, colon ca
s/p transverse colectomy in [**2122**] c/b incisional hernia/poor
wound healing, advanced dementia, and HTN. He presented from his
[**Hospital1 1501**] with fever, abd distention, vomiting X2, and lethargy. Pt is
a resident of [**Location 10059**] Nursing Centre. He had 3 days of cold
symptoms, 2 days of constipation and was noted to have decreased
appetite and overall depressed functioning compared to baseline.
On [**5-14**], he had a fever to 100.8 and emesis of yellowish
nonbloody material X2 which led to transfer to ED.
In the ED, initial vs were: T 106.1 P 111 BP 161/82 R 18 94%O2on
RA, Patient was given 1 g Vanc, 4.5 g Zosyn, Tylenol 1g and 2
litres of NS. Ice packs were placed to cool him. He was admitted
to MICU for consideration of artic sun for cooling.
However, since in MICU, remained afebrile. Hemodynamically
stable. MS appears to be at his baseline. Was found to have UTI
so Abx changed to CTx. CXR was negative for PNA. Blood cx
negative. He got total 3L IVFs in ICU and ER. Given his prompt
improvement he was transfered out of MICU next day. On the floor
he continued to do well. MS appeared at baseline, occasional
sundowning but was redirectable. Abx were converted to cefpodox
for UCx showing pansensitive enterobacter, for total 10day
course. He had ARF on CKD on admission, which resolved back to
baseline 1.2 with fluids. He developed mild pulm edema after 3L
on admission, but this improved when resuming his home dose of
lasix. As for his constipation, he had several BMs here that
were well formed. There were no other issues. Discharged back to
[**Hospital1 1501**].
.
See progress note below for details of plan:
82 year old man with h/o DM, colon ca s/p transverse colectomy
in [**2122**] c/b incisional hernia/poor wound healing, advanced
dementia, chronic dCHF and HTN. He presented from his [**Hospital1 1501**] with
fever and lethargy and is found to have enterobacter UTI.
Transfered to floor after brief MICU stable. Doing well and
ready for t/f back to [**Hospital1 1501**].
.
UTI, bacterial: Temp 106 reported in ED on admission (?error,
may be was 100.6) but otherwise has been stable hemodynamically.
Mild delirium that has resolved. Recieved empiric vanc/zosyn in
ER, then CTX X3 days, will change to cefpodox on discharge per
sensitivities of Enterobacter for 7day course. Blood Cx NTD.
foley placed in ER and removed next day. Other infectious w/u
with CXR (given URI symptoms) was negative.
.
ARF on CKD III: Recent baseline is 1.3 since 3/[**2124**]. Was 1.6 on
admission. Improved to 1.2 after fluids and treatment of UTI
which was stable on discharge.
.
Bicytopenia: hct and plt all lower this admission than previous.
Unclear what hct baseline is (prior ones are during GIB and post
op). Repeat HCT here were stable around 28-29 after fluids. Plt
in past 300s, now 160s on admission for few days, likely [**2-29**]
infection. Repeat plt improved to 220s on discharge. Coags were
okay.
.
Acute Delirium in setting of advanced dementia: report of
increased lethargy on admission, which is likely due to UTI.
This resolved by next day. He appeared to be at baseline. He had
occ episodes of agitation which may be sundowning rather than
delirium. He did not need any medications.
.
Colon cancer: s/p resection. No abdominal pain. ventral hernia
stable but pt has chronic abd stage II ulceration/wound. Seen by
wound care who provided some recs which will be relayed to [**Hospital1 1501**].
.
Chronic dCHF: Did develop mild pulm edema on CXR after fluids
with some wheezing. This improved once his lasix was resumed and
he did very well, never required O2. Kept on his BB/CCB.
.
DMII: SSI. resumed glipizide. Was on SSI here but resumed his
insulin regimen on discharge. kept on statin.
.
HTN: stable on prior doses of verapamil, lopressor, lasix
.
GERD and h/o UGIB: Continued on PPI.
.
Constipation: resolved with bowel regimen. kept on this on
discharge.
.
Dispo/Code: DNR/DNI, POA is [**Name (NI) **] [**Name (NI) 79682**] [**Telephone/Fax (1) 70408**],
[**Telephone/Fax (1) 79684**]. Updated on admission/discharge. Will d/c back to
[**Hospital1 1501**] today.
.
.
Medications on Admission:
Medications:
Colace
Milk of Mag
Dulcolax
MVI
Iron 325
Lasix 20
Glipizide 5
Humalog ISS
Lantus 9 U qHS
Lipitor 10 mg
Lopressor 25 TID
Verapamil 120
Trazodone 50 qhs
Protonix 40
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
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. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: Three (3)
Tablet Extended Rel 24 hr PO DAILY (Daily): total 7.5mg.
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
14. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 6 days.
15. Lantus 100 unit/mL Cartridge Sig: 12U Subcutaneous at
bedtime.
16. Lantus 100 unit/mL Cartridge Sig: see below Subcutaneous
three times a day: 7 U before breakfast, 3U before lunch and
dinner. also continue sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 10140**] Nursing Center - [**Location (un) 10059**]
Discharge Diagnosis:
UTI, enterobacter
mild acute dCHF
ARF on CKD resolved
hypoactive delirium resolved
abd chronic wound
Discharge Condition:
Mental Status: Confused - sometimes-->baseline dementia and
A&OX1.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for fever, lethargy, and found to have UTI.
You will complete Abx course as prescribed.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 4154**] in a couple weeks. The [**Hospital1 1501**] will
call for an appointment
|
[
"584.9",
"041.89",
"998.83",
"E878.8",
"585.3",
"599.0",
"293.0",
"403.90",
"553.21",
"V10.05",
"294.8",
"428.0",
"250.00",
"564.00",
"530.81",
"428.33"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9926, 10021
|
3951, 8160
|
321, 327
|
10165, 10165
|
3524, 3928
|
10509, 10641
|
2427, 2486
|
8387, 9903
|
10042, 10144
|
8186, 8364
|
10379, 10486
|
2501, 3505
|
276, 283
|
1131, 1266
|
355, 1113
|
10180, 10355
|
1288, 1770
|
1786, 2411
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,481
| 188,844
|
18017
|
Discharge summary
|
report
|
Admission Date: [**2149-5-21**] Discharge Date: [**2149-5-30**]
Date of Birth: [**2086-3-1**] Sex: M
Service: General/Endocrine Surgery
ADMITTING DIAGNOSIS: Thyroid cancer.
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old man
with a somewhat complicated medical history. He is
originally from South [**Country 10181**] but has lived in this country for
three or four months post retirement. His daughter and son
have lived in this country for several years. The patient
has had a long-standing history of hypertension. He recently
was worked up by his oncologist because of an elevated CEA.
A PET scan showed an abnormality in the right thyroid lobe as
the only positive finding. Subsequent ultrasound and
ultrasound-guide fine-needle aspiration biopsy was positive
for a papillary carcinoma. The patient has elevated
phosphate levels as expected. His parathyroid hormone levels
were moderately elevated at 120-150 and his calcium level was
within normal. During his office visit the patient was
clinically euthyroid on examination. Neck examination
revealed an approximately 1 cm moderately firm nodule on the
right thyroid lobe, middle to lower portion. There were no
nodules appreciated on the left side. There was no
lymphadenopathy along the neck or in the supraclavicular
fossa.
Regarding the patient's other medical history, he has had
renal insufficiency for approximately seven years and has
been receiving hemodialysis twice per week since [**2143**]. He
also has a medical history significant for peptic ulcer
disease and pneumonia. The patient underwent colon resection
for a C2 colon cancer in [**2143**]. He received postoperative
adjuvant chemotherapy which was shortened because of side
effects from the chemotherapy.
PAST MEDICAL HISTORY: 1. End-stage renal disease on dialysis
twice a week. 2. Hepatitis C. 3. Liver cirrhosis. 4. Colon
cancer.
PAST SURGICAL HISTORY: Colon cancer resection.
SOCIAL HISTORY: The patient is retired, lives with spouse,
and was previously employed as an architect. The patient
only speaks Korean.
ALLERGIES: Penicillin, cephalosporin, and vancomycin.
MEDICATIONS: 1. Renagel. 2. Nephro-Vite. 3. Avapro. 4.
Minipress. 5. Norvasc.
HOSPITAL COURSE: The patient was admitted on [**2149-5-22**]
following total thyroidectomy and removal of right upper and
left lower parathyroid glands. The operation was performed
by Dr. [**Name (NI) 5183**] [**Name (STitle) 5182**]. Surgical findings included a
right thyroid nodule as well as possible partial injury to
the branch of recurrent laryngeal nerve on the left.
Postoperatively the patient's vital signs were stable.
Estimated blood loss was 200 cc. The patient's voice was
hoarse however there was no evidence of hematoma and his
dressing was clean, dry and intact.
On postoperative day number one the patient had difficulty
with coughing and change in his voice was noted by the
patient's family. ENT surgery was consulted.
Recommendations made by ENT consult included Decadron 10 mg
IV q. 8 x 24 hours, proton pump inhibitor, speech and swallow
consult, continuous O2 saturation monitoring, n.p.o. diet as
well as video modified barium swallow and video stroboscopy.
