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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
48,253
| 196,415
|
27387+57544
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-9-8**] Discharge Date: [**2169-9-15**]
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
fall from wheelchair
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 88M with a h/o of a SDH in [**2167**], AFib, who fell from his
wheelchair this morning. Taken to OSH where CT showed C1-C2
fracture, no intracranial injury.
Currently complaining of significant suboccipital pain and some
R
frontal pain. No change in vision. No change in hearing. No
pain/paraesthesias/numbness elsewhere. No LOC and no preceding
symptoms.
CODE STATUS: DNR/DNI
Past Medical History:
AFib, SDH [**2167**], L Knee replacement
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
O: T: 97.4 BP: 131/92 HR: 87 R:16 O2Sats: 95% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5->2mm, reactive EOMs intact
bilaterally
R supraorbital ecchymosis
Neck: Firm collar in place
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.
Motor:
3+ (pain) in deltoids, biceps, triceps, bilaterally. 4+ (pain)
hand strength, bilaterally. Normal LE strength
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: Normal bilaterally
Propioception intact
Toes flat bilaterally
Rectal exam normal sphincter control
On Discharge: Alert and Oriented x3, Nonfocal, full strength in
all muscle groups
Pertinent Results:
TRAUMA #2 (AP CXR & PELVIS PORT) Study Date of [**2169-9-8**] 5:50 PM
IMPRESSION:
1. Difficult to exclude left-sided rib fractures on this study
and if of
clinical concern, suggest dedicated rib series.
2. Cardiomegaly with minimal interstitial edema.
3. Diffuse osteopenia of the pelvis. The patient is obliqued,
making
evaluation of the left femoral neck and bilateral inferior pubic
rami
suboptimal and if concern at these locations, suggest
repeat/dedicated
imaging. Otherwise, no acute fracture seen.
HIP UNILAT MIN 2 VIEWS LEFT Study Date of [**2169-9-8**] 5:51 PM
FINDINGS: AP and lateral views of the left hip were obtained.
Please note
that due to patient positioning, the evaluation of the left
femoral neck is suboptimal. If high clinical concern, consider
repeat. Otherwise, no
evidence of acute fracture or dislocation is seen. Vascular
calcifications
are noted.
HAND (AP, LAT & OBLIQUE) RIGHT Study Date of [**2169-9-8**] 5:51 PM
IMPRESSION:
1. Severe degenerative changes involving the carpocarpal joints
and first
carpometacarpal joint, with inferior subluxation of the first
metacarpal.
Additionally, there is flattening of the scaphoid bone and the
lunate appears rotated flattened, although no definite
dislocation is seen, avascular necrosis of the lunate is not
excluded.
2. 4-mm well-corticated-appearing ossific structure seen dorsal
to the
proximal carpal row on the lateral views may be degenerative,
although
triquetral fracture cannot be excluded, although appears old.
3. Extensive vascular calcifications.
CT Chest/ABD & PELVIS WITH CONTRAST Study Date of [**2169-9-8**] 8:02
PM
IMPRESSION:
1. No evidence of acute injury in the chest, abdomen, or pelvis.
2. Bilateral dependent atelectasis with possible superimposed
aspiration.
Possible very trace left pleural effusion. Minimal pericardial
fluid.
3. Gas seen within the nondependent portion of the bladder.
Recommend
correlation with recent instrumentation. If none, recommend
correlation with
the urinalysis to assess for infection.
4. Old fractures of bilateral ribs, bilateral inferior pubic
rami, and
possibly of the right superior pubic ramus.
CT C-SPINE W/O CONTRAST Study Date of [**2169-9-8**] 10:44 PM
IMPRESSION:
1. Unchanged appearance of comminuted [**Location (un) 26524**] fracture of
C1, as detailed
above.
2. Unchanged appearance of type 2 dens fracture with 4 mm dorsal
displacement
and 30-35% dorsal angulation of the dens.
3. Findings concerning for epidural hematoma in the upper
cervical spine,
which may be better assessed by MRI, if clinically indicated.
These findings
were reported to neurosurgery APN [**Doctor Last Name **] at 12 pm on [**2169-9-9**].
4. Extensive multilevel degenerative disease. Moderate spinal
canal stenosis
at C5-6. Mild anterolisthesis at C3-4 and C4-5, likely due to
facet
arthropathy. Multilevel neural foraminal narrowing.
5. Emphysema and extensive dependent opacities at the imaged
lung apices.
6. Extensive calcification at the origins of the internal
carotid arteries,
but the degree of associated stenosis cannot be quantified on
this noncontrast
exam.
CT HEAD W/O CONTRAST Study Date of [**2169-9-12**] 8:16 AM IMPRESSION:
1. Near resolution of previously seen right orbital soft tissue
hematoma and swelling.
2. Fluid level seen in the right frontal and sphenoid sinuses
with mucosal
thickening seen in the ethmoid air cells and sphenoid sinus.
CHEST (PORTABLE AP) Study Date of [**2169-9-13**] 1:49 PM
FINDINGS: Single AP view of the chest shows bibasilar
atelectasis. Left
hemidiaphragm is elevated secondary to underlying fat as seen on
the CT exam. Moderate dextroscoliosis. No pneumothorax or
pleural effusion. The lateral view would help exclude underlying
pneumonia.
IMPRESSION: Bibasilar atelectasis.
Brief Hospital Course:
Mr. [**Known lastname 9056**] was admitted to the neurosurgery service on [**2169-9-8**]
after sustaining a fall from his wheelchair. He was initially
taken to an OSH where a CT scan showed a C1-C2 fracture with no
intracranial injury. Transferred to [**Hospital1 18**] where repeat CT showed
a comminuted fracture of the anterior arch of C1, with 2 mm
anterior
displacement of the anterior arch fragment, as well as type 2
dens fracture with 4 mm posterior displacement of the dens. An
Aspen cervical collar was placed and he was admitted for
observation.
On [**9-9**] he complained of nasal congestion and was started on
Benadryl prn. He was noted to have some confusion with
sundowning.
On [**9-10**] he was noted to have some swelling in his posterior
pharynx with an enlarged uvula. A strep culture was sent and he
was started on Nystatin for possible thrush.
By [**9-11**] he had developed significant swelling throughout the
posterior pharynx and he was transferred to the ICU for closer
monitoring. ENT was consulted and recommending starting Decadron
10mg Q8hrs and nasal trumpet placement. A Monospot test was also
sent. Per discussion with his HCP his [**Name2 (NI) 835**] status was temporarily
reversed to allow for intubation for airway protection if
needed.
On [**9-12**], patient was lethargic on AM rounds, a stat head CT was
done which showed no intracranial process. He remained in the
ICU with a nasal trumpet per ENT for respiratory aide. His exam
improved throughout the day.
On [**9-13**], he was alert and oriented and moving all extremities.
His tonsils and palate remained swollen, but no stridor was
heard. A trial removal of the nasal trumpet was performed and
the patient tolerated it well. Oxygen saturations remained
within normal limits and the patient had no signs of respiratory
distress. Both strep and monospot tests were negative.
On [**9-14**] Speech and language therapists performed a swallow
evaluation on the patient in the setting of soft palate edema
and cleared him for a regular diet.
On [**9-15**], the day of discharge, the patient is tolerating a
regular diet, ambulating with assistance, afebrile with stable
vital signs. Physical therapy recommends discharge to rehab.
The patient is expected to stay in the rehabilitation center for
less than 30 days.
Medications on Admission:
Atenolol, ciprofloxacin, celexa,
tamsulosin, tramadol
Discharge Medications:
1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**6-21**]
hours as needed for fever or pain.
2. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed for spasm.
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
C2 fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Cervical Collar at all times
Discharge Instructions:
General instructions:
?????? Do not smoke.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Wear your cervical collar at all times.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 6 weeks.
??????You will need CT-scan of your cervical spine prior to your
appointment.
Completed by:[**2169-9-15**] Name: [**Known lastname 11644**],[**Known firstname 33**] E. Unit No: [**Numeric Identifier 11645**]
Admission Date: [**2169-9-8**] Discharge Date: [**2169-9-15**]
Date of Birth: [**2080-10-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 599**]
Addendum:
Foley catheter was removed at 10am and the patient is due to
void between 4pm and 6pm.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 170**] Senior Healthcare - [**Location (un) 171**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2169-9-15**]
|
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"E884.3",
"780.09",
"528.9"
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,588
| 104,801
|
23466
|
Discharge summary
|
report
|
Admission Date: [**2145-4-5**] Discharge Date: [**2145-5-5**]
Service: SURGERY
Allergies:
Fosamax
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
[**4-13**]
1. Oversewing bleeding duodenal ulcer.
2. Antrectomy.
3. Loop gastrojejunostomy.
4. Placement of left-sided chest tube.
[**4-14**]
Primary repair 6 cm laceration to left forearm.
History of Present Illness:
The patient is an 89-year-old gentleman who
presented with a GI bleed, underwent negative EGD times two
before positive tagged red blood cell scan localizing to the
upper GI tract. The patient on endoscopy of [**4-13**] was
noted to have a clot adherent to the medial wall of the
duodenum just distal to the bulb at the junction of the
second part of the duodenum in proximity to the ampulla. The
patient was injected and cauterized. Today surgical service
was called to see the patient, however, at that time the
patient's hematocrit was 30.2 and vital signs stable.
Subsequently, the patient became unstable with an hematocrit
of 13 and surgery was notified. In the intervening period, a
triple-lumen catheter was placed in the left side with
multiple attempts and again the surgery service was consulted
for access. Surgical house officers discussed the findings
and risks with the family who were cleared with their wishes
to proceed with the operation at this time. Because the
patient was unstable, the option for interventional radiology
was not recommended. The patient was resuscitated with blood
transfusions, intubated, access achieved and the patient
transferred urgently to the operating room.
Past Medical History:
Past Medical History:
c. diff
COPD
Asthma
S/p enterococcus urosepsis ([**12-3**]) c/b hypotension and ARF
BPH
PVD
Nonhealing LLE diabetic ulcer (+) pseudomonas [**Last Name (un) 36**] to gent,
zosyn, resistant to imipenem/meropen
DM-2
Peripheral neuropathy with burning pain
Nephropathy
CRI secondary to diabetic nephropathy, b/l Cr 1-1.5
CHF diastolic dysfunction
Echo ([**12-3**]) LVEF 50% without WMA
Chronic venous stasis
CAD
PMIBI (+) small reversible inferior reversible wall defect
Hx of pneumonia (aspiration)
PSH:
S/P DEBRIDEMENT LEFT LEG ULCER [**1-2**]
PICC line [**1-2**]
Social History:
resident of an assistated living complex
Family History:
unknown
Physical Exam:
confused but able to follow simple commands only
mucous membranes very dry, pale
crackles L>R (anterior and lateral only)
RRR, II/VI systolic murmur
soft TTP difusely slight distention, NABS, no HSM
no edema LLE wrapped with dressing c/d/i
Pertinent Results:
[**2145-4-5**] 09:57PM CK(CPK)-25*
[**2145-4-5**] 09:57PM CK-MB-NotDone cTropnT-0.04*
[**2145-4-5**] 01:00PM GLUCOSE-227* UREA N-29* CREAT-1.4* SODIUM-141
POTASSIUM-5.8* CHLORIDE-112* TOTAL CO2-20* ANION GAP-15
[**2145-4-5**] 01:00PM ALT(SGPT)-24 AST(SGOT)-28 LD(LDH)-311* ALK
PHOS-88 AMYLASE-100 TOT BILI-0.3
[**2145-4-5**] 01:00PM LIPASE-15
[**2145-4-5**] 01:00PM WBC-10.4 RBC-3.42* HGB-10.3* HCT-32.5* MCV-95
MCH-30.1 MCHC-31.6 RDW-17.6*
[**2145-4-5**] 01:00PM NEUTS-81* BANDS-17* LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2145-4-5**] 01:00PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2145-4-5**] 01:00PM PLT SMR-NORMAL PLT COUNT-151
[**2145-4-5**] 08:40AM GLUCOSE-262*
[**2145-4-5**] 08:40AM CK(CPK)-12*
[**2145-4-5**] 08:40AM CK-MB-NotDone cTropnT-0.03*
[**2145-4-5**] 02:37AM TYPE-ART TEMP-40.4 PO2-91 PCO2-38 PH-7.34*
TOTAL CO2-21 BASE XS--4
[**2145-4-5**] 02:31AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2145-4-5**] 02:31AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2145-4-5**] 02:31AM URINE RBC-1 WBC-[**4-3**] BACTERIA-RARE YEAST-FEW
EPI-1
[**2145-4-5**] 02:31AM URINE HYALINE-1*
[**2145-4-5**] 02:25AM cTropnT-0.04*
[**2145-4-5**] 02:23AM GLUCOSE-126* UREA N-25* CREAT-1.2 SODIUM-141
POTASSIUM-4.9 CHLORIDE-112* TOTAL CO2-18* ANION GAP-16
[**2145-4-5**] 02:23AM CK(CPK)-13*
[**2145-4-5**] 02:23AM CK-MB-NotDone
[**2145-4-5**] 02:23AM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-1.6
[**2145-4-5**] 02:23AM WBC-9.7 RBC-3.87* HGB-11.9*# HCT-36.4*#
MCV-94 MCH-30.8 MCHC-32.8 RDW-18.1*
[**2145-4-5**] 02:23AM NEUTS-80* BANDS-4 LYMPHS-11* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2145-4-5**] 02:23AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
TEARDROP-OCCASIONAL
[**2145-4-5**] 02:23AM PLT COUNT-180
[**2145-4-5**] 02:23AM PT-12.9 PTT-26.3 INR(PT)-1.0
[**2145-4-5**] 02:16AM LACTATE-1.7
CBC:
[**2145-4-5**] 02:23AM BLOOD WBC-9.7 RBC-3.87* Hgb-11.9*# Hct-36.4*#
MCV-94 MCH-30.8 MCHC-32.8 RDW-18.1* Plt Ct-180
[**2145-4-5**] 01:00PM BLOOD WBC-10.4 RBC-3.42* Hgb-10.3* Hct-32.5*
MCV-95 MCH-30.1 MCHC-31.6 RDW-17.6* Plt Ct-151
[**2145-4-6**] 06:01AM BLOOD WBC-8.5 RBC-2.76* Hgb-8.3* Hct-26.3*
MCV-95 MCH-30.2 MCHC-31.7 RDW-17.7* Plt Ct-163
[**2145-4-6**] 04:00PM BLOOD Hct-28.7*
[**2145-4-7**] 05:25AM BLOOD WBC-7.4 RBC-2.49* Hgb-7.4* Hct-23.7*
MCV-95 MCH-29.8 MCHC-31.2 RDW-17.8* Plt Ct-203
[**2145-4-7**] 11:46PM BLOOD Hct-28.0*
[**2145-4-8**] 03:31AM BLOOD WBC-7.5 RBC-3.10* Hgb-9.2* Hct-28.2*
MCV-91 MCH-29.6 MCHC-32.6 RDW-17.5* Plt Ct-191
[**2145-4-8**] 07:50AM BLOOD WBC-8.4 RBC-2.96* Hgb-9.0* Hct-27.1*
MCV-92 MCH-30.4 MCHC-33.1 RDW-17.7* Plt Ct-199
[**2145-4-8**] 01:51PM BLOOD Hct-24.0*
[**2145-4-9**] 06:51AM BLOOD WBC-7.6 RBC-3.71*# Hgb-11.0* Hct-32.9*#
MCV-89 MCH-29.6 MCHC-33.4 RDW-16.9* Plt Ct-164
[**2145-4-9**] 08:01PM BLOOD Hct-32.5*
[**2145-4-10**] 06:59AM BLOOD WBC-9.0 RBC-3.70* Hgb-10.9* Hct-32.7*
MCV-88 MCH-29.5 MCHC-33.4 RDW-17.3* Plt Ct-152
[**2145-4-10**] 11:30PM BLOOD Hct-31.3*
[**2145-4-11**] 06:22AM BLOOD WBC-8.4 RBC-3.62* Hgb-10.8* Hct-32.2*
MCV-89 MCH-29.9 MCHC-33.7 RDW-17.4* Plt Ct-150
[**2145-4-11**] 11:30PM BLOOD Hct-29.3*
[**2145-4-12**] 02:31AM BLOOD Hct-25.8*
[**2145-4-12**] 04:37AM BLOOD WBC-13.6*# RBC-3.13* Hgb-9.0* Hct-27.1*
MCV-87 MCH-28.9 MCHC-33.3 RDW-17.8* Plt Ct-166
[**2145-4-12**] 10:45AM BLOOD Hct-32.8*
[**2145-4-12**] 05:12PM BLOOD Hct-32.9*
[**2145-4-12**] 10:26PM BLOOD Hct-28.9*
[**2145-4-13**] 06:07AM BLOOD WBC-18.9* RBC-3.59* Hgb-11.0* Hct-30.6*
MCV-85 MCH-30.6 MCHC-35.8* RDW-17.3* Plt Ct-130*
[**2145-4-13**] 08:09AM BLOOD Hct-30.1*
[**2145-4-13**] 12:04PM BLOOD WBC-19.1* RBC-3.63* Hgb-11.2* Hct-30.2*
MCV-83 MCH-30.8 MCHC-37.0* RDW-15.8* Plt Ct-75*
[**2145-4-13**] 03:07PM BLOOD Hct-20.6*#
[**2145-4-13**] 05:04PM BLOOD Hct-13.2*#
[**2145-4-13**] 06:36PM BLOOD Hct-24.5*#
[**2145-4-13**] 11:00PM BLOOD Hct-25.9* Plt Ct-71*
[**2145-4-14**] 01:57AM BLOOD WBC-12.7* RBC-3.90* Hgb-11.3* Hct-32.8*#
MCV-84 MCH-29.0 MCHC-34.4 RDW-15.1 Plt Ct-68*
[**2145-4-14**] 05:49AM BLOOD WBC-13.4* RBC-2.91*# Hgb-8.4*# Hct-24.1*#
MCV-83 MCH-28.7 MCHC-34.6 RDW-15.3 Plt Ct-69*
[**2145-4-14**] 11:00AM BLOOD Hct-30.9*#
[**2145-4-14**] 03:41PM BLOOD Hct-25.8*
[**2145-4-14**] 07:16PM BLOOD Hct-26.5*
[**2145-4-14**] 10:59PM BLOOD Hct-25.3*
[**2145-4-15**] 05:14AM BLOOD WBC-14.5* RBC-3.39* Hgb-10.0* Hct-28.1*
MCV-83 MCH-29.4 MCHC-35.5* RDW-15.8* Plt Ct-124*
[**2145-4-15**] 10:00AM BLOOD Hct-31.9*
[**2145-4-16**] 02:55AM BLOOD WBC-18.9* RBC-4.33*# Hgb-12.6*# Hct-36.3*
MCV-84 MCH-29.2 MCHC-34.8 RDW-16.3* Plt Ct-113*
[**2145-4-16**] 05:15PM BLOOD Hct-35.1*
[**2145-4-16**] 08:58PM BLOOD WBC-14.5* RBC-4.20* Hgb-12.2* Hct-36.1*
MCV-86 MCH-29.1 MCHC-33.9 RDW-16.5* Plt Ct-87*
[**2145-4-17**] 03:37AM BLOOD WBC-16.5* RBC-4.51* Hgb-13.1* Hct-39.3*
MCV-87 MCH-29.1 MCHC-33.4 RDW-16.8* Plt Ct-115*
[**2145-4-18**] 04:10AM BLOOD WBC-15.6* RBC-4.22* Hgb-12.5* Hct-37.4*
MCV-89 MCH-29.7 MCHC-33.5 RDW-16.9* Plt Ct-117*
[**2145-4-18**] 10:48AM BLOOD WBC-14.8* RBC-4.10* Hgb-12.3* Hct-36.2*
MCV-88 MCH-29.9 MCHC-33.9 RDW-17.0* Plt Ct-108*
[**2145-4-18**] 03:49PM BLOOD WBC-14.8* RBC-4.33* Hgb-12.9* Hct-38.4*
MCV-89 MCH-29.7 MCHC-33.5 RDW-16.9* Plt Ct-102*
[**2145-4-19**] 02:53AM BLOOD WBC-15.4* RBC-4.28* Hgb-12.9* Hct-38.4*
MCV-90 MCH-30.1 MCHC-33.5 RDW-16.9* Plt Ct-114*
[**2145-4-20**] 02:47AM BLOOD WBC-15.5* RBC-4.00* Hgb-12.0* Hct-36.2*
MCV-90 MCH-30.1 MCHC-33.3 RDW-16.9* Plt Ct-114*
[**2145-4-20**] 08:30AM BLOOD WBC-14.6* RBC-4.10* Hgb-12.2* Hct-37.6*
MCV-92 MCH-29.8 MCHC-32.5 RDW-16.8* Plt Ct-114*
[**2145-4-21**] 01:47AM BLOOD WBC-14.8* RBC-4.19* Hgb-12.7* Hct-37.6*
MCV-90 MCH-30.2 MCHC-33.6 RDW-17.0* Plt Ct-141*
[**2145-4-21**] 05:48PM BLOOD Hct-38.4*
[**2145-4-22**] 02:22AM BLOOD WBC-14.5* RBC-3.88* Hgb-11.4* Hct-34.8*
MCV-90 MCH-29.3 MCHC-32.7 RDW-16.5* Plt Ct-125*
[**2145-4-23**] 03:17AM BLOOD WBC-14.9* RBC-3.10* Hgb-9.1* Hct-27.7*
MCV-89 MCH-29.4 MCHC-33.0 RDW-16.8* Plt Ct-135*
[**2145-4-23**] 04:55AM BLOOD Hct-27.7*
[**2145-4-23**] 08:52AM BLOOD Hct-31.0*
[**2145-4-23**] 02:14PM BLOOD Hct-28.9*
[**2145-4-23**] 05:56PM BLOOD Hct-31.3*
[**2145-4-23**] 08:00PM BLOOD WBC-23.0*# RBC-3.46* Hgb-10.3* Hct-31.0*
MCV-90 MCH-29.8 MCHC-33.3 RDW-16.3* Plt Ct-163
[**2145-4-24**] 12:02AM BLOOD Hct-29.8*
[**2145-4-24**] 04:00AM BLOOD WBC-21.0* RBC-3.17* Hgb-9.6* Hct-28.7*
MCV-90 MCH-30.3 MCHC-33.5 RDW-16.6* Plt Ct-161
[**2145-4-24**] 09:28AM BLOOD Hct-27.6*
[**2145-4-24**] 05:25PM BLOOD WBC-17.0* RBC-2.78* Hgb-8.0* Hct-25.0*
MCV-90 MCH-28.9 MCHC-32.1 RDW-16.3* Plt Ct-146*
[**2145-4-25**] 12:28AM BLOOD WBC-13.4* RBC-3.08* Hgb-9.2* Hct-27.8*
MCV-90 MCH-29.9 MCHC-33.2 RDW-15.9* Plt Ct-130*
[**2145-4-25**] 04:14AM BLOOD WBC-12.2* RBC-2.93* Hgb-8.8* Hct-26.5*
MCV-90 MCH-30.0 MCHC-33.2 RDW-16.1* Plt Ct-128*
[**2145-4-25**] 01:00PM BLOOD WBC-9.3 RBC-2.80* Hgb-8.5* Hct-25.3*
MCV-90 MCH-30.3 MCHC-33.6 RDW-16.1* Plt Ct-129*
[**2145-4-26**] 12:02AM BLOOD WBC-9.7 RBC-2.89* Hgb-8.6* Hct-26.7*
MCV-92 MCH-29.7 MCHC-32.3 RDW-16.2* Plt Ct-143*
[**2145-4-27**] 02:48AM BLOOD WBC-9.5 RBC-2.88* Hgb-8.6* Hct-26.9*
MCV-93 MCH-29.8 MCHC-31.9 RDW-16.1* Plt Ct-151
[**2145-4-28**] 01:30AM BLOOD WBC-11.7* RBC-3.03* Hgb-9.1* Hct-28.0*
MCV-92 MCH-29.9 MCHC-32.4 RDW-15.9* Plt Ct-198
[**2145-4-28**] 12:00PM BLOOD Hct-28.3*
[**2145-4-29**] 02:53AM BLOOD WBC-12.3* RBC-3.37* Hgb-10.1* Hct-31.8*
MCV-94 MCH-29.8 MCHC-31.6 RDW-16.2* Plt Ct-185
[**2145-4-30**] 03:15AM BLOOD WBC-18.8*# RBC-3.55* Hgb-10.6* Hct-33.3*
MCV-94 MCH-29.9 MCHC-31.9 RDW-16.9* Plt Ct-205
[**2145-5-1**] 02:57AM BLOOD WBC-12.7* RBC-3.21* Hgb-9.7* Hct-30.4*
MCV-95 MCH-30.2 MCHC-32.0 RDW-17.0* Plt Ct-190
[**2145-5-2**] 03:53AM BLOOD WBC-16.2* RBC-3.37* Hgb-10.2* Hct-31.5*
MCV-94 MCH-30.2 MCHC-32.3 RDW-16.6* Plt Ct-217
[**2145-5-3**] 03:06AM BLOOD WBC-14.1* RBC-2.93* Hgb-8.8* Hct-27.4*
MCV-94 MCH-29.9 MCHC-32.0 RDW-16.9* Plt Ct-205
[**2145-5-3**] 04:37PM BLOOD Hct-26.9*
[**2145-5-4**] 03:07AM BLOOD WBC-15.4* RBC-2.92* Hgb-8.5* Hct-26.9*
MCV-92 MCH-29.2 MCHC-31.8 RDW-16.5* Plt Ct-225
[**2145-5-5**] 03:10AM BLOOD WBC-9.9 RBC-3.34* Hgb-9.8* Hct-33.2*
MCV-100*# MCH-29.5 MCHC-29.6* RDW-16.1* Plt Ct-320
Brief Hospital Course:
HD 1([**4-5**]) Patient was admitted to [**Hospital1 139**] on medical service. He
was managed medically with an active problem list including: c.
diff- vanc and flagyl, COPD-nebs, CHF- secondary to flash
pulmonary edema tx with diuresis, steroid dependence-solumedrol,
diabetes, CRI
CXR:
1. Mild congestive heart failure, not significantly changed
since the prior examination.
2. Small bilateral pleural effusions.
3. Retrocardiac opacity which may represent
collapse/consolidation
HD 3 ([**4-7**])
Left upper extremity edema and swelling. A doppler did not show
any DVT.
Transfused 2units PRBC.
HD 4 ([**4-8**])
Tc-[**Age over 90 **]m bleeding scan showed no evidence of active
gastrointestinal bleed.
Transfused 4units PRBC.
EGD showed:
Oral secretions pooled in hypopharynx and valeculae. These
secretions were thick and difficult to suction. Most were able
to be suctioned from the region.
Atrophy and erythema in the antrum and stomach body compatible
with gastritis.
Ulcers in the distal bulb, posterior bulb and second part of the
duodenum.
Erosions in the second part of the duodenum.
Food in the middle third of the esophagus.
HD 8([**4-12**]) Patient was transferred to the MICU under
[**Last Name (LF) **],[**First Name3 (LF) 4514**] [**Doctor First Name **].
Transfused 2units PRBC.
EGD showed:
There was no blood seen in the intestine.
There was evidence of oral secretions in the hypopharynx and
valeculae.
Erythema in the duodenal bulb compatible with duodenitis.
Erosions in the second part of the duodenum and third part of
the duodenum.
A submucosal lesion suggestive of a lipoma was detected in the
3rd part of the duodenum.
Ulcers in the distal bulb, first part of the duodenum and second
part of the duodenum (thermal therapy).
EKG showed:
Wandering atrial pacemaker with rate approximately 60.
Generalized low voltage. Right bundle-branch block. Occasional
ventricular premature beats.
Non-specific repolarization changes. Cannot exclude old inferior
myocardial
infarction. Given low voltage and wandering atrial pacemaker, a
pericardial
process and/or pericardial effusion must be susepcted.
Consistent with this
view is considerable diminution in QRS voltage compared to the
previous
tracing.
CXR:
1) Placement of right internal jugular central venous catheter,
terminating in the right atrium. No pneumothorax.
2) Left lung base consolidation improving.
3) Bilateral pleural effusions; the left-sided effusion is
definitively smaller when compared to the prior exam.
HD 9 ([**4-13**])
Transfused 14 units PRBC. Platelets 7 units.
EGD: A large blood clot was noted in the distal bulb. There was
fresh red blood noted coming from the clot with pooling of red
blood in the dependant part of the duodenum. The clot seemed to
be adherant to the medial wall of the duodenum just distal to
the bulb at the junction to the 2nd part of the duodenum. This
appeared to be anatomically close to where the ampulla would be
expected to be. A total of 16 ml of Epinephrine 1/[**Numeric Identifier 961**]
injections were applied in multiple sites around the clot for
hemostasis with success. Lavage of the clot after the procedure
did not demonstrate any fresh red blood welling up in the
duodenum any more.
KUB: no free air
Repeat bleeding scan:
Active GI bleeding, abnormal tracer activity noted in the left
upper quadrant, most likely within the stomach or duodenum.
Patient was taken urgently to OR for:
1. Oversewing bleeding duodenal ulcer.
2. Antrectomy.
3. Loop gastrojejunostomy.
4. Placement of left-sided chest tube
Pathology showed would eventually show:
1. Area of marked edema of antral mucosa and submucosa with
prolapse into duodenum.
2. Brunner's gland hyperplasia consistent with chronic
duodenitis.
3. Unremarkable fundic-type mucosa at proximal margin.
4. Duodenal mucosa at distal margin.
5. No ulcer seen
HD 10 ([**4-14**])
Platelets: transfused 10units. Transfused 2units PRBC.
The patient is an 89-year-old
gentleman who went antrectomy and oversewing of a duodenal
ulcer. Prior to moving the patient to the ICU, an adhesive
pad was removed from his left arm. Given his history of
presumed steroids, this caused an avulsion of the skin on his
left arm with a J-shaped injury of approximately 6 cm. The
patient was still intubated and had not yet been moved. At
this time, the wound was prepped with Betadine and draped in
a sterile fashion. The wound was reapproximated with seven
interrupted 3-0 nylon sutures using a vertical mattress
suture. It came across easily and a sterile gauze dressing
was applied. The patient tolerated the procedure well.
There was no blood loss. No complications related to the
repair. I was present for all components of this procedure.
ECHO:The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is
dilated. Right ventricular free wall motion may be depressed.
The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
HD 11 ([**4-15**]) Transfused 2units PRBC.
HD 15 ([**4-19**]) Left lower extremity swelling and LENI showed:
1) Extensive thrombus involving the right common femoral,
superficial femoral, and popliteal veins.
2) Additional long segment thrombus involving the right common
femoral, superficial femoral, and deep femoral veins.
These findings were called to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who was caring
for the patient at the time of the exam, at 4:00 p.m. on
[**2145-4-19**].
The patient was started on a heparin drip.
HD 17 ([**4-21**])
the chest tube was taken out CXR did not show pneumothorax but
did show
unchanged layering right pleural effusion and small left basilar
pleural effusion. Minimal bibasilar atelectasis
HD [**4-23**] Transfused 1unit PRBC.
HD [**4-24**] Transfused 1unit PRBC.
HD 26 ([**4-30**])
CT to look for source of sepsis:
1) Small left pneumothorax and pleural effusion. Left-sided
chest tube appears somewhat kinked. Adjacent subcutaneous
emphysema. Moderate right pleural effusion.
2) Small amount of mesenteric fluid likely postoperative in
nature. No definite abscesses observed.
3) Stable left renal cyst.
4) Continued wall thickening of the rectum and sigmoid colon,
which is consistent with the patient's history of C. diff.
colitis.
HD 29 ([**5-3**]) Left foot films to r/o osteo:
The patient is in some form of supportive air filled boot. The
material associated with this obscures portions of the bone.
However, allowing for this, I can see the ulceration along the
posterior aspect of the calcaneus. No focal bone destruction or
focal lytic or sclerotic lesion in this area to confirm the
presence of osteomyelitis is identified. Moderately severe
diffuse osteopenia and IP joint degenerative changes are noted.
HD 30 ([**5-4**]) Patient was made DNR/DNI. This was confirmed with
family prior to order. Patient was extubated.
HD 31 ([**5-5**]) The patient died in early morning.
Medications on Admission:
albuterol
tylenol #3
bisacodyl
atrovent
vit D
zinc
prednisone
zocor
MVI
Lopressor
Monteleukant
calcium
docusate
Riss
prevacid
flovent
Discharge Medications:
does not apply
Discharge Disposition:
Expired
Discharge Diagnosis:
death
Discharge Condition:
dead
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2145-5-25**]
|
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|
18436, 18452
|
18505, 18512
|
18278, 18413
|
18564, 18568
|
2374, 2615
|
172, 194
|
452, 1667
|
1711, 2276
|
2292, 2334
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,117
| 148,588
|
44884
|
Discharge summary
|
report
|
Admission Date: [**2202-3-15**] Discharge Date: [**2202-3-25**]
Date of Birth: [**2117-3-5**] Sex: F
Service: MEDICINE
Allergies:
Gentamicin
Attending:[**First Name3 (LF) 14961**]
Chief Complaint:
Hypoxia, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 F with HTN, h/o PE [**2197**], chronic systolic and diastolic HF,
GERD who is a NH resident was diagnosed with PNA on night of
[**11-13**] and started on levaquin found to be in afib RVR this AM and
brought into ER at [**Hospital1 18**]. Patient is normally AOx3 per
conversation with HCP and is currently [**Name (NI) 96023**]. ROS is
unobtainable.
CXR in ER with RLL opacity. In the ER given 2L IVF, diltiazem 10
then gtt, vanco and levo.
Past Medical History:
Past Medical History
1. Chronic systolic and diastolic congestive heart failure, EF
50% per TTE [**4-/2198**]
2. Pulmonary embolus [**3-/2198**]
3. Hypertension
4. Gastroesophageal reflux disease
5. Meniere's disease
6. Distal radius fracture managed conservatively
.
Past Surgical History
1. Status post L3, L4, L5 decompressive lumbar laminectomy for
lumbar
spinal stenosis [**4-/2195**]
2. Status post jaw surgery for cyst removals - unknown date
3. Status post abdominal wall lipoma excision [**12/2194**], [**2-/2195**]
4. Status post breast lumpectomy for benign lesion - unknown
date
5. Status post right ear surgery [**2169**]
Social History:
Lives NH. 60 pack-year smoking history. Has been in nursing
facility for several months
Family History:
no fam h/o heart dz, although father died suddenly at age 37 due
to "heart problems" possibly associated with service in WWI, no
h/o abnl clotting
Physical Exam:
On Admission:
.
Vitals: T:97.6 BP:96/58 P:61 R:16 O2: 100% 2L
General: Alert, AAOx2
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, poor inspiratory
effort
CV: Irregular rhythm, tachycardic, 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
.
On Discharge:
.
Tachypnic, VS otherwise stable. aaox0, however will answer
questions and makes good eye contact. Lungs [**Name2 (NI) 96024**]
throughout, coarse upper airway sounds.
Cardiac rhythm is irregular, however normal rate. Abd with mild
tenderness. Exam otherwise unchanged from admission.
Pertinent Results:
On admission:
.
[**2202-3-15**] 04:15PM BLOOD WBC-17.1* RBC-3.46* Hgb-9.9* Hct-31.8*
MCV-92 MCH-28.6 MCHC-31.1 RDW-17.1* Plt Ct-322
[**2202-3-15**] 04:15PM BLOOD Glucose-192* UreaN-114* Creat-2.8*#
Na-140 K-4.9 Cl-100 HCO3-27 AnGap-18
[**2202-3-15**] 04:26PM BLOOD Glucose-176* Lactate-3.3* Na-142 K-4.6
Cl-99* calHCO3-27
.
On discharge:
[**2202-3-24**] 05:59AM BLOOD WBC-20.0* RBC-3.61* Hgb-10.2* Hct-33.4*
MCV-92 MCH-28.2 MCHC-30.5* RDW-17.4* Plt Ct-332
[**2202-3-24**] 05:59AM BLOOD Glucose-103* UreaN-20 Creat-0.9 Na-148*
K-4.0 Cl-115* HCO3-24 AnGap-13
[**2202-3-23**] 08:00AM BLOOD ALT-10 AST-19 LD(LDH)-262* AlkPhos-76
Amylase-36 TotBili-0.5
[**2202-3-24**] 05:59AM BLOOD Calcium-8.8 Phos-2.4*
.
Blood cxs pending on discharge, 2 sets negative, cdiff negative
.
Legionella negative
.
Urine cx: yeast
.
CXR [**3-15**]: Findings consistent with congestive heart failure.
.
CXR 4/07:1. Right hilar opacity, concerning for pneumonia.
Recommend followup to
resolution to exclude underlying mass.
2. Unchanged volume overload.
.
[**3-21**] CXR :Comparison is made to the previous study from [**2202-3-17**].
There is unchanged cardiomegaly.
There is interval increase in the bilateral pleural effusions,
left side worse than right. Consolidation in the lung bases
cannot be excluded. There is again seen some prominence of the
interstitial markings consistent with fluid overload which is
stable.
.
[**3-22**] KUB: No evidence of bowel obstruction.
.
[**3-24**] CXR: final read pending
Brief Hospital Course:
85 F with HTN, chronic systolic and diastolic HF, h/o PE
admitted with PNA and atrial fibrillation with RVR. During this
admission, goals of care discussion was held with family and
HCP, with plan to transition to hospice.
.
# Hypoxic respiratory failure- evidence of pneumonia on CXR, pt
was treated with vancomycin, levofloxacin and zosyn and
supportive care and respiratory status and oxygen sats initially
improved with treatment, however then pt developed pleural
effusions and increased work of breathing. CHF exacerbation was
thought to be less likely given that pt appeared clinically dry.
After discussion with the family and HCP, it was decided that
the pt would not want to have thorocentesis and request was made
for a focus on comfort.
.
# Atrial fibrillation with RVR- has biatrial enlargement on past
TTE. Suspect PNA as trigger for this. Patient initially started
on dilt gtt in the ICU setting, at most was on 15, but weaned
off on AM of [**3-16**], and restarted on PO metoprolol and diltiazem
with improved rate control. Anticoagulation was held after
discussion with the family out of concern for recurrent GI bleed
and focus on comfort.
.
# Acute renal failure- improved with volume repletion
.
# Delirium- likely due to PNA and afib RVR. She initially
improved with control of her afib and abx, however pleural
effusions developed and the pt became less responsive and less
interactive. Focus was switched to comfort.
.
# GERD- she was continued on her home PPI
.
# HTN- clonidine was held during the hospitalization and on
discharge given low BPs
.
# Psychiatric- meds were held given unclear indication.
.
# Code- DNR/DNI status was confirmed with HCP. Decision was
made to focus on comfort and transfer back to nursing facility
with hospice consult on arrival.
Medications on Admission:
Omeprazole 20 mg PO DAILY
Metoprolol tartrate 37.5mg PO TID
Calcium carb 500mg PO BID
Clonidine 0.3mg PO bid
Gabapentin 200mg PO TID
Duoneb Q6H while awake
Lidoderm patches to shoulder and toe
Spiriva daily
Trazodone 12.5mg PO daily
Bisacodyl supp daily
MOM
Albuterol prn
Aspirin 81 mg PO DAILY
Ritalin 2.5mg PO BID
Remeron 45mg PO daily
Mucinex 600mg PO daily
MVI daily
Tylenol prn
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Date Range **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Gabapentin 100 mg Capsule [**Date Range **]: Two (2) Capsule PO three times
a day.
3. Ipratropium Bromide 0.02 % Solution [**Date Range **]: One (1) Inhalation
Q6H (every 6 hours): while awake.
4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
[**Date Range **]: One (1) Inhalation once a day.
5. Diltiazem HCl 90 mg Tablet [**Date Range **]: One (1) Tablet PO QID (4
times a day).
6. Levofloxacin 250 mg Tablet [**Date Range **]: Three (3) Tablet PO DAILY
(Daily) for 7 days: Pt may refuse, do not force medication.
7. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO BID
(2 times a day).
8. Morphine 10 mg/5 mL Solution [**Date Range **]: One (1) ml PO q2-4 hrs as
needed for Pain or difficulty breathing.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Date Range **]: One (1) Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary: pneumonia, atrial fibrillation with rapid ventricular
response.
Secondary: GERD, hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 18**]. You were hospitalized for pneumonia and atrial
fibrillation with rapid ventricular response. You required a
stay in the ICU to help control your heart rate. You were
treated with antibiotics for the pneumonia and medications to
help control your heart rate. During the hospital stay, we had
a meeting with your family and the decision was made to
transition you back to your nursing facility with hospice.
.
Please take your medications as prescribed. The following
changes have been made to your medications:
1) Your metoprolol dose has been increased
2) You were started on diltiazem
3) You were provided with morphine for pain control
4) Your clonidine was discontinued
5) Start taking levofloxacin for 7 days
6) Several other non-essential medications were discontinued.
Please see your new medication list
Followup Instructions:
Please follow up with the doctors at your nursing facility. The
hospice team will also meet with you and your family on arrival.
|
[
"428.42",
"293.0",
"511.9",
"486",
"584.9",
"276.0",
"427.31",
"530.81",
"518.81",
"V12.51",
"V15.51",
"783.7",
"263.9",
"285.9",
"276.7",
"401.9",
"428.0",
"V66.7",
"386.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7362, 7434
|
4059, 5853
|
300, 307
|
7581, 7581
|
2548, 2548
|
8645, 8778
|
1562, 1712
|
6286, 7339
|
7455, 7560
|
5879, 6263
|
7717, 8622
|
1727, 1727
|
2886, 4036
|
232, 262
|
335, 781
|
2562, 2872
|
7596, 7693
|
803, 1440
|
1456, 1546
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,838
| 116,859
|
11779
|
Discharge summary
|
report
|
Admission Date: [**2114-1-2**] Discharge Date: [**2114-1-27**]
Date of Birth: [**2039-2-18**] Sex: F
Service: General Surgery
ADMITTING DIAGNOSIS: Chest pain.
DISCHARGE DIAGNOSIS: Chest pain, status post cardiac stent
complicated by retroperitoneal bleed with repair and
postoperative small bowel obstruction.
PROCEDURES:
1. Cardiac catheterization with stent of LAD.
2. Exploration and repair of right external iliac artery
laceration.
3. Re-exploration and repair of retroperitoneal bleeder.
HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old
female transferred to [**Hospital1 69**] on
[**2114-1-2**] with new onset angina. The patient was taken to the
cardiac catheterization lab on [**2114-1-3**] and was noted to have
an 80% stenosis of the mid LAD that was stented. The
procedure was complicated by a large retroperitoneal bleed
and the patient was taken emergently to the operating room,
underwent a right external iliac repair. Postoperatively the
patient had ongoing hypotension and transfusion requirement
and was taken back to the operating room for re-exploration
and repair of a retroperitoneal bleeder. She stabilized
hemodynamically. The patient was extubated on postoperative
day #6 and was transferred to the floor and required
aggressive pulmonary toilet. She started on Levo and Flagyl
for presumptive aspiration pneumonia. She was also noted to
have increased total bilirubin to 3.1, direct bilirubin to 2
and alkaline phosphatase to 496. A right upper quadrant
ultrasound showed gallbladder sludge but no stones. There
was no intra or extrahepatic ductal dilatation. Subsequently
the patient was noted to develop abdominal distention and
emesis as well as a white blood cell count of 15,000. On
[**1-14**] the patient underwent a CAT scan that showed a small
bowel obstruction and an NG tube was placed with 1-2 liters
output in 24 hours.
PAST MEDICAL HISTORY: 1) MI status post left circumflex
stent [**11-4**] with an EF of 50-55%.
PAST SURGICAL HISTORY: 1) Right total hip replacement. 2)
Hernia repair. 3) Appendectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Aspirin 325 mg po q d, Lopressor
12.5 mg po bid, Plavix - patient had completed course.
PHYSICAL EXAMINATION: The patient is afebrile, vital signs
are stable. She is confused and oriented only to person.
Heart is regular rate and rhythm. There are decreased breath
sounds at her bases bilaterally. Her abdomen is soft,
distended, nontender, her incision is clean, dry and intact.
Extremities are soft and warm, well perfused.
HOSPITAL COURSE: As noted in the history of present illness,
the patient was admitted on [**1-2**] and was taken to the cath
lab. She underwent a mid LAD stent and post procedure noted
to have a large retroperitoneal bleed. She was taken
emergently to the OR. This was repaired. The right external
iliac artery was repaired. She had ongoing hypotension and
transfusion requirement postoperatively. She was taken back
to the operating room for re-exploration and repair of a
retroperitoneal bleeder. Hemodynamically she stabilized and
was extubated on postoperative day #6. She was then
transferred to the floor and was started on Levo and followed
for presumptive aspiration pneumonia. Her LFTs were noted to
be elevated and right upper quadrant ultrasound only revealed
gallbladder sludge, no stones, no intra or extra hepatic
ductal dilatation. She subsequently developed abdominal
distention, emesis and a white blood cell count to 15,000.
CT scan on [**1-14**] showed distal small bowel obstruction and NG
tube was placed with approximately 2 liters output. The
patient was then transferred to the general surgery service
for further management. The patient's NG tube continued to
have high output. As the patient's urine output was low, she
was aggressively hydrated, she was kept npo, she was started
on Somatostatin. She was also started on a Heparin drip in
place of her Plavix for her cardiac stents. Her TPN was
continued. From a vascular standpoint the patient had an
essentially uneventful postoperative course as well. The
patient remained npo until she was noted to have some return
of bowel function at which time her diet was advanced, her
Heparin drip was stopped, she was started on her outpatient
cardiac meds. As she was tolerating this well and her
abdominal exam remained benign, it was decided that she would
be discharged to rehab on [**2114-1-27**] in stable condition.
DISCHARGE MEDICATIONS: Lopressor 12.5 mg po bid, Serevent
MDI 2 puffs [**Hospital1 **], Albuterol nebs q 4 hours prn wheezing,
Aspirin 325 mg po q d, Plavix 75 mg po q d to be taken
through [**2-4**], Haldol 1 mg po q h.s., Tylenol 650 mg po q 4-6
hours prn, Colace 100 mg po bid. The patient was told to
call Dr.[**Name (NI) 5695**] office for follow-up as well as to call
Dr.[**Name (NI) 10946**] office for follow-up and to call her
primary care doctor as well as her cardiologist for
follow-up. She was told to call or return for any questions
or problems.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2114-1-26**] 17:07
T: [**2114-1-26**] 19:54
JOB#: [**Job Number 37241**]
|
[
"599.0",
"996.62",
"507.0",
"V70.7",
"998.2",
"414.01",
"560.9",
"E870.6",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"36.01",
"54.0",
"37.23",
"96.07",
"96.72",
"39.31"
] |
icd9pcs
|
[
[
[]
]
] |
4538, 5353
|
204, 523
|
2616, 4514
|
2030, 2255
|
2278, 2598
|
552, 1909
|
169, 182
|
1932, 2006
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,552
| 105,459
|
48087+59059
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-12-29**] Discharge Date: [**2137-12-30**]
Date of Birth: [**2060-10-12**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The pt is a 77 y/o woman who presents with Headache and
Comatose. Pt has history of respiratory failure, A-fib on
Coumadin, HTN, Parkinson's. P/W Headache of abrupt onset around
4:30 pm. Was with daughter [**Name (NI) 8368**] who said she held her left
hand
to the left side of the head. Her daughter then stepped out for
a
bit and when she came back she was unresponsive. She called EMS
after unable to get her to respond. Headache was sudden onset.
no
symptoms before 4:30 per daughters report.
- came to ED and found to have extensive Left sided ICH. was
intubated in ED for airway protection. placed on propofol.
Neurosurgery consulted and no intervention on there side.
- Talked with HCP ([**Doctor First Name **]) and other daughter ([**Doctor First Name **]) who want
everything done at this moment. [**Name2 (NI) **] intubated and sedated
currently.
Past Medical History:
SLE, Parkinson's disease
Atrial fibrillation/aflutter
Paralysis agitans
Episodic hypertension during previous hospitalizations
H/O respiratory failure requiring tracheostomy placement
Tracheal and subglottic stenosis
Glaucoma, blind in R eye
Social History:
Patient lives at [**Hospital **] Rehabilitation and Nursing Center.
Denies any history of tobacco, alcohol, or illit drug use. She
is originally from [**Country **] and worked at [**Company 22916**] Corporation in
[**Location (un) 86**]. Daughters [**Name (NI) **] lives in [**Location 686**] and [**Doctor First Name **] in
[**Location (un) 101401**], FL.
Family History:
non-contributory
Physical Exam:
Vitals: T: P:70 R: 14 BP:129/90 (on Nicardipine gtt)
SaO2:100
intubated. BG 130's
General: sedated/ Intubated
PUlm: CTA b/l frontal fields
CV: Murmur at LUSB grade II
Abd: Soft.
Ext 1+ edema b/l with LE contracture at the ankles
Neuro: Intubated/ sedated on propofol. Not responding to sternal
rub or pinch at all 4 ext. Pupils Left is fixed at 4.5mm Right
is
4mm with hazy sclera. No movement noted. Reflexes not
appreciated
in lower upper extremities. No cough, no gag, no corneal, no
dolls eyes. toes mute
EXAM
T 98 P absent BP absent R 0
Brain death protocol was initiated and cranial nerves were
absent
and apnea test showed CO2 elevation. Test was performed by both
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD attending of record and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**], MD,
SICU attending.
Pupils 8mm b/l and non-reactive
No eye movement w/ cold calorics
Absent corneals
Gag absent
Cough absent
Pertinent Results:
[**2137-12-29**] 07:04PM TYPE-ART RATES-/14 TIDAL VOL-400 O2-100
PO2-196* PCO2-31* PH-7.49* TOTAL CO2-24 BASE XS-2 AADO2-495 REQ
O2-82 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-RECTAL TEM
[**2137-12-29**] 07:04PM GLUCOSE-160* LACTATE-1.5 NA+-140 K+-3.8
CL--105
[**2137-12-29**] 06:50PM GLUCOSE-164* UREA N-16 CREAT-0.8 SODIUM-143
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-23 ANION GAP-16
[**2137-12-29**] 06:50PM estGFR-Using this
[**2137-12-29**] 06:50PM LIPASE-34
[**2137-12-29**] 06:50PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.8
[**2137-12-29**] 06:50PM WBC-10.7 RBC-3.57* HGB-9.9* HCT-29.4* MCV-82
MCH-27.6 MCHC-33.6 RDW-14.5
[**2137-12-29**] 06:50PM NEUTS-85.7* LYMPHS-10.8* MONOS-2.3 EOS-0.9
BASOS-0.2
[**2137-12-29**] 06:50PM PT-25.9* PTT-32.2 INR(PT)-2.5*
[**2137-12-29**] 06:50PM PLT COUNT-215
[**2137-12-29**] 06:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2137-12-29**] 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-150
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2137-12-29**] 06:15PM URINE RBC-0-2 WBC-[**2-22**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2137-12-29**] 06:15PM URINE HYALINE-<1
[**2137-12-29**] 06:15PM URINE MUCOUS-FEW
Brief Hospital Course:
Patient was admitted with large left frontal intracerebral
hemorrhage with interventricular extension. She was intubated
and admitted to the neuro-ICU. By the following morning it was
noted that brainstem reflexes were absent. A brain death
protocol was performed and completed at 14:30 pm. Family were
present and the patient had ventilator stopped.
Patient expired at 14:30 on [**2137-12-30**].
Medications on Admission:
1. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q 8H (Every 8 Hours).
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for Constipation.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for Constipation.
12. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO QID (4 times a day) as needed for GI upset.
13. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q8H (every 8 hours).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
16. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
17. Pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO Q6 ().
18. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID
(twice daily).
19. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Follow INR with [**Hospital **] clinic.
20. Acetylcystein Neb 1-2mL PRN mucous plugging
21> Duoneb Q2HR:PRN SOB
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral hemorrhage - expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2138-1-1**] Name: [**Known lastname 16305**],[**Known firstname **] M Unit No: [**Numeric Identifier 16306**]
Admission Date: [**2137-12-29**] Discharge Date: [**2137-12-30**]
Date of Birth: [**2060-10-12**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1886**]
Addendum:
Her head CT scan showed a large left frontal ICH with IVH,
significant midline shift & herniation. Of course, these
findings were clinically significant & resulted in her death.
Discharge Disposition:
Expired
[**Name6 (MD) **] [**Last Name (NamePattern4) 1887**] MD, [**MD Number(3) 1888**]
Completed by:[**0-0-0**]
|
[
"348.4",
"427.32",
"401.9",
"V58.61",
"348.89",
"710.0",
"E934.2",
"369.60",
"365.9",
"332.0",
"430",
"427.31",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7335, 7480
|
4143, 4542
|
336, 348
|
6532, 6541
|
2907, 4120
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6597, 7312
|
1895, 1913
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6413, 6422
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6475, 6511
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4568, 6390
|
6565, 6574
|
1928, 2888
|
269, 298
|
376, 1238
|
1260, 1504
|
1520, 1879
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,371
| 199,595
|
50721
|
Discharge summary
|
report
|
Admission Date: [**2143-12-23**] Discharge Date: [**2143-12-30**]
Date of Birth: [**2096-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Mr. [**Known lastname 1683**] is a 47yo man with DM on insulin, EF 50%, CRI who
presented to the ER with hyperglycemia to 742 in setting of
missing his insulin dose. He has had frequent admissions for
DKA. He was recently admitted to [**Hospital1 18**] from [**Date range (1) 82097**]/06 with
chest pain and DKA. At that time he was diagnosed with [**Female First Name (un) **]
esophagitis. He also was noted to have acute angle glaucoma and
underwent several ophthalmalogic procedures. He denies F/C/S,
N/V, diarrhea, constipation. He had some mild abdominal pain
yesterday which has now resolved. He denies CP, SOB, cough, and
dysuria.
.
When asked about his home insulin regimen, he states that he
missed one dose of long acting insulin. He recalls his regimen
as NPH 1U qam and 14U qpm. His actual regimen as of last d/c
was lantus 30U qam. He also does not recall any of his other
home medications.
.
In the ED he was noted to have an AG of 28. Urine or serum
ketones were not sent. UA was negative for infection, and CXR
was also negative for pneumonia. He was started on an insulin
gtt and given IV hydration.
Past Medical History:
# HTN
# Insulin dependent DM
- has had multiple admissions for DKA in setting EtOH use
- last HgbA1C 7.6 ([**2143-10-31**])
- has peripheral neuropathy, retinopathy
# CRI - thought to be due to diabetic and hypertensive
nephropathy
# Sarcoid
- CT [**6-/2129**] = hilar/subcarinal [**Doctor First Name **], nodules in parenchyma
- [**1-/2134**] = L eye proptosis -> CT showed L maxillary mass -> bx
showed non caseating granulomas c/w sarcoid
- decision was made not to begin systemic tx since pt asx
# H/o Chronic RUQ pain
- Present for over 13 yrs (by [**Hospital1 18**] records), evaluated with at
least 12 abdominal/RUQ ultrasounds and multiple abdominal CT's
without evidence of suspicious pathology
# Polysubstance abuse
- Pt drinks regularly 2-3drinks daily; occasionally uses cocaine
(last use many weeks ago)
Social History:
Lives w/ a friend, no children. Works part time as a
tire-changer. Denies tobacco use. Denies recent EtOH or
cocaine use (per report daily EtOH use in past).
Family History:
Mother had diabetes, niece has diabetes. Denies FH of coronary
artery disease, hypertension, cancer, liver disease, or renal
disease.
Physical Exam:
VS: 97.7, 152/63, 92, 24, 98% on RA
Gen: Middle aged man in no apparent distress
HEENT: Patch over L eye. Marked conjunctival injection of L
eye. MM slightly dry. OP clear
Neck: No JVD, no LAD.
Cor: RRR, II/VI systolic murmur at base.
Pulm: CTAB
Abd: +BS, soft, NT/ND
Ext: no edema
Skin: no rash
Pertinent Results:
[**2143-12-23**] 11:25PM GLUCOSE-134* UREA N-50* CREAT-3.3* SODIUM-140
POTASSIUM-4.0 CHLORIDE-117* TOTAL CO2-13* ANION GAP-14
[**2143-12-23**] 11:25PM CALCIUM-8.3* PHOSPHATE-3.7 MAGNESIUM-1.8
[**2143-12-23**] 11:25PM WBC-6.9 RBC-3.32* HGB-10.0* HCT-30.8*#
MCV-93# MCH-30.1 MCHC-32.5 RDW-13.3
[**2143-12-23**] 11:25PM PLT COUNT-254
[**2143-12-23**] 04:43PM GLUCOSE-75 UREA N-52* CREAT-3.5* SODIUM-142
POTASSIUM-3.5 CHLORIDE-116* TOTAL CO2-15* ANION GAP-15
[**2143-12-23**] 04:43PM CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2143-12-23**] 04:43PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-12-23**] 03:01PM URINE HOURS-RANDOM
[**2143-12-23**] 03:01PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2143-12-23**] 12:55PM GLUCOSE-332* UREA N-53* CREAT-3.6* SODIUM-139
POTASSIUM-3.6 CHLORIDE-112* TOTAL CO2-15* ANION GAP-16
[**2143-12-23**] 12:55PM CALCIUM-8.6 PHOSPHATE-3.8# MAGNESIUM-2.0
[**2143-12-23**] 11:15AM GLUCOSE-415* K+-3.7
[**2143-12-23**] 10:39AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2143-12-23**] 10:39AM URINE BLOOD-TR NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2143-12-23**] 10:39AM URINE RBC-0-2 WBC-0-2 BACTERIA-0 YEAST-NONE
EPI-0
[**2143-12-23**] 10:03AM GLUCOSE-547* UREA N-51* CREAT-3.7* SODIUM-136
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-10* ANION GAP-24*
[**2143-12-23**] 10:03AM CALCIUM-8.7 PHOSPHATE-5.5* MAGNESIUM-2.1
[**2143-12-23**] 08:09AM GLUCOSE-556*
[**2143-12-23**] 08:00AM GLUCOSE-642* UREA N-52* CREAT-3.7*
SODIUM-131* POTASSIUM-7.6* CHLORIDE-103 TOTAL CO2-6* ANION
GAP-30*
[**2143-12-23**] 07:16AM GLUCOSE-613* K+-4.3
[**2143-12-23**] 05:46AM PO2-122* PCO2-13* PH-7.08* TOTAL CO2-4* BASE
XS--24
[**2143-12-23**] 05:46AM GLUCOSE-737* LACTATE-2.1* NA+-132* K+-5.1
CL--106
[**2143-12-23**] 05:46AM freeCa-1.29
[**2143-12-23**] 05:25AM GLUCOSE-742* UREA N-49* CREAT-3.7* SODIUM-133
POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-6* ANION GAP-33*
[**2143-12-23**] 05:25AM WBC-8.5 RBC-4.18*# HGB-12.7*# HCT-42.2#
MCV-101*# MCH-30.4 MCHC-30.1* RDW-13.0
[**2143-12-23**] 05:25AM NEUTS-77* BANDS-0 LYMPHS-17* MONOS-4 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2143-12-23**] 05:25AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2143-12-23**] 05:25AM PLT SMR-NORMAL PLT COUNT-307
[**2143-12-23**] 05:25AM PT-13.1 PTT-35.4* INR(PT)-1.1
Brief Hospital Course:
ICU course:
DKA: Pt was admitted to the ICU for hydration and controll of
his hyperglycemia. He was started on an insulin drip and his
FSBS normalized. The drip was discontinued and pt was placed on
a sliding scale of insulin. He was not tolerating po well and
his sugars rised. He was placed back on an insulin drip. On
HOD #2 the drip was again discontinued and the patient began
taking a regular diet. He was then transfered to the floor.
Floor course:
47yo man with DM presents with DKA and initial AG of 28.
Transferred to floor when gap closed.
<I>## DKA/DM2:</I> Likely exacerbant appears to be medication
noncompliance. UA negative for signs of infection. CXR without
sign of infection. EKG without ischemic changes. No culture data
sent, afebrile with no leukocytosis. Aggressively hydrated in
the unit and maintained on insulin drip, then long-acting.
Followed by [**Last Name (un) **]. Havin difficulty with hypoglycemia. In
setting of difficult IV access, will loosen reins on tight
control. [**Last Name (un) **] followed while in-house. Recommended pt get 15
units of 75/25 in am and 8 units with dinner. Nursing attempted
to teach pt and his girlfriend how to use insulin, but did not
feel as though either of them could appropriately administer
insulin. Rather than stay and wait for possible VNAS help, the
pt signed out against medical advice. He was also continued on
his ACE inhibitor.
<I>## Ophthalmologic issues:</I> On last admission, had acute
angle glaucoma and underwent avastin treatment, as well as L
cataract removal, endocyclophotocoagulation, vitrectomy,
membranectomy, and retinal endolaser tx on [**2143-12-13**]. He was
continued on his eye drops.
<I>## Acute on chronic renal failure:</I> Baseline Cr 3.5, up to
~4 on admission. Likely [**3-14**] volume depletion, but does not
represent a large drop in GFR.
<I>## Metabolic acidosis:</I> No gap. Likely RTA, as pt has no
diarrhea. Most likely is a mixed RTA. Pt has no IV access, so
diagnostic trial of sodium bicarb will be difficult.
<I>## [**Female First Name (un) 564**] esophagitis:</I> Discharged on fluconazole from
last admission. Completed course here.
<I>## Gastritis/Barretts/duodenal bulb erosions:</I> Noted on
EGD last admission. Currently asymptomatic. Conitnued [**Hospital1 **] PPI
<I>## Diastolic dysfunction with h/o CHF:</I> Relatively
preserved EF of 40-45%. On previous admission developed fluid
overload during aggressive fluid resuscitation for DKA. No
evidence of volume overload currently. Continued outpt
diuretics.
<I>## Anemia:</I> Hct 42 admission, which is far above baseline.
Was hemoconcentrated. Slightly below baseline of ~30, likely
[**3-14**] CKD.
Medications on Admission:
1. Aspirin 325 mg daily
2. Atorvastatin 80 mg daily
3. Pantoprazole 40 mg Q12H
4. Nifedipine 90 mg daily
5. Labetalol 400 mg TID
6. Furosemide 40 mg daily
7. Calcium Acetate 1334 mg TID W/MEALS
8. Albuterol 1-2 puffs q4h prn
9. Acetazolamide 250 mg Q6H
10. Fluconazole 100 mg daily for 6 days (to finish [**12-24**])
11. Scopolamine HBr 0.25 % 1 Drop QID to left eye.
12. Tobramycin-Dexamethasone 0.3-0.1 % 1 Drop QID to left eye.
13. Apraclonidine 0.5 % 1 Drop QID to left eye.
14. Dorzolamide-Timolol 2-0.5 % 1 Drop QID to left eye.
15. Latanoprost 0.005 % 1 Drop HS to left eye.
16. Tobramycin-Dexamethasone 0.3-0.1 % Ointment 1 Appl QHS to
left eye.
17. Insulin Glargine 30U qAM.
18. Humalog sliding scale qachs as directed
19. Epoetin Alfa 3,000 unit/mL QMOWEFR
(Monday-Wednesday-Friday).
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
6. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One
(1) Drop Ophthalmic QID (4 times a day).
7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
8. Epoetin Alfa 3,000 unit/mL Solution Sig: 3000 (3000) Units
Injection QMOWEFR (Monday -Wednesday-Friday).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
11. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
12. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25) Insulin
Pen Sig: Twenty Five (25) Units Subcutaneous twice a day: Please
take 25 units in the morning and 25 units with dinner.
Disp:*qs qs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperglycemia [**3-14**] missed insulin dose
Secondary:
- HTN
- DM2, on insulin
- CKD (baseline Cr 3.5)
- Sarcoid with hilar LAD and maxillary involvement
- Polysubstance abuse
- h/o CHF with preserved EF (EF 40-45%)
Discharge Condition:
Stable, ambulatory
Discharge Instructions:
Please return to the hospital or call your PCP if you experience
chest pain, shortness of breath, fevers.
Please take all of your medications as prescribed. We have
changed your insulin schedule. You will now take 15 units of
75/25 mix in the morning and 8 units at bedtime of a 75/25 mix.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2144-1-7**] 7:20
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2144-2-26**] 9:00
|
[
"276.51",
"272.0",
"112.84",
"250.13",
"585.9",
"365.22",
"285.9",
"428.30",
"428.0",
"584.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10495, 10501
|
5520, 8210
|
321, 328
|
10763, 10784
|
2995, 5497
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10808, 11101
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278, 283
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356, 1491
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1513, 2331
|
2347, 2509
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,029
| 170,462
|
32269+57794+57795
|
Discharge summary
|
report+addendum+addendum
|
Unit No: [**Numeric Identifier 75437**]
Admission Date: [**2145-10-18**]
Discharge Date: [**2145-11-19**]
Date of Birth: [**2071-3-19**]
Sex: F
Service: VSU
CHIEF COMPLAINT: Mesenteric ischemia.
HISTORY OF PRESENT ILLNESS: This is a 74-year-old female who
presented to [**Hospital6 3105**] on [**2145-9-23**]
with complaints of weakness, weight loss, cough, fever,
chills, dyspnea and low back pain. She had an extensive
workup which is most pertinent for SMA and celiac stenosis
with a coral reef plaque, aortic stenosis with right renal
occlusion by MRI. Diagnostic studies during that
hospitalization included a VQ scan on [**9-24**] which was
negative but the d-dimer was positive. A transthoracic
echocardiogram on [**9-24**] showed an ejection fraction of
55% with mild diastolic dysfunction, no valvular disease, no
PFO. A TEE was done on [**9-29**] which showed normal left
and right ventricular function, no valvular disease, trace of
pericardial effusion, negative bubble study. A right pleural
effusion which was tapped on [**9-29**] was sterile
transudate. A temporal artery biopsy on [**10-4**] was
negative. A right renal cyst aspiration on [**10-6**].
On admission to our institution, the patient states she has
been having abdominal pain but this has subsided after she
got Visicol suppository and Lactulose. She states that until
today she has not had a bowel movement for one week. She
denies any nausea, emesis, bright red rectal bleeding,
melena. She denies fever, chills, dyspnea, chest pain at
present. She does acknowledge periprandial pain and weight
loss of 15 pounds over months.
PAST MEDICAL HISTORY:
1. Hiatal hernia.
2. Acute renal failure, end-stage disease on hemodialysis.
Last dialysis was [**2145-10-18**]. SP right IJ
tunnel catheter placement.
1. Anemia.
2. Congestive heart failure.
3. Diastolic dysfunction.
4. Restrictive lung disease by PFT's.
5. History of hypertension controlled.
6. History of positive PPD.
7. History of DVT remote with pulmonary embolus in [**2097**]'s.
8. History of diverticulosis.
9. History of sero negative polyserositis.
10.History of acute renal failure.
11.History of hiatal hernia.
12.History of GERD.
PAST SURGICAL HISTORY:
1. Bilateral lower extremity vein ligation in [**2101**].
2. Cardiac catheterization in [**2132**] which was negative per
patient.
3. Bilateral cataract surgeries in [**2136**] and [**2137**].
4. Last colonoscopy was in [**2143**] which was normal per
patient.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER:
1. Lasix.
2. Amlodipine.
3. Labetalol.
4. Xopenex.
5. Atrovent.
6. Vicodin.
7. A recent course of azithromycin.
FAMILY HISTORY: Mother died of colon cancer at age 65.
Brother died of heart disease in the 50's. Six healthy
children.
SOCIAL HISTORY: Denies tobacco, wine with dinner every
night. She is retired for two years from working as a health
care administrative assistant.
PHYSICAL EXAMINATION: Vital signs 98.6, 70, 20, O2 sat 95%
on room air. Blood pressure 118/52. General appearance: Thin
female sitting in bed in no acute distress. HEENT exam is
unremarkable. Trachea is midline. Neck is soft without
lymphadenopathy. Cardiac: Regular rate and rhythm without
murmur, gallop or rub. Lungs are clear to auscultation
bilaterally. Abdominal exam is unremarkable except for some
mild voluntary guarding in the right lower quadrant. No
hernias, abdominal bruits noted. Peripheral vascular: She has
bilateral pedal edema, left greater than right. Feet are warm
without ulceration. Pulses are palpable femorals, popliteals,
DP and PT's bilaterally. Neurologic exam is appropriate,
nonfocal.
LABORATORY DATA: Admitting labs were lactate 1.9, BUN 14,
creatinine 1.7, K 3.5, ALT, AST are normal. Amylase was 83,
lipase 45, LDH 280, total bili 0.9, albumin 3.3. White count
14.5, hematocrit 39.9, platelets 138,000. Diff 90
neutrophils, lymphocytes 6.4, monos 3.1, eos 0, basos 0.1.
Coags were normal.
HOSPITAL COURSE: The patient was admitted to the vascular
service. Renal was consulted for any hemodialysis needs. At
the time, they felt that the patient was stable from a renal
standpoint and they would continue to monitor her renal
function and electrolytes to determine whether further
dialysis was required. The patient received surgery on
[**10-26**]. She underwent an open aortic visceral
endarterectomy with primary closure. She was transferred to
the PACU, become hypotensive, returned to the surgical suite.
She was reopened and explored. There was no source of
bleeding or source for the hypotension. The patient remained
intubated, was transferred from the PACU to the ICU. The
patient remained in the ICU and was extubated on [**10-28**]
and was transferred to VICU for continued monitoring and
care. The patient's chest tube was placed to water fill on
[**10-29**] and this was removed on [**2145-10-31**]. The
patient experienced episodes of MAT, requiring amiodarone and
labetalol for rate suppression. She also required IV
nitroglycerin and beta blockers for her hypertension. Her CVL
was placed. Iatrogenic pneumothorax, requiring a chest tube.
The patient's diet was advanced on [**10-30**] and she was
delined at that time. A steroid wean was begun on [**10-31**].
Oncology was consulted for initial findings of an
angiosarcoma by pathology. The chest tube was removed 24
hours after water fill. The post chest tube x-ray was without
pneumothorax. It was oncology's recommendation that no
further is recommended at this time. No radiation or
chemotherapy at this time unless the patient has recurrence.
On [**11-2**], C. dif for stool was sent. The results on
[**11-3**] were positive. Flagyl was begun. The patient was
converted to p.o. vancomycin on [**11-4**]. The patient
experienced an episode of hypotension secondary to
hypovolemia secondary to diarrhea. The patient was fluid
resuscitated and transferred to the VICU for continued
monitoring and care. Because of need for further pressor
support for her hypotension, the patient underwent a CT scan
which showed a large left psoas muscle hematoma. It was
determined no intervention at this time. Her C. dif was
treated with antibiotics, vanco and Flagyl. Platinum service
was consulted and felt that she did not have an acute abdomen
at this time and that they would not do anything unless
clinically indicated, then consider colonoscopy. The
patient's symptoms improved over the next 48 hours. She
continued to be followed by the renal service. She was
continued on TPN. The patient continued with the sero exams,
TPN and NPO. The patient finally passed flatus on [**2145-11-9**] and without diarrhea. KUB did not show any
obstruction and resolving ileus. The patient was begun on
sips on [**2145-11-10**].
Abdominal exams continued to improve. There was no tenderness
noted. Clears were started on [**2145-11-11**]. The patient
tolerated that. Her abdominal exam remained stable. She
continued to be followed by physical therapy who recommended
continue current management and she would require rehab at
the time of discharge. Her line was changed on [**2145-11-12**] resulting in a pneumothorax requiring chest tube
placement. Right IJ tunnel catheter was removed on [**2145-11-12**]. Chest tube went to water seal on [**2145-11-13**].
Chest tube was removed on [**2145-11-16**]. On [**2145-11-14**], the patient passed flatus and stool. KUB showed
resolution of ileus. Diet was advanced which the patient
tolerated. TNP
was discontinued on [**11-16**] and the patient was
transferred to regular floor status. Rehab screening was
instituted and physical therapy continued to work with the
patient. On [**2145-11-17**], it was anticipated that the
patient would be discharged to rehab but her AM labs showed a
potassium of 2.3. The potassium was repleted. Repeat
potassium this morning on [**11-18**] was 3.5. She was
repleted again. PM potassium and hematocrit will be checked.
If those are stable, the patient will be discharged to rehab
for continued care.
The remaining discharge summary will be dictated at the time
of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2145-11-18**] 13:35:42
T: [**2145-11-18**] 17:34:15
Job#: [**Job Number 75438**]
Name: [**Known lastname 12385**],[**Known firstname 6709**] K Unit No: [**Numeric Identifier 12386**]
Admission Date: [**2145-10-18**] Discharge Date: [**2145-11-19**]
Date of Birth: [**2071-3-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
patient was d/c to rehab on [**2145-11-19**] stable tolerating po's. off
antibiotics.
Major Surgical or Invasive Procedure:
aortic endartectomy, of rt. renal,SMA,celiac arteries [**2145-10-26**]
right ct placed [**2145-10-26**], d/c'd [**2145-10-29**]
left chest tube placed [**2145-11-13**],d/c'd [**2145-11-15**]
left cvl placement [**2145-11-13**]
right IJ tunell cath d/c'd [**2145-11-15**]
Medications on Admission:
see d/c summary
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic [**Hospital1 **] ().
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
PRN (as needed).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
6. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4-6H () as
needed.
10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 4415**]
Discharge Diagnosis:
aortic stenosis with SMA,[**Last Name (un) 12387**] occlusion and rt. renal artery
stenosis
high grade aortic sarcoma
acute renal failure,s/p rt. IJ hemodialysis access catheter
placement
history of hiatal hernia
history of anemia
history of diastolic CHf
history of restrictive lung disease
history of positive PPD
history of DVt with pulmonary embolism
history of diverticulisis
history of seronnegative polyserositis
history of bilateral vein lligations [**2101**]
history of cardiac cath [**2132**], negative for CAD
history of catracts,s/p OU catract surgery [**2136**],[**2137**]
history of GERD
history of left renal cyst ,s/p aspiration [**9-5**]
history of rt. pleural effusion s/p thorcentesis [**9-5**]
s/p left temporal artery bx [**10-6**]
RML nodual with T/L spine leshions by CT scan
postop proxsimal AF converted with amidarone gtt and lopressor
postop retropertoneal hematoma, contained-left
postop blood loss anemia-transfused
postop left PTZ secondary to line placement,s/p chest tube
placement
postop ileus
postop c diff-treated
Discharge Condition:
stable
Discharge Instructions:
call if any questions
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **]. Call his office at
[**Telephone/Fax (1) 236**] to set up an appointment.