On postoperative day number one the patient was seen by renal
consultation and subsequently us hemodialysis. The patient
was scheduled to resume his hemodialysis on Mondays,
Thursdays and Saturdays. The patient was subsequently
transferred to the surgical intensive care unit for closer
monitoring of his airway and continuous O2 saturations. The
patient was saturating 98-99% on room air. There was no
stridor or shortness of breath.
On postoperative day number two the patient remained in the
surgical intensive care unit and was receiving 50%
humidification air. A laryngoscopy performed by ENT surgery
revealed bilateral vocal cord paralysis. On postoperative
day number two the patient received a Dobbhoff nasogastric
tube.
On postoperative day number three the issue of the patient's
clotted arteriovenous fistula was raised. On postoperative
day four the patient was brought back to the operating room
for thrombectomy of his arteriovenous fistula. Following the
procedure the patient had a palpable thrill. He tolerated
the procedure well without complications.
On [**5-26**], postoperative day five, the patient underwent
video stroboscopy. Movement of the arytenoids appeared to be
restricted more on the left than right side. Vocal cords
appeared to rest in the paramedian position. The vocal cords
did not adduct completely and there was a severe glottal gap.
Abduction was restricted as well. There was no mucosal wave
secondary to absent true vocal fold adduction. The
arytenoids appeared symmetric. There was edema and erythema
in the posterior cricoid and interarytenoid region. The
airway was limited but patent. There was trace pooling of
secretions in the piriform sinuses more so on the left side.
A video swallow study was also performed. The results are as
follows: The patient aspirated during the swallow secondary
to poor laryngeal vestibular and true vocal fold closure. He
aspirated after the swallow secondary to piriform sinus
residue spilling into his airway. His paresis appeared to be
bilateral. He aspirated 80-90% of thin liquids and purees.
A chin tuck was ineffective. Although he did spontaneously
cough, his cough was not strong enough to clear his airway of
the aspirated material.
An endocrinology consultation was obtained on [**5-27**]. Given
the patient's pathology and age, they determined that he will
eventually need iodine 131. Whether the patient could
receive this treatment through his G tube warranted further
investigation.
On [**5-28**] the patient was transferred to the floor. On [**5-29**] the patient underwent repeat video stroboscopy. No
improvement was noted. There continued to be apparent
bilateral true vocal fold immobility with vocal cords in the
paramedian position. Airways still appeared patent. Repeat
video swallow study on [**5-29**] revealed significantly improved
pharyngeal swallow. Although he still aspirates, he
aspirates much less and is able to effectively clear the
aspirated material from his airway with a series of: 1.
Cough. 2. Dry swallow. 3. Cough. 4. Dry swallow after
initially swallowing a bolus with a chin tuck. Recommended
diet was nectar-thick liquids and ground solids. The patient
should remain bolt upright for all p.o.'s. On [**5-29**] the
patient tolerated ground moist solids and nectar-thick
liquids well. There were no signs or symptoms of aspiration.
The patient's wife and daughter assisted him with his
feedings.
DISPOSITION: On [**2149-5-30**] the patient was discharged to
home.
FOLLOW-UP INSTRUCTIONS: The patient was discharged to follow
up with Dr. [**Last Name (STitle) 5182**] in two weeks, he will call to schedule
an appointment. The patient will go home with VNA services
for wound checks and to monitor signs and symptoms of
aspiration. The patient will also attend outpatient speech
pathology.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 49859**]
Dictated By:[**Last Name (NamePattern1) 4348**]
MEDQUIST36
D: [**2149-5-30**] 07:29
T: [**2149-5-30**] 07:53
JOB#: [**Job Number 49860**]
|
[
"996.73",
"571.5",
"997.09",
"070.54",
"193",
"403.91",
"V10.05",
"957.1",
"478.33"
] |
icd9cm
|
[
[
[]
]
] |
[
"06.95",
"06.4",
"31.42",
"39.49",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
2260, 6765
|
1938, 1963
|
224, 1781
|
178, 195
|
6790, 7352
|
1804, 1914
|
1980, 2242
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,868
| 171,900
|
52115+59400
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-3-27**] Discharge Date: [**2132-4-1**]
Date of Birth: [**2073-8-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
increasing DOE
Major Surgical or Invasive Procedure:
MVR ([**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 29mm) [**3-27**]
History of Present Illness:
58 yo F with history of MVP who presented to [**Hospital1 **] [**Location (un) 620**] with DOE
and cough. Patient ruled out for MI, found to have pulmonary
edema, diuresed and transferred to [**Hospital1 18**] for further eval. Cath
here showed no CAD and 3 + MR. Referred for surgery.
Past Medical History:
HTN
hyperlipidemia
MVP
colitis - [**5-5**], per old d/c summary appears to be infectious
GERD
depression
s/p C-section
s/p pelvic sling
Social History:
Social history is significant for the absence of current tobacco
use (infrequent use >30 years ago). There is no history of
alcohol abuse - drinks 2 glasses of wine a night with dinner.
Lives with husband in [**Name (NI) 912**].
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father with stroke at age 80.
Physical Exam:
NAD HR 80 RR 16 BP 134/79
Lungs CTAB
Heart RRR, soft murmur
Abdomen benign
Extrem warm, no edema
No carotid bruits
Pertinent Results:
[**2132-3-31**] 05:25AM BLOOD WBC-7.2 RBC-2.92* Hgb-8.8* Hct-26.7*
MCV-91 MCH-30.3 MCHC-33.1 RDW-12.7 Plt Ct-207#
[**2132-4-1**] 05:35AM BLOOD PT-20.8* INR(PT)-2.0*
[**2132-3-31**] 05:25AM BLOOD PT-21.8* INR(PT)-2.1*
[**2132-3-30**] 08:10AM BLOOD PT-20.1* INR(PT)-1.9*
[**2132-3-31**] 05:25AM BLOOD Glucose-122* UreaN-14 Creat-0.6 Na-139
K-4.3 Cl-104 HCO3-28 AnGap-11
CHEST (PORTABLE AP) [**2132-3-28**] 9:37 AM
CHEST (PORTABLE AP)
Reason: r/o ptx s/p ct's removed
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with
REASON FOR THIS EXAMINATION:
r/o ptx s/p ct's removed
HISTORY: Chest tube removal to evaluate for pneumothorax.
FINDINGS: In comparison with study of [**3-27**], all of the tubes
have been removed. No evidence of pneumothorax. The left
hemidiaphragm is again not well seen and the possibility of
retrocardiac atelectasis, effusion, and even consolidation
cannot be excluded. Mild atelectatic changes persist at the
right base.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 107846**] (Complete)
Done [**2132-3-27**] at 9:09:54 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2073-8-23**]
Age (years): 58 F Hgt (in): 65
BP (mm Hg): 110/50 Wgt (lb): 180
HR (bpm): 65 BSA (m2): 1.89 m2
Indication: Intraop Mitral Valve Replacement
ICD-9 Codes: 440.0, 424.0
Test Information
Date/Time: [**2132-3-27**] at 09:09 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: aw1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.8 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 5.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *3.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: 2.6 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.1 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec
Mitral Valve - Mean Gradient: 3 mm Hg
Mitral Valve - Pressure Half Time: 58 ms
Mitral Valve - MVA (P [**1-30**] T): 3.8 cm2
Findings
LEFT ATRIUM: Marked LA enlargement. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.
Left-to-right shunt across the interatrial septum at rest.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
regional LV systolic function. Overall normal LVEF (>55%).
[Intrinsic LV systolic function likely depressed given the
severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal aortic
arch diameter. No atheroma in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Partial mitral
leaflet flail. [**Month/Day (2) **] MR jet. Severe (4+) MR. Uninterpretable
LV inflow pattern due to MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR. No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
Conclusions
Pre-Bypass: The left atrium is markedly dilated. No thrombus is
seen in the left atrial appendage. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. Left ventricular wall thicknesses and cavity size
are normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are myxomatous. There is partial mitral leaflet flail. An
[**Month/Day (2) 34486**], posteriorly directed jet of Severe (4+) mitral
regurgitation is seen. There is no pericardial effusion.
Post bypass: Preserved biventricular function. LVEF >55%. A
mechanical mitral valve prosthesis is seen insitu with normal
bilateral washing jets. Peak gradient 6, mean 4-5 mm Hg. Aortic
contours intact. Remaining exam is unchanged. All findings
discussed with surgeon at the time of the exam.
Brief Hospital Course:
She was taken to the operating room on [**3-27**] where she underwent
an MVR with a mechanical valve. She was transferred to the ICU
in stable condition on neo and propofol. She was extubated later
that day. She was started on coumadin for her mechanical valve.
She was transferred to the floor on POD #1. Her wires and chest
tubes were pulled without incident. She did well postoperatively
and awaited therapeutic INR. She was ready for discharge home on
POD 5. Spoke to Dr. [**Last Name (STitle) 40318**] office who has agreed to manage her
coumadin.
Medications on Admission:
Citalopram 20', Pantoprazole 40', ASA 81', Lovastatin 20',
Atenolol 25', Furosemide 20', Lisinopril 10'
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
5. 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:*0*
6. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day for 2
days: Check INR [**4-3**] with results to Dr. [**Last Name (STitle) **].
Disp:*90 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 7
days: Sig: 40 mg [**Hospital1 **] x 7 days, then 20 mg daily as prior to
surgery.
Disp:*50 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
MR/MVP now s/p MVR
HTN, hyperlipidemia, , colitis, GERD, depression, s/p C-section,
s/p pelvic sling
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incisions or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Already scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3833**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2132-5-27**]
2:15
Completed by:[**2132-4-1**] Name: [**Known lastname 5493**],[**Known firstname **] D. Unit No: [**Numeric Identifier 17618**]
Admission Date: [**2132-3-27**] Discharge Date: [**2132-4-1**]
Date of Birth: [**2073-8-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 4551**]
Addendum:
discharge diagnoses updated.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2333**] Area VNA
Discharge Diagnosis:
MR/MVP now s/p MVR
Acute on chronic systolic and diastolic heart failure
HTN, hyperlipidemia, , colitis, GERD, depression, s/p C-section,
s/p pelvic sling
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**]
Completed by:[**2132-4-15**]
|
[
"272.4",
"530.81",
"427.31",
"458.29",
"424.0",
"428.43",
"311",
"428.0",
"E878.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.24"
] |
icd9pcs
|
[
[
[]
]
] |
10277, 10341
|
6878, 7432
|
293, 417
|
9225, 9233
|
1417, 1887
|
9547, 10254
|
1155, 1267
|
7586, 8994
|
1924, 1947
|
10362, 10674
|
7458, 7563
|
9257, 9524
|
1282, 1398
|
239, 255
|
1976, 6855
|
445, 732
|
754, 892
|
908, 1139
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,205
| 189,207
|
54603
|
Discharge summary
|
report
|
Admission Date: [**2188-8-16**] Discharge Date: [**2188-8-29**]
Date of Birth: [**2114-10-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
Incisions and Drainages of left foot (bedside as well as in OR)
PICC line insertion
History of Present Illness:
73 yo M w/ DM2 (c/b left plantar ulcer), CAD s/p MI and CABG
[**2174**] (LIMA-LAD, rSVG-CX, SVG-PDA, SVGPL) who p/f [**Hospital1 1501**]([**Hospital1 **])
with nausea and SOB. Pt denies CP. Notes that emesis started 4
days ago (once daily), none today. Describes SOB as DOE that he
has at baseline and not a new symptom. No oxygen requirement at
[**Hospital1 1501**]. Limited in his ability to ambulate to due diabetic ulcer on
left foot, not limited by SOB. Of note patient has been poorly
compliant with meds x 4 month and almost fully refusing meds x 3
days, notes that 4 months ago [**Hospital1 1501**] staff changed his room around
not to his liking and 3 days ago again similar issue. Stopped
oral meds, continued insulin injections. Confirms DNR/DNI.
.
In the ED, initial vitals were 98.6 107 117/76 16 98% 4L. Labs
and imaging significant for BS>500, TnT 0.50, Cr 1.6, CK 69, MB
5, WBC 13.7, 87.7%PMNs, CXR showed pulmonary edema could not r/o
PNA, ED interpretation of EKG: STE 1mm aVR/V1, STD 1-2mm I, II,
L, V3-6, septal Q's. He was seen by cardiology in the ED and it
was explained to him that he may be having a STEMI, but patient
refused catheterization.
.
Patient given Glipizide 10mg, Metformin 500, Insulin 10 Units,
Azithro, not started Insulin gtt, not started on heparin gtt, no
ASA, no BB. BS from 565 to 480. DNR/DNI (confirmed with nursing
home). Has left plantar diabetic ulcer treated every Friday at
[**Doctor Last Name 1263**] with wet to dry dressing changes.
.
Vitals on transfer were 103 103/68 27 98%.
.
Vitals on arrival: NAD, 100, 132/77, 24, 89-92% on RA.
.
OVERNIGHT: Did not allow lab draw, checked FSBG 230, did not
want any interventions other than sq insulin, and some oral
meds. Refused Heparin gtt, refused plavix, refused cath. No CP,
no SOB. Fell while going to the bathroom, did not want
assistance.
Past Medical History:
DM2 (Diabetic foot ulcer treated at [**Doctor Last Name 1263**] wound clinic every
Friday)
Dyslipidemia
Hypertension
CABG [**2174**] (LIMA-LAD, rSVG-CX, SVG-PDA, SVGPL)
Bell's Palsy
Diverticular disease w/hx GIB
Social History:
-Tobacco history: smoked for 1 year in past 50 years ago
-ETOH: none currently briefly in past
-Illicit drugs: none
- never married, no kids
- former CPA
- lives at [**Hospital1 1501**] [**Hospital1 **]
Family History:
- Father MI in 60s, no heart history in mother
- Brother alive, no heart history
Physical Exam:
ADMISSION:
VS: 132/77, 100, 25, 89-93% on RA
GENERAL: looks stated age, poor hygeine, poor odor, Oriented x3,
Requires full control of situation and very clear about what he
does and does not want done.
HEENT: MMM, Sclera anicteric, EOMI, No pallor or cyanosis of the
oral mucosa. Poor dentition.
NECK: JVP seems to be to tragus?
CARDIAC: Tachycardic, +S1+S2, no M/R/G.
LUNGS: On RA. CrackleS 2/3 up b/l. Accessory muscle use. Can
speak in full sentences.
ABDOMEN: Distended but soft, non tender, no rebound.
EXTREMITIES: Pitting edema b/l Left > Right up to mid thigh,
patietn did not allow visualization of left plantar ulcer, right
toe nails yellow and dysmorphic.
- No Sensation up to knee on left lateral leg, right foot, left
foot
PULSES: [**Name (NI) **] PT on left (did not allow DP), DP/PT on
right
DISCHARGE:
VS: 98 94/57 p89 R16 99RA
I/O: 1640/725 yest + BMx3
GEN: Seated in chair. In no apparent distress.
LUNGS: CTA B/L but limited excursion.
CV: S1, S2 Regular rhythm. No murmurs/gallops/rubs.
BACK: No CVA tenderness. No presacral edema
EXTREMITIES: 2+ pitting edema b/l. dorasalis pedis 2+ on right.
Left foot wrapped in bandage clean/dry/intact. Ulcer covered in
black eschar to left great toe.
Pertinent Results:
ADMISSION:
[**2188-8-16**] 04:29PM BLOOD WBC-13.7*# RBC-3.78* Hgb-11.4*# Hct-33.8*
MCV-89 MCH-30.0 MCHC-33.6 RDW-16.3* Plt Ct-378#
[**2188-8-16**] 04:29PM BLOOD Neuts-87.7* Lymphs-8.4* Monos-3.3 Eos-0.5
Baso-0.1
[**2188-8-16**] 04:29PM BLOOD PT-13.0* PTT-23.4* INR(PT)-1.2*
[**2188-8-16**] 04:29PM BLOOD Glucose-452* UreaN-59* Creat-1.6* Na-134
K-4.4 Cl-98 HCO3-22 AnGap-18
[**2188-8-16**] 04:29PM BLOOD ALT-40 AST-30 CK(CPK)-69 AlkPhos-87
TotBili-0.4
[**2188-8-16**] 04:29PM BLOOD Albumin-4.3 Calcium-9.4 Phos-2.8 Mg-2.5
[**2188-8-16**] 04:29PM BLOOD CK-MB-5
[**2188-8-16**] 04:29PM BLOOD cTropnT-0.50*
[**2188-8-17**] 08:37PM BLOOD CK-MB-4 cTropnT-0.49*
[**2188-8-18**] 04:19AM BLOOD CK-MB-4 cTropnT-0.49*
INTERVAL:
[**2188-8-17**] 01:00AM BLOOD %HbA1c-10.9* eAG-266*
[**2188-8-20**] 07:35AM BLOOD CRP-179.6*
[**2188-8-23**] 06:15AM BLOOD CRP-123.1*
[**2188-8-25**] 06:05AM BLOOD cTropnT-0.36*
[**2188-8-27**] 07:45AM BLOOD Triglyc-80 HDL-34 CHOL/HD-2.8 LDLcalc-44
[**2188-8-27**] 07:45AM BLOOD Glucose-81 UreaN-32* Creat-1.6* Na-141
K-4.3 Cl-109* HCO3-23 AnGap-13
DISCHARGE:
[**2188-8-29**] 05:53AM BLOOD WBC-5.7 RBC-2.99* Hgb-8.7* Hct-26.7*
MCV-89 MCH-29.2 MCHC-32.7 RDW-15.8* Plt Ct-254
[**2188-8-29**] 05:53AM BLOOD PT-14.5* PTT-33.1 INR(PT)-1.4*
[**2188-8-29**] 05:53AM BLOOD Glucose-67* UreaN-29* Creat-1.9* Na-142
K-4.7 Cl-110* HCO3-22 AnGap-15
[**2188-8-29**] 05:53AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
IMAGING:
PORTABLE CHEST: [**2188-8-16**].
FINDINGS: Single portable view of the chest is compared to
previous exam from [**2175-9-16**]. Indistinct pulmonary
vascular markings are seen
bilaterally. Blunting of the costophrenic angle and
silhouetting the
hemidiaphragm suggestive of bilateral effusions.