You need repeat imaging with a PET/CT and/or MRI for evaluation
of lesions found in your spine on CT imaging.
Provider: [**First Name8 (NamePattern2) 7209**] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1578**]
Date/Time:[**2145-11-22**] 11:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1578**]
Date/Time:[**2145-11-22**] 11:00
Please follow up with Dr. [**Last Name (STitle) 12388**] on [**11-29**] at 11:15AM at
his [**Hospital6 11271**] office. Phone: [**Telephone/Fax (1) 12389**]. Fax
[**Telephone/Fax (1) 12390**].
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2145-11-19**] Name: [**Known lastname 12385**], [**Known firstname 6709**] K
Unit No: [**Numeric Identifier 12386**]
Admission Date: [**2145-10-18**]
Discharge Date: [**2145-11-19**]
Date of Birth: [**2071-3-19**]
Sex: F
Service: VSU
ADDENDUM
DISCHARGE DIAGNOSIS: Aortic stenosis semiocclusion was
celiac stenosis, status post esophagogastroduodenoscopy on
[**9-/2145**], renal artery stenosis, high-grade sarcoma aortic
mass, acute renal failure status post hemodialysis, status
post right internal jugular hemodialysis catheter access,
history of hiatal hernia, history of anemia--transfused,
history of congestive heart failure--diastolic, history of
restrictive lung disease, history of positive PPD, history of
hypertension, history of DVT with pulmonary embolus in the
[**2097**], history of diverticulosis, history of seronegative
polyserositis, history of vein ligations in [**2101**]--bilateral,
history of cardiac catheterization in [**2132**]-- negative for
coronary artery disease, history of cataracts status post
cataract surgery bilaterally in [**2136**] and [**2137**], history of
hiatal hernia, gastroesophageal reflux disease, history of
renal cyst left status post aspiration [**9-/2145**], history of
right pleural effusion status post thoracentesis [**9-/2145**],
status post left temporal artery biopsy [**9-/2145**], right middle
lobe nodule with thoracolumbar spine lesions on CT scan of
[**9-/2145**], postoperative paroxysmal atrial fibrillation
converted with amiodarone and Lopressor, postoperative
retroperitoneal hematoma--contained, postoperative blood loss
anemia--transfused, postoperative left pneumothorax secondary
to subclavian line placement, status post CT, chest tube
placement, postoperative ileus resolved, postoperative
Clostridium difficile infection--treated.
MAJOR PROCEDURES: Aortic endarterectomy with renal superior
mesenteric artery and celiac artery endarterectomies right
renal with primary closure on [**2145-10-26**] with immediate
reopen for hypotension with a negative lap on [**2145-11-25**],
right chest tube placement on [**2145-11-25**] and removal
[**2145-10-30**], left chest tube placement on [**2145-11-13**] and
discontinued on [**2145-11-15**], left subclavian placement on
[**2145-11-13**], discontinued right internal jugular hemodialysis
tunnel catheter on 12/[**2144**].
DISCHARGE INSTRUCTIONS: Please call our office if there are
any questions. Her vancomycin and Flagyl should be continued
until the patient is seen in follow-up in 2 weeks with Dr.
[**Last Name (STitle) **]. Please call for an appointment at ([**Telephone/Fax (1) 5218**].
The patient should have weekly CBCs while still on her
vancomycin and Flagyl. Please call our office if she develops
any elevation in her white count. Please follow up with her
physician in [**Name9 (PRE) **] for a PET CT or MRI to evaluate the
spine lesions found on CT imaging. She should follow up with
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1718**] of Oncology on [**2145-11-22**] at 11:00, and
follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] on the same date at
11:00. She should follow up with Dr. [**Last Name (STitle) 12388**] [**11-29**] at
11:15 at his [**Hospital6 11271**] office.
DISCHARGE MEDICATIONS: Aspirin 81 mg daily, cyclosporin
0.05% drop eye b.i.d., camphor/menthol lotion to affected
areas as needed, calcium carbonate 500 mg tablets 1 b.i.d.,
Miconazole nitrate powder q.i.d. to affected areas, Hep-Lock
flush 100 units/cc 1 cc daily and as needed, atorvastatin 10
mg daily, pentamidine 20 mg daily, hydromorphone 4 mg tablets
q. 4-6h. p.r.n., Reglan 5 mg before meals and at bedtime,
metoprolol 37.5 mg t.i.d., vancomycin 250 mg capsules q. 6h.
for 14 days, albuterol sulfate 0.083% solution 1 inhalation
q. 6h. as needed, ipratropium bromide 0.02% solution 1
inhalation q. 6h. as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 10055**]
Dictated By:[**Last Name (NamePattern1) 5143**]
MEDQUIST36
D: [**2145-11-18**] 13:50:55
T: [**2145-11-20**] 09:08:29
Job#: [**Job Number 12391**]
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3,792
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43345
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Discharge summary
|
report
|
Admission Date: [**2206-10-5**] Discharge Date: [**2206-10-11**]
Date of Birth: [**2147-6-23**] Sex: M
Service: MEDICINE
Allergies:
Lovenox / Keflex
Attending:[**Last Name (un) 11974**]
Chief Complaint:
VT storm
Major Surgical or Invasive Procedure:
Ventricular Tachycardia ablation
History of Present Illness:
59yoM with nonischemic cardiomyopathy (EF 35% in [**7-12**]), s/p
BiV/ICD device in [**12/2199**] with recent admission for firing in
[**7-12**], chronic afib on dabigatran, HTN, pulm HTN, CKD who
presents with increasing frequency of ICD firing, having gone
off 9 times today, 14 times total in past 1.5 weeks. First
episode of was about 1.5 weeks ago, was seen in clinic 6 days
ago and things settled down by then. Yesterday was at bed bath
and beyond when received first shock and has been going in and
out of VT storm since. Pt denies any chest pain or shortness of
breath, however right before he gets shocked he experiences
feelins of heartburn, jaw pain, diaphosesis and palpitations. He
does not have any sx of heart failure despite recent decrease in
torsemide from 40->30 mg/daily and aldactone 25mg -->12.5 mg.
Volume status is euvolemic currently.
.
He was recently admitted to the hospital in [**2206-7-2**] for an
increasing frequency of symptomatic ventricular tachycardia
noted on device interrogations. It was noted that he was on
Amiodarone 200mg daily instead of 400mg daily when these
episodes occurred. Cardiac catheterization (left sided) was done
which showed no evidence of coronary artery disease. His
amiodarone dose was increased to 600 mg daily with plan to
decrease to 200mg twice daily after two weeks - which he is
currently on. Prior to this admission, he reports that whenever
he got defribrillated he would be out and did not feel anything.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. 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.
.
In the ER, initial VS:
He received lidocaine bolus and was started on a gtt. On
transfer from the ER, VS 98.6 po 92/67 70 15 96&2L
Past Medical History:
-Recent infected right leg hematoma ([**Year (4 digits) 8974**], completed Bactrim
[**2205-7-5**])
-Nonischemic cardiomyopathy s/p BiV ICD implantation: EF 40%,
?viral
-Hypertension
-Systolic CHF: secondary to cardiomyopathy, EF 40%
-Heart block: etiology unclear, R sided PPM placed then replaced
with ICD (R)/BiV PPM (L) ([**12/2199**])
-Atrial fibrillation
-Tracheobronchomalacia (recently diagnosed on CT chest [**3-/2205**])
-Sarcoidosis involving lungs, lymph nodes, ?heart
-Pulmonary hypertension
-Subglottic stenosis
-Ventral hernia repair w/ prolonged respiratory failure,
hospitalization
-Obstructive sleep apnea (central and obstructive, untreated)
-Obesity
-Depression
-Panic attacks
-CKD, baseline Cr. ~1.5
-Neuropathy, following gastric stapling in [**2192**]
- Left ankle reconstruction, bilateral knee surgeries
Cardiac Risk Factors: -Diabetes, -Dyslipidemia, +Hypertension
.
Cardiac History:
Biventricular Pacemaker/ICD, in [**12/2199**]
Social History:
Former consultant, married with two children but wife recently
left him. Just went to daughter's college graduation. No current
tobacco or alcohol use.
Family History:
Father had coronary artery disease and hypertension. Mother had
hypertension, diabetes, ear tumor. Brother had renal cell
carcinoma.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS:BP=96/62.HR=71 RR= 18.O2 sat= 99%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP flat.
CARDIAC: PMI located in 5th intercostal space. heart sounds were
distant with no appreciable murmurs, RR, normal S1, S2. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
DISCHARGE EXAM:
VS: BP 100s/ 60s HR 60s-70s RR: 14 96% RA
Cardiac: rub heard best over precordium s/p ablation procedure
Remainder of PE unchanged from admission
Pertinent Results:
Admission Labs:
[**2206-10-5**] 03:05AM BLOOD WBC-7.1 RBC-4.62 Hgb-13.5* Hct-40.3
MCV-87 MCH-29.3 MCHC-33.6 RDW-15.4 Plt Ct-224#
[**2206-10-5**] 03:05AM BLOOD Neuts-80.2* Lymphs-13.4* Monos-4.6
Eos-1.5 Baso-0.4
[**2206-10-5**] 03:05AM BLOOD Glucose-138* UreaN-45* Creat-2.1* Na-141
K-3.9 Cl-104 HCO3-24 AnGap-17
[**2206-10-5**] 03:05AM BLOOD CK(CPK)-82
[**2206-10-5**] 03:05AM BLOOD CK-MB-5
[**2206-10-5**] 03:05AM BLOOD cTropnT-0.04*
[**2206-10-5**] 03:05AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4
[**2206-10-5**] 03:05AM BLOOD Digoxin-0.7*
[**2206-10-5**] 01:39PM BLOOD Digoxin-0.6*
Discharge Labs:
[**2206-10-11**] 05:30AM BLOOD WBC-8.1 RBC-3.61* Hgb-10.8* Hct-31.8*
MCV-88 MCH-30.0 MCHC-34.0 RDW-15.5 Plt Ct-183
[**2206-10-11**] 05:30AM BLOOD Glucose-100 UreaN-30* Creat-1.7* Na-143
K-3.8 Cl-110* HCO3-25 AnGap-12
[**2206-10-11**] 05:30AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.2
CHEST (PORTABLE AP) Study Date of [**2206-10-5**]
Low lung volumes, no acute cardiopulmonary process
Portable TTE (Focused views) Done [**2206-10-7**]
LV systolic function appears depressed. with depressed free wall
contractility. There is no pericardial effusion. Poor image
quality
Portable TTE (Focused views) Done [**2206-10-10**]
The right ventricular cavity is dilated with depressed free wall
contractility. There is moderate pulmonary artery systolic
hypertension. There is a small pericardial effusion. The
effusion appears circumferential. There are no echocardiographic
signs of tamponade. No right atrial or right ventricular
diastolic collapse is seen
Portable TTE (Focused views) Done [**2206-10-11**]
LV systolic function appears depressed. RV free wall
contractility is depressed. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a very small pericardial effusion.
IMPRESSION: Very small residual pericardial effusion
Pathology Results SCAR TISSUE, NORM TISSUE (2 JARS)
1. Heart, "scar tissue," biopsy (A):
Minute fragment of loose connective tissue with mild acute and
chronic inflammation and macrophages; see note.
2. Heart, "normal tissue," biopsy (B):
Fragment of myocardium with no diagnostic abnormalities
recognized; see note.
Note: Eight (8) levels examined on both samples. There is no
evidence of inflammation, amyloid, iron deposition, or
granulomas. No necrosis of myocytes or degeneration is noted.
Case reviewed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 93333**].
Brief Hospital Course:
59yoM with nonischemic cardiomyopathy (EF 35% in [**7-12**]), s/p
BiV/ICD device in [**12/2199**] with recent admission for firing in
[**7-12**], chronic afib on coumadin, HTN, pulm HTN, osa, CKD who
presents with VT storm.
# Ventricular Tachycardia:
The pt was admitted to the CCU and started on a Lidocaine drip
from rhythm control. He underwent a VT ablation procedure for
prior multiple episodes of Vtach s/p ICD firings. He was found
to have VT with multiple morphologies, epicardial in origin. The
procedure was complicated by a RV puncture during difficult
epicardial access resulting in a stable pericardial effusion
without signs of tamponade physiology. Following the procedure
the pt was restarted on Amiodarone and Mexilitene and sent back
to CCU for observation. He was noted to have a new pericardial
rub present on PE following procedure. This was felt to be due
to pericardial inflammation as well as from the small effusion
post procedure. He had one episode of asymptomatic hypotension
following the ablation procedure with sbps in 70s that required
dopamine administration but ultimately responded to fluid
boluses. Dopamine was able to be weaned off. An echo obtained
during the hypotensive episode showed pericardial constriction
which was believed to be due to inflammation post procedure. The
effusion size was noted to be trivial. Also repeat serial echos
on succeeding days showed the pericardial effusion to be stable
in size without evidence of tamponade. He was started on a 3 day
course of steroids to help resolve the pericardial inflammation
s/p ablation which he finished prior to discharge. No further
episodes of Vtach were noted on tele after the ablation was
performed. The pt also had no further episodes of hypotension
either. His home Amiodarone dose was reduced to 200mg daily from
[**Hospital1 **] and Mexiletine 150mg TID was added to his home regimen for
rhythm control.
# CHF- Upon admission the pt appeared euvolemic. He developed
bilateral crackles at the lung bases during this admission
following fluid boluses due to an episode of hypotension.
Diuresis was resumed with his home dose of torsemide and the
pleural effusion improved. Prior to discharge the pt was
restarted on Digoxin 125mcg daily, metoprolol tartrate was
reduced to 12.5mg [**Hospital1 **] from 50mg [**Hospital1 **] in setting of baseline low
sbps and HRs consistently in 60s post ablation. His torsemide
dose was also reduced to 30mg QOD from daily. He was continued
on aspirin, spironolactone and lisinopril at his home doses.
#A.Fib- Initially his home dose of Pradaxa was held prior to VT
ablation and then was resumed post procedure for
anticoagulation. He remained rate controlled during this
hospitalization.
#Chronic Kidney Disease- His baseline Cr is approximately 1.9
per OMR records. On admission his Cr was 2.1 which was believed
to be due to poor forward flow s/p his multiple episodes of
Vtach prior to admission. We continued to trend renal function
and prior to discharge his Cr trended down to 1.7. His
Lisinopril was restarted prior to discharge.
#[**Name (NI) 12730**] Pt slept with home BiPAP at 14-16/11 with 2L O2 his home
settings. He slept well with the device on at night.
#Transitional- He has follow up appointments with his PCP and
cardiology following this admission. His blood pressures and
volume status should be re-evaluated at these follow up visits
considering we changed his home medication regimen during this
admission.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler prn
ALLOPURINOL - 150mg daily
AMIODARONE - 200 mg [**Hospital1 **]
BUDESONIDE-FORMOTEROL [SYMBICORT] - 160 mcg-4.5 mcg/Actuation
HFA Inhaler - 1 puff inh twice a day
CLINDAMYCIN PHOSPHATE - 1 % Lotion - apply to bumps on chest
twice daily as needed Qday as needed for PRN
CLOBETASOL - 0.05 % Solution - at bedtime to the affected area
DABIGATRAN ETEXILATE [PRADAXA] - 150 mg [**Hospital1 **]
DIGOXIN - 125 mcg daily
FLUOCINOLONE [DERMA-SMOOTH/FS BODY OIL] - 0.01 % Oil - apply to
areas of rash daily Qday as needed apply to damp skin as needed,
avoid face
KETOCONAZOLE - 2 % Shampoo - Apply as directed
LISINOPRIL - 2.5 mg daily
METOPROLOL SUCCINATE - 100 mg daily
OMEPRAZOLE - 40 mg [**Hospital1 **]
SERTRALINE - 50 mg Qdaily
SPIRONOLACTONE - 12.5 mg daily
TORSEMIDE - 30 mg daily
VARDENAFIL [LEVITRA] - 10 mg PRN
ASPIRIN - (OTC) - 325 mg daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
10. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for rash on back.
11. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
13. torsemide 20 mg Tablet Sig: 1.5 Tablets PO QOD ().
14. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
Scarcoidosis
Congestive Heart failure
Chronic atrial fibrillation
Hypertension
Pulmonary hypertension
Chronic kidney disease
Gout
Tracheobronchomalacia
Subglottic stenosis
-Ventral hernia repair
-Obstructive sleep apnea - on CPAP
-Obesity
-Depression
-Panic attacks
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 19940**],
You were admitted to the hospital after you had several firings
of your ICD device. You underwent an ablation in the cath lab
to help prevent future events. You also had low blood pressures
post-procedure and required medications and fluids to increse
your blood pressure. The doses of your heart medications were
changed and you will need to follow up with your cardiologist in
the next 5-7 days.
Medication Changes:
-amiodarone 200 mg daily (from twice daily)
-digoxin 125 ugm daily (restart)
-metoprolol tartrate 12.5 mg twice daily (dose reduced)
-spirnolactone 12.5 mg daily (continue)
-Torsimide 30 mg every other day (dose reduced)
-Mexiletine 150 mg three times a day (new medication)
-Asprin 325 mg daily (continue)
-Lisinopril 2.5 mg daily (continue)
-Pradaxa 150 mg daily (continue)
Addtionally please weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight goes up more than 3 lbs.
Followup Instructions:
Department: Cardiology
-please schedule an appointment with Dr. [**Last Name (STitle) 93334**] for [**Last Name (STitle) **]
[**2206-10-17**]
Department: CARDIAC SERVICES
When: [**Month/Day/Year **] [**2206-10-17**] at 2:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2206-10-16**] at 11:30 AM
With: DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/[**Company 191**] POST [**Hospital 894**] CLINIC
Phone: [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
|
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icd9cm
|
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[
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|
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[
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,843
| 122,352
|
50389
|
Discharge summary
|
report
|
Admission Date: [**2141-8-4**] Discharge Date: [**2141-8-8**]
Date of Birth: [**2060-11-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Zestril / Diovan / Hydrochlorothiazide / Univasc /
Verapamil / Cimetidine / Bactrim / Ketoconazole
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
Colonoscopy [**2141-8-5**] s/p epinephrine injections, three clips
placed
History of Present Illness:
80 year old Cantonese woman with history of paroxysmal atrial
fibrillation on coumadin, tachybrady syndrome s/p pacemaker
placement, coronary artery disease, hypertension, bladder tumor,
amiodarone induced pulmonary fibrosis, hemorrhoids and temporal
lobe epilepsy (single seizure [**2113**]) who presents with bright red
[**Year (4 digits) **] per rectum. The patient developed painless rectal bleeding
at 3pm [**2141-8-4**] and proceeded to have four bowel movmeents
mixed with [**Year (4 digits) **] clots, the last two with loose stools. The
patient's last bloody, clotted bowel movement was at 9pm before
presenting to the [**Hospital1 18**] ED. The patient endorsed "very active
belly rumbling" but no frank crampy abdominal pain. She has
chronic constipation at baseline and takes metamucil,
occasionally sennakot. She underwent colonoscopy on [**2141-7-27**]
with transverse colon polypectomy. The patient denied dizziness,
chest pain, shortness of breath, decreased appetite.
.
In the [**Hospital1 18**] ED, initial vitals were: T96.9, BP168/62, RR18,
HR66, 97% on RA. The patient was admitted to the medicine
service where she developed sensation of bloating at midnight
and proceeded to "fill the toilet bowl" with [**Last Name (LF) **], [**First Name3 (LF) **] her
daughter. The patient continued to "leak clots" per rectum at
4:30 am onto a pad. She was transfused one unit of pRBC at
4:30am. She continued to bleed bright red [**First Name3 (LF) **], clotted [**First Name3 (LF) **],
mixed with loose stools at 6am, 7am, 9am, 10:45am, 11am. She
received another unit of pRBC at 8:30am. The MICU was called to
evaluate the patient in the setting of ongoing bleeding and she
passed two more [**First Name3 (LF) **] bowel movements with loose stools (~250cc
each time) at 12:30 pm and 1:30pm. The patient continued to deny
dizziness, chest pain, shortness of breath, abdominal
pain/discomfort. She did endorse some mild positional dizziness
when going to the commode the last two times.
.
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.
Past Medical History:
# Paroxysmal a-fib/flutter/tachy s/p multiple cardioversions
- followed by Dr [**Last Name (STitle) **]
- on coumadin and dofetilide
- prior amio, but stopped d/t pulmonary and thyroid toxicity
- Post-cardioversion pulmonary edema
-Status post dual-chamber pacemaker in the setting of tachybrady
syndrome with a junctional rhythm.
# Valvular disease - Followed by Dr. [**First Name (STitle) **].
# CAD - Cardiac cath in [**2130**] with 2VD, mild MR, mod systolic and
diastolic dysfunction
# Transient CHF in setting of LAD ischemia
# Hypertension - multi-drug resistent
# Bladder tumor - CTU on [**2135-1-13**] with likely TCC, s/p cystoscopy
[**2135-1-18**] and cystoscopy [**2135-1-24**] for excision, most recent excision
on [**2139**]
# H/O + PPD
# Amiodarone induced pulmonary fibrosis - restrictive
ventilatory defect in [**8-22**] with FEV1/FVC on 115% predicted
# Adrenal adenoma ([**2131**])
# Hemorrhoids
# Constipation
# H/o pulmonary edema ([**2129**])
# Chronic pericardial effusions - not amenable to bx, no
tamponade
# Temporal lobe epilepsy with single seizure ([**2113**]) and none
since with carbamazepine therapy
# Gastritis (hx h.pylori)
Social History:
Cantonese speaking woman who lives in [**Location 583**] with husband. She
denies ETOH, tobacco or illicit drugs. Pt is accompanied by
daughter who serves as translator. Reports that she has no
difficulty completing ADLs on her own, and that she has
significant support at home from her husband.
Family History:
No known family history of disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Tm 98.0, Tc 96.5, BP: 143/61 (105/52 on admission), P:
60, R: 18 O2: 98% on RA
General: Alert, oriented, no acute distress, mildly anxious
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs/rubs/
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present
(hyperactive), no rebound tenderness or guarding, no
organomegaly
Skin: Streaks of ecchymosis across back bilaterally and left
antecubital region [**1-18**] coining per patient
GU: No foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Chemistry:
[**2141-8-8**] 06:40AM [**Month/Day/Year 3143**] Glucose-102* UreaN-9 Creat-0.8 Na-142
K-4.1 Cl-105 HCO3-28 AnGap-13
[**2141-8-7**] 09:20AM [**Month/Day/Year 3143**] Glucose-166* UreaN-9 Creat-0.7 Na-141
K-3.5 Cl-106 HCO3-25 AnGap-14
[**2141-8-6**] 12:03AM [**Month/Day/Year 3143**] Glucose-98 UreaN-15 Creat-0.7 Na-137
K-3.9 Cl-106 HCO3-25 AnGap-10
[**2141-8-5**] 12:52PM [**Month/Day/Year 3143**] Glucose-106* UreaN-16 Creat-0.7 Na-140
K-4.0 Cl-108 HCO3-26 AnGap-10
[**2141-8-4**] 08:00PM [**Month/Day/Year 3143**] Glucose-228* UreaN-19 Creat-0.9 Na-135
K-5.6* Cl-100 HCO3-30 AnGap-11
[**2141-8-8**] 06:40AM [**Month/Day/Year 3143**] Calcium-8.8 Phos-3.5 Mg-2.1
.
Coagulation Profile:
[**2141-8-8**] 06:40AM [**Month/Day/Year 3143**] PT-12.8 INR(PT)-1.1
[**2141-8-6**] 12:03AM [**Month/Day/Year 3143**] PT-16.5* PTT-32.5 INR(PT)-1.5*
[**2141-8-4**] 08:00PM [**Month/Day/Year 3143**] PT-25.5* PTT-32.9 INR(PT)-2.4*
.
Complete [**Month/Day/Year **] Count:
[**2141-8-8**] 06:40AM [**Month/Day/Year 3143**] WBC-5.4 RBC-3.06* Hgb-10.2* Hct-27.9*
MCV-91 MCH-33.2* MCHC-36.4* RDW-16.1* Plt Ct-125*
[**2141-8-7**] 09:20AM [**Month/Day/Year 3143**] WBC-6.4 RBC-2.90* Hgb-9.6* Hct-26.7*
MCV-92 MCH-33.0* MCHC-35.9* RDW-16.0* Plt Ct-120*
[**2141-8-7**] 03:30AM [**Month/Day/Year 3143**] Hct-25.9*
[**2141-8-6**] 09:00PM [**Month/Day/Year 3143**] Hct-27.6*
[**2141-8-6**] 05:00PM [**Month/Day/Year 3143**] Hct-27.3*
[**2141-8-6**] 06:00AM [**Month/Day/Year 3143**] Hct-25.5*
[**2141-8-6**] 12:03AM [**Month/Day/Year 3143**] WBC-7.6 RBC-2.94* Hgb-10.0* Hct-26.6*
MCV-90 MCH-33.8* MCHC-37.5* RDW-16.0* Plt Ct-92*
[**2141-8-5**] 05:47PM [**Month/Day/Year 3143**] WBC-9.1 RBC-2.83* Hgb-9.6* Hct-25.7*
MCV-91# MCH-33.8* MCHC-37.2* RDW-16.2* Plt Ct-103*
[**2141-8-5**] 12:52PM [**Month/Day/Year 3143**] Hct-22.7*
[**2141-8-5**] 02:38AM [**Month/Day/Year 3143**] Hct-24.7*
[**2141-8-4**] 08:00PM [**Month/Day/Year 3143**] WBC-6.7 RBC-2.93* Hgb-10.4* Hct-28.9*
MCV-99* MCH-35.5* MCHC-36.0* RDW-13.1 Plt Ct-171
.
EKG [**8-4**]
Sinus rhythm with left ventricular hypertrophy and
repolarization
abnormalities. Compared to the previous tracing of [**2141-5-26**] no
diagnostic
change.
.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 194 102 442/456 55 8 90
.
Micro:
[**2141-8-6**] 6:00 am MRSA SCREEN NASAL SWAB.
MRSA SCREEN (Final [**2141-8-8**]): No MRSA isolated.
.
Images:
Colonoscopy [**2141-7-27**]
Findings:
Protruding Lesions A single sessile 1 cm polyp was found in the
transverse colon. A single-piece polypectomy was performed using
a hot snare in the transverse colon. The polyp was completely
removed. A single sessile 5 mm polyp was found in the transverse
colon. A single-piece polypectomy was performed using a cold
snare in the transverse colon. The polyp was completely removed.
Excavated Lesions Several diverticula were seen in the whole
colon.
Impression: Polyp in the transverse colon (polypectomy)
Diverticulosis of the whole colon
Polyp in the transverse colon (polypectomy)
Otherwise normal colonoscopy to cecum
Recommendations: follow-up biopsy results
Colonoscopy in 3 years
High Fiber Diet
.
Colonoscopy [**2141-8-5**]
The site of a previously removed polyp was identified in the
transverse colon. The site was 1cm-wwide approximately, and
actively oozing. 4 5 cc. Epinephrine 1/[**Numeric Identifier 961**] injections were
applied for hemostasis with success. Three endoclips were
successfully applied for the purpose of hemostasis at the
bleeding site. After careful washing of the area and further
observation for 3-4 minutes, no further bleeding was seen.
Otherwise normal colonoscopy to cecum
.
.
Polypectomy Pathology:
.
DIAGNOSIS:
Colon polyps, polypectomies:
.
A. Transverse polyp:
Adenoma.
.
B. Transverse:
Aggregates of bacterial forms consistent with actinomyces.
No colonic tissue seen.
Brief Hospital Course:
80 year old woman with history of atrial fibrillation on
coumadin, tachy-brady syndrome s/p pacemaker, coronary artery
disease, hypertension, bladder tumor, amiodarone-induced
pulmonary fibrosis, hemorrhoides, chronic pericardial effusions,
temporal lobe epilepsy who presents with bright red [**Numeric Identifier **] per
rectum status post colonoscopy with polypectomy. See below for
detailed hospital course by issues.
.
# Acute anemia/[**Numeric Identifier **] loss from lower GI bleed
Patient presented with [**Numeric Identifier **] with clots per rectum and crampy
abdominal pain likely due to lower GI bleed rather than from an
upper GI source. She was transfused two units of packed red
[**Numeric Identifier **] cells in the emergency department. Her vitals in the ED
and on transfer were normal and stable, but her INR was
therapeutic for atrial fibrillation at 2.4. While on the floor
she continued to have bright red clots from bowel movements
every hour. She was transferred to the intensive care unit
where repeat colonoscopy identified an actively oozing source in
the transverse colon from a site consistent with recent
polypectomy from [**2141-7-27**]. She received epinephrine and 3
endoclips were placed, all at the bleeding site. She received
5mg IV vitamin K for INR reversal to 1.5. Subsequently, she was
transferred back to the floor in stable conditions without
further bleeding episodes. On the floor her hematocrit trends
were 27.3 --> 27.8 --> (received 1 liter normal saline) --> 25.9
--> 26.7. As she left the hospital, she was hemodynamically
stable and had no more grossly bloody stools. Patient will have
repeat PT/INR performed at primary care clinic on Thursday [**8-10**].
Coumadin was resumed the day prior to discharge.
.
# Atrial fibrillation
The patient was paced at HR 60, which could mask a hemodynamic
response to ongoing bleed. She is status post multiple
cardioversions which was complicated by pulmonary edema. She
took amiodarone but developed pulmonary fibrosis and had a
history of thyroid aberrations. Instead, she has been taking
dofetilide with close electrolyte monitoring. She is on both
aspirin and coumadin. Her INR was therapeutic at 2.4 on
admission but was reversed to 1.5 with vitamin K in the ICU. On
transfer she had one episode of atrial fibrillation with rapid
ventricular response, which lasted only minutes before
spontaneously returning to sinus rhythm. She was asymptomatic
and normotensive through the entire episode. This episode was
thought to be related to holding her metoprolol during the ICU
stay from concerns for hypovolemia. Metoprolol tartrate was
restarted on the medicine floor. She was in sinus rhythem with
heart rate in the 60s throughout the remainder of her stay. As
she left the hospital, she was on all home medications including
warfarin, and had stable vital signs. INR on discharge was 1.1
and patient will resume home dose of coumadin, with INR check on
Thurday, [**8-10**], with PCP.
.
# Actinomyces Infection
Pathology reports from colonoscopy revealed actinomyces
involvement from one of the samples from transverse colon.
Infectious diseases was consulted and will touchbase with the GI
attending who performed the repeat colonoscopy prior to making
treatment decisions. Patient was discharged with a script for
doxycycline, to be filled once Dr. [**Last Name (STitle) 3197**] contacts the
patient's family in the outpatient setting.
.
# Hypertension
Her antihypertensives were held in setting of bleed. Her home
furosemide was held throughout the hospital stay but was
restarted on discharge.
.
# Tachybrady syndrome
Stable, with pacemaker
.
# Coronary Artery Disease
Held felodipine, losartan and aspirin during LGIB. All home
medications resumed on discharge.
.
# Temporal Lobe Epilepsy
No episodes since [**2113**]. Continued carbamazepine
.
# Bladder Tumor
Chronic, Stable
.
# Gastritis
History of H.pylori, presumed treated. Bleeding during this
hospitalizatino was not consistent with brisk upper GI bleed.
.
Transitional Issues:
- Follow up with PCP for PT/INR on [**8-10**]
- Follow up with infectious diseases regarding doxycycline
treatment for actinomyces
Medications on Admission:
* Carbamazepine 200mg daily
* Clonazepam 0.5mg qAM, 1mg qHS
* Dofetilide 250mg daily
* Felodipine 10mg ER daily
* Losartan 100mg daily
* Trazodone 50mg qHS
* Warfarin 5mg daily
* Aspirin 81mg daily
* Calcium citrate-Vitamin D3 daily
* Metamucil daily
Discharge Medications:
1. warfarin 5 mg Tablet Sig: AS DIRECTED Tablet PO AS DIRECTED:
One pill (5mg) daily for six days per week, Half pill (2.5mg)
for one day per week.
2. carbamazepine 200 mg Tablet Extended Release 12 hr Sig: One
(1) Tablet Extended Release 12 hr PO DAILY (Daily).
3. dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Calcium Citrate + D Oral
7. Metamucil Oral
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. felodipine 2.5 mg Tablet Extended Release 24 hr Sig: Four (4)
Tablet Extended Release 24 hr PO DAILY (Daily).
10. clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO QHS (at
bedtime).
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO qam.
13. BLOODWORK
Please have PT/INR [**Month/Year (2) **] test on Thursday, [**2141-8-10**].
Please send results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] ([**Company 191**], phone [**Telephone/Fax (1) 250**]).
14. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
twice a day for 30 days.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. hematochezia, [**Telephone/Fax (1) **] per rectum
2. atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 36061**],
.
It was a pleasure taking care of you during your stay at [**Hospital1 1535**]. You were admitted to the
hospital because you began to pass bright red [**Hospital1 **] from the
rectum. This is likely due to your recent colonoscopy when two
polyps were removed from your colon, and you began to bleed from
one site. You were monitored closely in the intensive care and
underwent urgent colonoscopy. The GI team placed three clips,
which stopped your bleeding. You were also given vitamin K,
which reverses the effects of coumadin on your ability to clot.
You were then transferred back to the inpatient floor, where
your red [**Hospital1 **] cell levels (hematocrit) stabilized. While your
coumadin was held during your ICU stay, it was restarted one day
prior to your discharge. You were discharged after your vital
signs stabilized and your stool stopped showing visible [**Hospital1 **].
.
The pathology report for your colonoscopy showed some bacteria
growth on the colonic polyps. Infectious disease experts were
called and they recommend no acute intervention.
.
MEDICATION CHANGES:
- None
.
Please seek medical attention for any concerning symptoms.
Please attend your appointments below. Please have INR checked
with Dr. [**Last Name (STitle) 9006**] at upcoming visit on Thursday, [**8-10**]. Weigh
yourself every morning. Please call your doctor if your weight
increases by more than three pounds.
MEDICATION ADDED:
You have been given a prescription for :Doxycycline 100mg twice
daily for one month.
*** Please DO NOT start taking this medication until you have
spoken to Dr [**Last Name (STitle) 3197**].
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2141-8-10**] at 10:10 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
Completed by:[**2141-8-9**]
|
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icd9cm
|
[
[
[]
]
] |
[
"45.43"
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icd9pcs
|
[
[
[]
]
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14912, 14918
|
9045, 13082
|
385, 460
|
15057, 15057
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5190, 9022
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16339, 16870
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333, 347
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488, 2488
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14958, 15036
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2913, 4073
|
4089, 4386
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,897
| 101,014
|
12021
|
Discharge summary
|
report
|
Admission Date: [**2127-3-5**] Discharge Date: [**2127-3-7**]
Date of Birth: [**2091-11-6**] Sex: F
Service:
CHIEF COMPLAINT: Dyspnea.
HISTORY OF PRESENT ILLNESS: The patient is a 35 year-old
female with the past medical history significant for morbid
obesity. The patient underwent gastric restrictive surgery on
[**2127-2-19**]. This was complicated by a staple line leak and
required an exploratory laparotomy and oversew of the leak on
[**2127-2-20**]. Her post-operative recovery was complicated by poor
pulmonary status requiring prolonged ventilator requirement
and a reintubation. She was discharged from [**Hospital1 190**] on [**2127-2-27**]. Following discharge the patient had
three days of increasing chest pain. The patient presented to the
Emergency Department for evaluation of shortness of breath and
chest pain. She denied productive sputum, fevers or chills. She
was tolerating the diet well on stage III diet.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. L5 S1 herniated disc with spinal stenosis.
3. Mild hypertension.
PAST SURGICAL HISTORY:
1. Exploratory laparotomy for ectopic pregnancy.
2. Gastric bypass [**2127-2-19**]
3. Status post exploratory laparotomy on [**2127-2-20**] for
anastomotic leak of the gastric bypass.
MEDICATIONS:
1. Flexeril 10 milligrams po tid prn.
2. Roxicet Elixir po q four to six hours prn pain.
3. Zantac.
ALLERGIES: No known medical allergies.
REVIEW OF SYSTEMS: Cardiovascular - Positive chest pain
times three days but slightly improving. Respiratory - Chest
pain for three days left side greater than right.
Gastrointestinal - Negative nausea and vomiting, positive
bowel movements and flatus. Infectious Disease - Positive
fevers but no night sweats or chills.
PHYSICAL EXAMINATION: Respirations are 34, 02 saturation 88%
on room air, 99 to 100% on face mask. Cardiovascular -
Regular rate and rhythm. Respiratory - Decreased breath
sounds on the left with wheezing, normal breath sounds on the
right. Left bronchial breath sounds. Gastrointestinal - Obese,
soft, nontender, positive bowel sounds. Genitourinary - Negative
CVA tenderness. Extremities - Negative peripheral edema, negative
calf tenderness.
LABORATORY DATA: Chem 7 normal. Glucose of 110. ALT 26, AST 36,
amylase 26, alkaline phosphatase 206, lipase 76, total bilirubin
0.6, albumin 3.2, white cell 20, crit 34.6, PT 13.5, PTT 28.5,
INR 1.3.
Chest x-ray showed a large left effusion.
EKG was normal sinus rhythm.