Cardiomediastinal silhouette appears enlarged, likely slightly
accentuated by low inspiratory effort.
Median sternotomy wires are noted, now with a fracture of the
top two wires. Osseous and soft tissue structures are
unremarkable.
IMPRESSION: Findings suggestive of congestive failure with mild
pulmonary edema and bilateral effusions. Component of
superimposed infection should be considered based on a clinical
basis.
ABDOMEN (SUPINE & ERECT) FINDINGS: Supine and upright views of
the abdomen were obtained. Bowel gas pattern is unremarkable
without dilated loops of small and large bowel. Gas is present
within the rectum. No fluid level or pneumoperitoneum is
present on the upright exam. Several metallic clips overlie the
right femoral head, compatible with prior inguinal repair.
Sternotomy wires are intact.
IMPRESSION: Normal bowel gas pattern without evidence of bowel
obstruction.
ECHO [**2188-8-18**]: Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is severely
depressed (LVEF= 25-30 %) with global hypokinesis and akinesis
of the infero-posterior segments. No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
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. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2178-4-8**], the LVEF has decreased
FOOT AP,LAT & OBL LEFT
FINDINGS: No previous images. There have been resection of the
phalanges and a portion of the metatarsal of the fifth digit.
Either previous infectious changes or surgical change about the
metatarsophalangeal joints of the second, third, and fourth
digits in this patient with vascular calcification
consistent with diabetes.
In the absence of previous images, it is extremely difficult to
determine
whether there could be acute osteomyelitis. MRI would be the
next imaging modality to attempt to make this clinical decision.
VENOUS DUP EXT UNI (MAP/DVT) Left Lower Extremity Venous Duplex
Findings: Duplex evaluation was performed on the left lower
extremity veins. There is normal compression and augmentation of
the common femoral, proximal femoral, mid femoral, distal
femoral, popliteal, posterior tibial and peroneal veins. There
is normal phasicity of the common femoral veins bilaterally.
Impression: No evidence of left lower extremity deep vein
thrombosis.
ART EXT (REST ONLY) Bilateral lower extremity ABIs, Doppler
waveforms and PVRs were performed at rest.
FINDINGS:
RIGHT: The right ABIs are 1.17/1.12 at DP/PT. Right-sided
Doppler waveforms are triphasic at all levels with normal PVRs.
LEFT: The left ABIs are 1.12/1.17 at the DP/PT. Left-sided
Doppler waveforms are all triphasic with normal PVRs.
IMPRESSION: No evidence of any peripheral vascular disease at
rest.
PICC LINE PLACEMENT [**2188-8-27**]: IMPRESSION: Uncomplicated
ultrasound and fluoroscopically guided single-lumen PICC
placement via the right brachial venous approach. Final internal
length is 32 cm, with the tip positioned in SVC. The line is
ready to use.
PATHOLOGY/MICRO:
DIAGNOSIS: Bone, left foot, debridement:
Bone with reactive changes and granulation tissue with focal
acute inflammation consistent with healing ulcer. See note.
Note: The findings may be compatible with treated/resolving
osteomyelitis. Clinical correlation is recommended.
Gross: The specimen is received fresh in a container labeled
with the patient's name, "[**Last Name (LF) 111697**], [**Known firstname **]", medical record
number and "left foot bone". It consists of a 3 x 3 cm
aggregate of bone fragments; the largest fragment measures 2.2
cm in maximum dimension. The specimen is represented in A
following decalcification.
Brief Hospital Course:
73M with PMH of CAD s/p MI and 4 vessel CABG [**2174**], DM2
complicated by multiple L foot ulcers, presented from [**Hospital1 1501**] for
nausea, FSBG > 500 and poor med compliance. In ED found to have
Troponin T of 0.5, and non-specific ST depression on EKG. He was
also determined to have LLE osteomyelitis, decompensated
systolic CHF, osteomyelitis and a UTI. He is being treated with
broad spectrum antibiotics for his LLE osteomyelitis. His heart
failure has attempted to be optimized but has been limited by
fluctuating creatinine. Delivery of care has also been hindered
by psychiatric co-morbidities (e.g. narcissitic personality
disorder) with patient refusing care at some times.
.
# CAD with demand ischemia/Troponinemia : On evaluation in the
ED, he was found to have an elevated troponin (0.50) with ST
depressions in lateral leads on EKG, in the absence of chest
pain. This was concerning for evolving STEMI in the Emergency
department, so a cardiac catheterization was recommended, but
patient refused intervention, even if this were STEMI. In CCU pt
was started on IV Metop 10mg Q6H for HR 60s-70s, ASA 325mg and
Atorvastatin 80mg if patient agrees to take. Pt transferred to
medicine since he does not require CCU level of care and no
potential cardiac interventions will be done. He was
transferred to the CCU for further management. Cardiology
consult stated that he likely had demand ischemia from heart
failure as discussed below and no apparent NSTEMI or STEMI.
There, he refused majority of medical care, including ASA and
Clopidogrel. His troponins have remained stable (~0.4) with
improvement of ST depressions on EKG. His troponinemia was most
likely demand ischemia/troponin spill in setting of CHF and
metabolic stress. Not likely ischemic event. He remained chest
pain free throughout his stay.
# Acute on Chronic sCHF exacerbation (Echo [**2177**] EF 50%): Patient
likely had decompensated systolic heart failure from infection
and poor medication compliance. Initially, patient had SaO2
89-92% on RA with B/L crackles 2/3 up. At baseline pt does have
DOE but unclear distance he can walk given left foot ulcer
limits mobility significantly. CXR showed significant pulmonary
edema. Patient had a TTE this admission that demonstrated an EF
of 25-30% (down from 50% approx 10 yrs ago). The patient was
given furosemide diuresis after which his saturations and
crackles improved. He was saturating well and without shortness
of breath by the day of discharge. He is being discharged on a
limited anti-ischemic regimen given SBP in 90s/low 80s including
a statin. He should start lasix 20 mg PO qD. Future
considerations should be re-starting metoprolol, ACEi when renal
function stabilizes.
.
# Osteomyelitis: Patient was found to have a left foot ulcer
with dry and wet gangrene of left toe and lateral foot, which on
evaluation probed to bone and was purulent. He is being treated
with IV Vancomycin and Cefepime. Foot xray inconclusive.
Apparently, patient has been evaluated at [**Hospital 1263**] hospital for
this and recently (w/in a month) had an MRI there. Those records
were unable to be obtained, but there was high clinical
suspicion for osteomyelitis (secondary to elevated inflammatory
markers, L foot lateral plantar lower extremity probes to bone
and has purulence). Podiatry consulted and performed bedside
incisions and drainages followed by debridement under general
anesthesia on [**8-22**].
Patient will follow-up with podiatry as scheduled. He is being
discharged with a wet-to-dry and should have wound vac as
instructed re-started at rehab. He should keep wound vac on
until podiatry follow-up.
.
# Refusal of treatment in setting of Personality Disorder - Pt
is very difficult to manage and will intermittently refuse
various IV and PO medications daily, despite understanding the
risks and consquences. Additionally, the patient would not allow
any care whatsoever, including vital signs, repletion of vital
electrolytes, antibiotics for his foot medications, heparin SQ,
etc during evening and nighttime hours. Psychiatry was consulted
and determined that he had the mental capacity to make
decisions, even though he understood that he could die. Social
work was also consulted and determined from discussions with
patient's HCP that pt "will often respond well to encouragement
and reasoning behind a procedure/test but will 'dig his heels
in' should he be told he needs to have something done."
.
# Elevated FSBG: 565 in ED, AG = 14, FSBG fluctuates. Home dose
40U Lantus qHS. No signs and symptoms of DKA or non-ketotic
hyperosmolar come. HgA1C 10.6. [**Last Name (un) **] Diabetes was consulted and
assisted in the management of his blood glucose while an
inpatient with a standing lantus and a humalog insulin sliding
scale. His metformin and glipizide were discontinued and kept
off at discharge due to significant noncompliance with PO
medications.
.
# Acute vs chronic CKD? - Cr this admission fluctuated between
1.5 to 2, which is consistent with OSH records from earlier this
year, but values down to 1.2 seen in [**Month (only) 205**] records. Increase here
was likely secondary to diuresis vs poor renal perfusion in
setting of sCHF. His Cr was 1.9 on day of discharge.
.
# Complicated cystitis secondary to E. Coli resistant to cipro:
He had evidence of infection on a urinalysis. He denied
dysuria, but may have been confused so it was decided to treat
as a UTI. He was initially treated with Cipro, but his E. coli
was resistant so he was switched to Cefepime for 7 total doses.
Patient lost IV access so missed 2 doses in the middle of the
course. His course was also complicated by intermittent and
unpredicatble refusal of medications at times. He was
asymptomatic and urinating without issues by day of discharge.
.
# Acute encephalopathy,toxic-metabolic, resolved: The patient's
course was likely complicated by delirium, with report of
aggression towards medical staff requiring administration of
Haldol in the ED and CCU. On the medical floor, psychiatry was
consulted and by that time patient was alert and fully oriented
as well as capacitated.
.
# LLE swelling - Remained stable during the admission. Likely
due to CHF and/or PVD. Lower extremity noninvasive imaging
showed no DVT
.