HOSPITAL COURSE: The patient was seen in the Emergency
Department and was noticed to have a very large left
effusion. The patient had an ultrasound guided thoracentesis in
which 2.5 liters of serousanguinous fluid was removed. The
patient was transferred to the ICU in stable condition. She
was treated for a presumed pneumonia with IV Levaquin. Her
respiratory status significantly improved. Physical therapy
followed the patient throughout her hospital stay. She was
treated for a small decubitus of her back with duoderm dressings.
On [**2127-3-6**] the patient's chest x-ray was shown to be
improved from the admission x-ray. At that time it was
decided the patient may be transferred to the floor. On [**2127-3-7**]
the patient had a repeat chest x-ray which showed resolution of
the effusion. A pain consult was obtained for her chronic back
pain and decreased resulting mobility. A duragelsic patch was
recommended and started in the hospital. Throughout her stay,
she tolerated stage III diet will. SHe was discharged home with
[**Hospital 37739**] home health aid and VNA and will follow-up in the office in 3
weeks at which time her Gtube will be removed.
slight improvement. She will be discharged on a 10 day course of
po Levaquin.
DISCHARGE PHYSICAL EXAMINATION: T max 99.6 F, current 98.7 F,
[**Age over 90 **] F, 138/80, 22, 93 on room air. Alert and oriented, in no
acute distress. Cardiovascular - Regular rate and rhythm.
Respiratory - Clear to auscultation bilaterally. Abdomen - Soft,
nontender, nondistended, positive bowel sounds. The incision is
intact, clean and dry. The Gtube site is clean.
DISCHARGE DIAGNOSIS:
1. Morbid obesity status post gastric bypass with anastomotic
leak, status post exploratory laparotomy and oversew of the
gastric staple line.
2. Large left pleural effusion, status post thoracentesis for
presumed pneumonia.
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: Home.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13186**], M.D. [**MD Number(1) 13187**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2127-3-7**] 08:45
T: [**2127-3-7**] 09:31
JOB#: [**Job Number **]
|
[
"707.0",
"722.10",
"278.01",
"511.9",
"V45.89",
"V44.1",
"401.9",
"486",
"724.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
4409, 4688
|
4378, 4385
|
4129, 4356
|
2502, 3743
|
1088, 1434
|
3765, 4108
|
1454, 1759
|
146, 156
|
184, 952
|
974, 1065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,321
| 166,020
|
24722
|
Discharge summary
|
report
|
Admission Date: [**2186-4-19**] Discharge Date: [**2186-5-5**]
Date of Birth: [**2112-1-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
left metatarsal ischemic ulcer
Major Surgical or Invasive Procedure:
[**2186-4-20**]: Irrigation and debridement of left foot abcess
[**2186-4-26**]: left below knee [**Doctor Last Name **]-plantar artery bpg with right
greater saphenous vein
[**2186-4-28**]: debridment of left foot
History of Present Illness:
Patient with known PVd who presented to Dr.[**Name (NI) 1720**] office with
left foot fissure, and cellulitis with WBC of 24K. Admitted for
IV antibiotics and diagnostic angiiogram.
Past Medical History:
PMH:
left met-head ischemic ulcer with cellultits
Diabetes 2
CRI (Cr 1.1-1.4)
history of GI bleed
history of CAD,s/p CABG's x3 [**9-12**]
history of PVD:
s/p PTA of rt. Bkpop,TPT and PT artery and stenting of TPT and
Pt [**2185-8-16**]
s/p amputations rt ist toe [**8-12**], rt. #2 open ray amputation
postop blood loss anemia, transfused
history of [**Doctor Last Name 360**] [**Location (un) 2452**] exposure
Social History:
Pt is a [**Country 3992**] veteran with exposure to [**Doctor Last Name 360**] [**Location (un) 2452**]. He has
had little medical care in the past.
Family History:
Noncontributory
Physical Exam:
afebrile
General alert and oriented x3, no acute distress
HEENT : no thyroid megaly, [**Location (un) **];tid bruits
Lungs: clear to auscultation
Herat: RRR no mumur,gallop or rub
ABD: no bruits,masses or organamegly
PVD: rt. femoral palpaable,DP/Pt dopperable signal
lt. graft palpable,DP/PT dopperable signal
rt. ray amp site well healed
ankle foot edema 1+ rt,
LLE Ulcer 3X 1.5: clean, granulating, VAC in place
Neuro nonfocal
Pertinent Results:
[**2186-5-2**] 7:50A WBC 12.5* RBC 3.43* Hgb10.0* HCT 30.4* PLT 357
[**2186-5-4**] 5:56A Glu 102 Bun 23* Cr 1.3* Na 137 K 5.3* Ca 8.5 Phos
3.9 Mg 2.0
Last Vanco through: 9.3 on [**2186-5-4**]
Brief Hospital Course:
[**2186-4-19**] admitted .wound c/s MRSA, beta strep and GNRx2. Placed
on Vancomycin,levofloxcin and flagyl.Podiatry consulted, they
are awaiting angiogram to make further recommendations.
[**2186-4-20**] I/d lfet foot
[**2186-4-24**] angiogram via rt. femoral access with left leg runoff.
tibial disease with occluded TPT with constution of PT and
peroneal @ ankle.
[**2186-4-25**] evaluated by cardiology, patient at intermediate risk,
proceede to surgery.
[**2186-4-26**] left BKpop-plantar artery with right GSV,angiioscopy and
valve lysis.
[**2186-4-27**] POD#! no overnight events graft palpable. diuresed
[**2186-4-28**] left foot debridment by podiatry.
[**2186-4-29**] foot dressing removed., normal saline wet to dry [**Hospital1 **]
began, ace wrap to foot
good granular base.required continued diuresis. foley d/c'd
[**2186-4-30**] transfused 1 unit PRBC's for Hct 25.8 delined and
transfered to regular nursing floor
[**2186-5-1**] evaluated by physical thearphy, recommend rehab prior to
d/c to home.
[**2186-5-2**] excisional left foot debridment. VAC dressing
placement.foot films pending.
[**2186-5-3**] VAc dressing changes q3days. antibiotics x 9 more days.
awaiting bed
[**2186-5-4**] Antibiotics x 8 more days. awaiting bed. LLE graft is
palpable. Wound is clean and well granualating. VSS. K 5.3-
given Kayexelate. Recheck K tomorrow at rehab.
Medications on Admission:
Asa 81mgm daily
lipitor 10mgm daily
toprol xl 100mgm HS
glyburide 5mgm daily
folic acid 1mgm daily
lisinopril 10mgm daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Last day [**2186-5-12**].
14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): last day [**2186-5-12**].
15. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale-see scale Injection Before meals .
16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous Q
24 hours for 8 days days: Last dose [**2186-5-12**]
Check through around 3rd dose.
17. Labs: Recheck Cr, K, CBC weekly
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
left metatarsal head ischemic ulcer with cellullitis
diabetes type 2
history of GI bleed
history of coronary arterydisease s/p CAGB's x3 [**9-12**]
histeory of PVD,s/p rt. angiogram [**9-12**],PTA of rt. bkpoop,TPT,PT
artery with stenting of TPT and PT [**8-12**],rt, angio1/06
s/p rt. toe amp #1, s/p rt. #2 ray amp.
postop blood loss anemia,transfused
Discharge Condition:
stable
Discharge Instructions:
heel touch down left foot
keep leg elevated when sitting
VAC change q3 days. last change [**2186-5-2**]
call if develope fever >101.5
call if wound become swollen,erythematous or change in drainage
take all medications as directed
Followup Instructions:
followup with Dr. [**Last Name (STitle) **] 2 weeks ,call for appoointment
[**Telephone/Fax (1) 1241**]
followup with Dr. [**Last Name (STitle) **], 7-10 days ,call for appointment
[**Telephone/Fax (1) 543**]
Completed by:[**2186-5-4**]
|
[
"440.24",
"250.80",
"707.15",
"V45.81",
"285.1",
"731.8",
"730.07",
"403.91",
"682.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.88",
"39.29",
"93.57",
"38.93",
"88.47",
"38.22",
"88.48",
"86.04",
"86.22",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5155, 5241
|
2094, 3462
|
344, 561
|
5638, 5647
|
1878, 2071
|
5926, 6164
|
1391, 1408
|
3634, 5132
|
5262, 5617
|
3488, 3611
|
5671, 5903
|
1423, 1859
|
274, 306
|
589, 772
|
794, 1207
|
1223, 1375
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,401
| 138,373
|
1241
|
Discharge summary
|
report
|
Admission Date: [**2194-8-1**] Discharge Date: [**2194-8-4**]
Date of Birth: [**2138-6-10**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Difficulty Breathing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56 y.o. male PMH sarcoidosis and h/o L vocal cord paralysis s/p
mediastinoscopy presented on [**2194-7-31**] for L VC gelfoam injection.
Patient was stable when discharged from PACU however approx 3
hours later began to develop respiratory distress. The patient
first presented to [**Hospital 1474**] Hospital ED where he received 10mg
Decadron and was then transfered to [**Hospital1 18**] SICU.
Past Medical History:
Sarcoidosis
Lupus
Arthritis
Bipolar
GERD
Anemia
Asthma
HTN
Social History:
Denies tobacco, EtOH. Works at [**Company 7546**]
Family History:
Non contrib
Physical Exam:
At D/C
97.7 97.7 80 120/70 18 97-99%RA
NAD
HEENT: EOMI, PERRL
FOE: L TVC paralysis, R TVC mobile. Patent airway - 8mm. LAE
fold edema markedly decreased.
CV: RRR
LUNGS: CTA b/l no w/r/r
Pertinent Results:
[**2194-8-2**] 01:26AM BLOOD WBC-11.4* RBC-4.17* Hgb-12.1* Hct-35.1*
MCV-84 MCH-28.9 MCHC-34.4 RDW-14.8 Plt Ct-228
[**2194-8-1**] 04:55AM BLOOD WBC-13.0*# RBC-4.44* Hgb-12.7* Hct-36.7*
MCV-83 MCH-28.5 MCHC-34.5 RDW-14.9 Plt Ct-213
[**2194-8-1**] 04:55AM BLOOD Neuts-96.7* Lymphs-1.9* Monos-0.8*
Eos-0.3 Baso-0.4
[**2194-8-2**] 01:26AM BLOOD Plt Ct-228
[**2194-8-2**] 01:26AM BLOOD PT-12.2 PTT-21.8* INR(PT)-1.0
[**2194-8-1**] 04:55AM BLOOD Poiklo-1+ Microcy-1+
[**2194-8-1**] 04:55AM BLOOD Plt Ct-213
[**2194-8-1**] 04:55AM BLOOD PT-12.3 PTT-21.8* INR(PT)-1.1
[**2194-8-2**] 01:26AM BLOOD Glucose-144* UreaN-12 Creat-1.0 Na-145
K-4.1 Cl-107 HCO3-28 AnGap-14
[**2194-8-1**] 04:55AM BLOOD Glucose-172* UreaN-12 Creat-1.1 Na-142
K-3.8 Cl-106 HCO3-22 AnGap-18
[**2194-8-2**] 01:26AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.2
Brief Hospital Course:
Patient was initally admitted to the [**Hospital1 18**] SICU. He was started
on Decadron 8mg IV q8h as well as heliox. He improved t/o the
DOA and on HD2 was moved to the floor with continuous O2 Sat
monitoring. On HD3 the patient had the Decadron discontinued
and was then re-started on his normal dose of Prednisone.
While on the floor the patient was on RA without hypoxia - sats
ranging from 97-100%. The patient was anxious t/o hospital stay
due to hoarseness in throat - this was addressed with
phenaseptic throat spray. He also had some complaints of mild
SOB, however CV/Pulm PE were normal and CXR was clear without
abnormalities. All of the patients symptoms continued to
improve at time of discharge.
Medications on Admission:
Prednisone 8mg PO qd
Singulair
Wellbutrin
Exelon
Fosamax
Imipramine
Lithium
Abilify
Plaquenil
Advair
Testosterone patch
B12
Atenolol
Discharge Medications:
1. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane every 4-6 hours as needed.
Disp:*1 Bottle* Refills:*0*
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
3. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*1*
4. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left AE Fold Edema s/p LTVC gelfoam injection
Discharge Condition:
Stable
Discharge Instructions:
Continue soft solid diet
Continue Home meds as well as new prescriptions
[**Name8 (MD) **] MD or return to ED if any of the following:
Difficulty breathing
Temp >101.5
Intractable Nausea/Vomiiting
Followup Instructions:
F/U with Dr. [**First Name (STitle) **] at regular scheduled Post-OP appointment
[**2194-8-13**]. ([**Telephone/Fax (1) 7767**]
F/U with PCP for PMH maintenance.
Completed by:[**2194-8-4**]
|
[
"493.90",
"478.31",
"710.0",
"135",
"296.80",
"478.6",
"401.9",
"715.90",
"530.81",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"31.0"
] |
icd9pcs
|
[
[
[]
]
] |
3394, 3400
|
2020, 2739
|
340, 347
|
3490, 3499
|
1182, 1997
|
3745, 3937
|
940, 953
|
2922, 3371
|
3421, 3469
|
2765, 2899
|
3523, 3722
|
968, 1163
|
280, 302
|
375, 774
|
796, 856
|
872, 924
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,183
| 121,063
|
18506
|
Discharge summary
|
report
|
Admission Date: [**2195-8-5**] Discharge Date: [**2195-8-11**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 84-year-old woman
with cardiac risk factors of smoking and age, and no cardiac
history, who presented to an outside hospital for substernal
chest pressure, which awoke her this morning from sleep. She
describes the pain as knife like and sharp without radiation,
but associated with nausea, vomiting, and diaphoresis rated
[**9-4**], no associated shortness of breath. No back or
abdominal pain. Patient activated EMS and was taken to
[**Hospital1 **] at which ECG demonstrated anterior ST elevations.
Her initial laboratories are unremarkable and chest x-ray was
consistent with congestive heart failure. She was treated
with aspirin, Heparin drip, nitroglycerin drip, and Morphine,
and was transferred to [**Hospital1 69**]
for cardiac catheterization.
Coronary angiography demonstrated severe left main, two
vessel coronary artery disease. The LMCA had a proximal 80%
stenosis. The LAD had a thrombotic 100% proximal occlusion
and RCA had a 50% ostial stenosis. The LAD was a 3 x 13 mm
Hepakote stent and the left main was stented with a 3.5 x 8
mm Cypher stent. Resting hemodynamics demonstrated evidence
of elevated right sided filling pressures and decreased
cardiac index.
Integrilin was initially held secondary to history of
prior stroke and bleeding, but was given after
initiating complex left main stent procedure. An intra-aortic
balloon pump was not placed due to history of abdominal aortic
aneurysm.
PAST MEDICAL HISTORY:
1. Hemorrhagic CVA in 10/00.
2. Abdominal aortic aneurysm of 6.5 cm on pyelogram on [**1-25**].
3. Renal cancer status post resection.
ALLERGIES: Penicillin.
MEDICATIONS: Multivitamin.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 150/94,
pulse 81, respirations 22, and sating 92% on room air.
General: Well-developed and well-nourished in no apparent
distress. HEENT: Normocephalic, atraumatic. Extraocular
movements are intact. Oropharynx is clear. Chest: Coarse
breath sounds bilaterally anteriorly. Cor: Regular, distant
heart sounds, normal S1, S2, no rub or gallop appreciated.
Positive JVD, no bruits. Abdomen: Soft, nontender, and
nondistended, positive bowel sounds. Extremities are warm
and well perfused, 2+ dorsalis pedis pulses bilaterally.
Hematoma on the right groin. Neurologic: Cranial nerves II
through XII intact. Moves all four extremities.
LABORATORIES: White count 10.2, hematocrit 38.2, platelets
210. Sodium 134, potassium 4.6, chloride 104, bicarb 20, BUN
19, creatinine 1.1, and glucose of 164. AST 345, ALT 53,
alkaline phosphatase 119, and total bilirubin 0.5. CK peak
4488, CK MB 494, troponin-T 24.8.
EKG post intervention, sinus rhythm at 84, Q waves in V1, V2,
and V3 with persistent ST elevation, improved from prior,
poor R-wave progression, T-wave inversion in V1 through V3,
aVL, normal axis, and no left ventricular hypertrophy.
Chest x-ray: Pulmonary edema, overlying emphysema.
Echocardiogram: Normal left atrium, normal left ventricular
wall thickness and cavity size. Moderate regional left
ventricular systolic dysfunction with an ejection fraction of
30-40%, apical akinesis, hypokinesis of the mid and distal
anterior wall and hypokinesis of the anterior septum, mid and
distal inferior walls, moderate pulmonary artery systolic
hypertension.
HOSPITAL COURSE:
1. ST elevation MI: The patient's CK had peaked at admission
at 4488. Postcatheterization, she was treated with aspirin,
Plavix, beta blocker, ACE inhibitor and a statin. She had no
recurrent chest pain throughout her hospitalization. She will
need a relook angiography in three months to evaluate her LMCA
stent. Echocardiogram demonstrated systolic dysfunction with an
ejection fraction of approximately 30%, focal hypokinesis.
Patient was diuresed for her congestive heart failure and did
well.
It was felt that anticoagulation was not indicated in this
patient despite her poor ejection fraction and akinesis,
secondary to bleeding risk. The patient did have one
episode of hematemesis while on Integrilin as well as a right
groin hematoma. Her hematocrit was followed serially and
required transfusion of 2 units of packed red blood cells.
2. Abdominal aortic aneurysm: Patient is not a surgical
candidate at this time. This may be followed up on an
outpatient setting.
3. Pulmonary: The patient was in obvious failure responding
to diuresis, however, there seemed to be a component of COPD
which may be exacerbating her oxygen requirements. Pulmonary
function tests were obtained prior to discharge to be
followed up by her primary care provider.
4. Renal: The patient had acute renal failure. This was
felt secondary to large dye load received while undergoing
cardiac catheterization. This did trend down and finally
trended down prior to discharge. Discharge plan - Will be
followed up as an outpatient.
5. Smoking cessation: The patient was
counseled to quit smoking tobacco.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES:
1. ST elevation myocardial infarction.
2. Congestive Heart Failure
DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg p.o. q.d.
2. Clopidogrel 75 mg p.o. q.d.
3. Metoprolol XL 25 mg p.o. q.d.
4. Aspirin 325 mg p.o. q.d.
5. Bupropion one tablet p.o. q.d. x3 days, then one tablet
p.o. b.i.d. thereafter.
6. Nitroglycerin 0.3 mg sublingual prn.
FOLLOW-UP PLANS: Patient is to followup with Dr. [**Last Name (STitle) 1655**],
her cardiologist on [**8-17**] and with Dr. [**Last Name (STitle) 8049**] on
[**8-13**]. The patient will need re-catheterization
three months after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], M.D. [**MD Number(1) 9615**]
Dictated By:[**Name8 (MD) 11246**]
MEDQUIST36
D: [**2195-10-5**] 09:49
T: [**2195-10-5**] 11:52
JOB#: [**Job Number 50870**]
|
[
"416.0",
"428.20",
"428.0",
"492.8",
"584.9",
"999.8",
"997.3",
"998.12",
"410.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"36.07",
"36.05",
"37.23",
"88.56",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
5043, 5076
|
5097, 5165
|
5188, 5436
|
3412, 5021
|
1783, 3395
|
5454, 5943
|
110, 1548
|
1570, 1760
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,481
| 147,668
|
48173
|
Discharge summary
|
report
|
Admission Date: [**2197-1-6**] Discharge Date: [**2197-1-27**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer from OSH for fever, low Hct, new a-fib, CHF.
Major Surgical or Invasive Procedure:
ERCP
CTA of abdomen/pelvix
PICC placement
History of Present Illness:
89F s/p remote CABG underwent left main stent [**2196-11-21**] at [**Hospital1 18**],
then had a relook for atypical pain [**2196-12-8**] with patent stent
but c/b left femoral artery bleed, s/p balloon tamponade and
stablizied. Pt was D/C'd to [**Hospital1 **] rehab. Pt has a hx
of spinal stenosis and has been complaining of worsening back
pain since he could not get his pain shot due to [**Hospital1 **]. Per
Rehab, pt c/o worseing back pain and also DOE. EKG with
?ischemic changes; tx with nitro, morphine. Pt c/o abdominal
pain/ back pain since the cath. Pain and SOB got worse and
initially planned to tx to [**Hospital1 **] but re-reouted b/c pt unstable. On
arrival to [**Name (NI) **], pt noted to be febrile T102, hypotension
70/40, new a-fib, CHF (+CXR, BNP 1220). Pt transiently on Neo
for hypotension, received PRBC + IVF. WBC noted for 21.3 and Hct
26.4 (31.6 on [**12-17**]). Pt was started on Digoxin and Amiodarone
for a-fib, received IV Lasix. BCx + UCx grew MRSA and was
started on Vanc, Timentin, and Levofloxacin. She was ruled out
by enzymes. Since she had severe back pain, worrisome for
worsening RP bleed given Hct and was transferred.
Past Medical History:
1) coronary artery disease
2) hypertension
3) dyslipidemia
4) hypothyroidism
5) dejenerative joint disease
6) h/o spinal stenosis - treated with epidural injections
7) COPD
8) hiatal hernia
9) s/p cholecystectomy
[**02**]) chronic renal insufficiency (crn. baseline 1.8)
Social History:
Quit smoking 30yrs ago. No alcohol. Lives alone in senior
houing. Ambulates with cane.
Family History:
mother - ca
father - MI at age 60
Physical Exam:
T 97.5 BP 106/26 HR 73 RR 23 O2sat 96% on 10L shovel mask
GEN: Appears somnolent, on shovel mask, minimally conversant,
seems to be in pain.
HEENT: NC/AT, nl conjunctiva, anicteric sclera, neck supple, no
neck stiffness, mucous membrane dry
Neck: JVP 6 cm, no thyromegaly
Cor: RRR nl S1, S2, II/VI SEM @ LSB, no S3
Lungs: decreased BS at the bases, +expiratory wheezes
bilaterally
Abd: +guiac, diffuse abdominal pain to palpation, non-focal, no
rebound.
Back: No spinal tenderness to palpation but pain at paraspinal,
cervical region
Ext: No edema, 1+ DP bilaterally, [**2-5**]+ carotids bilaterally, no
bruit
Neuro: somnolent, moving all 4 extremitities, no posturing,
PERRL, EOMI, tongue midline, symmetric facial expression.
Unable to assess higher cognitive function as pt was somnolent.
Pertinent Results:
ABD/PELVIX CT [**1-4**], [**1-6**] (from OSH): Stable L RP bleed [**1-6**]
slightly larger. +dilated intrahepatic and common bile duct.
adrenal gland atenuation, large umbilical hernia, multiple
diverticuli.
CXR [**1-4**]: c/w CHF
EKG: A-fib in 74 BPM, RBBB, nl axis, nl ST changes.
RUQ U/S: Status-post cholecystectomy. Prominent common bile duct
without evidence of stones or sludge within the bile duct.
CXR: Probable CHF with small pleural effusions. Small focal
ill-defined opacities in right upper lobe, right lung base, and
left lower lobe are consistent with multifocal areas of
pneumonia. No prior films for comparison. Correlate clinically
and with follow-up after therapy.
CTA ABDOMEN/PELVIS ([**2197-1-8**]):
1) Bilateral pleural effusions slightly increased from previous
exam.
2) Diffuse atherosclerotic disease of the abdominal aorta and
its major branches as described. However, normal appearing bowel
with patency of the mesenteric vasculature; no evidence for
bowel ischemia.
3) Uncomplicated anterior abdominal wall hernia
4) Interval mild decrease in size of left retroperitoneal
hematoma.
5) Persistent common bile duct dilatation and intrahepatic
ductal dilatation with no evidence for choledocholithiasis or
obstructing mass.
6) Sigmoid diverticulosis without diverticulitis.
Echo ([**2197-1-9**]): EF>55%, [**2-5**]+ MR; essentially unchanged from
[**2196-12-9**]
ERCP ([**2197-1-14**]): Five fluoroscopic spot film images were
obtained from ERCP. The images show cannulation of the common
bile duct with opacification with contrast. The common bile duct
is massively dilated. The films then show passing of a wire into
the intrahepatic ducts which are also opacified. Opacification
of the intrahepatic ducts show dilatation also. No filling
defects are identified. Pt got stented in the common bile duct
CT ABD/PEVIS/THIGH: ([**2197-1-17**])
1) Interval development of a right thigh swelling consistent
with hematoma.
2) Interval placement of a PTCA catheter, with subsequent
decrease in intrahepatic biliary ductal dilatation. The PTCA
catheter is seen extending from the right thorax through to the
second portion of the duodenum.
3) Interval decrease in size of left retroperitoneal hematoma.
4) Interval decrease in bilateral pleurarl effusions, with
compressive atelectasis.
5) Diffuse atherosclerotic disease of the abdomen aorta and its
major branches as described.
6) Uncomplicated anterior abdominal wall hernia.
7) Sigmoid diverticulosis without evidence of diverticulitis.
8) 2.4 x 1.9 cm right ovarian cyst, again noted. Ultrasound is
recommended for a patient of this age.
[**2197-1-7**] 12:00AM BLOOD WBC-18.4*# RBC-3.84* Hgb-11.4* Hct-35.5*
MCV-93 MCH-29.7 MCHC-32.1 RDW-15.7* Plt Ct-373#
[**2197-1-18**] 04:45AM BLOOD WBC-17.3* RBC-3.56* Hgb-10.7* Hct-32.0*
MCV-90 MCH-30.2 MCHC-33.6 RDW-15.9* Plt Ct-143*
[**2197-1-27**] 06:09AM BLOOD WBC-11.0 RBC-3.34* Hgb-10.0* Hct-30.2*
MCV-91 MCH-30.0 MCHC-33.2 RDW-14.6 Plt Ct-159
[**2197-1-7**] 12:00AM BLOOD Neuts-91.6* Lymphs-3.9* Monos-3.0 Eos-1.4
Baso-0
[**2197-1-25**] 05:25AM BLOOD Neuts-90.3* Lymphs-5.6* Monos-2.0 Eos-2.1
Baso-0
[**2197-1-7**] 12:00AM BLOOD PT-14.0* PTT-27.9 INR(PT)-1.2
[**2197-1-26**] 03:59AM BLOOD PT-12.5 PTT-28.8 INR(PT)-1.0
[**2197-1-16**] 03:15PM BLOOD Fibrino-752*
[**2197-1-16**] 03:15PM BLOOD FDP-0-10
[**2197-1-9**] 04:09AM BLOOD ESR-38*
[**2197-1-7**] 12:00AM BLOOD Glucose-110* UreaN-48* Creat-1.4* Na-139
K-4.4 Cl-104 HCO3-26 AnGap-13
[**2197-1-27**] 06:09AM BLOOD Glucose-100 UreaN-41* Creat-0.7 Na-140
K-4.7 Cl-106 HCO3-29 AnGap-10
[**2197-1-10**] 06:38AM BLOOD Glucose-183* UreaN-67* Creat-2.6*# Na-141
K-5.5* Cl-105 HCO3-30* AnGap-12
[**2197-1-12**] 05:16AM BLOOD Glucose-82 UreaN-89* Creat-4.1* Na-129*
K-5.8* Cl-95* HCO3-23 AnGap-17
[**2197-1-13**] 05:49AM BLOOD Glucose-165* UreaN-68* Creat-3.4* Na-134
K-4.3 Cl-100 HCO3-25 AnGap-13
[**2197-1-7**] 12:00AM BLOOD ALT-20 AST-25 LD(LDH)-212 AlkPhos-386*
Amylase-70 TotBili-0.6
[**2197-1-24**] 06:37AM BLOOD ALT-21 AST-27 LD(LDH)-265* AlkPhos-193*
TotBili-1.3
[**2197-1-7**] 12:00AM BLOOD Lipase-56 GGT-386*
[**2197-1-20**] 02:40PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2197-1-20**] 10:30PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2197-1-21**] 03:20AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2197-1-7**] 12:00AM BLOOD Albumin-2.6* Calcium-8.3* Phos-4.3#
Mg-2.4 UricAcd-8.7*
[**2197-1-16**] 03:15PM BLOOD Hapto-269*
[**2197-1-24**] 06:37AM BLOOD Hapto-161
[**2197-1-10**] 06:38AM BLOOD Triglyc-87
[**2197-1-7**] 12:00AM BLOOD TSH-1.1
[**2197-1-15**] 03:07AM BLOOD Cortsol-22.1*
[**2197-1-16**] 03:15PM BLOOD Cortsol-21.6*
[**2197-1-16**] 04:15PM BLOOD Cortsol-41.3*
[**2197-1-7**] 12:00AM BLOOD Vanco-7.1*
[**2197-1-26**] 03:57PM BLOOD Vanco-15.8*
[**2197-1-24**] 12:40PM BLOOD Type-ART pO2-72* pCO2-41 pH-7.45
calHCO3-29 Base XS-3
[**2197-1-8**] 01:49PM BLOOD Lactate-1.8
[**2197-1-11**] 04:52PM PLEURAL WBC-611* RBC-9778* Polys-19* Lymphs-62*
Monos-2* Plasma-7* Meso-6* Macro-3* Other-1*
[**2197-1-11**] 04:52PM PLEURAL TotProt-2.1 Glucose-92 LD(LDH)-86
Albumin-1.2
[**2197-1-14**] 6:12 pm SWAB Source: COCCYX DECUB.
**FINAL REPORT [**2197-1-18**]**
GRAM STAIN (Final [**2197-1-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2197-1-17**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing E. coli and Klebsiella species.
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2197-1-18**]): NO ANAEROBES ISOLATED.
[**2197-1-15**] 3:06 am SPUTUM Site: EXPECTORATED
**FINAL REPORT [**2197-1-18**]**
GRAM STAIN (Final [**2197-1-15**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2197-1-18**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH. PREDOMINATING
ORGANISM.
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
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
Pt was transferred to the [**Hospital1 18**] CCU since she has a history of
RP bleed several weeks prior to admission and there was a Hct
drop at the outside hospital. The Abdominal CT done at OSH on
[**1-4**] and [**1-6**] showed stable retroperitoneal hematoma. Pt came
in with fever, leukocytosis, Blood Cx and Urine Cx positive for
MRSA, and was started on Vancomycin, Timentin, and levofloxacin
at the OSH. CXR on admission showed multilobar pneumonia/CHF,
and the patient was breathing on non-rebreather and appeared
very somnolent. Pt had diffuse abdominal pain on admission with
elevated alk phos and leukocytosis. Abd CT from the OSH showed
dilated common bile duct and intrahepatic bile duct.
Antibiotics were changed to Vanc and levofloxacin (d/c'd
timentin), and Flagyl was later added for the history of
diarrhea prior to presentation suspicious for C.diff. Pt
remained somnolent, breathing heavily on [**Last Name (LF) 597**], [**First Name3 (LF) **] IV Lasix were
given with minimal effect. Due to the diffuse abdominal pain,
surgery and GI were consulted. There was a concern for
cholangitis, and MRCP was recommended but she was unstable at
that time to go down for the study. There was also concern for
mesenteric ischemia, so pt underwent to CTA of the
abdomen/pelvis which showed patent major mesenteric vasculature,
persistent dilated common bile duct, and stable/slightly
decreased retroperitoneal hematoma. In a setting of getting the
IV contrast and lasix for diuresis for CHF, pt developed acute
renal failure secondary to contrast. Pt was oliguric for
several days requiring HD x3, but eventually UOP improved and
her creatinine came down to her baseline (Cr 1.0). During the
placement of HD quintin cath, she had a complication of R thigh
hematoma but her Hct was stable after transfusion. Due to
persistent abdominal pain, pt underwent ERCP which showed no
evidence of cholangitis; however a stent was placed in the
common bile duct. Prior to ERCP, pt was electively intubated
for ERCP but was noted to have laryngeal edema since it was
difficult to pass the endoscope. Although there was no evidence
of cholangitis, after the stent placement, her alk phos came
down as well as improvement in her abdominal exam showing less
tenderness/guarding and eventually became completely benign.
The stent in the common bile duct should be removed in 3 months.
ID team has been following her and the abx was changed from
Vanc/Levo ->Vanc/levo/flagyl but no improvement in white count
with C.diff negative, so levofloxacin and flagyl were
discontinued and meropenem was added since the culture from her
sacral decub ulcer grew multi-resistant Klebsiella only
sensitive to meropenem/Zosyn/sulfa. All of her blood cultures
showed no growth, and the sputum culture grew MRSA. She had
episodes of hypotension requiring Dopamine for few days until
meropenem was initiated. After meropenem was started in
addition to Vancomycin, pt showed clinical improvement with
decrease in white count, improvement in her respiratory status,
improvement in BP and was able to come off the pressors. Pt got
WBC scan to look for other source of infection but only showed
positive area in the lungs consistent with pneumonia. No
abdominal source of infection was detected. Since she has a
documented Blood culture with MRSA, she will need to complete a
6 week course of vancomycin. She will complete a 2 week course
of meropenem. Her stage II decubitous ulcer on sacrum is cared
by duoderm q 3days. Pt remained intubated after the elective
intubation for ERCP because she had a laryngeal edema and also
to keep her stable for the WBC scan. Pt received IV Solu-Medrol
for 3 days and was successfully extubated on [**1-20**]. When
extubated, pt was found to have difficulty hearing which
improved gradually over time. If she were to have persistent
hearing impairment, she should be seen by ENT as outpatient. In
terms of cardiac issues, pt presented with new a-fib but
immediately converted to sinus rhythm on admission after
receiving amiodarone and metoprolol. There were episodes of
sinus bradycardia to the 30's-40's, so both medications were
held at times. However, once pt was extubated and stable, she
was able to be re-started on metorpolol and Losartan.
Amiodarone was not continued since she was briefly in atrial fib
which was converted immediately and remained in sinus rhythm
since. Since she had a recent left main coronary stent, she
will need to be on [**Last Name (LF) **], [**First Name3 (LF) **], as well as metoprolol, statin,
and [**Last Name (un) **]. She was noted to have copious thick secretion
requiring frequent suctioning, use of flutter valve, mucinex,
and chest PT. There were few episodes where she desaturated to
the low 80's which improved after suctioning. Pt should be
continued on frequent suction, chest PT, and mucinex once
discharge. She complained of R thigh pain prior to discharge
which was though to be musculoskeletal in origin since LENI was
negative for DVT. It did show left perneal superficial thrombus
but no anticoagulation needed to be started.
Medications on Admission:
Meds on Transfer:
Digoxin 0.125 mg po qhs
Amiodarone 400 mg po bid
Vanc 1 gm q12
Tylenol 650 mg po qAM
Albuteral neb
Ipratropium Neb
Levothyroxine 25 mcg po qAM
[**Last Name (un) **] 325 mg po qd
[**Last Name (un) **] 75 mg po qd
Lansoprazole 30 mg po qd
Simvastatin 20 mg po qd
Tylenol
Levofloxacin
Ticarcillin/clvunate 3.1 mg Iv q
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**2-5**] Adhesive Patch, Medicateds Topical Q12 ().
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
9. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): For wound healing.
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): For wound healing.
13. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours) for 3 weeks: Until [**2-15**].
Need to complete 6 week course for MRSA. Day 1 [**1-4**].
14. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 5 days: Need 2 week
course. Day 1: [**2197-1-16**].
15. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
16. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
MRSA Pneumonia / Sepsis
Congestive heart failure
A-fib
Retroperitoneal bleed - stable
Right thigh hematoma
Contrast nephropathy - resolved
Dilated common bile duct s/p stent
Decubitous ulcer colonized with multi-resistant Klebsiella
Malnutrition
Hypothyroid
Discharge Condition:
Hemodynamically stable, breathing on minimal oxygen, able to
tolerate po.
Discharge Instructions:
Patient needs to take all of the medications listed as directed.
Pt needs to seek medical attention if she were to become more
SOB, tachycardic, chest pain, changes in UOP, worsening
abdominal pain, changes in mental status,
fever/chills/nausea/vomiting, or any other concerning symptoms.
Followup Instructions:
Follw up with her PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] in [**2-5**] weeks.
|
[
"995.91",
"707.03",
"482.41",
"576.8",
"518.81",
"038.11",
"427.31",
"584.9",
"998.12",
"459.0",
"285.9",
"428.0",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"96.6",
"38.91",
"99.04",
"38.95",
"38.93",
"96.72",
"93.90",
"99.15",
"34.91",
"96.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
17878, 17948
|
10779, 15907
|
267, 311
|
18250, 18325
|
2781, 10756
|
18663, 18811
|
1919, 1954
|
16291, 17855
|
17969, 18229
|
15933, 15933
|
18349, 18640
|
1969, 2762
|
174, 229
|
339, 1504
|
1526, 1798
|
1814, 1903
|
15951, 16268
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,326
| 101,523
|
4890
|
Discharge summary
|
report
|
Admission Date: [**2118-1-5**] Discharge Date: [**2118-1-14**]
Date of Birth: [**2058-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
fever/hypotension
Major Surgical or Invasive Procedure:
Dialysis catheter removal- left groin
Dialysis catheter placement- left groin temporary [**2118-1-11**] and
permanent [**2118-1-12**]
History of Present Illness:
59M h/o of ESRD due to hypertensive nephropathy with R femoral
tunneled HD line due to multiple AV graft infections (MSSA in
[**10-29**] and [**6-30**], VRE (gallinarum) in [**2105**], CAD s/p MI, CHF,
seizure disorder and CVA, sent from dialysis with fever to
101.8. Blood cultures were sent from HD and he was given
vancomycin 1 gram x1. Able to complete HD. Had not had fevers
prior to HD today. Denies changes in his chronic cough or yellow
sputum production. No abdominal pain, diahrea, soar throat,
nausea, vomiting, or neck stiffness. Also endorses being
constipated x 2 weeks. + Chronic back pain, currently [**7-2**]. No
CP/palpitations. Got H1N1 vaccine 2 days ago; seasonal flu
vaccine 2 weeks ago.