# low normal BP/Hypotension (systolic in high 80s to low 90s) -
Likely due to hypovolemia s/p diuresis. Patient remained
asymptomatic at all times, mentating at his baseline. Offered
compression stockings to help increase venous return, as patient
spent all day in the chair and refused the bed unless it is
nighttime.
Metoprolol and lisinopril held due to hypotension. By day of
discharge His BP was stable with systolic 90s to low 100s with
HR 80s.
.
# TRANSITIONAL ISSUES:
1) Patient is DNR/DNI
2) Weekly Labs: Chem 7 including BUN, Cr, ESR, CRP, CBC with
differential
3) Continue diabetes therapy
4) Continue to advance heart failure therapy as above
5) Continue wound vac for LLE wound
6) Monitor diabetes regimen and PO intake
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Metoprolol Tartrate 50 mg PO BID
hold for sbp < 100, hr < 55
2. Omeprazole 40 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. Lantus *NF* (insulin glargine) 40 U Subcutaneous HS
7. Aspirin 81 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. Ceftaroline 400 mg IV Q12H
d1 = [**2188-8-26**] for osteomyelitis. Course to be determined by
infectious disease.
6. Furosemide 20 mg PO DAILY
hold for SBP < 100
7. Heparin 5000 UNIT SC TID
8. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
d1 = [**2188-8-26**] for osteomyelitis.
10. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN groin rash
11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
12. Outpatient Lab Work
Fax weekly safety labs to the below infectious disease provider:
[**Name10 (NameIs) 23870**], [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D.
Phone:([**Telephone/Fax (1) 4170**]
Fax:([**Telephone/Fax (1) 1353**]
ICD-9: 730 (osteomyelitis)
Start date: [**2188-9-1**]
Frequency: weekly
Labs: Chem 7 including BUN, Cr, ESR, CRP, CBC with differential
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Northeast Hospitial
Discharge Diagnosis:
Primary: Osteomyelitis
Secondary: Acute on chronic systolic heart failure, complicated
cystitis, Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. [**Known lastname 111698**]:
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted because you were found to
have several issues, including very high blood sugars, worsening
of your heart failure (characterized by fluid in your lungs and
your legs), a serious infection of your foot, and a urinary
tract infection. We treated you with insulin to control your
sugar, antibiotics for your infections, and used a "water-pill"
to remove fluid from your body. The foot doctors (Podiatry)
opened up and drained/removed some of the infected material of
your foot.
You will need to follow-up with the podiatry and infectious
disease doctors for further [**Name5 (PTitle) **].
Followup Instructions:
Please follow-up with your primary care physician as below after
discharge from rehab:
[**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 8894**]
Department: INFECTIOUS DISEASE
When: TUESDAY [**2188-9-16**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: PODIATRY
When: FRIDAY [**2188-9-5**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2188-10-8**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23870**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2188-9-2**]
|
[
"V58.31",
"272.4",
"730.27",
"V15.81",
"595.9",
"V45.81",
"414.00",
"731.8",
"585.9",
"250.82",
"428.0",
"V58.67",
"707.14",
"041.49",
"411.89",
"785.4",
"349.82",
"584.9",
"428.23",
"V49.86",
"250.72",
"V49.87",
"301.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"77.60"
] |
icd9pcs
|
[
[
[]
]
] |
18556, 18619
|
9997, 16721
|
286, 372
|
18778, 18778
|
4053, 9974
|
19612, 20834
|
2721, 2803
|
17466, 18533
|
18640, 18757
|
17028, 17443
|
18886, 19589
|
2818, 4034
|
233, 248
|
400, 2250
|
18793, 18862
|
16744, 17002
|
2272, 2485
|
2501, 2705
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,899
| 129,444
|
41621
|
Discharge summary
|
report
|
Admission Date: [**2144-10-12**] Discharge Date: [**2144-10-24**]
Date of Birth: [**2086-11-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times two(Left interior mammary
artery to left anterior descending, saphenous vein grafting to
obtuse marginal) on [**2144-10-20**]
History of Present Illness:
Mr. [**Known lastname 90470**] is a 57 year-old white male with known coronary
artery disease/ischemic cardiomyopathy who presented to [**Hospital3 12748**] on [**10-9**] with two syncopal episodes while at
rest. He was admitted and ruled out for a myocardial infarction
by enzymes. An interrogation of his AICD was benign. A cardiac
catheterization revealed multi-vessel disease and a depression
ejection fraction of 25%. He was transferred for surgical
work-up for his coronary artery disease.
Past Medical History:
Left Anterior Descending PCI/stent [**12-24**], Non-Insulin Dependent
Diabetes Mellitus, dilated cardiomyopathy, hypertension,
hyperlipidemia, depression, St. [**Male First Name (un) 923**] AICD [**6-25**] ([**Hospital3 **])
Social History:
Mr. [**Known lastname 90470**] lives with:friend in rooming house. He is an
unemployed beer truck driver. He last smoked a cigarette on
[**10-9**] and reports smoking two packs per day. He smokes crack
cocaine every Tuesday, last on [**10-9**].
Family History:
non-contributory
Physical Exam:
Pulse: Resp:14 O2 sat:
B/P Right:122/70 Left: 122/70
General:Thin [**Male First Name (un) 4746**], appears sl cachectic and older than stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [n]LT 2nd toe
surgically absent, well healed.
Varicosities: None [x]few spider veins rt thigh medially
Neuro: Grossly intact []
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 275**] [**Hospital1 18**] [**Numeric Identifier 90471**] (Complete)
Done [**2144-10-20**] at 12:44:02 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2086-11-11**]
Age (years): 57 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Coronary artery disease. Left
ventricular function. Mitral valve disease.
ICD-9 Codes: 424.1, 424.0, 424.2
Test Information
Date/Time: [**2144-10-20**] at 12:44 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 3% to 40% >= 55%
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild LA enlargement. 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. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Moderate-severe regional left ventricular systolic
dysfunction.
LV WALL MOTION: Regional left ventricular wall motion findings
as shown below; remaining LV segments contract normally.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
thickening of mitral valve chordae. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses and cavity
size are normal. There is moderate to severe regional left
ventricular systolic dysfunction with akinetic apex. The
remaining left ventricular segments contract normally. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are mildly thickened (3 leaflets). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is moderate
thickening of the mitral valve chordae. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
POST CPB:
1. Unchanged left and right ventricular systolci function
2. No change in valve structure and function
3. Intact aorta
Brief Hospital Course:
Mr. [**Known lastname 90470**] was admitted [**2144-10-12**] for pre-operative work-up for a
coronary artery bypass grafting. He underwent and
echocardiogram which showed no significant valve disease and an
ejection fraction of less than 40% and a carotid ultrasound
which revealed less than 40% stenosis bilaterally. His surgery
was delayed for a plavix washout as he was given plavix after
his cardiac catheterization. On [**10-15**] he had chest pain with EKG
changes and was transferred to the surgical intensive care unit
for heparin and nitroglycerin infusions. His chest pain quickly
abated. He began treatment for a urinary tract infection. He
was transferred back to the floor. Lantus was started for
better glucose management. On [**2144-10-20**] he underwent a coronary
artery bypass grafting times two(Left interior mammary artery to
left anterior descending, saphenous vein grafting to obtuse
marginal) performed by Dr. [**Last Name (STitle) **]. Please see the operative
note for details. During the procedure he underwent an
inappropriate AICD shock and was assessed by electrophysiology.
They felt the shock was due to electrocautery. He was
transferred in critical but stable condition to the surgical
intensive care unit. He quickly extubated on the day of
surgery. By the following day he weaned from neosynepherine and
was transferred to the floor. He was started on betablocker,
statins, and gently diuresed toward his pre-op weight. He was
evaluated by physical therapy and discharge to rehab was
recommended. On POD#3 he experienced a brief episode of post-op
afib. On POD#4 he was cleared for discharge to Blueberry [**Doctor Last Name **]
Rehab. His expected lenth of stay at rehab is less than 30 days.
Medications on Admission:
Plavix 75mg daily, Gabapentin 800mg [**Hospital1 **], Zocor 40mg daily, ASA
81mg daily, Glipizide 5mg [**Hospital1 **], Metformin 500mg [**Hospital1 **], Trazadone
50mg daily
Discharge Medications:
1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): on [**10-31**] decrease to 400mg daily for 7 days then
decrease to 200mg daily.
12. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. metformin 500 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
14. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: stop
when edema resolves and at pre-op weight 79kg.
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours): while on
lasix.