In the ED, initial vs were: T102.8 119 97/52 22 92% on RA.
Patient was given tylenol and levofloxacin 750 mg IV. CXR with
RLL opacity, though does not appear to be significantly changed
from prior. R EJ placed. BPs as low as 81/40, then up to 104/57
and 100/54 prior to transfer to MICU. Received total of 2L IVFs
with 3rd liter hanging.
Past Medical History:
- MSSA HD line infection with septic lung emboli [**9-1**] with left
pleural effusion
- h/o Hepatitis B, treated
- Non-ischemic cardiomyopathy, last EF 40-45%
- MI [**2086**] per pt
- CVA [**2086**] per pt (?residual LE weakness)
- ESRD on hemodialysis [**1-25**] HTN. Currently dialyzed through R
femoral line. EDW 80 kg as of [**2118-1-3**].
- Multiple thrombectomies in LUE and R thigh AV fistula
- Graft excision for infected thigh graft [**2117-5-26**]
- Seizure disorder since mid [**2097**] after starting dialysis
- Hungry bone syndrome status post parathyroidectomy
- Pituitary mass
- Anemia of chronic disease
- s/p PEG tube placement [**2117-10-29**]
Social History:
Patient has a Ph.D. in history. He was an organist and choir
director at a local church.
No recent ETOH, tobacco, or illicit drugs.
Family History:
Father - DM
Mother - Deceased age 41 of renal failure
One son - healthy
Physical Exam:
Vitals: BP 100/54
General: Alert, oriented, no acute distress, midly diahrphoretic
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
Pertinent Results:
Admission labs:
[**2118-1-5**] 12:15PM BLOOD WBC-12.2* RBC-3.29* Hgb-7.9* Hct-27.5*
MCV-84 MCH-24.0* MCHC-28.6* RDW-19.0* Plt Ct-327
[**2118-1-6**] 04:07AM BLOOD PT-14.2* PTT-30.6 INR(PT)-1.2*
[**2118-1-5**] 12:15PM BLOOD Glucose-88 UreaN-20 Creat-3.5*# Na-143
K-3.8 Cl-104 HCO3-32 AnGap-11
[**2118-1-7**] 11:53AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.1
.
Discharge Labs: [**2118-1-14**]
WBC RBC Hgb Hct MCV Plt Ct
6.0 3.52* 8.4* 29.5* 649*
Glucose UreaN Creat Na K Cl HCO3 AnGap
81 23* 6.6*# 141 3.9 98 34* 13
.
[**2118-1-5**] 8:30 am BLOOD CULTURE
**FINAL REPORT [**2118-1-8**]**
Blood Culture, Routine (Final [**2118-1-8**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2118-1-5**]- [**3-27**] sets of positive blood cultures
[**2118-1-6**] - [**2118-1-12**] blood cultures: NGTD
[**2118-1-5**] 10:11 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2118-1-7**]**
MRSA SCREEN (Final [**2118-1-7**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2118-1-6**] 4:03 pm CATHETER TIP-IV Source: Left femoral HD
line.
**FINAL REPORT [**2118-1-8**]**
WOUND CULTURE (Final [**2118-1-8**]): No significant growth.
[**2118-1-5**] CXR:
IMPRESSION:
1. Right lower lobe opacity, similar to the prior examinations;
however, new pneumonia or underlying pulmonary lesion cannot be
excluded. Recommend
follow-up to resolution after appropriate treatment. Small right
pleural
effusion.
2. Slightly more cranial position of a femoral catheter with its
tip in the right atrium.
[**2118-1-6**] ECHO:
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with akinesis of the inferior
septum, inferior and inferolateral segments. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2117-9-6**],
pulmonary artery pressures can be estimated on the current study
and are mildly elevated. The wall motion abnormalities and other
findings are similar.
[**2118-1-6**] FEMORAL ULTRASOUND:
IMPRESSION:
1. No pseudoaneurysm, or fluid collections. There is an enlarged
lymph node within the right groin.
2. Clotted AV graft within the right leg, present on prior CT
examination.
[**2118-1-6**]
IMPRESSION:
Successful removal of a tunneled right common femoral
hemodialysis catheter. The tip was sent for culture.
[**2118-1-11**]
PFI: Successful placement of non-tunneled left femoral
hemodialysis catheter, with tip in the IVC, 24 cm in length,
ready to use. After resolution of hyperkalemia, the patient
should return to interventional radiology for conversion to a
tunneled line.
Brief Hospital Course:
59M with ESRD on HD with tunnelled femoral line, recent
prolonged hospital admission with MSSA bacteremia and lung
abscesses, presents w/ fever and hypotension later found to be
[**1-25**] MSSA.
.
# Hypotension: Patient initially admitted to MICU with
significant hypotension, but resolved upon arrival after
receiving IVF boluses. The most likely etiology of his
hypotension was bacteremia. He grew [**3-27**] sets of positive blood
cultures of MSSA on arrival. His hypotension resolved quickly.
He maintained his blood pressures throughout his
hospitalization. He never required pressors during his MICU
course.
.
# Bacteremia: Patient was initially febrile and hypotensive. He
was found to have 4 sets of MSSA positive blood cultures. The
most likely source was his HD line. He was treated with
vancomycin initially, then transitioned to cefazolin once
sensitivities were back. His femoral dialysis catheter was
removed, and after a line holiday of 5 days, the patient had a
permanent tunnelled left groin dialysis catheter placed without
any difficulty. His CXR also was initially concerning for
possibly a PNA, but the findings were stable since his last
hospitalization. The patient will continue on cefazolin at HD
until [**2-6**]. ID would like weekly CBC w/ differential and LFTs
faxed to [**Hospital **] clinic nurses at ([**Telephone/Fax (1) 1353**]. All questions
regarding outpatient antibiotics should be directed to the
when clinic is closed.
.
# ERSD on HD: Renal was following and received dialysis during
this hospitalization as needed. The patient will continue on his
MWF HD as an outpatient. Will continue calcium carbonate,
lanthanum, sevelamir and renal diet.
# Seizure disorder: Will continue home oxcarbazepine and kepra.
.
# Chronic systolic CHF: As it was unclear why the patient was
not on an ace inhibitor prior to admission, he was started on
lisinopril 10mg daily. A statin was also started while he was
hospitalized, and his digoxin and aspirin were continued. The
patient has cardiology follow up arranged.
Medications on Admission:
- Renagel 1600 mg TID
- PhosLo 2668 mg TID with meals
- OXcarbazepine 300 mg TID plus additional pill post HD.
- Keppra 500 mg TID plus additional pill post HD
- Gabapentin
- ASA 81 mg daily
- Digoxin 125 mcg QOD
- Allopurinol 100 mg daily
- Dilaudid 2-4 mg PO Q4H prn pain
- Epogen [**Numeric Identifier **] units TIW with HD
- Folate 1 mg daily
- ?HSQ
- Sarna lotion
Discharge Medications:
1. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
3. Cefazolin 10 gram Recon Soln Sig: Two (2) grams Injection QHD
(each hemodialysis).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QHD (each
hemodialysis).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q2H as needed
for wheeze.
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
16. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
DAILY (Daily).
17. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
injection Injection three times a day: subcutaneously.
18. Dilaudid-5 1 mg/mL Liquid Sig: 1-4 mg PO every four (4)
hours as needed for pain: hold for sedation or rr<12.
19. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application
Topical as directed: 0.5-0.5% Lotion
APPLY LIBERALLY TO SKIN ON HANDS, FEET .
20. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**] Center
Discharge Diagnosis:
Primary Diagnosis:
1. MSSA bactermia
2. CKD stage V on HD
.
Secondary Diagnosis:
- Non-ischemic cardiomyopathy, EF 35-40% per echo in [**12/2117**]
- MI [**2086**] per pt
- CVA [**2086**] per pt
- Seizure disorder
- Hungry bone syndrome status post parathyroidectomy
- Anemia of chronic disease
Discharge Condition:
Alert, not currently ambulatory
Discharge Instructions:
You were admitted to the hospital for fevers. You were found to
have a bacteria growing in your blood, called MSSA. This was
most likely from your right femoral HD line. Your right femoral
HD line was removed and we temporarily stopped your
hemodialysis. You were treated with antibiotics. You will
continue to get antibiotics at HD. You had another HD line
placed in your left groin, and your resumed hemodialysis. You
tolerated your procedures well.
.
We have made the following changes to your medications:
1. Started Cephazolin 2mg IV at hemodialysis until [**2-6**].
Infectious disease doctors [**First Name (Titles) **] [**Last Name (Titles) 20407**] this date and will
continue to follow you.
2. Started Chlestyramine 4grams by mouth every day
3. Started Atorvostatin 10mg by mouth each day
4. Discotninue PhosLo
5. Started Lanthanum 500mg by mouth twice a day
6. Started calcium carbonate 500mg by mouth three times a day
with meals
7. Started lisinopril 10mg daily
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Appointment #1
MD: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date/ Time: [**2118-2-3**] 2:15pm
Location: [**Location 20408**], [**Location (un) 86**] MA
Phone number: [**Telephone/Fax (1) 5068**]
Special instructions for patient:
.
Appointment #2:
Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Date/Time:[**2118-1-27**] 1:30
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2118-1-14**]
|
[
"585.6",
"428.22",
"412",
"285.21",
"414.01",
"996.62",
"995.91",
"403.91",
"345.90",
"438.89",
"428.0",
"038.11",
"V45.11",
"E879.1",
"274.9",
"275.5",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"39.95",
"38.95",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
11748, 11802
|
7426, 9478
|
331, 466
|
12141, 12175
|
3014, 3014
|
13288, 13871
|
2397, 2471
|
9898, 11725
|
11823, 11823
|
9504, 9875
|
12199, 12681
|
3381, 7403
|
2486, 2995
|
12710, 13265
|
274, 293
|
494, 1545
|
11904, 12120
|
3030, 3365
|
11842, 11883
|
1567, 2231
|
2247, 2381
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,622
| 165,374
|
7139+55818+55813
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2112-10-20**] Discharge Date: [**2112-11-15**]
Date of Birth: [**2032-10-5**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Nortriptyline / Ultram / Diltiazem / Ace
Inhibitors / Norvasc / Percocet / Lipitor / Zetia / Cymbalta
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
labile BP / abdomnal pain
Major Surgical or Invasive Procedure:
Left renal artery stent
History of Present Illness:
79 y/o F returning for abdominal pain and found to have labile
BP in ER.
Past Medical History:
Post-operative AF [**8-5**]
SVT s/p ablation [**4-6**]
CHF, excerbation [**5-6**]
Carotid disease. Asymptomatic. Rt. 60-69% Lt. 40-59%
HTN
Hypercholestremia
COPD
Hiatal hernia with reflux
Gastritis
CRI
Anemia
Past Surgical History
AAA 4.7 cm. s/p Endovascular AAA repair [**1-7**]
s/p ovarian cyst ecxision with appendectomy [**4-/2059**]
s/p CCY [**2-/2080**]
s/p spinal surgery [**6-/2085**]
s/p spinal fusion [**8-5**]
s/p Rt. SFA-TPT vein graft [**10-4**]
[**3-9**] Extensor hallucis longus tenoplasty, Z-lengthening. and
Fifth toe proximal interphalangeal joint derotational
arthroplasty.
[**2112-7-12**] Brachial access with aortogram, celiac balloon
angioplasty and stent, superior mesenteric artery stent.
ALLERGIES: sulfa - nausea and vomiting SOB. Elavil - rash. Ace -
creatinine elevation. Ultram - rash.
Social History:
The patient lives at home with a daughter in [**Name (NI) 4628**],
previously a homemaker
Tobacco: 60 years x 2PPD: 120 pk-yr, quit [**2096**]
ETOH: None
Illicits: None
Family History:
Non-contributory
Physical Exam:
a/o
supple
farom
neg lyphandopathy
cta
regular
abd / hard to assess / pt c/o pain - work-up neagative
left flank incision / well healed
Right DP/PT palp Left DP dop, PT palp
Pertinent Results:
[**2112-11-2**] 08:40AM BLOOD
WBC-5.3 RBC-3.29* Hgb-10.3* Hct-31.3* MCV-95 MCH-31.4 MCHC-32.9
RDW-18.0* Plt Ct-348#
[**2112-10-26**] 05:45AM BLOOD
PT-12.8 PTT-28.0 INR(PT)-1.1
[**2112-11-2**] 08:40AM BLOOD
Glucose-102 UreaN-15 Creat-1.0 Na-145 K-4.4 Cl-114* HCO3-25
AnGap-10
[**2112-11-2**] 08:40AM BLOOD
Calcium-8.7 Phos-3.4 Mg-2.1
[**2112-10-21**] 10:15PM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
URINE RBC-0 WBC-37* Bacteri-MOD Yeast-OCC Epi-0
[**2112-10-21**] 10:15 pm URINE Source: Catheter.
URINE CULTURE (Final [**2112-10-24**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
pt admitted from er with labile BP
pre-hydrated for angio
angiogram - underwent arteriography today for renovascular
hypertension. A high-grade stenosis was seen at the origin of
the left renal artery. The distal artery appeared normal. This
was dilated with a 6-mm balloon expandable stent with a good
technical result. She has less significant stenosis of the
right
renal artery. Her celiac and SMA stents appeared to be patent.
sheath pulled with out sequele
BP control with IV medications / swithed to PO / on DC BP stable
post labs stable
pt was c/o vague abdominal pain / work-up negative
Pain consult / pain meds adjusted
pt
stable for dc to rehab
Medications on Admission:
CloniDINE 0.3 mg PO TID hold for SBP<110, HydrALAzine 100 mg PO
Q6H hold for SBP<110, Isosorbide Dinitrate 40 mg PO TID hold for
SBP<110, Metoprolol 50 mg TID, Bisacodyl 10 mg PRN , Docusate
Sodium 100 mg [**Hospital1 **], Losartan Potassium 25 , Aspirin EC 81 mg,
Albuterol PRN Simvastatin 40 mg, Ipratropium Bromide prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for breakthrough.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): wean .
18. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
renal artery stenosis
abdominal pain, labile BP
COPD, CHF, HTN, ^Chol,GERD, CRI, Anemia
Discharge Condition:
good
Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
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 [**2-6**]
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 [**3-6**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2112-12-16**] 9:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2112-12-19**]
8:00
Electrophysiology Lab Cardiology W/[**Hospital Ward Name **] 4 [**Hospital1 18**] ([**Telephone/Fax (1) 8793**].
call to schedule an appointment for pacer interogation
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2112-12-28**] 9:00
Completed by:[**2112-11-3**] Name: [**Known lastname 4583**],[**Known firstname 69**] B. Unit No: [**Numeric Identifier 4584**]
Admission Date: [**2112-10-20**] Discharge Date: [**2112-11-15**]
Date of Birth: [**2032-10-5**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Nortriptyline / Ultram / Diltiazem / Ace
Inhibitors / Norvasc / Percocet / Lipitor / Zetia / Cymbalta
Attending:[**First Name3 (LF) 1546**]
Addendum:
Pt had one day extension
Pt dropped BP to 48/20
fluid resusitated
stat HCT 29
r/o for MI
Culprit was Medication combo of BP meds and pain meds
meds adjusted
pt stable for Dc
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2112-11-4**] Name: [**Known lastname 4583**],[**Known firstname 69**] B. Unit No: [**Numeric Identifier 4584**]
Admission Date: [**2112-10-20**] Discharge Date: [**2112-11-15**]
Date of Birth: [**2032-10-5**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Nortriptyline / Ultram / Diltiazem / Ace
Inhibitors / Norvasc / Percocet / Lipitor / Zetia / Cymbalta
Attending:[**First Name3 (LF) 1546**]
Addendum:
Addendum to hospital course:
On the planned day of discharge, pt had a low grade fever
initially. UA showed likely UTI. Oral Cipro was started. That
afternoon pt had rigors, tachypnea. Trigger was initiated.
Temp was 103.1, HR 120s. EXG showed Atrial flutter with some ST
depressions. Was rate controlled with IV lopressor which
reversed these changes. IV Zosyn, Vanco, and Fluconazole was
started. She was hydrated as well. Her vital signs improved.
Over night she became hypotensive and had low urine output,
likely septic physiology due to urosepsis. She was bolused with
good response. The next day, after hydration, it was noted her
Hct was 25 down from 34. She was transfused 2 units of PRBC.
A ID consult was obtained. PAN cx'd as below.
URINE CULTURE (Final [**2112-11-9**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2112-11-7**] 1:24 pm BLOOD CULTURE Source: Venipuncture.
AEROBIC BOTTLE (Final [**2112-11-10**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
PICC line placed
CHEST PORT. LINE PLACEMENT [**2112-11-12**] 3:13 PM
REASON FOR EXAM: Assess repositioning of right PICC.
Comparison is made with prior study performed two hours early.
Right PICC has been repositioned, the tip now projects in the
mid SVC. There are no other acute interval changes. There is no
pneumothorax.
IV AB tailored to above organisms. Pt to recieve 8 weeks of IV
VANCOMYCIN. PT TO BE ON PO TETRACYLINE FOR LIFE. ID TO do this
on follow-up.
PT Consult / OT consult
ON DC pt is stable
f/u arrangements made
Major Surgical or Invasive Procedure:
Left renal artery stent [**2112-10-24**]
PICC line placement [**2112-11-10**]
Brief Hospital Course:
Addendum to hospital course:
On the planned day of discharge, pt had a low grade fever
initially. UA showed likely UTI. Oral Cipro was started. That
afternoon pt had rigors, tachypnea. Trigger was initiated.
Temp was 103.1, HR 120s. EXG showed Atrial flutter with some ST
depressions. Was rate controlled with IV lopressor which
reversed these changes. IV Zosyn, Vanco, and Fluconazole was
started. She was hydrated as well. Her vital signs improved.
Over night she became hypotensive and had low urine output,
likely septic physiology due to urosepsis. She was bolused with
good response. The next day, after hydration, it was noted her
Hct was 25 down from 34. She was transfused 2 units of PRBC.
A ID consult was obtained. PAN cx'd as below.
URINE CULTURE (Final [**2112-11-9**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
[**2112-11-7**] 1:24 pm BLOOD CULTURE Source: Venipuncture.
AEROBIC BOTTLE (Final [**2112-11-10**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
PICC line placed
CHEST PORT. LINE PLACEMENT [**2112-11-12**] 3:13 PM
REASON FOR EXAM: Assess repositioning of right PICC.
Comparison is made with prior study performed two hours early.
Right PICC has been repositioned, the tip now projects in the
mid SVC. There are no other acute interval changes. There is no
pneumothorax.
IV AB tailored to above organisms. Pt to recieve 8 weeks of IV
VANCOMYCIN. PT TO BE ON PO TETRACYLINE FOR LIFE. ID TO do this
on follow-up.
PT Consult / OT consult
ON DC pt is stable
f/u arrangements made
Medications on Admission:
[**Last Name (un) **]: CloniDINE 0.3 mg PO TID hold for SBP<110, HydrALAzine 100
mg PO Q6H hold for SBP<110, Isosorbide Dinitrate 40 mg PO TID
hold for SBP<110, Metoprolol 50 mg TID, Bisacodyl 10 mg PRN ,
Docusate Sodium 100 mg [**Hospital1 **], Losartan Potassium 25 , Aspirin EC
81 mg, Albuterol PRN
Simvastatin 40 mg, Ipratropium Bromide prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for breakthrough.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): wean .
18. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
19. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
20. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
21. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
22. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
23. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-5**] Sprays Nasal
QID (4 times a day) as needed.
24. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4H (every 4 hours) as needed.
25. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO three times a
day: hold for SBP<110.
26. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every six
(6) hours: Hold for SBP<110.
27. PICC line Care
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.
28. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day for 8 weeks: Moniter trough / creat / trough goal is
15-20.
29. Tetracycline 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] - [**Location (un) **]
Discharge Diagnosis:
renal artery stenosis
abdominal pain, labile BP
COPD, CHF, HTN, ^Chol,GERD, CRI, Anemia
post angio constipation,treated
post renal stenting hypertention,resolved
post angio fever 102.1,MRSA septcemia
post angio E coli urinary infection
Discharge Condition:
good
Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Angioplasty/Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
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 [**2-6**]
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 [**3-6**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range **] office [**Telephone/Fax (1) 283**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
moniter vanco trough, cbc, bun and creatinine while patient is
on antibiotics for 6-8 weeks
PICC line care as to protochol
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], MD Phone:[**Telephone/Fax (1) 283**]
Date/Time:[**2112-12-16**] 9:00
Provider: [**Name10 (NameIs) 282**] LAB Phone:[**Telephone/Fax (1) 283**] Date/Time:[**2112-12-19**]
8:00
Electrophysiology Lab Cardiology W/[**Hospital Ward Name **] 4 [**Hospital1 8**] ([**Telephone/Fax (1) 4585**].
call to schedule an appointment for pacer interogation
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3268**], MD Phone:[**Telephone/Fax (1) 227**]
Date/Time:[**2112-12-28**] 9:00
Provider: [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 4586**], MD Phone:[**Telephone/Fax (1) 496**]
Date/Time:12/o3/07 11:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2112-11-15**]
|
[
"272.0",
"789.00",
"372.30",
"458.29",
"V09.0",
"428.30",
"V45.01",
"428.0",
"405.01",
"038.11",
"496",
"599.0",
"338.29",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"00.40",
"88.45",
"38.93",
"00.45",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
18536, 18601
|
13092, 13104
|
12989, 13069
|
18882, 18889
|
1805, 3190
|
21625, 22513
|
1577, 1595
|
15780, 18513
|
18622, 18861
|
15410, 15757
|
13122, 15384
|
18913, 20897
|
20923, 21602
|
1610, 1786
|
339, 366
|
457, 531
|
553, 1374
|
1390, 1561
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,654
| 131,701
|
14500
|
Discharge summary
|
report
|
Admission Date: [**2132-6-25**] Discharge Date: [**2106-1-18**]
Date of Birth: [**2075-7-17**] Sex: M
Service: Vascular
CHIEF COMPLAINT: Bilateral blue toes
Information was obtained from chart review and the patient,
who is reliable.
HISTORY OF PRESENT ILLNESS: This is a 56-year-old white male
with a history of carotid disease, status post right internal
carotid artery stenting in [**Month (only) 116**] of this year, known coronary
artery disease, status post coronary artery bypass graft, who
was referred to Dr. [**Last Name (STitle) **] for "blue toes". He was seen by
Dr. [**Last Name (STitle) **] on [**2132-6-10**]. He gives a 10 year history of
bilateral calf claudication. At one block, he denies rest
pain with onset of blue toes, left greater than right, one
week ago. The patient is to undergo arteriogram and then be
admitted over night for observation. The patient was
evaluated by cardiology prior to discharge. Their
recommendations were that a P-MIBI was optional, given the
patient has had recent revascularization and he is
asymptomatic and subsequently decreased his amount of
smoking. Recommendations were to discontinue the Plavix five
days prior to surgery, follow electrocardiograms and cycle
enzymes postoperatively. The patient returns now for
elective revascularization.
PAST MEDICAL HISTORY:
1. Coronary artery disease
2. Non Q wave myocardial infarction in [**Month (only) 116**] of this year with
subsequent coronary artery bypass x5 with a left internal
mammary artery to LAD and saphenous to the left PDA and
saphenous to the obtuse marginal and diagonal on [**2132-4-21**].
3. History of carotid stenosis, status post stenting of the
right internal carotid artery on [**2132-4-17**] with a recently
diagnosed subclavian steal syndrome on the right.
4. History of transient ischemic attacks
5. History of congestive heart failure, ejection fraction of
30%
6. History of insulin dependent diabetes
7. History of hypertension
8. History of peripheral vascular disease
9. History of chronic obstructive pulmonary disease
10. History of mild mitral regurgitation
11. History of dyslipidemia
12. History of prostate carcinoma
MEDICATIONS:
1. Glipizide XL 5 mg qd
2. Metoprolol 50 mg [**Hospital1 **]
3. Pravastatin 10 mg qd
4. Plavix 75 mg qd
5. Aspirin 325 mg qd
6. Ambien 5 mg at hs prn
7. Levaquin 500 mg qd
PREOPERATIVE LAB WORK: White count 8.5, hematocrit 39.5,
platelets 320,000. INR, PTT, PT were all normal. BUN 27,
creatinine 1.1, potassium 4.6.
Cardiac catheterization prior to coronary artery surgery,
left main trunk was 60% stenosis with diffuse disease of the
left anterior descending with a mid 80% stenosis. The left
circumflex was diffuse disease with a proximal stenosis of
50% and distal stenosis of 70%. The left PDA had luminal
irregularities. The right coronary was non dominant with
hepatic vessel. There was elevation of the left ventricular
and diastolic pressure. The PA pressure was 26/9. Mean
pulmonary artery pressure was 11 mm. There was global
hypokinesis with an ejection fraction of 39%. There was no
segmental ostial disease of the innominate, the left
subclavian or left common carotid arteries. Abdominal angio
did show that the left renal artery was non visualized, but
the [**Female First Name (un) 899**] was occluded with a patent SMA and celiac arteries.
Otherwise, there was no other disease of the infrarenal, the
bilateral common iliacs were okay. The patient is now
admitted for elective revascularization.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2132-6-25**]. He underwent
aortobifemoral bypass with bilateral femoral popliteal
bypasses with Dacron. He tolerated the procedure well. He
was transferred to the PACU in stable condition. He remained
afebrile, hemodynamically stable. Blood gases were 7.33, 37,
150, 20 minus 5. He was on an SIMV of 50%, 700 x10 with 5 of
PEEP. His MV was 70%. The patient continued to do well. He
had a faintly palpable right PT with triphasic dopplerable
signal on the right and triphasic dopplerable PT on the left.
The patient was transferred to the SICU for continued care
and respiratory support. He was followed by the acute pain
service and analgesic control with an epidural.
Postoperative day 1, the patient had no overnight events. He
did require fluid bolusing and nitroglycerin for afterload
reduction. His postoperative hematocrit was 31.6. BUN,
creatinine and potassium remained stable. The patient was
extubated. Epidural was continued.
Postoperative day 2, his hematocrit was 27.0. His troponin
was less than 0.3. He remained hemodynamically stable. He
had been extubated. His Lopressor was increased for
afterload reduction. He received 1 unit of packed red blood
cells with Lasix and he was transferred to the VICU for
continued monitoring and care. His epidural infusion was
augmented to 10 mg for analgesic control.
Postoperative day 4, he continued to do well with a low grade
temperature though of 100.4??????. Hematocrit remained stable at
27.2. BUN and creatinine were stable at 14 and 1.0.
Epidural was discontinued and he was converted to oral
analgesics. He was begun on a regular diet.
DICTATION ENDS ABRUPTLY
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3409**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2132-7-1**] 11:10
T: [**2132-7-1**] 11:20
JOB#: [**Job Number 42846**]
|
[
"276.2",
"440.22",
"428.0",
"250.00",
"V45.81",
"V10.46",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"96.71",
"39.25",
"39.29",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
3568, 5555
|
159, 258
|
287, 1335
|
1357, 3550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,041
| 155,671
|
13293
|
Discharge summary
|
report
|
Admission Date: [**2152-3-28**] Discharge Date: [**2152-5-25**]
Date of Birth: [**2152-3-28**] Sex: F
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 40474**] is a former
26 [**1-13**] week female born at 540 gm delivered at 7:17 on [**2152-3-28**].
screens 0 positive, antibody negative, hepatitis B surface
antigen negative, RPR nonreactive, GBS unknown and human
immunodeficiency virus negative. Mom developed severe
pregnancy-induced hypertension which progressed to eclampsia
with a seizure at 4:20 AM on the morning on delivery. Fetal
heart tracings showed decelerations during this event but
stabilization afterwards. Mother initially presented on
The baby was known to have intrauterine growth restriction.
Mother was treated with Betamethasone on [**3-26**].
Past obstetric history revealed two miscarriages and one term
infant in [**2137**].
Delivery was by cesarean section with Apgars 5 at one minute
and 7 at five minutes. The baby was intubated in the
Delivery Room and was transferred to the Newborn Intensive
Care Unit for ongoing care.
PHYSICAL EXAMINATION: On admission weight 540 gm, less than
10th percentile, length 30.5 cm 10th percentile, head
circumference 22.5 cm 10th percentile. Current weight 1465
gm, 10th percentile, length 35 cm, 10th percentile, head
circumference 30.25 cm, less than 25th percentile.
Vital signs on admission revealed temperature 37, heartrate
156, respiratory rate 40s, blood pressure 49/25 with a mean
of 34. The baby appeared slightly dysmorphic on admission
with prominent frontal bossing and possibly rocker-bottom
feet. Anterior fontanelle soft and flat, large with sutures
slightly open and large posterior fontanelle. Red reflexes,
not clearly visible. Pupillary membrane present.
Respiratory equal with slightly forced breathsounds.
Cardiovascular, S1 and S2 normal intensity, no murmur.
Abdomen soft, three vessel cord. Genitourinary normal for
gestational age female. Extremities, feet somewhat flat.
Neurological, good tone, active responses to touch. Of note,
chromosomes ultimately were sent and were 46 XX within normal
limits.
Current physical examination reveals with endotracheal tube,
3.0 cm tube taped at 7.4 cm marker at the lip on ventilator
settings of 27/7 and a rate of 36, requiring FIO2 of 30 to
40%. Bilateral breathsounds are coarse and equal. Heartrate
is 140s to 160s with a soft systolic murmur. Pulses are
equal times four. Baseline blood pressure is 60s to 70s/30s
to 40s with means in the 40s to 50s. Abdomen is distended,
full, no bowel sounds. Small umbilical hernia. [**Last Name (un) 37079**]
tube to slow intermittent suction. Anterior fontanelle, soft
flat and full with suture split. Baby is lethargic with a
Fentanyl drip running. She has a central PICC line in and a
peripheral intravenous line.
HOSPITAL COURSE: Respiratory - The baby initially received
three doses of Surfactant and required conventional
ventilation with peak pressures of 22/5 and a rate of 35.
She transitioned to the high frequency ventilator on day of
life #2. She had peak pressures of MAP of [**9-15**] and Delta P
of 22, required several bicarbonate boluses for metabolic and
respiratory acidosis. She ultimately transitioned again to
the conventional ventilator on day of life #12 with settings
of 22/6 and a rate of 28, requiring 35% oxygen. Her
respiratory and general support escalated around [**4-19**] when
she developed Staphylococcus aureus pneumonia with a positive
trach aspirate. She was critically ill which required not
only high ventilator settings but also prolonged course of
antibiotics, see Infectious Disease below. The baby
ultimately developed large bilateral pneumatoceles which are
present on chest x-ray. She has remarkably weaned her vent
settings over the last several days from 28/7 and a rate of
40, overnight on [**5-23**] to 19 escalated to 100% oxygen and
began a watch for necrotizing enterocolitis. Today she had a
gas at 5 AM of 7.28, 54. She has had her rate weaned over
the course of the day with her last decrease down to a rate
of 36 with 27/7 and oxygen requirement of 30 to 40%. Her
last gas approximately 1600 hours of 740, 43, 59, 28 and 0
which prompted decrease in rate from 38 to 36.
Cardiovascular - The baby initially did not require any
pressor support on admission, had a soft murmur. She has had
numerous echocardiograms, the first one being on [**3-29**]
which showed a probable patent ductus arteriosus with
supersystemic right ventricular pressure. She received
another echocardiogram on day of life #3 which showed a large
patent ductus arteriosus with left to right flow and right
ventricular hypertrophy. She had completed that course and
ultimately progressed without further issues of the duct.
She had a follow up echocardiogram on [**4-3**] that showed no
patent ductus arteriosus with right ventricular pressure
greater than half the systemic and again on [**4-17**], which
showed no patent ductus arteriosus, no evidence of vegetation
and no ventriculoseptal defect. Plan would have been to
repeat another echocardiogram when she completed her
antibiotics if not indicated sooner. On [**5-15**], Pulmonary
was consulted and agreed with the current treatment plan.
The baby had been receiving [**Name (NI) 19188**] 2 puffs q. 8 hours
which continues. She was receiving Diuril 30 mg p.g. b.i.d.
which is 20 mg/kg/dose. This has been on hold since she was
made NPO on [**5-24**]. The last dose was on [**5-23**]. She also
was receiving [**Doctor First Name 233**]-Cl supplements 1.5 mEq p.g. b.i.d., last
dose on [**5-23**], in PM.
Fluids, electrolytes and nutrition - The baby initially was
NPO. She had a radial artery line inserted and a double
lumen umbilical vein catheter through which she received
maintenance intravenous fluids and parenteral nutrition.
Trophic feedings were started on day of life #7. She
achieved full feedings by day of life #12. When she became
sick with Staphylococcus aureus she was once again made NPO
and enteral feedings were reintroduced on day of life #42.
She had frequent stops and starts but ultimately achieved
full enteral feedings of breastmilk or PE 22. Feedings again
were held on [**5-23**] into [**5-24**] when her belly became
distended and on [**5-24**] she passed a bloody mucousy stool.
She currently is receiving PN 12.5% glucose, 2 gm of protein
and 1 gm of fat with 2 mEq/100 cc of sodium chloride and 2
mEq/100 cc of potassium acetate. She currently has a central
PICC line in place and a peripheral intravenous line. She
had electrolytes within normal limits on [**5-22**] with a
sodium of 135, potassium of 4.6, chloride 101 and carbon
dioxide of 23. Her sodium has trended downward with a low of
127, 3.4, 89, 21, on [**5-25**] in AM BUN 22, creatinine .5. At
the time of this dictation, there is a set of electrolytes
pending. Her PN written for [**5-24**] has not been hung at the
time of this dictation. She is NPO with [**Last Name (un) 37079**] to low
intermittent suction. This has put out approximately 2 cc of
tan mucousy fluid. Her abdominal girth as increased over the
last several days from 24 cm to 27 cm. She has had no stools
since [**5-24**] and her urine output in the past 24 hours is
approximately 2 cc/kg/hr.
Gastrointestinal - The baby initially demonstrated
physiologic jaundice and received phototherapy and has
demonstrated a high direct bilirubin for which she has been
treated with Phenobarbital and Actigall which was started nearly
2 days ago . Her Phenobarbital started on [**4-18**] when her
bilirubin was 8.9/7.3, 1.6. Her last bilirubin on [**5-22**] was
8/6.1 1.9. Her Phenobarbital current dose is intravenously 7 mg
q.d. Actigall was started on [**5-23**], dose 15 mg p.g. q. 12
hours, this is currently on hold.
Hematology - The baby is 0 positive, Coombs negative and has
received numerous blood transfusions. Her hematocrit has
dropped over the last 24 hours from 43 to 28. She is
currently receiving a total of 20 cc/kg divided into two
aliquots, the first is in the progress of infusing now. The
baby also has required platelets in the last 24 hours. Her
platelet count dropped from 73,000 down to 42,000. She
received 20 cc/kg of platelets this morning [**5-25**] and
platelet count is pending at the time of this dictation.
PT/PTT and fibrinogen are also pending as well as D-Dimer.
Infectious disease - The baby's original blood culture and
complete blood count on admission had a white count of 2.2
with 26 polys, 0 bands, 63 lymphocytes and platelet count of
137,000 and hematocrit of 39. Her neutropenia was thought to
be related to maternal pregnancy-induced hypertension and
bone suppression. At 48 hours the cultures were negative and
the antibiotics were discontinued. On [**4-6**], day of life 9
she for lability had a repeat blood culture and complete
blood count sent and was started on 48 hours of Vancomycin
and gentamicin. She received a blood transfusion at that
time and looked clinically improved and antibiotics were
discontinued. Again on [**4-17**] to [**4-18**] she had a sepsis
evaluation because of instability and also right upper lobe
collapse on chest x-ray. She was started on Vancomycin,
Gentamicin, and Ceftazidime. On [**4-19**], her trach aspirate
was positive for Staphylococcus aureus. She was continued on
Vancomycin and Gentamicin and was ultimately switched to
Gentamicin and Oxacillin. She received 21 days of
Gentamicin, Oxacillin continued for 29 days and then was
switched to Zosyn. After consulting with Infectious Disease
and General Surgery her current regime includes Meropenem 30
mg/kg q. 8 hours which equals 44 mg/dose and Gentamicin 4.5
mg intravenously which is 3 mg/kg q. 24 hours.
Other positive results - [**5-16**], Urine culture positive for
Escherichia coli which was resistant to Ampicillin,
Piperacillin and Trimethoprim. [**5-17**], Urine fungal culture
negative. [**5-17**], Blood fungal culture negative.
Cerebrospinal fluid fungal culture negative. [**5-18**], Blood
culture negative for fungus and bacteria. [**5-15**], she had
an abdominal ultrasound done to rule out abscess. No abscess
was seen. She was noted to have nephrocalcinosis and a small
sludge gallbladder. [**5-20**], Cerebrospinal fluid was
negative. [**5-24**], Blood culture remains negative to date.