Discharge Disposition:
Extended Care
Facility:
Blueberry [**Doctor Last Name **] Healthcare - [**Hospital1 **]
Discharge Diagnosis:
coronary artery disease
LAD PCI/stent [**12-24**],NIDDM,ischemic dilated
Cardiomyopathy,HTN,hyperlipidemia, depression,St. [**Male First Name (un) 923**] AICD [**6-25**]
([**Hospital3 **]), Left 2nd toe amp
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] on [**11-25**] at
1:30pm in the [**Hospital **] Medical office building [**Last Name (NamePattern1) **],
[**Location (un) 86**] [**Hospital Unit Name **]
Cardiologist: [**First Name9 (NamePattern2) **] [**Doctor Last Name 4922**] on [**11-17**] at 3:00pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 59225**] in [**4-21**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2144-10-24**]
|
[
"V45.82",
"996.72",
"250.00",
"599.0",
"311",
"272.4",
"425.4",
"E879.8",
"411.1",
"V45.02",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9840, 9930
|
6322, 8066
|
321, 487
|
10183, 10416
|
2352, 5189
|
11256, 12025
|
1547, 1565
|
8292, 9817
|
9951, 10162
|
8092, 8269
|
10440, 11233
|
5238, 6165
|
1580, 2333
|
274, 283
|
515, 1016
|
1038, 1265
|
1281, 1531
|
6176, 6299
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,849
| 165,100
|
29213
|
Discharge summary
|
report
|
Admission Date: [**2106-2-23**] Discharge Date: [**2106-3-12**]
Date of Birth: [**2055-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Transfer from MICU (s/p fall with C-spine and nasal fractures,
EtOH intoxication)
Major Surgical or Invasive Procedure:
Peripherally inserted central catheter
History of Present Illness:
51-year-old homeless male, h/o EtOH abuse presented with altered
mental status after a fall. By report, the pt was sitting at a T
stop and fell forward off a bench while sitting, striking his
left forehead against the concrete. He was brought to the ED by
EMS for eval of left frontal hematoma, but was agitated and
combative in the ED, requiring restraints and sedation to
complete head CT. He was treated w/ 5mg haldol IV, and 2mg
ativan IV, and then returned from CT somnolent and unable to
protect his airway. He was intubated for airway protection.
.
Also in the ED, head CT showed anterior C3 osteophyte fracture
with soft tissue thickening concerning for possible ligamentous
injury, also with C-spine fx, nasal fractures. The pt was
initially hypothermic w/ rectal temp 93 F, but improved w/
warming blanket. Utox and Stox negative except for alcohol.
Given banana bag. Admitted to the MICU for further care.
.
In the MICU, the patient was stabilized and extubated on [**2-25**].
He was seen by plastics, neurosurg, and ENT. His nasal fracture
were reduced and will need 1 more day of clinda s/p nasal
manipulation. Plan for c-spine collar for 6 weeks. Initially
required significant amounts of valium for EtOH withdrawal but
now improved (last dose 2/16). Also with mild hypernatremia, now
resolved, and hypertension that was not treated as he will not
follow-up. Transferred to the medical floor for continued care.
.
Currently complaints of bilateral 'burning' foot pain. Denies
other pain, SOB, tremulousness, hallucinations, or other
complaints.
Past Medical History:
- homeless
- EtOH abuse
- pneumonia ([**12-16**])
- h/o scabies, lice
- seizure disorder
- HTN
- peripheral neuropathy
Social History:
Homeless; multiple ED visits with alcohol intoxication over the
past 2 years; further history unavailable.
Family History:
unavailable
Physical Exam:
T 99.2 HR 86 BP 120/90 RR 24 O2sat 98% RA
Gen: thin, lying flat, sleeping, NAD
HEENT: PERRL, supraorbital hematoma, left supraorbital abrasion,
OP clear, poor dentition, MMM
CV: RRR, mo m/r/g, no JVD
Pulm: Decreased air movement bilat, coarse expiratory breath
sounds, no wheeze or crackles
Abd: +BS, soft, NT, ND
GU: foley draining dark yellow urine
Ext: warm, 2+ DP, no edema, foot exam without ulcers
Neuro: Sleepy but arousable and appropriate, speech muffled,
uncooperative with exam, moves all 4 extremities
Pertinent Results:
Hematology:
[**2106-2-23**] 09:40PM BLOOD WBC-5.2 RBC-4.55* Hgb-11.5* Hct-35.7*
MCV-78* MCH-25.2* MCHC-32.2 RDW-15.6* Plt Ct-183
[**2106-2-23**] 09:40PM BLOOD Neuts-40.7* Lymphs-53.3* Monos-4.0
Eos-1.4 Baso-0.5
.
Chemistry:
[**2106-2-23**] 09:10PM BLOOD Glucose-105 UreaN-6 Creat-0.6 Na-146*
K-3.7 Cl-108 HCO3-25 AnGap-17
[**2106-2-24**] 07:00AM BLOOD ALT-13 AST-42* LD(LDH)-331* AlkPhos-44
Amylase-52 TotBili-0.2
[**2106-3-4**] 06:20AM BLOOD ALT-19 AST-29 AlkPhos-83 Amylase-142*
TotBili-0.2
[**2106-2-23**] 09:10PM BLOOD CK(CPK)-104
[**2106-2-24**] 07:00AM BLOOD Lipase-20
[**2106-3-4**] 06:20AM BLOOD Lipase-50
[**2106-2-24**] 07:00AM BLOOD Calcium-3.6* Phos-1.4* Mg-0.8* Iron-14*
[**2106-3-2**] 04:52AM BLOOD VitB12-1037*
[**2106-2-24**] 07:00AM BLOOD calTIBC-189* Ferritn-15* TRF-145*
[**2106-3-2**] 04:52AM BLOOD TSH-1.2
[**2106-2-23**] 09:10PM BLOOD ASA-NEG Ethanol-381* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2106-2-24**] 09:48PM BLOOD Ethanol-NEG
[**2106-2-24**] 05:19AM BLOOD Type-ART pO2-439* pCO2-39 pH-7.41
calTCO2-26 Base XS-0 Comment-I.D. BY RI
[**2106-2-24**] 11:06AM BLOOD freeCa-0.69*
[**2106-2-24**] 10:03PM BLOOD freeCa-1.08*
[**2106-2-25**] 02:42AM BLOOD freeCa-1.12
RPR non-reactive
.
Urine:
[**2106-2-23**] 07:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2106-2-23**] 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2106-2-23**] 07:00PM URINE RBC-0 WBC-0 BACTERIA-0 YEAST-NONE EPI-0
[**2106-2-23**] 07:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
EKG: NSR @ 95 bpm, nl axis, LVH, unchanged from prior tracing
[**2106-1-26**].
.
CXR ([**2-23**]): There is no pleural effusion or pneumothorax. No
focal consolidation is identified. Chronic deformity of the
distal right clavicle is again noted and likely due to prior
trauma.
.
CXR ([**2-25**]): No evidence of focal consolidation or significant
change from prior.
.
CXR ([**2-28**]): The right-sided PICC line is unchanged in position.
Endotracheal tube has been removed. There are no focal
consolidation, pleural effusions, or signs for acute pulmonary
edema. Bony structures are intact. IMPRESSION: Extubated
without signs for acute cardiopulmonary process.
.
CT head: No evidence of acute intracranial hemorrhage. Left
orbital floor fracture and nasal fractures. The orbital floor
fracture is age indeterminate, while the nasal fractures are
clearly acute. Large soft tissue hematoma of the left forehead
and periorbital region.
.
CT c-spine: No fracture or malalignment. C4-5 prominent anterior
osteophytes There is a broken anterior C3 osteophyte,
indeterminate age. Althogh there is no fracture, there is
increased prevertebral soft tissue thickening. MRI would be
helpful to look for soft tissue/ligamentous injury not visible
on CT.
.
MRI c-spine: Acute fracture through large anterior osteophyte at
the C3/4 interspace. Extensive surrounding prevertebral soft
tissue swelling likely represents ligamentous injury, although
no overt tear in the anterior longitudinal ligament is seen.
Brief Hospital Course:
51M homeless presented s/p fall with C-spine and nasal
fractures, EtOH intoxication. Intubated for airway protection
initially and admitted to MICU, then extubated, stablized, and
tranferred to floor for further care.
.
# Alcohol withdrawal: Serum ethanol over 300 on presentation.
Denies h/o alcohol withdrawal, seizures, and DTs, but [**Hospital1 2177**]
records notable for h/o seizure disorder NOS possible related to
EtOH given the overwhelming number of visits to this hospital
for EtOH intoxication. Continued folate, thiamine, MVI. Received
significant valium in MICU, then tapered off on floor. CIWA
scales <10 x 48 hours and discontinued. The patient was
intermittently agitated on the floor demanding to leave
requiring code [**Doctor Last Name 352**], haldol prn, and 1:1 sitter. Psych was
consulted and deemed him not competent to care for self (see
dispo below).
.
# C-spine fracture: s/p fall from sitting while intoxicated.
Osteophyte fracture discovered at C3/4 level. Also with
ligamentous injury but no obvious tear. Neurosurgery consulted
and recommended Aspen C-collar at all times x 6 weeks and follow
up with Dr. [**Last Name (STitle) 548**] in 6 weeks for evaluation and repeat CT
c-spine (call [**Telephone/Fax (1) 1669**] for appointment) Neurosurgery will
contact the pt. at the pine street shelter to schedule an
appointment. The patient continually attempted to remove
C-collar and required constant redirection as he did not recall
that he had a cervical fracture (see memory loss below).
Psychiatry consultation obtained to determine capacity for
refusing collar. It was determined he lacked capacity for this
decision. Initially the decision was that we would proceed to
guardianship, but given that there is no practical way to force
him to wear the collar even with guardianship short of 4-point
restraints and sedation for 6 weeks, we consulted legal
services. There was consensus that although this is an unstable
lesion, that there is nothing to do to force him to wear it, and
that we would send him to a shelter with the collar and
reiteration to the patient as well as contacting the shelter
staff about wearing the collar.