Complete blood count serially from [**5-24**], started with
white count of 14.3 with 40 polys, 0 bands, 61 lymphs and
platelet count of 73,000, hematocrit of 43.8. Later in the
day white count dropped to 6.2 and platelet count to 42,000,
hematocrit 36.7. Early AM on [**5-25**], white count was 4.6
with 49 polys, 13 bands and platelet count of 42,000. At
that time she received 20/kg as stated above of platelets and
is receiving packed red blood cells. Serial KUBs are
included with this dictation and are concerning for dilated
bowel loops, possible pneumatosis and we have been watching
closely for free air. Dr. [**Last Name (STitle) 40475**] from the [**Hospital3 18242**] from the Surgical Department has consulted and we
have also consulted with the Infectious Disease Team at the
[**Hospital3 1810**].
While she is at [**Hospital1 **], if it's possible for her to have
immunology consultation due to the fact that she had multiple
bout of infections with this time with multiple bacteria.
Neurology - The baby has had serial head ultrasounds done,
the last one being on [**4-18**], all within normal limits. The
baby is on a Fentanyl drip, was on 2 mcg/kg/hr on [**5-25**] AM,
which was increased to 3 mcg/kg/min. She has been on a
Fentanyl drip since [**4-28**]. She was started at 2 mcg/kg/hr,
achieved a maximum of 4 mcg/kg/hr by [**5-12**] and has been
weaning down with her dose being down to 2 mcg/kg/hr on [**5-23**] and [**5-24**]. Today we resumed to 3 mcg/kg/hr.
Sensory audiology screening has not been done to date.
Ophthalmology - Her eye examination, last one done on [**5-17**], which showed immature Zone 2 with a plan to repeat in two
weeks. Dr. [**Last Name (STitle) 5444**] is the pediatric ophthalmologist that
has done her eye exam.
Psychosocial - Social Work has been following Mom. Social
worker is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 40476**] in Newborn Intensive Care Unit at
[**Hospital6 256**]. Parents are Mom
[**Name (NI) 6177**] and father [**Name (NI) **] [**Name (NI) 5621**], each have a 14-ish year
old child from previous relationships. They all live
together. Parents visit frequently, Mom daily and are
appropriately concerned about [**Known lastname 40477**]. They are aware of the
transport to the [**Hospital3 1810**] and severity of illness.
CONDITION ON DISCHARGE: Guarded.
DISCHARGE DISPOSITION: To [**Hospital3 1810**]. Pediatrician
is Dr. [**Last Name (STitle) **], [**First Name3 (LF) 3924**] [**Hospital **] Medical Associates.
CARE RECOMMENDATIONS:
1. Continue NPO with close observation for necrotizing
enterocolitis.
2. Medications - She is currently on Meropenem 44 mg
intravenously q. 8 hours which equals 38 mg/kg q. 8 hours,
Gentamicin 4.5 mg intravenously which equals 3 mg/kg,
[**Hospital 19188**] 2 puffs via endotracheal tube q. 8 hours,
Phenobarbital 7 mg intravenously q.d. Diuretics are on hold.
[**Doctor First Name 233**]-Ciel supplements are on hold. Zosyn was discontinued
[**5-25**]. Fentanyl drip 3 mcg/kg/hr.
3. State newborn screens have been serially done, initially
there were some repeats done because of presumed prematurity
and the last one was in range.
4. Immunizations received, due for 60 day immunizations this
week, none received to date.
5. Immunizations recommended - I. Synagis respiratory
syncytial virus prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: A. Born at less than 32 weeks; B. Born between
32 and 35 weeks with plans for daycare during respiratory
syncytial virus season, with a smoker in the household or
with preschool siblings; or C. With chronic lung disease.
Influenza immunization should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
6. Follow up appointments - Per routine.
DISCHARGE DIAGNOSIS:
1. Former 26 weeker, currently corrected to 34 2/7 weeks
2. Respiratory distress syndrome
3. Status post pulmonary hemorrhage
4. Status post Staphylococcus aureus pneumonia
5. Chronic lung disease with pneumatoceles
6. Status post patent ductus arteriosus with treatment with
Indomethacin
7. Positive trach aspirates for stenotrophomonas maltophilia 8.
Escherichia coli urinary tract infection
9. Hyper direct bilirubinemia
10. Rule out necrotizing enterocolitis
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (NamePattern1) 38253**]
MEDQUIST36
D: [**2152-5-25**] 16:34
T: [**2152-5-25**] 22:00
JOB#: [**Job Number 26684**]
|
[
"769",
"776.1",
"V30.01",
"771.8",
"038.42",
"774.2",
"765.02",
"482.41",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.72",
"96.6",
"38.93",
"03.31",
"96.04",
"38.91",
"99.83"
] |
icd9pcs
|
[
[
[]
]
] |
12777, 12915
|
14451, 15173
|
2867, 12718
|
12937, 14430
|
1113, 2849
|
151, 1090
|
12743, 12753
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,960
| 105,322
|
31693
|
Discharge summary
|
report
|
Admission Date: [**2185-10-17**] Discharge Date: [**2185-10-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP and papillotomy with removal of 3 gallstones:
Details as follows:
1. A single periampullary diverticulum with small opening was
found at the major papilla.
2. Cannulation of the biliary duct was successful and deep with
a sphincterotome using a free-hand technique.Three round stones
ranging in size from 4mm to 6mm that were causing partial
obstruction were seen at the lower third of the common bile
duct. The CBD was mildly dilated to 10 mm.
3. The intrahepatic cholangiogram was normal with no filling
defects.
4. A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire.
5. Three stones and sludge were extracted successfully using a
12 mm balloon.
History of Present Illness:
87 yo M who was admitted to the vascular surgery service on
[**2185-10-17**] with intermittent epigastric pain w/ eating x ~1 week.
He also had several episodes of vomiting after eating which
releaved the pain. CTA at OSH found questionable evidence of
aortic dissection in 3 areas and he was transferred to [**Hospital1 18**] for
further care. On further review of CT scan after admission it
was determined that the patient had stable endovascular
ulcerations and not an aortic dissection.
.
On further investigation of abdominal pain the patient was found
to have elevated LFT's and bilirubin and was found to have
suggestion of cholecystitis and choledocholithiasis on MRCP. He
was treated with ERCP and sphincterotomy with extraction of
three stones and sludge on [**2185-10-19**].
.
Following ERCP he was transferred to the MICU for concern for
hypertensive urgency vs emergency. He was treated with
metoprolol and captopril as well as NTG drip with goal MAP of
85. Mental status change felt to be [**3-4**] combination of pain
medications and underlying dementia.
Past Medical History:
PMH:
1. Prostate CA s/p XRT
2. Hypercholesterolemia
3. Low back pain
.
PSH: Prostate surgery (lower midline scar)
Social History:
Retired from state legislature. Lives with his wife near
[**Name (NI) 1474**]. Plays golf frequently. Smoked 1PPd x 30 yrs but quit
30 years ago. Drinks an alcoholic beverage 1- 2 x month. No hx
of heavy EtOH use. No hx of tatoos or IVDU.
Family History:
father w/ CVA in 80s
Physical Exam:
Vitals:
Gen: well appearing, nad
HEENT: no scleral icterus, EOMI, op - mmm
Neck: no lad
Lungs: clear bilaterally
Cards: distant heart sounds, regular, no murmurs
Abd: + bs, soft, non-tender, no hsm
Ext: no edema
Neuro: aao x 3, no asterixis
Skin: no jaundince, no telangiectasias
Pertinent Results:
[**2185-10-19**] 06:05AM BLOOD WBC-7.0 RBC-4.03* Hgb-13.7* Hct-38.9*
MCV-97 MCH-33.8* MCHC-35.1* RDW-13.5 Plt Ct-182
[**2185-10-19**] 06:05AM BLOOD Plt Ct-182
[**2185-10-19**] 06:05AM BLOOD Glucose-105 UreaN-13 Creat-1.0 Na-140
K-3.9 Cl-106 HCO3-24 AnGap-14
[**2185-10-19**] 06:05AM BLOOD ALT-124* AST-38 AlkPhos-126* Amylase-23
TotBili-1.2
[**2185-10-19**] 06:05AM BLOOD Albumin-3.3* Calcium-8.7 Phos-1.7* Mg-2.2
[**2185-10-18**] 02:40AM BLOOD Lipase-15
[**2185-10-17**] 08:00AM BLOOD Lipase-15
.
[**2185-10-17**] RADIOLOGY Final Report
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2185-10-17**] 10:35 AM
Reason: eval for gallbladder path
COMPARISON: None.
[**Doctor Last Name **] scale and doppler images of the right upper quadrant. The
liver is unremarkable in echotexture without evidence of focal
lesion. There is hepatopetal flow demonstrated in the portal
vein. Multiple shadowing stones are noted within the
gallbladder. There is no son[**Name (NI) 493**] [**Name2 (NI) 515**] sign, biliary duct
dilatation, or pericholecystic fluid to suggest acute
cholecystitis. The common bile duct measures 4 mm. The pancreas
is grossly unremarkable. The right kidney is unremarkable
without hydronephrosis. No ascites is seen.
.
IMPRESSION:
.
Cholelithiasis without evidence of acute cholecystitis.
.
MRCP (MR ABD W&W/OC) [**2185-10-18**] 5:45 PM
INDICATION: Transaminitis, hyperbilirubinemia.
COMPARISON: CT from [**Hospital 1474**] Hospital dated [**2185-10-17**]. Right upper
quadrant ultrasound from [**2185-10-17**].
TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen
were obtained on 1.5 Tesla magnet including dynamic 3D imaging
obtained prior to, during, and after the uneventful intravenous
administration of 0.1 mmol/kg of gadolinium-DTPA. Multiplanar 2D
and 3D reformations along with subtraction images were generated
on an independent workstation.
.
MRI OF THE ABDOMEN WITHOUT AND WITH INTRAVENOUS CONTRAST:
Gallbladder is distended and filled with innumerable small
gallstones. The extent of gallbladder distention is unchanged
compared to the recent CT and ultrasound, however,
circumferential gallbladder wall edema appears markedly
increased in the interval. In addition, there is a sliver of
pericholecystic fluid identified. After administration of
contrast, there is subtle hyperemia within the hepatic
parenchyma surrounding the gallbladder fossa. All these findings
suggest acute cholecystitis in the appropriate clinical setting.
.
No intra- or extra-hepatic biliary duct dilatation is
demonstrated. Within the distal common bile duct, at least three
intraluminal round filling defects, measuring up to 2 mm in
diameter are identified adjacent to one another, likely
representing nonobstructing stones. Common bile duct is smooth
in contour and normal in caliber without evidence of caliber
change. Incidentally noted, the right posterior hepatic duct
originates from the proximal left hepatic duct.
.
The liver, spleen, adrenal glands are within normal limits.
Within the uncinate process of the pancreas is a branching T2
hyperintense cystic lesion measuring approximately 1 x 1 cm
which appears to communicate with the main pancreatic duct and
likely represents dilated side branches. The main pancreatic
duct is normal in caliber and smooth in contour. Pancreatic
parenchyma enhances normally and is normal in signal intensity.
.
Multiple well-circumscribed T2 hyperintense lesions within the
cortices of both kidneys are consistent with cysts, the majority
of which are simple in nature. A 2.3-cm cyst within the
interpolar region of the right kidney contains a single
septation but without internal enhancement or nodularity. Both
kidneys demonstrate preservation of corticomedullary
differentiation with normal enhancement. There is no
hydronephrosis or solid renal masses.
.
A moderate-sized hiatal hernia is present. Visualized bowel
loops otherwise appear unremarkable.
.
Diffuse atherosclerotic disease is seen throughout the abdominal
aorta, which otherwise is normal in caliber. As noted on the
recent CT, three atherosclerotic ulcers are seen within the
descending aorta, one at the aortic hiatus, one at the level of
the renal arteries, and a third just inferior to the renal
arteries. None of these ulcers appear to project beyond the
confines of the aortic wall. No dissection is identified or
aneurysmal dilatation. There is focal high- grade narrowing
involving the celiac artery and SMA origins, which was
visualized on the recent CT, and secondary to atherosclerotic
disease. No collaterals are identified. Subcentimeter porta
hepatis lymph node is identified. No pathologically enlarged
mesenteric or retroperitoneal lymph nodes are seen. No free
fluid is seen within the abdomen.
.
A T1 and T2 hyperintense lesion within the L3 vertebral body is
consistent with a vertebral hemangioma.
.
Multiplanar 2D and 3D reformations were essential in providing
multiple perspectives for the dynamic series.
.
IMPRESSION:
1. Gallbladder appearance is concerning for acute cholecystitis
in the appropriate clinical setting. HIDA scan can be performed
for further evaluation.
2. Choledocholithiasis with three nonobstructing stones seen in
the distal common bile duct.
3. Approximately 1-cm branching cystic structure within the
uncinate process of the pancreas likely representing dilated
side branches, but IPMN remains in the differential. Six-month
followup MRCP is recommended to evaluate for stability of this
finding.
4. Celiac and SMA origin stenoses. Diffuse atherosclerotic
disease involving the abdominal aorta without aneurysmal
dilatation or dissection.
5. Moderate-sized hiatal hernia.
.
[**2185-10-20**] Echocardiogram:
Conclusions: EF 50%
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic
dysfunction with hypokinesis of the basal inferior and
inferolateral segments.
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The
mitral valve leaflets are structurally normal. An eccentric,
posteriorly
directed jet of mild (1+) mitral regurgitation is seen. The
estimated
pulmonary artery systolic pressure is normal.
Brief Hospital Course:
87 yo M who was admitted to the vascular surgery service on
[**2185-10-17**] with epigastric pain and concern for aortic dissection
on CT scan at OSH. On further review of CT scan after admission
it was determined that the patient had stable endovascular
ulcerations and not an aortic dissection. He was also found to
have choledocholithiasis and was treated with ERCP and
sphincterotomy. He was transferred to the MICU following ERCP
for hypertensive urgency which resolved with medications.
1) Choledocolithiasis s/p ERCP: On evaluation of his abdominal
pain he was found to have evidence of cholycystitis and
choledocholithiasis. He had ERCP, three stones were removed and
sphincterotomy performed. Since stone removal and decompression
he has been pain free and afebrile. Felt unlikely to have been
cholecystitis as following ERCP he remained afebrile without
leukocytosis or fever. Initially he was treated with levaquin
and flagyl however this was stopped following ERCP. In addition
his LFT's continued to improve and were essentially normal prior
to discharge with AST 23 ALT 68. He will need cholecystectomy
in the future and will follow up with general surgery.
2)Endovascular ulcerations of abdominal aorta - initially
admitted from OSH with concern for aortic dissection however
after further review of CT scan it was determined that he had
stable endovascular ulcerations not requiring surgery. He
should follow up with vascular surgery and have repeat CT scan
in 6 months.
3) Hypertensive urgency: Following ERCP there was concern as he
became very hypertensive with associated confusion requiring
admission to the MICU and IV antihypertensives. While patient
denies history of hypertension, he reportedly had been
hypertensive since admission. His blood pressure was controlled
in the ICU and he was discharged on lisinopril 10mg daily,
toprol xl 100mg daily and doxazosin2mg [**Hospital1 **]. He will follow up
with his PCP
4) hematemasis: started on the evening of [**10-20**] post ERCP with
approximately 50-100 cc hemoptysis. ERCP fellow contact[**Name (NI) **],
patient bolused with 1L NS and PPI IV BID started. Hct remained
stable since with no recurrent episodes of bleeding throughout
the rest of his admission. He was discharged on prilosec [**Hospital1 **].
5) likely CAD: suggested by regional LV systolic dysfunction on
TEE. Patient currently on home statin and beta-blocker.
Recommended that he start ASA in one week, holding for time
being [**3-4**] ERCP and post op hematemasis
6) Altered mental status: initially with increased confusion and
mental status change following ERCP. Thought to be most likely
due to pain medciations given during surgery. Per discussions
with patients wife and son he returned to his baseline prior to
discharge.
7) Hypercholesterolemia: restarted pravachol at home dose prior
to discharge. This medication was held throughout admission due
to elvated liver enzymes in the setting of choledocholithiasis.
8) Prostate cancer s/p prostatectomy: No acute issues.
9)Code: Full
Medications on Admission:
pravachol 20mg daily
tylenol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Prilosec 20 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. Pravastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
Please do not start taking this medicine until one week after
discharge in order to allow your body time to heal. Aspirin
increases your risk for bleeding. On [**2185-10-30**] you can start
taking one enteric coated aspirin daily on .
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
1. Abdominal Aorta Dissection - 3 focal areas of ulceration
2. Accelerated Hypertension.
3. Cholecystitis.
4. Choledocholithiasis.
5. Regional LVSD - basal inferior/inferolateral.
6. Celiac and SMA origin high grade stenoses.
7. Hematemesis.
8. Right Carotid Artery Stenosis.
Secondary:
1. Prostate CA s/p XRT.
2. Hypercholesterolemia.
3. Chronic Low Back Pain.
4. Hypertension
Discharge Condition:
Good
Discharge Instructions:
Call Vascular Surgery or General Surgery with any new abdominal
pain, back pain, nausea, vomiting.
Followup Instructions:
Call Vascular Surgery Dr. [**Last Name (STitle) **]/[**Doctor Last Name **] office at
[**Telephone/Fax (1) 2395**] to schedule follow up and CT scan in 1 month.
Call General surgery Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 600**] to schedule follow
up visit in 2weeks
|
[
"458.29",
"788.20",
"338.29",
"724.2",
"401.0",
"272.0",
"185",
"574.91",
"576.1",
"441.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
13115, 13170
|
9211, 11751
|
277, 989
|
13602, 13609
|
2840, 9188
|
13756, 14039
|
2502, 2524
|
12355, 13092
|
13191, 13581
|
12298, 12332
|
13633, 13733
|
2539, 2821
|
223, 239
|
1017, 2092
|
11766, 12272
|
2114, 2230
|
2246, 2486
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,816
| 121,051
|
8621
|
Discharge summary
|
report
|
Admission Date: [**2153-5-13**] Discharge Date: [**2153-5-23**]
Date of Birth: [**2072-1-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
decreased PO intake, lethargy
Major Surgical or Invasive Procedure:
placement of central lines and dialysis catheter
placement of chest tubes x3
History of Present Illness:
This is an 81 year old female with a history of diabetes,
bipolar, CHF, HTN and atrial fibrillation who presented to the
ED as she was found to be lethargic at home. Per family she has
been having 3-4 days of increasing lethargy. A finger stick was
noted to be 29. She has been having more nausea and a dry cough
and decreased PO intake.
.
Of note patient had been having hyperkalemia recently per Dr.
[**Last Name (STitle) **] notes. ACE-i had been held two weeks prior and K had
normalized by [**5-10**].
.
In the ED initial vitals were: 96.0 60 146/46 24 98%. Exam
showed kussmal respirations and patient "looked bad", very
lethargic. ECG showed QRS at 160. She was given calcium and
bicarb. Kayexelate was not given for mental status. Patient was
noticed to have dips of SBP to 90s. CXR with increased
interstitial markings and was sat O2 sats remained 100% 3L
breathing at 18. Labs sig for severe acidosis. Renal was
consulted and recommended forced diuresis which ED did not do as
her BP was tenuous.
.
Meds given in ED: 4 amps calc gluc, 4 amps Na bicarb, 3 amps
D50, 20 U regular insuln (2 separate doses), Vanc, Zosyn, 2L
fluid - Put out total of 500cc urine.
Past Medical History:
- Atrial fibrillation
- HTN
- Hypercholesterolemia
- Hypothyroidism
- DM type II
- Systolic CHF
- COPD
- Bipolar affective disorder with psychotic features
- Osteoarthritis
- S/p thyroid removal for polyps
- S/p cholecystectomy
Social History:
She is divorced. She has three children who are quite involved.
The patient currently lives alone in a senior housing apartment.
She no longer has services, but her daughter reports that Mrs.
[**Known lastname 30215**] is doing well, caring for herself since her lithium dose
was adjusted. She does go to the senior center for lunch. No
alcohol. She has been smoking for approximately 35 years and is
trying to cut down. Key relationships: daughter and son.
Family History:
mother had rheumatic fever and bipolar disorder. Her father had
pernicious anemia. Both sisters have thyroid disorders and one
had ovarian cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: Tm 97, BP 99/36, HR 60, RR 25, 98% RA
General: Alert, oriented
HEENT: Sclera anicteric, very dry mucous membranes
Neck: supple, JVP flat
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular rhythm 3/6 systolic murmur at upper stenal border,
no rubs or gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
Ext: Cool, no edema
.
DISCHARGE EXAM:
Vitals: T 98.1,
General: Alert, oriented x2-3 (able to state her name, month,
occasionally gets confused by where she is)
HEENT: Sclera anicteric, very dry mucous membranes
Neck: supple, JVP flat
Chest: well-healing incisions on left upper chest and side from
chest tubes
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rhythm, normal S1/S2, 3/6 systolic murmur at upper
sternal border, no rubs or gallops
Abdomen: soft, non-tender, non-distended, NABS
Ext: WWP, no peripheral edema, 2+ pedal pulses
Skin: no rashes or lesions, no decubitus ulcers
Pertinent Results:
ADMISSION LABS:
[**2153-5-13**] 11:15AM BLOOD WBC-28.1*# RBC-3.51* Hgb-10.1* Hct-31.7*
MCV-90 MCH-28.8 MCHC-31.9 RDW-14.1 Plt Ct-294
[**2153-5-13**] 11:15AM BLOOD Neuts-85* Bands-1 Lymphs-8* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2153-5-13**] 11:15AM BLOOD PT-15.4* PTT-27.6 INR(PT)-1.3*
[**2153-5-13**] 11:15AM BLOOD Glucose-25* UreaN-70* Creat-7.8*# Na-125*
K-8.0* Cl-89* HCO3-5* AnGap-39*
[**2153-5-13**] 01:30PM BLOOD ALT-28 AST-39 LD(LDH)-232 CK(CPK)-83
AlkPhos-85 TotBili-0.2
[**2153-5-13**] 11:15AM BLOOD Lipase-30
[**2153-5-13**] 01:30PM BLOOD Albumin-3.3* Calcium-12.5* Phos-8.4*#
Mg-2.1
[**2153-5-13**] 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2153-5-13**] 11:15AM BLOOD Type-[**Last Name (un) **] pO2-112* pCO2-23* pH-6.88*
calTCO2-5* Base XS--29 Comment-GREEN TOP
[**2153-5-13**] 11:15AM BLOOD Lactate-11.0*
[**2153-5-13**] 11:15AM BLOOD Lithium-1.0
.
CARDIAC ENZYMES:
[**2153-5-13**] 11:15AM BLOOD cTropnT-0.04*
[**2153-5-14**] 04:57AM BLOOD CK-MB-23* MB Indx-8.9* cTropnT-0.23*
[**2153-5-14**] 08:10AM BLOOD CK-MB-23* MB Indx-8.6* cTropnT-0.31*
[**2153-5-14**] 03:38PM BLOOD CK-MB-18* cTropnT-0.39*
[**2153-5-15**] 12:27AM BLOOD CK-MB-12* cTropnT-0.48*
[**2153-5-15**] 12:25PM BLOOD CK-MB-7 cTropnT-0.36*
[**2153-5-15**] 04:22PM BLOOD CK-MB-6 cTropnT-0.33*
[**2153-5-17**] 08:05AM BLOOD cTropnT-0.34*
.
LACTATES:
[**2153-5-13**] 11:15AM BLOOD Lactate-11.0*
[**2153-5-13**] 05:20PM BLOOD Lactate-10.4*
[**2153-5-13**] 09:12PM BLOOD Lactate-7.2*
[**2153-5-13**] 10:16PM BLOOD Lactate-8.0*
[**2153-5-14**] 02:24AM BLOOD Lactate-8.6*
[**2153-5-14**] 05:24AM BLOOD Lactate-8.4*
[**2153-5-14**] 08:26AM BLOOD Lactate-8.1*
[**2153-5-14**] 01:17PM BLOOD Lactate-5.9*
[**2153-5-14**] 04:00PM BLOOD Lactate-5.0*
[**2153-5-14**] 08:30PM BLOOD Lactate-2.5*
[**2153-5-15**] 04:23AM BLOOD Lactate-1.6
[**2153-5-16**] 04:09AM BLOOD Lactate-1.3
.
URINALYSIS:
[**2153-5-13**] 11:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2153-5-13**] 11:55AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2153-5-13**] 11:55AM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-0
[**2153-5-13**] 11:55AM URINE CastHy-1*
[**2153-5-14**] 05:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2153-5-14**] 05:30PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-NEG
[**2153-5-14**] 05:30PM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
[**2153-5-20**] 01:31PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2153-5-20**] 01:31PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
[**2153-5-20**] 01:31PM URINE RBC-2 WBC-9* Bacteri-FEW Yeast-MOD Epi-0
.
URINE CHEMISTRY:
[**2153-5-15**] 17:94PM URINE Creat-23 Na-91 K-7 Cl-55 Osmol-276
[**2153-5-23**] 08:13AM URINE Creat-23 Na-52 K-3 Cl-33 Osmol-172
.
DISCHARGE LABS:
[**2153-5-23**] 07:30AM BLOOD WBC-8.4 RBC-2.77 Hgb-7.8 Hct-24.4 MCV-88
RDW-16.2 Plt Ct-207
[**2153-5-23**] 07:30AM BLOOD Glucose-143 UreaN-26 Creat-1.9 Na-145
K-4.4 Cl-113 HCO3-21 Ca-9.8 Mg-1.9 Phos-3.1
.
MICROBIOLOGY:
[**2153-5-13**] Blood Culture: no growth
[**2153-5-13**] Urine Culture: no growth
[**2153-5-18**] Vaginal Swab: yeast
[**2153-5-20**] Urine Culture: yeast
.
IMAGING:
[**2153-5-13**] CXR: There is prominence of the pulmonary vasculature
and interstitial markings, most consistent with mild pulmonary
edema. There are no focal areas of consolidation. There is no
pleural effusion or pneumothorax. Mild cardiomegaly is stable to
slightly worsened since the prior study. Hilar contours are
within normal limits. There is calcification of the aortic knob,
unchanged. Linear atelectasis is noted at the lung bases
bilaterally. Findings most consistent with mild CHF.
.
[**2153-5-14**] TTE: The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate global left ventricular hypokinesis (LVEF = 35 %).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg).The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion. Compared with
the prior study (images reviewed) of [**2152-11-23**], left ventricular
cavity size is smaller with slightly improved systolic function.
Pulmonary artery hypertension and right ventricular cavity
enlargement/free wall hypokinesis are now seen.
.
[**2153-5-22**] CXR (after chest tube removal): Stable tiny
pneumothorax residual in left apical area. No new abnormalities.
Brief Hospital Course:
81 year old woman with bipolar disorder and diabetes who
presented to the ED with several days of lethargy and and poor
po intake, and was found to have a severe lactic acidosis, acute
kidney injury, and hyperkalemia.
.
# Lactic acidosis/SIRS: Likely a result of her poor po intake in
the setting of continued metformin. Infection initially of
concern given elevated leukocytosis, therfore she was started on
Vanc/Zosyn. Nephrology was consulted for discussion of dialysis.
A subclavian and internal jugular line were placed and CVVHD was
initated. Line placement was complicated by large left-sided
pneumothorax (discussion below). The lactic acidosis improved
with dialysis and lactate trended down to normal. By HD#3 the
patient was still panculture negative with downtrending white
count, therefore antibiotics were discontinued. She has remained
afebrile with a normal WBC.
.
# Iatrogenic Pneumothorax: Consequence of central line placement
on admission. Thoracic surgery placed pigtail catheter, which
was removed after 24 hours. Follow up chest x-ray confirmed
re-expansion of lung. The patient was doing well and was
transferred to the medicine floor. On [**2153-5-19**] she experienced
shortness of breath and hypoxia and was again noted to have a
spontaneous left-sided pneumothorax requiring 2 chest tubes.
These were removed on [**2153-5-22**]. Chest x-rays on [**2153-5-22**] and [**2153-5-23**]
confirmed complete re-expansion of the left lung. O2 sats in the
mid-upper 90s on room air. Recommend checking a repeat CXR in
[**12-17**] weeks to assess for interval change. Her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] is
aware.
.
# Hyperkalemia: In the setting of severe acidosis and renal
injury. QRS widening noted, and given calcium insulin/D50,
kayexalate, bicarbonate. Started CVVH per above. Potassium
normalized without further intervention.
.
# Sodium balance/Diabetes Insipidus: Patient had hypovolemic
hyponatremia on presentation which resolved with IVF. She began
experiencing post-ATN diuresis with sodium levels in the high
140s requiring free water administration. She continues to have
high-normal sodium and has been requiring intermittent D5W. This
is likely secondary to diabetes insipidus from long-term lithium
use (as supported by her dilute urine with low urine
osmolarity). She is eating and drinking and should be encouraged
to continue to drink at least 2L of water per day. Recommend
checking daily electrolytes. If sodium is high would administer
1L of D5W at 50cc/hr.
.
# Urinary frequency/retention: The patient experinced several
days of urinary retention requiring a foley, which was believed
to be due to the anti-psychotics (Haldol and Zyprexa) that she
received when she was agitated. As her mental status improved
and she no longer required any anti-psychotics, the urinary
retention also resolved. The foley catheter was removed and she
is urinating adequately on her own. For the past day she has
been experiencing urinary frequency which is likely due to both
the fluids that she is receiving, and the diabetes insipidus
(see above). Urinalysis revealed several WBC and yeast, however
the patient is asymptomatic and this is likely related to her
recent foley. Should she develop symptoms, we would recommend
checking a repeat UA and considering fluconazole.
.
# Acute kidney injury: Cr up to 7.8 from baseline 1.2. In the
setting of severe dehydraion likely pre-renal with ATN. Received
CVVHD per above. Initially given Lasix as 18 lbs up from home
weight, however she began experiencing post-ATN diuresis with
large amounts of diluted urine output. Creatinine continued to
trend down and was 1.9 upon discharge. Recommend checking daily
chemistry panel to monitor the patient's electrolytes and renal
function.
.
# Elevated troponin: 0.04 on admission, and peaked at 0.48.
Likely demand ischemia in the setting of severe acidosis and
dehydration, exacerbated by acute kidney injury.
.
# Systolic CHF: Echo on [**2153-5-14**] revealed a LVEF 35%, which is
slightly improved from her previous echo in 12/[**2151**]. She is
currently euvolemic on exam. We continued her home carvedilol
3.125mg [**Hospital1 **], and are holding her lasix. She will see her PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] on [**5-31**] at which time she can decide whether to restart
the lasix. The patient is not currently on an ACE-I or [**Last Name (un) **] due
to a history of hyperkalemia.
.
# Diabetes: The patient was previously on metformin, which was
believed to have contributed to her lactic acidosis and was
therefore stopped. We started glypizide 2.5mg daily and her
blood sugars have been in the 100s-200s. She has a follow up
appointment with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**5-31**] at which time she can
decide what further medication adjustments need to be made.
.
# Bipolar disorder/Delirium: Held lithium on admission. Began
having hallucinations and delirium by HD#2. Removed lines and
minimized tethers but continued to be delirious. Psychiatry
consulted for aid in medical management. The patient was
restarted on her home perphenazine 2mg every morning and 4mg
every evening. As her renal function improved, the lithum was
restarted on [**5-22**] at her home dose 150mg daily. We recommend
checking daily lithium levels with uptitration as needed, with a
goal range 0.5-1.5. Her delirium and agitation have resolved.
She is alert and interactive and oriented x2-3 (person, month,
sometimes gets the name of the hospital wrong but knows that she
is in [**Location (un) 86**]).
.
# Anemia: Normocytic. Hematocrit has ranged from 23 to 30,
though the patient is asymptomatic. No GI bleeding or other
signs of blood loss. We sent iron studies, B12, folate, and
hemolysis labs which are pending at this time and will be
followed up by her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Hct is 24.4 upon discharge. We
started ferrous sulfate 325mg PO daily. Recommend checking
weekly CBCs, with the first check tomororrow ([**2153-5-24**]) and if the
hematocrit drops below 21 or the patient becomes symptomatic,
would transfuse 2 units of PRBCs.
.
# Vaginal discharge: The patient was noted to have increased
vaginal discharge, though asymptomatic. A vaginal swab revealed
a yeast infection which was treated with 1 tablet of fluconazole
150mg. She still remains asymptomatic and the discharge has
resolved.
.
# COPD: Asymptomatic. Continued tiotropium.
.
# HTN: Antihypertensives initially held in the setting of
hypotension. The carvedilol was eventually restarted. Amiloride
was started in place of furosemide, since it is renally
protective with the patient on lithium. We have continued to
hold the Imdur. Her BP has been in the 110s-140s/50s-60s. Pt has
a f/u appt with her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**5-31**] at which time she can
decide whether to restart the Imdur.
.
# Hypothyroidism: Continued levothyroxine 88mcg daily.
.
# Paroxysmal Afib: Asymptomatic. Not anticoagulated at baseline,
currently rate controlled with carvedilol 3.125 mg PO BID.
.
# Disposition: Patient will go to [**Doctor First Name 30216**] Rehab in
[**Hospital1 8**].
.
**The patient's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] has been following her course
throughout this admission and is aware of all events. She will
see Ms. [**Known lastname 30215**] on [**2153-5-31**].
Medications on Admission:
1. carvedilol 3.125mg [**Hospital1 **]
2. furosemide 10mg daily
3. isosorbide mononitrate 30mg ER daily
4. levothyroxine 88mcg daily
5. lithium carbonate 150mg daily
6. metformin 1,000mg [**Hospital1 **]
7. perphenazine 2mg QAM and 4mg QHS
8. simvastatin 80mg daily
9. tiotropium bromide 18mcg inh daily
10. aspirin 81mg daily
11. calcium carbonate-vitamin D3 600mg-400unit [**Hospital1 **]
Discharge Medications:
1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lithium carbonate 150 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
4. perphenazine 2 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
5. perphenazine 2 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
6. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
9. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Tablet
Sig: One (1) Tablet PO twice a day.
10. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. amiloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **] at [**Location (un) 1821**] Nursing & Rehab
Discharge Diagnosis:
primary: lactic acidosis, acute kidney injury, hyperkalemia
secondary: diabetes, bipolar disorder, paroxysmal atrial
fibrillation, systolic CHF
Discharge Condition:
Mental Status: Confused - sometimes. Alert and oriented x1-2
(person and month).
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 30215**],
It was a pleasure caring for you. You were admitted because you
were eating less and were more lethargic. You were found to have
several electrolyte abnormalities and acute kidney injury, which
is resolving.
.
We made the following changes to your medications:
- STOP metformin
- HOLD furosemide (Lasix) until you see Dr. [**Last Name (STitle) **]
- HOLD isosorbide moninitrate (Imdur) until you see Dr. [**Last Name (STitle) **]
- START glipizide
- START amiloride
- START ferrous sulfate (iron)
Followup Instructions:
**You have the following appointments scheduled:
Department: GERONTOLOGY
When: THURSDAY [**2153-5-31**] at 8:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
.
Department: GERONTOLOGY
When: MONDAY [**2153-7-23**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: THURSDAY [**2153-8-2**] at 10:00 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
.
**We would also like for you to follow up with the kidney
specialists. After you are discharged from rehab please call
([**Telephone/Fax (1) 10135**] to schedule an appointment with Dr. [**First Name (STitle) 30217**] [**Name (STitle) 28760**].
Completed by:[**2153-5-23**]
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|
[
[
[]
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] |
[
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28,091
| 195,013
|
51883
|
Discharge summary
|
report
|
Admission Date: [**2180-4-13**] Discharge Date: [**2180-4-18**]
Date of Birth: [**2115-2-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
PICC Line Placement
History of Present Illness:
65 year old male with a history of AVR (bioprosthetic) in [**2162**]
for history of recurrent endocarditis presenting with fever of
103.7 at home, altered mental status and incontinence of urine
and feces. Patient says that he began to feel unwell this
weekend. He noticed he was febrile to 103 two days prior to
admission but by the next day the fever appeared to have
resolved. The day of admission his long-term significant other
found him in the bathroom, covered in stool and urine and acting
confused. She called his PCP who advised to them to come in the
ED immediately for further assessment. Patient was seen at the
WX VA in [**Month (only) 958**] for "flu", with fevers, chills, productive cough,
and myalgias, and given IV hydration in the ED. He has also been
having diarrhea for the past few weeks, but attributed it to
drinking too many liquids. No recent dental work.
In the ED, patient had a lumbar puncture, CXR, and head CT which
were all unremarkable. received 1 gram Vancomycin and 750 mg of
levofloxacin. He also received 10 mg of IV Diltiazem. His ECG
showed dig changes and 1st degree AV block, which is old, and he
was noted to be in and out of a flutter with concurrent BP drop
80/50's, both of which are new.
Past Medical History:
NAFLD since [**2170**]
Endocarditis-multiple episodes
AVR in [**2162**]
Dyslipidemia
Hypertension
Depression
paroxysmal SVT
mild carotid stenosis
Obstructive sleep apnea
GERD
DJD
impaired fasting glucose
Social History:
Long-term signifcant other, has children and his son is his
health care proxy. Denies IVDU.
Family History:
non-contributory
Physical Exam:
VS: T: P: 78 BP: 99/63 RR: 22 O2 sat: 97% on RA
GEN: NAD
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM, neck supple, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL, no [**Doctor Last Name **] spots or [**Last Name (un) 1003**]
lesions, no splinter hemorrhages
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated.