.
#cervical collar: We strongly stressed to Mr. [**Known lastname **] that he must
wear the cervical collar for 6 weeks at all times. We have
explained to him the seriousness of his injury and the fact that
he could suffer from serious spinal cord injury if he does not
wear the collar, the patient was agreable to wearing the collar
on discharge.
.
# Nasal fractures, left orbital floor fracture: Plastics and ENT
consulted in MICU. s/p closed reduction of nasal fracture and
nasal packing (Dr. [**Last Name (STitle) **]. Unclear initially if orbital
fracture new or old (if old then deemed non-operative), but
after limited movement noted on reduction, plastics team
believed that these fracutres were likely old. Nasal packing
removed on [**2-25**]. There was no evidence of eye entrapment on ENT
evaluation. The patient received 5 days clindamycin per ENT due
to nasal manipulation.
.
# Memory loss: Likely due to chronic EtOH abuse, however
traumatic brain injury possibly contributing. Baseline appears
to be A&Ox2 per [**Hospital1 2177**] records obtained, and notes signify planned
outpatient w/u for dementia. Despite continued reminders, the
patient did not remember that he sustained C-spine fracture.
Neuropsych testing recommended in 6 weeks once acute issues
resolved.
.
# Anemia: Microcytic. Unknown baseline HCT. Iron studies c/w
iron-deficiency and he was started on iron supplements. Hct
remained stable in the mid-30s during hospital stay. No prior
colonoscopy. The patient will need further GI work-up.
.
# Nausea: Unclear cause. No associated abdominal pain, vomiting,
or diarrhea. LFTs, amylase, lipase without specific
abnormalities. Resolved spontaneously and was tolerating POs at
discharge.
.
# Peripheral neuropathy: Patient c/o pain bilat foot pain.
Neuropathy likely EtOH-related. He was given Tylenol 500mg q6h
and started on gabapentin 300mg tid trial with subjective
improvement, but pt. is still complaining of foot pain.
Therefore, it is unclear if this is really neuropathy, we did
not discharge the pt. with neurontin.
.
# h/o seizure disorder: Per [**Hospital1 2177**] records. Unclear etiology (?EtOH
related). Never been on medications.
.
# Low grade fever, cough: Concern for respiratory infection,
especially aspiration given EtOH abuse, somnolence, recent
intubation. Lung exam with coarse breath sounds throughout. CXR
without acute process and U/A negative. Cough resolved and
remained afebrile.
.
# Hypernatremia: Likely due to poor access to free water,
resolved with hydration. Cont to monitor sodium daily.
.
# ?Glaucoma: Right eye, discovered on ENT eval (elevated IOP @
35, enlarged cup-to-disc ratio). Initially on eye drops per
their recs but then they recommended d/c as repeat IOP when
patient more cooperative was normal (11). Recommended outpatient
comprehensive eye examination (call [**Telephone/Fax (1) 253**]).
.
# Dispo: Deemed incompetent to care for self by psych team. Will
be discharged to the Pine street shelter. He will also be
considered for a bed at the [**Doctor Last Name **] house.
Medications on Admission:
Medications (at home):
None
Medications (on transfer):
Clindamycin 600mg IV q8h
Folate 1mg IV qd
Thiamine 100mg IV qd
Heparin 5000 units sc tid
Ferrous sulfate 325mg qd
Diazepam 10mg q2h prn CIWA>10
Docusate
Senna prn
Tylenol prn
Morphine 2-4mg IV q4h prn
Dorzolamide 2%/Timolol 0.5% 1 drop OD [**Hospital1 **]
Latanoprost 0.005% 1 drop OD qhs
Nicotine patch
Protonix 40mg IV qd
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Nasal/orbital/cerivical spine fractures
Alcohol withdrawal
Memory loss
.
Secondary:
Alcohol abuse
Seizure disorder
Hypertension
Peripheral neuropathy
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed.
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
[**Location (un) **] UNIV FAMILY MED INC [**Telephone/Fax (1) 65318**]
Please follow up with Dr. [**Last Name (STitle) 548**], neurosurgery in 6 wks
[**Telephone/Fax (1) 70252**]
Comprehensive eye examination, call [**Telephone/Fax (1) 253**]
Gastroenterology
Completed by:[**2106-3-12**]
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3,482
| 186,355
|
50033
|
Discharge summary
|
report
|
Admission Date: [**2153-1-22**] Discharge Date: [**2153-1-25**]
Date of Birth: [**2097-4-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / Pork Derived (Porcine)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Endotracheal intubation
Right internal jugular central venous line
History of Present Illness:
55 year-old male with COPD on home oxygen, CAD s/p CABG admitted
with dyspnea. He was discharged on [**2153-1-21**] after 2[**Hospital **]
hospital course for hypercarbic respiratory failure due to COPD
exacerbation requiring intubation. He felt "so-so" on discharge
and this morning subsequently became more short of breath. He
did not experience chest pain, palpitations, or fever. History
otherwise limited as patient required urgent intubation on
arrival to MICU.
.
In [**11-10**] he was intubated for MRSA pneumonia.
.
During [**Date range (1) 104476**]/11 hospitalization he was intubated for
hypercarbic respiratory failure. He received IV pulse steroids
with PO taper, broad-spectrum antibiotics narrowed to
levofloxacin for total 7-day course and completed prior to
discharge, and nebulizers with reinitiation of Advair prior to
discharge. Hospital course was complicated by DVT in left
brachial vein for which coumadin was initiated. Discharging
team attempted to admit patient to pulmonary rehabilitation
program - claim was declined by insurance.
.
In the ED, 97.1 103 149/57 38 98% 4L NC. Triggered for
tachypnea.
Physical examination notable difficulty breathing. Laboratory
data significant for leukocytosis (17.1) with left-shift, HCO3
35, lactate 1.5, INR 1.8. Initial ABG 7.31/77/254 on unknown
settings (?after BiPap initiated). EKG with sinus tachycardia
108, NA/NI ST depressions II,III, aVF, V5-6 suspected to be rate
related. CXR 1V without acute abnormality. Received solumedrol
125mg IV x1, lorazepam 2mg IV x1, azithromycin 500mg IV x1,
Combivent neb x1. Initiated on BIPAP with improved . On
transfer to MICU, 97.1, 101, 143/59, 21, 95% BIPAP. Has 18G,
20G on right.
.
On arrival to MICU, patient was in respiratory distress and
required urgent intubation.
.
Review of systems:
Unable to obtain - intubated.
Past Medical History:
1) CAD s/p MI and CABG
PCI [**5-/2150**]: patent LIMA-->LAD, RIMA-->RCA, BMS--> RCA distal to
RIMA touchdown. Cath [**12/2150**]: widely patent LIMA and RIMA grafts;
patent distal RCA stent and known occluded native LAD and RCA.
Nuclear Stress [**1-/2151**] Nuclear Perfusion Stress: no anginal
symptoms or ischemic ST segment changes. REVEAL rhythm analyzer
placed in [**2152-12-2**].
2) Tobacco abuse - 1 ppd/3 days since age 21
3) Hypercholesterolemia
4) Hypertension
5) COPD on 2L home O2
6) History of head trauma in [**2118**] from MVA with post-traumatic
grand mal seizure, now off antiepileptics
7) Thoracic aortic anuerysm s/p repair [**2148**]
8) neurogenic claudication
9) s/p spinal stenosis surgery [**1-/2152**], on narcotics
10) MRSA PNA with cavitation, tx with linezolid [**2152-12-18**] x 14
days
Social History:
Widower. Patient lives with his sister-in-law and her children.
-Tobacco history: 30 pk/year hx, recently "quit" on previous
discharge. Has not smoked a cigarette since [**2152-11-1**]
-ETOH: previous hx of 16-30 beers/day, cut back a year ago, now
occasional 1-2 beers.
-Drug: denies hx of IVDU
Family History:
Mother died of MI at 59.
Father died at 61 of "MI and cancer."
Cousin with MI at 41.
Paternal uncle died with MI at 41.
Sister with borderline diabetes.
Brother died of throat cancer.
Physical Exam:
98.0, 94, 190/66, 17, 98% BIPAP -> after intubation, 81/40 99%
AC 450 x18, PEEP 8, FiO2 35%
General: Pre-intubation, in distress, using accessory muscles,
BIPAP in place
HEENT: Sclera anicteric, dry mucous membranes
Neck: No appreciable JVD
Lungs: Poor air movement, particularly on right; no appreciable
wheezes, rales, or rhonchi
CV: RRR, normal S1/S2, no murmrs
Abdomen: Hypoactive bowel sounds, soft, nontender, not
distended
Ext: Warm, well-perfused, no lower extremity edema
Discharge exam:
General: No acute distress, AAOx3, responds appropriately to
questions
HEENT: Sclera anicteric, dry mucous membranes
Neck: No appreciable JVD
Lungs: decreased air movement on right; no appreciable wheezes,
rales, or rhonchi
CV: RRR, II-III SEM heard best over left upper sternal border
Abdomen: Normoactive bowel sounds, soft, nontender (although
sedated), not distended
Ext: Warm, well-perfused, trace lower extremity edema to knees
bilaterally; weak, symmetric radial, DP pulses; LUE with notable
swelling and pain to palpation
Pertinent Results:
[**2153-1-22**] 04:05PM WBC-17.1*# RBC-4.32* HGB-11.8* HCT-36.6*
MCV-85 MCH-27.4 MCHC-32.3 RDW-17.9*
[**2153-1-22**] 04:05PM NEUTS-85.4* LYMPHS-11.0* MONOS-2.6 EOS-0.6
BASOS-0.3
[**2153-1-22**] 04:05PM PLT COUNT-267
[**2153-1-22**] 04:05PM PT-19.8* PTT-23.1 INR(PT)-1.8*
[**2153-1-22**] 04:05PM TYPE-ART PO2-254* PCO2-77* PH-7.31* TOTAL
CO2-41* BASE XS-9
[**2153-1-22**] 04:05PM cTropnT-<0.01
[**2153-1-22**] 04:14PM LACTATE-1.5
[**2153-1-22**] 11:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
On discharge:
[**2153-1-25**] 03:59AM BLOOD WBC-10.0 RBC-3.86* Hgb-10.3* Hct-32.6*
MCV-85 MCH-26.6* MCHC-31.5 RDW-18.5* Plt Ct-203
[**2153-1-25**] 03:59AM BLOOD PT-12.3 PTT-23.7 INR(PT)-1.0
[**2153-1-25**] 03:59AM BLOOD Glucose-100 UreaN-16 Creat-0.4* Na-142
K-4.3 Cl-99 HCO3-40* AnGap-7*
CXR 1V ([**2153-1-22**]):
In comparison with the earlier study of this date, there has
been placement of an endotracheal tube with its tip
approximately 5 cm above the carina. Orogastric tube to at least
the upper stomach, where it crosses the lower margin of the
image.
Little change in the appearance of the heart and lungs with no
evidence of acute cardiopulmonary disease. Intact midline
sternal wires relate to previous CABG procedure.
Brief Hospital Course:
55 year-old male with CAD, COPD s/p recent hospitalization for
hypercarbic respiratory failure, admitted one-day post-discharge
with recurrent dyspnea. [**Hospital 104477**] hospital course was as follows.
.
#. Acute on chronic hypercarbic respiratory failure. In the
ED, 7.31/77/254; most recent ABG 7.39/70/86 on face mask. He
has chronic respiratoy acidosis based on HCO3- 35 with likely
baseline PCO2 around 70. Patient intubated for apneic episodes,
fatigue shortly after arrival to MICU. Based on patient history
and recent medical course, etiology likely COPD exacerbation.
Trigger unclear - he has long history of medication/home oxygen
noncompliance, and on arrival to MICU he smelled of cigarette
smoke. Patient was given methylprednisolone 125mg IV Q8 hours
for first day and then weaned down to prednisone 40mg PO daily
with plan for prolonged taper. He was kept on standing
Ipratropium/albuterol nebs every 4 hours. He was initially
started on azithromycin but was later discontinued as patient
was afebrile, WBC returned to [**Location 213**] and his chest xray did not
reveal any infiltrate. On [**1-23**], (day after admission) patient
was successfully extubated and placed on his home O2 requirement
of 2L. On [**2153-1-25**], his sputum grew out Pseudomonas, new to
patient's respiratory flora per our prior microbiology;
ciprofloxacin should continue for 3-4 weeks until his follow up
appointment with Dr. [**Last Name (STitle) **]. Also placed on prednisone taper
which should continue until his appointment with Dr. [**Last Name (STitle) **], his
pulmonologist.
Of note, patient also had some improvement in symptoms with
diuresis. He was given Lasix 20mg IV x1 on [**2153-1-24**] with good
response. He should continue to be weighed regularly and Lasix
dose adjusted as necessary. He has known mild systolic
dysfunction, and is on an ACE inhibitor, beta-blocker, and Lasix
as outpatient.
.
#. Hypotension: Patient became mildly hypotensive in setting
of intubation. His pressures responded to IVF boluses; however
based on poor access, a central line was placed. Patient never
required pressors and pressures remained normotensive throughout
his hospital stay. Home furosemide, metoprolol, lisinopril were
held initially and resumed on discharge.
.
#. Leukocytosis: Last CBC [**2153-1-13**] with normal WBC 5.9. His
leukocytosis normalized after first day and was thought to be
stress response related. As above, his sputum cx grew out
Pseudomonas and he was started on ciprofloxacin. Urine and
blood cultures remained no growth.
.
#. Left brachial vein DVT: INR 1.8 on admission. Given urgent
need to place CVL, he was reversed with FFP. Anticoagulation
was discontinued given (1) low risk for embolization and (2)
patient's risk on coumadin given history of medication
noncompliance.
.
#. CAD: Cycled cardiac markers x2 on admission due to
possibility of dyspnea due to cardiogenic source, all negative.
Continued [**Month/Day/Year **] 325mg PO daily and Simvastatin 40mg PO daily per
home regimen. Metoprolol, lisinopril restarted on discharge per
home regimen.
.
#. Chronic back pain: Morphine, Percocet on held initially
given hypotension, they were restarted when hemodynamically
stable (Percocet 5/325mg 2 tablets Q6 hours PRN; MS Contin 15mg
PO Q12 hours).
Medications on Admission:
(per [**2153-1-21**] discharge summary)
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR): Take this medication three times
per week for as long as you are taking 20 mg or more per day of
prednisone.
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) inhallation/activation Inhalation [**Hospital1 **] (2 times a day).
6. guaifenesin 100 mg/5 mL Liquid Sig: Five (5) mL PO every six
(6) hours as needed for cough.
7. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
10. oxycodone-acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q6H (every 6 hours) as needed for pain: as we discussed - do
not drive or drink alcohol or operate machinery while taking
this medication.
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
12. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TIDAC (3 times a day (before meals)).
Disp:*180 Tablet, Chewable(s)* Refills:*0*
13. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
14. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours): as we discussed - do
not drive or drink alcohol or operate machinery while taking
this medication.
15. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Take this
medication once per day while you are taking prednisone.
17. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day for 3
months: your levels of this medication will need to be managed
and dosed by Dr [**Last Name (STitle) **] (your primary care MD). GOAL INR 2.0-3.0;
DO NOT TAKE THIS MEDICATION UNTIL INSTRUCTED TO DO SO BY YOUR
VISITING NURSE AND YOUR PRIMARY MD ([**Doctor Last Name **]).
18. prednisone 10 mg Tablet Sig: as per taper regimen Tablet PO
once a day for 22 days: [**Date range (1) 86563**]: 4 tab/day
[**Date range (1) 35039**]: 2 tab/day
[**Date range (1) 104475**]: 1 tab/day then stop.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR ([**Date range (1) 766**] -Wednesday-Friday).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation twice a day.
6. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
7. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation every six (6)
hours.
9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: [**Month (only) 116**] cause sedation. Do not drive or
operate machinery when taking this medication.
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
11. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO three times a day.
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
13. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO every twelve (12) hours: [**Month (only) 116**] cause sedation.
Do not drive or operate machinery when taking this medication.
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. prednisone 5 mg Tablet Sig: As listed below. Tablet PO once
a day for 1 months: 40mg daily for 4 days, then 35mg daily for 4
days, then 30mg daily for 4 days, then 25mg daily for 4 days,
then 20mg daily for 4 days, then 15 daily for 4 days, then 10mg
daily until seen by Dr. [**Last Name (STitle) **] on [**2153-2-22**].
17. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) 86**]
Discharge Diagnosis:
- Acute COPD exacerbation
- Bronchiectasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Requires supplemental oxygen with ambulation and at rest.
Discharge Instructions:
You were admitted to the intensive care unit at [**Hospital1 771**] for shortness of breath. You required
intubation and treatment with a breathing machine for
approximately 24 hours. We gave you steroids and Lasix, a
diuretic, and your symptoms improved. You also had a bacteria
called Pseudomonas in your sputum - you were started on
ciprofloxacin for treatment of this. For your COPD
exacerbation, you were started on a new taper of prednisone.
Finally, your coumadin was held at this time.
Other than these medication changes, your medication regimen was
not changed. Please continue your other medications as you were
prior to this hospitalization.
Please be sure to keep your appointments as listed below.
Followup Instructions:
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2153-1-29**] at 11:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**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: PULMONARY FUNCTION LAB
When: THURSDAY [**2153-2-22**] at 9:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2153-2-22**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"305.1",
"041.7",
"494.0",
"412",
"288.60",
"V58.61",
"272.4",
"V46.2",
"493.22",
"V45.81",
"724.5",
"518.84",
"785.0",
"401.9",
"V12.04",
"453.72",
"V45.89",
"V15.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14039, 14124
|
6047, 9374
|
335, 403
|
14210, 14210
|
4715, 5291
|
15161, 16158
|
3453, 3639
|
11985, 14016
|
14145, 14189
|
9400, 11962
|
14418, 15138
|
3654, 4143
|
4159, 4696
|
5305, 6024
|
2252, 2284
|
275, 297
|
431, 2233
|
14225, 14394
|
2306, 3123
|
3139, 3437
|
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