PSYCH: appropriate affect
Pertinent Results:
Admission Labs:
[**Age over 90 **]|92|19
--------<178
3.4|25|1.3
estGFR: 55/67
CK: 326 MB: 6 Trop-T: 0.02
Ca: 8.8 Mg: 1.5 P: 2.6
Dig: 0.5
UA: Color Yellow Appear Clear SpecGr 1.016 pH 5.0 Urobil Neg
Bili Neg Leuk Neg Bld Sm Nitr Neg Prot Tr Glu Neg Ket Neg
RBC <1 WBC <1 Bact Occ Yeast None Epi <1
Lactate:2.8
13.3
15.1>--<100
36.6
N:95.0 Band:0 L:2.7 M:2.1 E:0.1 Bas:0.1
CSF: Protein 32 Glucose 100 WBC 2 RBC 0 Poly 6 Lymph 60 Mono 0
Macroph 34
ALT: 32 AP: 73 Tbili: 0.9 Alb: 3.3 AST: 37 LDH: 370
Studies:
[**2180-4-13**] CT Abd/Pelv:
1. No CT explanation for fever of unknown origin.
2. 0.7cm cystic lesion in the pancreatic head new in comparison
to [**2177-9-30**];
recommend MRCP for further characterization.
CXR: ([**2180-4-12**]): No evidence of pneumonia or CHF.
Head CT ([**2180-4-12**]):
IMPRESSION:
1. No acute intracranial process.
2. Unchanged extraaxial CSF prominence in the left temporal
lobe.
3. Unchanged punctate subarachnoid calcifications, possibly
representing vascular calcification versus dystrophic
calcification from prior infection or inflammation.
[**2180-4-13**] Trans-esophageal ECHO:
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular free wall contractility is normal. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta. A bioprosthetic aortic valve
prosthesis is present. The prosthetic aortic valve leaflets are
thickened (consistent with age of prosthesis). The transaortic
gradient is normal for this prosthesis. No masses or vegetations
are seen on the aortic valve. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No evidence of endocarditis. Aortic valve
bioprosthesis with thickened leaflets and mild regurgitation.
MRI T/L Spine:
T spine IMPRESSION:
1. No evidence of discitis, osteomyelitis or epidural abscess.
2. Multilevel degenerative changes with small central
protrusions at T7-8 and T8-9 level slightly indenting the
anterior aspect of the spinal cord. No intrinsic spinal cord
signal abnormalities.
3. No evidence of compression fracture. Mild multilevel
degenerative
changes.
L spine IMPRESSION:
1. No evidence of discitis or osteomyelitis.
2. Degenerative changes at multiple levels as described above
with mild
antral spondylolisthesis of L4 over L5.
[**2180-4-15**] Knee Xray:
There is no evidence of fracture or dislocation. Mild
degenerative changes are in the patellofemoral and femoral
tibial compartments. There is evidence of joint effusion. There
are no osteolytic or osteoblastic osseous lesions. There are no
soft tissue calcifications.
[**2180-4-17**] CXR: Successful repositioning of right-sided PIC line
with tip in lower SVC.
Brief Hospital Course:
Mr. [**Known lastname **] is a 65 year old male with a history of bioprosthetic
AVR in [**2162**] for recurrent endocarditis presenting with fever of
103.7, altered mental status and incontinence with blood
cultures positive for Group A Strep
1)Group A strep Bacteremia: most likely explanation for
presentation of high fever and altered mental status. He was
initially admitted to the MICU for close monitoring due to
hypotension and high fevers. Source of bacteremia unclear, no
evidence of endocarditis on TEE. No evidence of infection on
UA, CXR or LP. Abdominal CT did not show any evidence of abscess
or other cause for bacteremia. He was initially treated with
vancomycin and gentamycin due to concern for staph bacteremia
and endocarditis however this was changed to Penicillin G once
cultures were positive for GAS. In addition he was treated with
clindamycin for 48 hours to treat GAC toxin given erythroderma
on exam. He continued to improve on this regimen with no
complications and he was discharged to rehab facility to
complete 2 week course of Penicillin G. A PICC line was placed
prior to discharge. Clinidamycin was stopped after 48 hours
given his improvement. Surviellance cultures were all negative.
2)Fecal incontinence - also with reduced rectal tone, otherwise
neurologically intact. Concerning for possiblity of cauda equina
compression, however he had an MRI which did not show any
evidence of nerve impingement. He was evaluated by the GI
service who recommended to follow up in clinic and to start
Immodium. Unlikely to be related to GAS bacteremia as [**Year (4 digits) **]
have been present x3-6 months, no evidence of epidural abscess
or osteo on MRI. Follow up was arranged in [**Hospital **] clinic prior to
discharge. C.diff was negative times and stool culture, ova and
parasite were all negative.
3)SVT - he has h/o SVT and had two episodes on admission while
acutely bacteremic associated with hypotension to the 80's. He
was started on diltiazem in the ICU. Has SVT at baseline that he
breaks with carotid massage. He was continued on diltiazem and
did not have any further episodes of SVT. He was discharged on
diltiazem and his hydrochlorothiazide was stopped.
4)left knee pain - warm, swollen L knee was somewhat concerning
for possibility of secondary seeding due to bactermia. He does
report history of a fall on the day before he presented to the
ED. He had a knee xray which did show evidence of effusion. He
was evaluated by orthopedics who did not feel that a
arthrocentesis was indicated at this time.
5)[**Last Name (STitle) **]inary Incontinence - he reports three month history of
intermittent urinary incontinence. Urinalysis did not show any
evidence of UTI. MRI did not show neural involvement as above.
He will follow up with Dr. [**Last Name (STitle) **] as an outpatient.
6)Thrombocytopenia - Unclear etiology, initially somewhat
concerning for possiblility DIC given GAS bactermia. DIC panel
negative and his PLT's slowly trending back up.
7)HTN: He was hypotensive on admission likely due to bacteremia.
His hydrochlorothiazide was stopped and was not restarted on
discharge as diltiazem was added.
8) Dyslipidemia: continue simvastatin
9) Depression: continue fluoxetine
10) GERD: continue omeprazole
CODE: FULL
Medications on Admission:
Fluoxetine 20 mg daily
HCTZ 12.5 mg daily
Provigil 200 mg daily
Omeprazole 20 mg daily
Simvastatin 20 mg daily
Digoxin 0.25 mg
Discharge Medications:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet 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 once a day.
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
11. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED): take as directed according to
sliding scale.
12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
13. Penicillin G Potassium in D5W 2,000,000 unit/50 mL Piggyback
Sig: 4 million units Intravenous every four (4) hours for 10
days: Last day of antibiotics is [**2180-4-28**].
14. Outpatient Lab Work
Please check Chem 7 and CBC twice per week.
15. Provigil 200 mg Tablet Sig: One (1) Tablet PO QAM.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Group A Strep Bacteremia
Urinary Incontinence
Diarrhea, fecal incontinence
===============
Aortic Valve Replacement
paroxysmal SVT
DJD
prior endocarditis
Dyslipidemia
Hypertension
Depression
OSA
GERD
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital because you were having fevers
and confusion. You were found to have Strep infection of your
blood. You were treated with IV antibiotics and your [**Location (un) **]
improved.
You had an MRI of your back to evaluate your [**Location (un) **] of
incontinence of urine and stool. The MRI did not show any nerve
impingement as the cause of your [**Location (un) **]. Your MRI did show
mild degenerative changes and disc bulging.
You were evaluated by the gastroenterology doctors for your
[**Name5 (PTitle) **] of loose stool and incontinence. You were started on
Immodium for your [**Name5 (PTitle) **] and you should follow up as an
outpatient in [**Hospital **] clinic as below.
You should follow up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] Urology for your [**Last Name (STitle) **]
of urinary incontinence as below.
Medications:
1)You were started on Penicillin which you will take at home to
complete 2 weeks of antibiotics for your Strep infection.
2)You had an episode of rapid heart rhythm and you were started
on diltiazem. Please continue to take this medication.
3)Your hydrochlorothiazide was stopped as you were started on
the diltiazem instead.
4) You were started on Loperamide to treat your loose stool.
Please call your doctor or return to the hospital if you
experience any concerning [**Last Name (STitle) **] including chest pain, fevers,
trouble breathing or any other concerning [**Last Name (STitle) **].
Followup Instructions:
1) You have an appointment scheduled with the [**Hospital 107421**]
clinic: Provider: [**Name10 (NameIs) 8758**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2180-5-9**] 2:00
2)You have an appointment scheduled with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] urology to
evaluate your [**Last Name (STitle) **] of urinary incontinence on [**2180-6-1**] at
10:00 AM. Please call [**Telephone/Fax (1) 921**].
3) Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2180-5-31**] 11:00
4)Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2180-7-7**] 1:40
|
[
"577.2",
"788.30",
"787.6",
"V42.2",
"038.0",
"530.81",
"287.5",
"785.52",
"995.92",
"427.89",
"272.4",
"427.32",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
10523, 10601
|
5554, 8862
|
320, 342
|
10845, 10852
|
2582, 2582
|
12392, 13113
|
1961, 1979
|
9040, 10500
|
10622, 10824
|
8888, 9017
|
10876, 12369
|
1994, 2563
|
275, 282
|
370, 1608
|
2598, 5531
|
1630, 1836
|
1852, 1945
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,034
| 123,528
|
41956
|
Discharge summary
|
report
|
Admission Date: [**2123-10-26**] Discharge Date: [**2123-10-29**]
Date of Birth: [**2041-5-30**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
stroke
Major Surgical or Invasive Procedure:
tPA administered at OSH
History of Present Illness:
[**Known firstname 5586**] [**Known lastname 91065**] is an 82-year-old man with a history of HTN,
DLP, remote lung CA, who was last seen normal at 16:15 on [**10-26**]
who presented with new onset dysarthria, gaze-deviatioin and
left neglect. He went to OSH where iv tPA was given via
telemedicine consult through [**Hospital1 2025**]. He was then transferred to
[**Hospital1 18**] as [**Hospital1 2025**] had no beds. Upon arrival to [**Hospital1 18**] he had an NIHSS
of 14 concerning for poor response to iv tPA. Thus advanced
neuroimging was requested. Given the combination of imaging
findings and advanced age no neurointervention was considered.
He was admitted to the Neuro ICU for post-tPA monitoring where
he remained stable. He was able to be sent to the floor when
his head CT showed no bleeding at 24hrs s/p tPA.
Past Medical History:
-Hypertension.
-Hyperlipidemia.
-PAD
-PUD
-remote lung cancer post resection
-prostate CA
-glaucoma
-macular degeneration
Social History:
Remote EtOH, Former smoker (40-80 pack years, stopped 7 years
ago). Lives at home with his girl-friend (introduced herself as
wife).
Family History:
unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
Physical Exam:
Vitals: T:afebrile P:75 R:16 BP:155/83 SaO2:95%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: regular
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: left elbow abrasion.
Neurologic:
Mental Status: Alert, Global aphasia
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. no reaction to threat in left
hemifield.
III, IV, VI: right gaze deviation not overcome by OCR
VII: left facial droop
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor:
RUE: at least 4+/5
RLE: at least 4+/5
LUE: extensor posturing to pain
LLE: can briefly lift against gravity
-Sensory: Grimaces to noxious in all 4 extremities but can't
localize pain on left side. Sensation R>L
-DTRs:
Plantar response was flexor on right and extensor on the left.
.
.
Physical Exam on Discharge:
Vitals: 96.1 BP 130/70 HR 60-80 RR 16 O2 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: regular
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: left elbow abrasion.
Neurologic:
Mental Status:
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. +R gaze preference. Decreased
blink to threat on left. +Visual neglect of left hemifield.
III, IV, VI: right gaze deviation, can look to the left with
encouragement, limited upgaze
VII: +Left lower facial droop
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor:
Full strength R upper and lower extremities
LUE: some proximal movement, extensor posturing to pain, no
distal movement
LLE: can briefly lift against gravity, no distal movement
-Sensory: Intact to light touch, withdraws briskly on L,
extinction to double simultaneous stimulation on left
-DTRs:
Plantar response was flexor on right and extensor on the left.
Pertinent Results:
ADMISSION LABS:
[**2123-10-26**] 08:00PM BLOOD WBC-13.6* RBC-4.72 Hgb-14.1 Hct-42.9
MCV-91 MCH-30.0 MCHC-32.9 RDW-13.5 Plt Ct-242
[**2123-10-26**] 08:00PM BLOOD Neuts-86.9* Lymphs-6.9* Monos-5.2 Eos-0.7
Baso-0.3
[**2123-10-26**] 08:00PM BLOOD PT-12.4 PTT-23.6 INR(PT)-1.0
[**2123-10-26**] 08:00PM BLOOD UreaN-22*
[**2123-10-26**] 08:16PM BLOOD Creat-1.1
[**2123-10-26**] 08:00PM BLOOD CK(CPK)-127
[**2123-10-26**] 08:00PM BLOOD CK-MB-6 cTropnT-<0.01
[**2123-10-26**] 08:00PM BLOOD Calcium-9.1 Phos-2.7 Mg-2.2
[**2123-10-27**] 05:44AM BLOOD %HbA1c-5.7 eAG-117
[**2123-10-27**] 05:44AM BLOOD Triglyc-111 HDL-50 CHOL/HD-3.0 LDLcalc-80
[**2123-10-26**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-10-26**] 08:20PM BLOOD Glucose-133* Na-142 K-4.2 Cl-108
calHCO3-21
IMAGING:
CTA [**2123-10-26**]: IMPRESSION:
1. Hypodensity in the right frontal and temporal lobes
suggestive of acute
infarct in right middle cerebral artery territory.
2. Focal high grade narrowing of one of the branches of M2
segment of the
right middle cerebral artery which may be due to thrombus or
atheromatous
disease.
3. Irregularity of the basilar artery likely due to
atherosclerotic disease
4. Atheromatous calcified and soft plaques in bilateral proximal
internal
carotid arteries causing approximately 20% stenosis on the left
side and no significant stenosis on the right side.
5. An 8-mm nodule in the right upper lobe, which needs
correlation with CT
chest if available or followup after three months.
MR head [**2123-10-27**]:
IMPRESSION:
1. Extensive central hemorrhagic conversion involving the acute
territorial infarction in the right MCA, predominantly superior
divisional territory.
2. No significant shift of the midline structures or central
herniation.
3. Punctate infarcts in additional right PCA distribution, with
no fetal-type PCA vessel demonstrated, suggest emboli from a
more central source.
4. Extensive sequelae of chronic small vessel ischemic disease
as well as
"etat crible" appearance represeenting marked central atrophy
related to
arteriosclerotic disease, as seen with poorly-treated
hypertension.
CT head [**2123-10-27**]:
IMPRESSION: Extensive hemorrhagic transformation of the large
right MCA
territorial infarct.
Transthoracic Echo [**2123-10-28**]:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF 70%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Brief Hospital Course:
82-year-old man with a history of HTN, DLP, remote lung CA, who
was last seen normal at 16:15 on DOA who presented with new
onset dysarthria, gaze-deviation and left neglect found to have
a R MCA infarction, s/p tPA at an OSH. He was admitted to the
Neuro ICU for post-tPA monitoring.
# Neuro: It was determined that he was not a good candidate for
further neuro intervention when he arrived. He had a repeat
head CT at 24 hrs s/p tPA which showed some bleeding into the
infarcted area, but no bleeding outside of the infarcted area.
He was started on ASA 325mg and subcutaneous heparin. He had an
MRI that again showed central hemorrhagic conversion involving
the area of his right MCA infarct along with punctate infarcts
in additional right PCA distribution and extensive sequelae of
chronic small vessel ischemic disease. His HgA1C and lipid panel
were unremarkable. He had a TTE that was unremarkable and
showed no source of embolus. We kept his SBP < 180 with PRN
hydralazine.
He will continue on aspirin 325mg for now but will need to be
started on coumadin in [**7-25**] days post-tPA ([**Date range (1) 11301**]) for
long-term prevention of future strokes in the setting of his a
fib.
# Cardiovascular: he ruled out for an MI with cardiac enzymes,
but we held his home antihypertensives to allow his SBP to
autoregulate. We used PRN hydralazine to keep his SBP <180.
On the evening of [**2123-10-27**] he went into a fib with RVR and was
restarted on his home metoprolol with good control.
# Endo: he was maintained on an ISS while an inpatient.
# Pulmonary: Pt with H/O lung CA, but no active issues. Nodule
noted on CXR and CTA which will need a repeat chest CT in 3
months.
# CODE: Full Code
# CONSULTS: Pt was seen by PT and OT who recommended acute rehab
placement upon discharge.
Pt was seen by speech therapy who recommended pureed diet with
honey thick liquids. They also recommended that he be followed
by nutrition at rehab in order to ensure he receives adequate
nutrition and to assess for any supplementation needs.
TRANSITIONAL CARE ISSUES:
Patient will need to be started on coumadin 7-10 days post-tPA
([**Date range (1) 11301**]) for long-term prevention of future strokes due to
his a fib.
He will need to be followed by PT and OT for intensive rehab in
order to return to his previous level of function. He will also
need to be followed by speech therapy and nutrition in order to
advance his diet as tolerated and ensure that he receives
adequate nutrition.
Patient will need a repeat chest CT to evaluate his lung nodule
in 3 months.
Medications on Admission:
Statin
B-Blocker
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. timolol 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
4. Lumigan 0.03 % Drops Sig: One (1) Ophthalmic at bedtime.
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Right middle cerebral artery infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 91065**],
You were admitted to [**Hospital1 69**] on
[**2123-10-26**] after a fall at home with left-sided weakness. You were
found to have a stroke in the right side of your brain. You were
first seen at an outside hospital where you were given tPA, a
clot busting drug. You were monitored in the Intensive Care Unit
overnight here to ensure that you did not have any complications
from this medication. A repeat CT scan did show some bleeding in
the area of the stroke but not a dangerous amount. You were
started on aspirin 325mg daily. We believe your stroke was
likely related to your atrial fibrillation. You will need to be
started on a blood thinner called coumain within 7-10 days in
order to reduce your future risk of strokes.
We made the following changes to your medications:
STARTED Aspirin 325mg daily
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
The following appointment has been made for you in our stroke
clinic:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2123-11-30**] 11:00
You should also make an appointment to follow up with your
primary care doctor Dr. [**Last Name (STitle) 83262**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"272.4",
"427.1",
"401.9",
"365.9",
"431",
"781.94",
"427.31",
"793.11",
"781.8",
"342.92",
"434.11",
"V15.82",
"V10.46",
"784.51",
"362.50",
"443.9",
"V10.11",
"V45.88"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9935, 10033
|
6740, 8793
|
314, 339
|
10117, 10117
|
3736, 3736
|
11351, 11793
|
1511, 1521
|
9388, 9912
|
10054, 10096
|
9346, 9365
|
10293, 11081
|
3007, 3717
|
1575, 1962
|
2588, 2974
|
11110, 11328
|
268, 276
|
8819, 9320
|
367, 1197
|
3753, 6717
|
10132, 10269
|
1219, 1343
|
1359, 1495
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 187,370
|
43032
|
Discharge summary
|
report
|
Admission Date: [**2186-5-20**] Discharge Date: [**2186-5-24**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
hypertensive urgency and apneic episodes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
37 M with h/o DMI, HTN, gastroparesis, ESRD on HD (T/Th/Sat),
with multiple recent admissions for hypertensive urgency, who
developed n/v/abd pain, and was found to have SBP 259/163
earlier at HD and was transferred to [**Hospital1 18**] after receiving 1"
nitropaste and 5mg lopressor. In the ED, he was unable to
tolerate PO medication, n/v x 1 enroute. He received labetalol
10mg iv, dilaudid 2mg iv, ativan 2mg iv, zofran x 1 with decline
in VS HR 86 SBP 138/87 18 100%RA. Pt taken to HD as he missed
his earlier scheduled HD [**3-17**] hypertensive urgency abd 3 liters
were removed. He BPs were stable overnight but he again
developed N/V and abd pain on the medical floor with BPs
200s/140s. He was given metoprolol 5 mg IVx1, the 10 mg IV as
well as ativan 2 mg x2, dilaudid 2 mg IV x2. After the ativan
and dilaudid, he was solmnolent and had some apneic episodes.
.
On transfer to the MICU he was AAOx3, abd pain was improved,
denied CP, SOB, headache still not able to take PO's.
Past Medical History:
# DM type I - Followed by Dr. [**Last Name (STitle) 92853**] was on lantus 3 units and
ISS on last admission
# ESRD on hemodialysis started [**2-/2184**] on Tu, Th, Sat - last [**5-20**]
# Severe autonomic dysfunction with multiple hospitalizations
for hypertensive emergency, gastroparesis, and orthostatic
hypotension.
# History of esophageal erosion, MW tear
# CAD with 1-vessel disease (50% stenosis D1), normal stress
[**11/2182**]
# Foot Ulcer - 2 months, healing slowly
# H/O clot in AV fistula clot on coumadin - [**Month (only) 958**]/[**2185-8-13**]
s/p multiple attempts to remove clot
# H/O coag neg staph bacteremia
Social History:
Denies alcohol or tobacco use. Endorses occassional marijuana
use. Lives with his [**Hospital1 **] mother and their three children
Family History:
His father recently died of ESRD and diabetes. His mother is in
her 50s and has hypertension. He has two sisters, one with
diabetes, and six brothers, one with diabetes.
Physical Exam:
VS: T 97.9 BP 206/137 HR 87 RR 15 100%RA
GEN: AAOx3 and answering questions
HEENT: sclera anicteric, no LAD, no carotid bruits. No JVD, MM
moist, OP clear, pupils small but reactive.
CV: regular, nl s1, s2, +3/6 sem
PULM: CTA b/l
CHEST WALL: right side PORT, right side HD catheter c/d/i.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL. LUE with av-fistula, no
thrill sutures in place, feets with drys skin, no open wounds,
dry well healed area on sole of right foot was site of recent
ulcer.
NEURO: alert & oriented x 3, CN II-XII in tact, strength in
upper and LE [**6-17**] and equal
Pertinent Results:
[**2186-5-20**] 12:38PM GLUCOSE-303* UREA N-44* CREAT-8.8* SODIUM-136
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-21* ANION GAP-19
[**2186-5-20**] 12:38PM ALT(SGPT)-8 AST(SGOT)-11 LD(LDH)-237 ALK
PHOS-97 AMYLASE-91 TOT BILI-0.3
[**2186-5-20**] 12:38PM LIPASE-66*
[**2186-5-20**] 12:38PM CALCIUM-9.7 PHOSPHATE-2.7# MAGNESIUM-1.7
[**2186-5-20**] 12:38PM WBC-8.5 RBC-3.94* HGB-10.7* HCT-32.4* MCV-82
MCH-27.0 MCHC-32.9 RDW-17.5*
[**2186-5-20**] 12:38PM NEUTS-70.8* LYMPHS-18.7 MONOS-3.8 EOS-5.8*
BASOS-0.8
[**2186-5-20**] 12:38PM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-1+
[**2186-5-20**] 12:38PM PLT COUNT-295
[**2186-5-20**] 12:38PM PT-15.0* PTT-150* INR(PT)-1.3*
[**2186-5-20**] 12:34PM GLUCOSE-275* K+-4.2 TCO2-22
Brief Hospital Course:
Hypertensive urgency: Likely secondary to autonomic instability.
? if abd pain and N/V come first or HTN, but this is consistent
with his typical pattern and controlling both N/V and pain help
with BP control and vice versa. He is not having any HA, visual
changes, CP or EKG changes to suggest end organ damage.
- received Labetolol IV Q4H for SBP>170 and PRN if SBP>200, no
drip as he has become hypotensive on this in the past, but if
has high requirement would consider this- BP under control, last
dose labetolol 10am [**5-22**] . after transfer to floor on [**5-23**] pt
stable on regimen with good Bp's. restarted on home regimen.
- continue clonidine patch
- continue home regimen of nifedipine CR, clonidine 0.2mg po
tid, metoprolol 25mg tid following episode of hypotension and
BP 119/70 upon transfer, will increase as needed.
- Continue reglan, ativan and dilaudid for pain and nausea
control
.
# Apneic episodes: Currently AAOx3 and easily arousable with
voice when sleeping. Likely apnea due to higher than usual does
of ativan and dilaudid given on the medical floor, but this was
not observed overnight despite that monitor alarming for apnea,
really just taking small breaths
- Continue ativan and dilaudid PRN with holding parameters for
sedation
- consider undiagnosed obstructive sleep apnea, although very
unlikely if not snoring and maintains his sats during sleep. No
respiratory inssues following transfer to floor on [**5-23**].
.
# N/V and abdominal pain: Pt with multiple admissions with
similar complaints, etiology [**3-17**] gastroparesis, improves
considerably with ativan, dilaudid, reglan, will continue usual
regimen odansetron/reglan/ativan IV for now and switch to PO
when able to take POs with holding parmeters as mentioned above.
Pt denies pain, nausea. Tolerating large meals in am [**5-24**].
requesting to leave.
.
# DMI: [**Last Name (un) 387**] following. Pt takes NPH 3 units [**Hospital1 **].
- f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**] recs
- do not hold NPH; support with dextrose in IVF if necessary
- continue HISS.
.
# CAD - pt denies cp/sob.
- continue asa/metoprolol/nifedipine
.
# ESRD: etiology [**3-17**] DM and HTN, tolerating HD well, last on
[**2186-5-20**] continue on usual schedule, usual T/Th/Sat.
- Calcium Acetate 667 mg, 3 capsules TID, increase according to
phos levels
.
# AV fistula: pt with h/o clot in fistula previously. No signs
of infection. Patient afebrile. Subtherapeutic INR again today,
and thus will continue heparin gtt but now given he is requiring
all IV meds and not taking POs and difficult access, will hold
on heparin drip.
- continue coumadin
.
on [**5-24**] pt. stable from MICU transfer and BP's stable. d/w Renal
PCP and will [**Name Initial (PRE) **]/u in one week with Dr. [**Last Name (STitle) 1366**] on [**6-1**]. sutures to
R shoulder and axilla removed, no signs infection, will d/c and
f/u.
Medications on Admission:
Metoclopramide 10 Q6H
Metoprolol Tartrate 75 TID (pt does not take this at home)
Calcium Acetate 667 mg Capsule TID W/MEALS
Ativan 1 mg Q6H prn agitation/nausea
Hydromorphone 4 PO Q3-4H prn
Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
Clonidine 0.2 TID
Warfarin 1.5 QHS
Nifedipine 30 mg SR QD
Pantoprazole 40 QD
Aspirin 81 mg QD
Humalog 100 unit/mL sc QID prn ISS
Insulin NPH Human Recomb 100 unit/mL, 4 units QD (per patient)
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Metoclopramide 10 mg Tablet Sig: 1-2 Tablets PO QID (4 times
a day).
4. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive Urgency
Discharge Condition:
good.
Discharge Instructions:
you were seen in the emergency room and admitted to the hospital
for the elevated blood pressures and pain. this was controlled.
you were placed in the ICU briefly for monitoring of your
breathing. when you returned to the floors your blood pressure
had stabilized, you were eating, and had no pain. you should
take all your medications as directed. return immediately to the
ER for any chest pain, shortness of breath, severe headaches,
nausea or vomiting. be sure to go to dialysis tomorrow and
follow up with Dr. [**Last Name (STitle) 1366**] as directed below.
Followup Instructions:
Follow up tomorrow at dialysis.
Follow up with Dr. [**Last Name (STitle) 1366**] on [**6-1**] at 1pm
|
[
"536.3",
"414.01",
"337.1",
"250.63",
"585.6",
"996.73",
"403.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8196, 8202
|
3764, 6685
|
356, 362
|
8267, 8275
|
3017, 3741
|
8888, 8992
|
2203, 2374
|
7213, 8173
|
8223, 8246
|
6711, 7190
|
8299, 8865
|
2389, 2998
|
276, 318
|
390, 1386
|
1408, 2039
|
2055, 2187
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,807
| 159,214
|
45116
|
Discharge summary
|
report
|
Admission Date: [**2187-11-23**] Discharge Date: [**2187-12-8**]
Date of Birth: [**2104-1-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ditropan XL / Norvasc
Attending:[**Doctor First Name 2080**]
Chief Complaint:
thrombosed LUE AV [**Doctor First Name **]
Major Surgical or Invasive Procedure:
[**2187-11-24**]: attempted thrombectomy of AV [**Month/Day/Year **] by IR
[**2187-11-24**]: placement of right tunneled line by IR
[**2187-11-27**]: successful thrombectomy of AV [**Month/Day/Year **] by IR
History of Present Illness:
Ms. [**Known lastname 96427**] is 83 year old with HTN, HLD, CAD, stage IV CKD
(HD MWF), COPD, dCHF (EF >55%) with multiple admissions for CHF
exacerbation, and recent admission for afib with RVR during
dialysis, who was admitted from [**Hospital **] clinic after failed dialysis.
She has a recent history of having an occluded LUE AV [**Hospital **],
requiring thrombectomy and stent placement on [**2187-10-22**]. Patient
had unremarkable HD session on Wednesday [**11-21**], then developed
some arm pain on [**11-22**] in the evening; this was attributed to
fatigue after having done arm exercises earlier in the day. On
the morning of admission, the patient also experienced transient
nausea. She denies any other symptoms. Diaylsis session today
could not even be started, and patient was sent to ED for
evaluation. In the ED, initial vs were: 98.7 72 110/p 18 97%.
Exam was notable for absence of thrill over [**Month/Year (2) **], a "cordlike
AVG" and bibasilar crackles. Bedside ultrasound demonstrated
100% fistula occlusion for 2-3 cm with no Doppler flow. Labs
were notable for creatinine elevated to 5.4, and INR 1.8.
Transplant surgery was consulted, and recommended admission to
medicine with plan to have IR perform thrombectomy. IR will do
thrombectomy tomorrow, after NPO tonight.
.
Vital signs prior to transfer were 96.1 po, 62, 106/73, 16, 100%
RA.
.
On the floor, patient was comfortable, though anxious because
her son, [**Name (NI) **], had not been reached yet. Initial vital signs
were 97.3 122/palp 71 16 99%RA, weight 53.3 kg.
.
Review of sytems:
(+) Per HPI. Also positive for increased sweating over the past
two months. Ambulates with a walker.
(-) Denies fever, chills, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. No falls.
Past Medical History:
PAST MEDICAL HISTORY:
1.) Stage 4-5 CKD c/b anemia and secondary hyperparathyroidism;
on HD since [**2187-5-9**], does make some urine
2.) Hypertension
3.) Hyperlipidemia
4.) CAD: per patient, no records at [**Hospital1 18**]
5.) dCHF
6.) R carotid stenosis
7.) Depression
8.) Asthma
9.) Osteoporosis
10.) Osteoarthritis
11.) Thyroid disease- h/o both hypo and hyperthyroidism
12.) Vitamin D deficiency - 25 OH 19 in [**2-/2186**]
13.) Benign adnexal cyst: followed [**8-/2186**] and planned again for
imaging [**8-/2187**]
14.) Chronic Aspiration: based on video swallow eval [**8-/2186**]
15.) Chronic labyrinthitis
16.) h/o L pneumothorax
.
PAST SURGICAL HISTORY:
1.) [**4-/2187**] LUE AV [**Year (4 digits) **] (Dr. [**First Name (STitle) **]
2.) hx bilat cataract surgery
3.) R hip fx s/p ORIF
4.) [**10/2187**] LUE AV [**Year (4 digits) **] thrombectomy and stent placement
Social History:
Patient is widowed, and she lives with her son, [**Name (NI) **]
[**Name (NI) 96427**], and his fiance, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1169**], with [**Last Name (NamePattern1) 269**] assistance and
private home care services. Denies any current or past smoking,
current or past alcohol, or current or past drug use. Has care
at the [**Location (un) 3137**] Center. Dialysis in [**Location (un) 1468**].
Family History:
Son with heart surgery for unknown reason in fall [**2185**]. No
family history of kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.3 122/palp 71 16 99%RA, weight 53.3 kg
General: Elderly, white female, hard-of-hearing, comfortable,
NAD
HEENT: Left pupil slightly larger than right, EOMI. Sclera
anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to angle of jaw, no LAD
Lungs: Crackles at bases bilaterally, otherwise clear.
CV: Irregular, diminished S1/S2, II/VI systolic murmur at the
RUSB without radiation to the carotids or LLSB.
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Stage 2 ulcer on left heel, stage 2 coccygeal ulcer.
Multiple eccyhmoses on arms and legs bilaterally.
Neuro: Left pupil larger than right, keeps left eye closed
because vision decreased in that eye. CNs II-XII grossly intact.
Moving all extremities.
.
Pertinent Results:
ADMISSION LABS:
[**2187-11-23**] 12:55PM BLOOD WBC-6.3 RBC-3.85* Hgb-12.7 Hct-39.7#
MCV-103*# MCH-33.0* MCHC-32.0 RDW-15.8* Plt Ct-226
[**2187-11-23**] 12:55PM BLOOD Neuts-68.9 Lymphs-21.4 Monos-4.6 Eos-4.8*
Baso-0.4
[**2187-11-23**] 12:55PM BLOOD PT-19.1* PTT-37.1* INR(PT)-1.8*
[**2187-11-23**] 12:55PM BLOOD Glucose-87 UreaN-32* Creat-5.4* Na-138
K-3.9 Cl-96 HCO3-31 AnGap-15
[**2187-11-25**] 12:35PM BLOOD Calcium-8.4 Phos-4.8*# Mg-2.2
.
RELEVANT LABS:
[**2187-11-28**] 06:23AM BLOOD WBC-10.2# RBC-3.39* Hgb-11.3* Hct-34.0*
MCV-100* MCH-33.2* MCHC-33.2 RDW-15.7* Plt Ct-198
[**2187-11-28**] 06:23AM BLOOD Neuts-87.1* Lymphs-9.3* Monos-2.9 Eos-0.3
Baso-0.3
[**2187-11-28**] 03:52PM BLOOD Lactate-2.4*
.
DISCHARGE LABS:
.
MICROBIOLOGY:
[**2187-11-28**] Blood cultures x2: NGTD
.
IMAGING:
[**2187-11-23**] LEFT UPPER EXTREMITY ULTRASOUND:
LEFT AV [**Month/Day/Year **] ULTRASOUND: Targeted evaluation of the antecubital
fossa reveals a completely occluded Dacron [**Month/Day/Year **], with no
detectable internal flow. The venous outflow limb, likely the
cephalic vein, is also nearly occluded by acute expansile and
heterogeneous thrombus, with minimal areas of residual flow. The
left subclavian and axillary veins are patent with normal
waveforms. The arterial inflow to the [**Month/Day/Year **] (brachial artery)
is widely patent, and demonstrates normal Doppler waveforms.
There is moderate overlying subcutaneous edema.
IMPRESSION: Complete AV [**Month/Day/Year **] occlusion, and near-complete
occlusion of the
.
[**2187-11-24**] AV FISTULOGRAM:
FINDINGS:
1. Complete thrombosis of the left arm AV [**Month/Day/Year **]. Flow was noted
in the arterial inflow on son[**Name (NI) **].
2. Near-complete thrombosis of the left arm venous outflow
tract. Of note,
was the extravasation of contrast from the [**Name (NI) **] adjacent to its
venous outflow anastomosis, presumably resulting from prior
[**Name (NI) **] access. Further
attempts at AV [**Name (NI) **] declot were abandoned.
IMPRESSION:
1. Uncomplicated AV [**Name (NI) **]-gram. Unsuccessful attempt at
declotting.
Fluoroscopy and son[**Name (NI) **] used for guidance.
2. Uncomplicated placement of a 12 French 20-cm temporary
hemodialysis catheter with VIP port via the patent left IJV and
with its tip in the lower SVC, under fluoroscopic and
son[**Name (NI) 493**] guidance.
.
[**2187-11-27**] AV FISTULOGRAM:
FINDINGS:
1. Successful mechanical and chemical thrombolysis of the left
arm AV [**Month/Day/Year **] and axillary vein.
2. Balloon dilatation of the axillary vein venous outflow and
the [**Month/Day/Year **] with a 7-mm x 40 mm balloon.
3. Balloon dilatation of the arterial anastomsois with 5 mm x 40
mm balloon.
.
ECHOCARDIOGRAM:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 2.6 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 1.7 cm
Left Ventricle - Fractional Shortening: 0.35 >= 0.29
Left Ventricle - Ejection Fraction: 75% to 80% >= 55%
Aorta - Sinus Level: 2.5 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *37 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 22 mm Hg
Aortic Valve - LVOT diam: 1.6 cm
Aortic Valve - Valve Area: *1.4 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 2.6 m/sec
Mitral Valve - Mean Gradient: 11 mm Hg
Mitral Valve - Pressure Half Time: 78 ms
Mitral Valve - MVA (P [**12-10**] T): 2.8 cm2
Mitral Valve - E Wave: 1.9 m/sec
Mitral Valve - A Wave: 2.0 m/sec
Mitral Valve - E/A ratio: 0.95
Mitral Valve - E Wave deceleration time: *316 ms 140-250 ms
Findings
This study was compared to the prior study of [**2187-2-28**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler. Normal IVC
diameter (<=2.1cm) with >50% decrease with sniff (estimated RA
pressure (0-5 mmHg).
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Hyperdynamic LVEF >75%.
Mid-cavitary gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated ascending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (area 1.2-1.9cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe
mitral annular calcification. Mod functional MS due to MAC. Mild
to moderate ([**12-10**]+) MR. [Due to acoustic shadowing, the severity
of MR may be significantly UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild [1+] TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). A
mid-cavitary gradient is identified. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is severe mitral
annular calcification. There is moderate functional mitral
stenosis (mean gradient 11 mmHg) due to mitral annular
calcification. Mild to moderate ([**12-10**]+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2-28**]/201, LV
systolic function is now hyperdynamic.
Brief Hospital Course:
Ms. [**Known lastname 96427**] is 83 year old with HTN, HLD, CAD, stage IV CKD
(HD MWF), COPD, dCHF (EF >55%) with multiple admissions for CHF
exacerbation, and recent admission for afib with RVR during
dialysis, who was admitted from [**Hospital **] clinic after failed dialysis,
and was found to have a thrombosed AV [**Hospital **].
.
.
ACTIVE ISSUES:
# Thrombosed AV [**Hospital **]: Prior to admission, patient developed
left arm pain, and was found to have non-functioning [**Hospital **] at
outpatient hemodialysis. Complete thrombosis of her AV [**Hospital **]
was demonstrated on ultrasound in Emergency Department. She was
admitted for thrombectomy for reinitiation of dialysis, although
there was no emergent need for dialysis. Thrombosis was likely
due to foreign material of [**Hospital **] (vs. fistula, which has lower
likelihood of thrombosis). On [**11-24**], Interventional Radiology
attempted a thrombectomy, but were unable to clear the [**Month/Year (2) **];
they placed a left internal jugular tunnelled catheter, which
did not function in dialysis later that day. Patient had an
abbreviated dialysis session via that tunnelled catheter on
[**11-26**]. On [**11-27**], Interventional Radiology again attempted
thrombectomy and were successful. The following day, the
patient restarted HD via her [**Month/Year (2) **]. Her tunnelled catheter was
then removed.
.
# Hypotension: Patient with a history of hypotension during
dialysis sessions and her family endorses that her baseline
blood pressure at [**Last Name (un) **] eis 90s/40s. At the start of HD on [**11-28**],
one day s/p thrombectomy and replacement of her tunnelled line,
patient was hypotensive to systolics in the 70s. This was in
the context of having been NPO for much of the days preceding
this session. During HD, she was persistently hypotensive, but
had some response to IV boluses of NS. On returning to the
floor, her BP was 90/60 but dropped again to 64/dopp. All the
while, patient was mentating well, only complaining of a
headache and new right lower quadrant pain. In the context of
recent instrumentation, sepsis from a [**Month/Year (2) **] site infection vs.
tunnelled line was of high suspition; this accompanied new onset
of a left shift with 87% PMNs. However, she did not have an
elevated lactate and did not develop fevers or redness at the
dialysis sites. Her antihyptertensives were discontinued.
Blood cultures had been sent from dialysis but are no growth to
date.
She was transferred to the ICU for closer monitoring of
her blood pressure. She continued to have blood pressures
80s-90s/40s and with good mentation. Infectious work-up
including cultures and chest x-ray were negative. There was no
clear infectious etiology for her hypotension and her
antibiotics were discontinue. Her volume status and blood
pressure continued to elude firm control for several days. On
[**Holiday **] she became tachycardic secodnary to betablocker
withdrawl and anxiety and flashed. She underwent bedside
ultrafultration however her blood pressures during the session
were too loow to accomodate any agressive fluid removal. She
improved with rate control. Cardiology was consulted and an
echocardiogram showed EF of 75% as well as mild Mitral stenosis
and LVOT gradient. It was decided that her LVOT gradient
worsened with tachycardia leading to hypotension (much in the
same way as HOCM patients) There was some discussion regarding
adding back some volume in addtion to pursuing rate control
however after discussin with primary team, cardiology and
nephrology a compromise was reached where she will remain on low
to medium dose betablockers and received 5mg of midodrine prior
to HD to increase SVR and overcome the LVOT gradient. This was
trialed on day prior to dischanrge and she tolerated the new
regimen well with stable blood pressures in the 110-120 systolic
ranges.
.
.
# Anticoagulation: Patient had been on oral anticoagulation with
warfarin for her paroxysmal atrial fibrillation, which was
diagnosed in 11/[**2186**]. Upon admission, her warfarin was held for
procedures, and restarted on [**2187-11-27**]. She will need continue
uptitration of her warfarin for goal INR [**1-11**] for CHADS of 3.
.
# ESRD/CKD V: Patient has been dialysis-dependent since [**Month (only) **]
[**2186**], but still makes some urine. Prior to admission on [**11-23**],
the patient's last hemodialysis session had been [**11-21**]. Based
on her labs and overall clinical picture, there was no emergent
need for dialysis. After placement of a right IJ tunneled cath
on [**11-24**], she was able to undergo an abbreviated HD session on
[**11-26**]. The patient continued her home nephrocaps and
sevelamer throughout hospitalization. Her diet included a 2g
phosphorus restriction. She will continue MWF HD with5 mg
midodrine given prior to each treatment.
.
.
CHRONIC ISSUES:
# Anemia: Baseline Hgb 11.5, likely secondary to ESRD. Patient
receives weekly Epogen. Blood counts were stable during this
admission.
.
# CHF, chronic diastolic: Diastolic, chronic with mild LVH, EF
60-65% in 3/[**2186**]. Patient was monitored with daily weights, and
strict in's and out's. There were no signs of volume overload.
Her goal daily balance was net even. She was continued on her
home beta blocker and ACE inhibitor.
.
# HTN: Well-controlled on home medications, which were
continued.
.
# Atrial fibrillation: Paroxysmal, diagnosed in [**2187-10-9**].
Patient was monitored on telemetry, and continued on her home
metoprolol and amiodarone. Warfarin was held, as discussed
above.
.
# HLD: Continued on home Lipitor.
.
# Depression: Well-controlled on home venlafaxine.
.
.
TRANSITIONAL ISSUES:
# Anticoagulation: Patient should have her INR checked daily.
Based on that level, her warfarin should be adjusted for a goal
INR 2.0-3.0 for her atrial fibrillation.
# Patient to receive 5mg midodrine MWF 30 min prior to HD
# If patient begins the flass first control heart rate than
assess volume status.
# CODE: Full, confirmed with patient
# CONTACT: [**First Name8 (NamePattern2) **] [**Known lastname 96427**], phone isn't working, contact number
is: [**Telephone/Fax (1) 96428**] (fiance, [**Doctor First Name 96429**], phone)
Medications on Admission:
- sevelamer carbonate 800 mg PO TID
- lorazepam 0.25-0.5 mg PO 1-2 times per day prn anxiety
- calcitriol 0.25 mcg PO daily (per family, has been D/C'd)
- lisinopril 5 mg PO daily
- Lipitor 40 mg PO daily
- venlafaxine XR 75 mg PO daily
- metoprolol succinate 100 mg PO daily
- docusate sodium 200 mg PO BID
- B complex-vitamin C-folic acid 1 mg Capsule by mouth daily
- Miralax 17 mg PO daily
- amiodarone 200 mg PO daily
- folic acid 1 mg PO daily
- Epogen every Wednesday at dialysis
- biascodyl 5 mg PO daily PRN constipation
- acetaminophen 650 mg PO q6 PRN fever/pain
- albumin 25% IV at dialysis on MWF for SBP < 100
- warfarin
- ipratropium bromide 0.02% via neb q6 PRN wheezing/sob
- DIET: mechanical soft, 2g sodium, 2g phosphorus
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. lorazepam 0.5 mg Tablet Sig: 0.5-1 Tablet PO once a day as
needed for anxiety.
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
5. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO QAM (once a day (in the morning)).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Epogen Injection
12. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing/sob.
15. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
16. midodrine 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR): please give 30 min prior to HD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnosis:
Thrombosed AV [**Hospital1 **]
.
Secondary diagnosis:
ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 96427**],
It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted after your
arteriovenous [**Hospital1 **] clotted off. The Interventional
Radiologists were unable to remove the clot from the [**Last Name (LF) **], [**First Name3 (LF) **]
they placed an access catheter in your neck, which was used for
hemodialysis successfully on Monday, [**11-26**], your clot was
later removed and your fistula is now working fine.
.
Your hospital course was further complicated by difficult blood
pressure control and your medications were modified to ensure
your pressures remained in the normal range.
While you were here we made the following changes to your
medications.
We CHANGED yoru metoprolol
We CHANGED your warfarin
We STOPPED your lisinopril
.
Also, please weigh yourself every morning, and call your primary
care physician if your weight goes up more than 3 pounds.
You will be discharged to a long term care facility that has
docitors on staff. When they deem you are medically clear you
will be discharged home and be given an appointment with yoru
PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) 96430**] keep this follow up appointment.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICNE
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 133**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.**
Department: CARDIAC SERVICES
When: TUESDAY [**2187-12-11**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"733.00",
"E849.0",
"V45.11",
"396.8",
"458.21",
"E878.2",
"453.84",
"V58.61",
"403.91",
"996.73",
"414.01",
"E879.1",
"588.81",
"428.33",
"427.31",
"428.0",
"311",
"272.4",
"585.6",
"493.20",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"39.42",
"38.95",
"88.49",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
19903, 19974
|
11465, 11805
|
341, 551
|
20096, 20096
|
5027, 5027
|
21483, 22253
|
3994, 4094
|
18510, 19880
|
19995, 19995
|
17745, 18487
|
20247, 21460
|
5750, 11442
|
3309, 3523
|
4134, 5008
|
17184, 17719
|
259, 303
|
11820, 16352
|
2163, 2620
|
579, 2145
|
20068, 20075
|
5043, 5733
|
20014, 20047
|
20111, 20223
|
16368, 17163
|
2664, 3286
|
3539, 3978
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,598
| 104,783
|
49192
|
Discharge summary
|
report
|
Admission Date: [**2184-12-10**] Discharge Date: [**2184-12-25**]
Date of Birth: [**2116-11-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Abnormal Stress Test
Major Surgical or Invasive Procedure:
[**2184-12-10**] Cardiac Catheterization
[**2184-12-13**] Redo CABG X 3 (LIMA->LAD, SVG-> PDA, SVG->OM1)
History of Present Illness:
Patient is a 68 year old male with known history of coronary
artery disease, status post bypass grafting in [**2163**]. (SVG-D1,
jump LAD, SVG->OM2 and SVG to RPDA (occluded)). He underwent
stenting of ostial vein graft to Diagonal and left anterior
descending arteries in '[**76**], in-stent restenosis in [**12-21**] status
post PTCA and more stenting in graft proximally, stenting of the
native left anterior descending artery. He had a relook
catheterization one week later due to chest pain which revealed
patent stents, a circumflex artery lesion was pressure wired
which was negative. The patient was scheduled for a knee
replacement next week and had a stress test as part of his
workup. He had an ETT yesterday which was positive for anterior
ischemia, patient also with runs
of ventricular tachycardia. Patient was going in to Dr. [**Name (NI) 103174**] office today to be setup with a Holter monitor. He
reports epigastric/chest
discomfort described as a burning ? indigestion pain. He took 2
nitroglycerin tabs without relief. He reported symptoms to Dr.
[**Last Name (STitle) 4469**] and
was sent to the [**Hospital3 **] emergency [**Hospital1 **]. ECG without
acute changes.
Pain free on arrival to Emergency [**Hospital1 **]. Patient reports he has
had this
epigastric/midsternal burning for several months that occurs
after eating. He reports occas lightheadedness and SOB but
these
symptoms are not associated with the discomfort in his chest.
Past Medical History:
Hyperlipidemia
Hypertension
Coronary Artery Bypass Grafting [**2163**]
Multiple percutaneous coronary interventions
Sleep apnea
Restless leg syndrome
Past bilateral hernia repairs
Right knee arthritis
Social History:
Widowed, lives with 2 sons in [**Name (NI) 1268**], retired but works at
golf course during spring/summer season, rare ETOH
Family History:
father 1st MI age 51, and died of MI at age 62
Physical Exam:
VS: 49-14 R) 119/91 L) 144/101 02 sat 100% 2L NC
General: WDWN [**Male First Name (un) 4746**], slightly pale sitting up in bed in NAD
HEENT: Oral mucosa pink, moist
Neck: 2+ carotids (-)bruit (-)JVD
CV: RRR S1, S2 (-)murmurs
Resp: lungs CTA bilat
Abdomen: soft, NTND, (+)bowel sounds x 4
PV: femoral 2+ pulses (-)bruit
DP 2+ bilat, PT 1+ bilat, (-)edema
Neuro: Alert and oriented x 3, MAEs
Pertinent Results:
[**2184-12-10**] 05:30PM WBC-5.2 RBC-3.97* HGB-12.5* HCT-35.3* MCV-89
MCH-31.5 MCHC-35.4* RDW-12.6
[**2184-12-10**] 05:30PM ALT(SGPT)-20 AST(SGOT)-20 ALK PHOS-71
AMYLASE-34 DIR BILI-0.2
[**2184-12-10**] 11:45PM URINE RBC-[**4-29**]* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2184-12-10**] 11:45PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2184-12-24**] 11:35AM BLOOD WBC-9.4 RBC-3.00* Hgb-8.6* Hct-26.6*
MCV-89 MCH-28.8 MCHC-32.5 RDW-15.0 Plt Ct-389
[**2184-12-25**] 05:00AM BLOOD PT-14.8* INR(PT)-1.4
[**2184-12-24**] 11:35AM BLOOD Glucose-121* UreaN-16 Creat-0.9 Na-131*
K-3.9 Cl-92* HCO3-32* AnGap-11
[**2184-12-10**] Cardiac Catheterization
1. Selective coronary angiography demonstrated severe
three vessel native coronary artery disease in this right
dominant
circulation. The LMCA had mild disease without flow limitation.
The LAD was totally occluded after the takeoff of a small
diagonal
branch. The LCX was without flow limiting disease and became a
small
vessel about the AV groove. The OM1 was totally occluded
proximally. The
OM2 was without flow limiting disease. The RCA had a 70-80%
proximal
in-stent restenosis present. There was diffuse disease in the
distal
vessel from 50-60%.
2. Graft angiography demonstrated the SVG-OM1 with diffuse
disease but otherwise patent. The SVG-D1-LAD showed a patent
proximal
stent. There was diffuse aneurysmal disease was seen in the
D1-LAD jump
graft with slow flow to the distal LAD without a discrete lesion
seen.
3. Angiography of the in-situ LIMA showed a normal vessel.
4. Left ventriculography demonstrated no mitral regurgitation
and
preserved left ventricular systolic function with an LVEF of
55%.
5. Limited resting hemodynamics demonstrated elevated left sided
filling
pressures with LVEDP=15mmHg.
[**2184-12-10**] EKG
Baseline artifact. Probable prominent sinus bradycardia with
prolonged
P-R interval at about 0.24 seconds. Leads VI-V2 were not
recorded. Borderline left axis deviation. Inferior Q waves are
not diagnostic but raise consideration of prior inferior
myocardial infarction. Non-specific ST-T wave changes. Since the
previous tracing of [**2181-2-4**] lead reversal has been corrected.
The heart rate is slower and the P-R interval is longer.
[**2184-12-12**] Chest X-Ray
Clear lungs. No acute process identified.
[**2184-12-21**] ECHO
1. The left atrium is dilated. No mass/thrombus is seen in the
left atrium or left atrial appendage. The right atrium is
dilated.
2. The left ventricular cavity is mildly dilated. There is
moderate global
left ventricular hypokinesis. Overall left ventricular systolic
function is moderately depressed.
3. There is moderate global right ventricular free wall
hypokinesis.
4. Trace aortic regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
6. There is a large (3-4 cm), posterior, loculated pericardial
effusion with fibrin deposits on the surface of the heart. These
findings were discussed with Dr. [**First Name4 (NamePattern1) 3692**] [**Last Name (NamePattern1) 284**].
[**2184-12-24**] Holter Monitor
The baseline recording was sinus rhythm at rates ranging from 85
to
86 BPM without ectopy. The baseline intervals were as follows:
at a rate
of 104 BPM, the QT was .35 (prolonged), the PR was .16 (normal),
and the
QRS was .08 (normal). Non-specific ST-T changes were noted at
baseline.
There were 11 daily recordings transmitted which showed sinus
rhythm at rates ranging from 68 to 100 BPM (Strips
#2,8,10,14,16,17,19,23,25,29,32).
There were 20 symptomatic recordings with complaints of "burning
and pressure at center of chest," "chest pressure,"
"A.Fib/nausea,"
"chest discomfort level 4," "A.Fib, dry mouth," "nausea, stomach
discomfort, slight chest discomfort" "shortness of breath,"
"nausea,
tired," and "chest pain."
Eighteen recordings showed sinus rhythm at rates ranging from 70
to
102 BPM (Strips #3-6,11-13,15,18,20-22,24,26,28,30,31). There
was 1
isolated VPB (Strip #22).
One recording on [**2184-12-28**] showed atrial fibrillation with average
ventricular response rates of 80 to 110 BPM with a maximum RR
interval
of 1.40 seconds.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2184-12-10**] for a cardiac catheterization. This revealed
severe native vessel and saphenous vein graft disease. Given the
severity of his disease, the cardiac surgical service was
consulted for surgical revascularization. Mr. [**Known lastname **] was
worked-up in the usual preoperative manner. On [**2184-12-13**], Mr.
[**Known lastname **] was taken to the operating room where he underwent a
redo sternotomy with coronary artery bypass grafting to three
vessels. Postoperatively he was taken to the cardiac surgical
intensive care unit for monitoring. On postoperative day one,
Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact and was extubated.
Plavix was resumed. The electrophysiology service was consulted
for atrial fibrillation which alternated with junctional
bradycardia. Heparin was started for anticoagulation. Low dose
beta blockade was used with the plan for cardioversion. On
postoperative day two, Mr. [**Known lastname **] was transferred to the
cardiac surgical step down unit. He was gently diuresed towards
his preoperative weight. He developed a ten second asystolic
pause which required ventricular back up pacing and his beta
blockade was discontinued. He spontaneously converted to a sinus
bradycardia for which he continued to be ventricularly paced. It
was assumed by the electrophysiology service that a pacemaker
would be needed, however they wanted to observe his rhythm a
little longer to see if his node would recover. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. Mr. [**Known lastname **] developed
atrial flutter / atrial fibrillation again and amiodarone was
started. As Mr. [**Known lastname **] did not tolerate his atrial flutter very
well, the plan was for a transesophageal echocardiogram, a
pacemaker and flutter termination. On [**2184-12-21**], Mr. [**Known lastname **] was
taken to the electrophysiology lab where he underwent ablation
of his atrial flutter. He tolerated the procedure well and felt
much improved with being in normal sinus rhythm. He again
developed symptomatic periods of atrial fibrillation for which
his amiodarone was increased. Mr. [**Known lastname **] was transfused with
packed red blood cells for a low hematocrit. Coumadin was
continued for anticoagulation. Mr. [**Known lastname **] continued to make
steady progress and was discharged home on postoperative day
twelve with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts Holter monitor. He will follow-up
with Dr. [**Last Name (STitle) **], his cardiologist, the electrophysiology
service and his primary care physician as an outpatient.
Medications on Admission:
Aspirn 325mg daily
Mirapex 0.125 [**11-21**] tablet twice daily
Atenolol 25mg Daily
Cardizem CD 180mg daily
Celexa 30mg daily
Lipitor 40mg daily
Protonix 40mg daily
Ativan as needed
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Pramipexole Dihydrochloride 0.125 mg Tablet Sig: One (1)
Tablet PO bid prn ().
Disp:*60 Tablet(s)* Refills:*2*
3. Citalopram Hydrobromide 20 mg Tablet Sig: 1.5 Tablets PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 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*
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q3-4H () as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Warfarin Sodium 1 mg Tablet Sig: Two (2) Tablet PO once a
day: on [**12-25**] & [**12-26**], then check with Dr.[**Name (NI) 29686**] office for
continued dosing.
Disp:*120 Tablet(s)* Refills:*2*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO twice a day for 7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
post-op A Fib
Discharge Condition:
good
Discharge Instructions:
no lifting > 10#, or driving for 1 month
may shower, no bathing or swimming for 1 month
no creams or lotions to incisions
Followup Instructions:
with Dr. [**Last Name (STitle) 34013**] in [**12-23**] weeks
with Dr. [**Last Name (STitle) 4469**] in [**12-23**] weeks
with Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2185-3-18**]
|
[
"414.01",
"997.1",
"780.57",
"401.9",
"272.4",
"300.00",
"427.81",
"423.9",
"715.36",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.22",
"88.56",
"37.34",
"36.15",
"88.53",
"36.12",
"39.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11764, 11822
|
7070, 9921
|
344, 451
|
11884, 11890
|
2826, 7047
|
12060, 12258
|
2331, 2380
|
10153, 11741
|
11843, 11863
|
9947, 10130
|
11914, 12037
|
2395, 2807
|
284, 306
|
479, 1949
|
1971, 2173
|
2189, 2315
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,982
| 147,278
|
35761
|
Discharge summary
|
report
|
Admission Date: [**2191-3-24**] Discharge Date: [**2191-3-30**]
Date of Birth: [**2155-8-25**] Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
lumbar puncture in ER on [**2191-3-24**]
History of Present Illness:
35 year old female s/p recent pituitary mass resection
presented to OSH with severe headache, nausea, vomiting, and
nasal drainage yesterday. She was sent home with Augmentin for a
presumed sinus infection after seeing opacified sinuses on CT
scan. The patient went back to the ER today because she was
unable to keep the medication down due to persistent vomiting.
The patient was then transferred to [**Hospital1 18**]. She reports that she
has had tenderness in her calves as well as chills this week but
she did not take her temperature at home. Currently she has a
fever of 101.7 in the ER. She also reports that she had nasal
drainage yesterday that was clear at times and brownish at
times.
The drainage was not positional, occuring throughout the day.
Additionlly she has photophobia and slight phonophobia. She does
not have any SOB or chest pain.
Past Medical History:
Hypertension, Headache, Hypothyroidism
Social History:
Resides at home with child.
Family History:
non-contributory
Physical Exam:
Exam upon admission:
T:101.7 BP:125/71 HR:125 RR:16 O2Sats:98% RA
Gen: Patient appears very uncomfortable in the bed. She is
wearing an eye patch over the left eye.
HEENT: Pupils:PERRL EOMs-see below
No drainage from the ears or nose.
Neck: Supple. No nuchal rigidity.
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.
Recall: [**2-22**] 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, 2 to 1 mm
bilaterally.
III, IV, VI: Extraocular movements intact on the left side. On
the right side she has a 6th nerve palsy.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-26**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Pertinent Results:
Head CT from OSH [**2191-3-24**]:
MPRESSION:
1. No acute intracranial process, including no hemorrhage,
edema, or mass
effect.
2. Opacification of the sphenoid sinuses and left maxillary
sinus. This is
slightly progressed compared to prior study performed [**2191-3-13**].
3. Post-surgical packing material adjacent to the clivus, well
characterized
by an MR [**First Name (Titles) 27533**] [**2191-3-10**], is not well visualized on this
study.
Brief Hospital Course:
The patient was admitted to the ICU after presenting with a
headache, nausea, vomiting, nasal drainage to the ER. While in
the ER she had a fever of 101.7, although she had not taken her
temperature at home prior to that time. She was started on IV
antibiotics until her cultures were back to cover for
meningitis. CT scan was done, showing stable intracranial
process; however opacification of the sinuses consistant with
sinusitis.
Endocrinology was consulted during this hospitalization to
monitor for diabetes insipidus. On [**3-28**], her urine output was
noted to be excessive with a climbing serum sodium. On [**3-29**], her
prednisone dosing was increased from 5mg to 7.5mg and DDAVP
50mcg given in the evening. Her sodium on the morning of [**3-30**] had
come down to 142 from 149 on the evening of [**3-28**]. Endocrinology
felt she would be safe for discharge to home given her response
to medical therapy. She was discharged to home on [**3-30**] with
instructions to follow up with endocrinology, as well as with
medications to treat DI symptoms should they re-occur.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Disp:*60 Capsule(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed. Disp:*30 Tablet(s)* Refills:*0*
3. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
4. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): continue to take as long as you require narcotic
pain medication.
Disp:*60 Capsule(s)* Refills:*0*
2. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
4. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours). Tablet(s)
5. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed: Caution not to exceed more than
4gm APAP in 24h.
Disp:*30 Tablet(s)* Refills:*0*
7. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days: Make sure to take with food or milk, as this
medication can cause stomach upset.
Disp:*20 Tablet(s)* Refills:*0*
8. DDAVP 0.1 mg Tablet Sig: [**12-24**] tablet(50mcg) Tablet PO as
directed by endocrinology for DI symptoms.
Disp:*25 Tablet(s)* Refills:*0*
9. Solu-Cortef 100 mg/2 mL Recon Soln Sig: One (1) Injection as
needed per endocrinology recommendations.
Disp:*1 vial* Refills:*2*
10. Intramuscular Syringes
Syringe 3cc/21Gx1-1/2"
please dispense 5 syringes for use with Solucortef. NO REFILLS.
Use as directed.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
CN VI palsy
Sinusitis
Diabetes Insipidus
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Continue Sinus Precautions for an additional two weeks. This
means, no use of straws, forceful blowing of your nose, or use
of your incentive spirometer.
?????? You have been discharged on Prednisone, take it daily as
prescribed. If on any day, you are ill and unable to take it by
mouth, you will need to give yourself an injection of
dexamethasone instead.
?????? You are required to take Prednisone, an oral steroid, make
sure you are taking a medication to protect your stomach
(Prilosec, Protonix, or Pepcid), as this medication can cause
stomach irritation. Prednisone should also be taken with a
glass of milk or with a meal. You may be required to take higher
doses if needs higher steroid doses if you have fevers, n/v, or
other stressors - and should call the endocrinologist should you
have these symptoms to have them prescribe the dose to be taken.
**you should also obtain a medic alert bracelet describing your
medication condition, should and untword event occur.
**You are also being prescribed DDAVP tablets for use as needed
at night (use to be directed by ENDOCRINOLOGIST ONLY). Please
call the endocrinologist if you notice your urine output being
200-300cc per hour, and you could be experiencing diabetes
insipidus. *During
the day, you may drink to thirst, but if you have excessive
urine output in the early evening, call endocrinology; and you
will be instructed to take 50mcg of DDAVP ([**12-24**] of the 1mg
tablet). Daytime doses may ultimatley be required, but this will
be determined at your follow up appointment.
-You were not discharged on you HCTZ, as this can mask the
symptoms of Diabetes Insipidus.
CALL YOUR DOCTOR 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.
?????? It is normal for feel nasal fullness for a few days after
surgery, but if you begin to experience drainage or salty taste
at the back of your throat, that resembles a ??????dripping??????
sensation, or persistent, clear fluid that drains from your nose
that was not present when you were sent home, please call.
?????? Fever greater than or equal to 101?????? F.
?????? If you notice your urine output to be increasing(200-300cc per
hour), and/or excessive, and you are unable to quench your
thirst, please call your endocrinologist.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with your
surgeon, Dr. [**Last Name (STitle) **], to be seen in two months. You will need a
CT scan of the brain without contrast prior to your appointment.
??????You have an appointment scheduled to see Dr.
[**Last Name (STitle) **](endocrinologist) on [**4-4**] at 12:30pm. Please call
[**Telephone/Fax (1) 81321**] if you need to resechedule this appointment.
Completed by:[**2191-3-30**]
|
[
"V45.89",
"461.3",
"378.54",
"255.41",
"461.0",
"401.9",
"253.5",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6560, 6621
|
3226, 4313
|
305, 347
|
6706, 6730
|
2755, 3203
|
9996, 10499
|
1358, 1376
|
5130, 6537
|
6642, 6685
|
4339, 5107
|
6754, 9973
|
1391, 1398
|
257, 267
|
375, 1234
|
2078, 2736
|
1412, 1785
|
1800, 2062
|
1256, 1296
|
1312, 1342
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,058
| 124,061
|
10241
|
Discharge summary
|
report
|
Admission Date: [**2157-4-15**] Discharge Date: [**2157-4-27**]
Date of Birth: [**2085-7-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline
Attending:[**First Name3 (LF) 34120**]
Chief Complaint:
Febrile Neutropenia
Major Surgical or Invasive Procedure:
Bronchoalveolar lavage
History of Present Illness:
71 y.o.f. with AML who presents with febrile neutropenia. Was
in USOH until last 3 nights when she developed a fever, the last
being to 101.3. She has no localizing signs or symptoms except
for a small punctate ulceration on her right butt cheek, a few
cm from the anal verge. She states that this appeared about 2
weeks ago and was moderately painful, but has improved. She was
started on acyclovir as an outpatient. She denies cough, URI
symptoms, headaches, chest pain, SOB, abdominal pain, nausea,
emesis, diarrhea, or constipation.
Past Medical History:
Past Oncologic History:
Acute myelogenous leukemia, with background of MDS (diagnosed in
[**2156-9-15**] on decitabine C1D1 on [**2156-10-11**])
- 2nd cycle of decitabine on [**2156-11-23**] at [**Hospital1 18**]
- admitted to [**Hospital1 112**] [**Date range (1) 34121**] for febrile neutropenia and was
given valtrex for lip lesions, also given decitabine C3D1. BMBx
showed slight improvement with 15-20% myeloblasts, no 5q
deletion on FISH
.
Other Past Medical History:
Hypertension
Hyperlipidemia
Goiter/Thyroid Issues (currently not on treatment)
Vitamin D deficiency
GERD
Social History:
Lives alone, works for the [**Location (un) 86**] Health Commission helping to
educate public school students.
- Tobacco: denies
- etOH: denies
- Illicits: denies
Family History:
one brother exposed to [**Doctor Last Name 360**] [**Location (un) 2452**] in [**Country 3992**]; one brother died
of lung cancer.
Physical Exam:
Admission Exam:
VS: T 98.2, BP 126/60, HR 84, RR 20, sat 100% on RA
GEN: AOx3, NAD
HEENT: Sclera and conjunctiva clear B/L. MMM.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, no rebound/guarding
Extremities: wwp, no edema.
Skin: Crusted over lesions at corner of lip on the right. 1 cm
right peri-rectal lesion. Clean, pink base with central area of
scab.
Neuro: no focal deficit.
Pertinent Results:
Admission Labs:
[**2157-4-15**] 02:00AM BLOOD WBC-0.7* RBC-3.06* Hgb-9.5* Hct-26.4*
MCV-86 MCH-31.2 MCHC-36.2* RDW-13.8 Plt Ct-27*
[**2157-4-15**] 02:00AM BLOOD Neuts-2* Bands-0 Lymphs-90* Monos-3 Eos-0
Baso-0 Atyps-5* Metas-0 Myelos-0 NRBC-2*
[**2157-4-15**] 02:00AM BLOOD PT-14.1* PTT-32.0 INR(PT)-1.2*
[**2157-4-15**] 02:00AM BLOOD Glucose-229* UreaN-13 Creat-0.6 Na-130*
K-3.9 Cl-100 HCO3-24 AnGap-10
[**2157-4-15**] 02:20AM BLOOD Lactate-1.7
.
CXR [**2157-4-15**]
No acute cardiopulmonary process. Smaller goiter.
.
CT TORSO04/05/11
1. New right-sided opacity in the right upper lobe most likely
pneumonia;
other etiologies such as hemorrhage could cause a similar
appearance;
neoplastic infiltrate less likely given rapid development of
findings.
2. Interval increase in size of mediastinal and right hilar
lymph nodes,
nonspecific, could be reactive; however, cannot exclude
neoplastic
involvement.
3. New small right pleural effusion.
4. Stable calcified right adnexal mass most likely calcified
fibroid, less
likely calcified ovarian mass or pedunculated broad ligament
fibroid.
5. Stable liver hypodensities, some appear as liver cysts, some
are too small
to be characterized.
6. Stable asymmetric enlargement of the thyroid gland.
[**2157-4-23**] 8:45 am BRONCHOALVEOLAR LAVAGE
ADD ON REQUEST FOR DAS, ACU, LCU, NCU, PER FAX BY [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] ON
[**2157-4-25**] AT 08:53 AM..
QNS FOR VIRAL CULTURES Reported to and read back by [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] ON
[**2157-4-25**] AT 08:54 AM..
GRAM STAIN (Final [**2157-4-23**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2157-4-26**]):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
YEAST. ~[**2146**]/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2157-4-23**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
YEAST.
ACID FAST SMEAR (Final [**2157-4-26**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
[**Year/Month/Day **] CULTURE (Pending):
Brief Hospital Course:
A 71yo F with PMH acute myelogenous leukemia, neutropenic fever,
throid goiter, admitted to OMED service for neutropenic fever
found to have right upper lobe infiltrate, she was treated with
broad spectrum antibiotics, her course was complicated by acute
renal failure after discussion with patient and family dialysis
was declined and the decision was made to provide comfort care
was made. She developed uremia and expired with her family at
the bedside.
.
# Goals of care: The patient developed acute renal failure and
uremia. Her oncologist identified her AML course as severely
progressive with an expceted life expectancy of days to weeks.
Given her poor prognosis, a family meeting was held and it was
decided that dialysis was not in her goals of care. She
developed uremia, hyprekalemia, hyponatraimia and expired on the
morning of hospital day 13 with her family at the bedside.
.
# Neutropenic fever: patient was admitted with neutorpenic fever
and no clear source of infection she was initially continued on
aztreonam/vanc with continuation of home acyclovir and
fluconazole. Fevers persisted; Flagyl was added for anaerobic
coverage. Given persistant fevers and lack of source, CT Torso
was performed [**2157-4-19**] and showed a right upper lobe pneumonia
that was new from her last scan in [**Month (only) 404**]. Her fluconazole was
changed to voriconazole, and gentamycin was added to her abx
regimen. Bronchoscopy was attempted, but could not be done in
the procedure suite as there was significant narrowing of the
trachea from compression by her goiter. Fever curve trended
downwards, but serial chest xray showed interval increase in the
size of the PNA. Voriconazole was changed to ambisome, and
levofloxacin was added for atypical coverage. She was taken to
the ICU for repeated bronchoscopy attempt. Bronchoscopy
performed which showed [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 34122**] drainage. It was difficult
to advance the scope suggesting post-obstructive pneumonia. Gram
stain showed gram positive rods which were likely [**Last Name (NamePattern1) 13607**],
negative for PCP. [**Name10 (NameIs) **] culture was added on and results were
pending at the time of death. She completed a course of
levofloxacin for atypical pneumonia and antibiotics were
narrowed to vanco/meropenem.
.
# Hyponatremia: Na began to trend downward on [**2157-4-19**]. Initially
thought to be hypovolemia given diaphoresis and poor po intake,
but after hydration Na continued to fall. Renal was consulted
who identifed SIADH. She was put on a fluid restriction, salt
tabs, and furosemide. Her sodium improved mildly however she
became anuric and free water could not be mobilized.
.
# Acute renal insufficiency: Creatinine trended up on [**2157-4-23**]
believed to be related to a combination of AML and ATN from
nephrotoxic antibiotics. Renal ultrasound was negative.
Medications were renally dosed and nephrotoxins were avoided.
Creatinine continued to rise and the patient became anuric.
Hyponatremia worsened as she became increasingly hypervolemic,
she developed uremia and hyperkalemia. Dialysis was not in her
goals of care. Cause of death is attributed to acute renal
failure.
.
# Pancytopenia: Patient was transfusion dependent related to AML
and bone marrow failure. She was ransfused intermittently for
platelets < 10 and Hct < 25.
.
# HTN, HLD, GERD: continued home meds
.
Code status was changed to DNR/DNI this admission and then to
comfort measures.
Medications on Admission:
Lisinopril 20mg PO daily
Simvastatin 20mg PO daily
Omeprazole 20 mg daily
Vitamin D 50,000 units qwednesday
Per patient was also on acyclovir, cipro, and fluconazole at
home
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: neutropenic fever
.
Secondary:
Acute myelogenous leukemia
renal failure
uremia
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"530.81",
"288.00",
"272.4",
"240.9",
"486",
"V49.86",
"253.6",
"284.1",
"276.7",
"205.00",
"401.9",
"268.9",
"780.61",
"584.9",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8568, 8577
|
4815, 8310
|
308, 332
|
8708, 8718
|
2306, 2306
|
8775, 8786
|
1703, 1836
|
8535, 8545
|
8598, 8687
|
8336, 8512
|
8742, 8752
|
1851, 2287
|
4540, 4651
|
4684, 4792
|
249, 270
|
360, 903
|
2322, 4504
|
1400, 1506
|
1522, 1687
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,229
| 198,020
|
10796+56177+56178
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2132-7-3**] Discharge Date: [**2132-8-30**]
Date of Birth: [**2056-10-19**] Sex: M
Service: VASCULAR SURGERY
CHIEF COMPLAINT: Lethargy and fevers as well as ruptured
abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 75 year-old
Venezuelan Spanish speaking male who developed a temperature
of 103 and was seen in the Emergency Department at [**Hospital1 1444**] and diagnosed with
bacteremia, but was found to have a ruptured abdominal aortic
aneurysm two days after admission. He presented to the
Emergency Room on [**7-3**], complaining of increased
weakness, inability to sleep, decreased appetite and
intermittent fevers. He also complained of low back pain
that was intermittent and less then approximately two hours
as well as abdominal pain. He was examined by the Emergency
Room team with a chest x-ray performed to rule out pneumonia,
which was negative for effusions, infiltrates, however, there
was a lesion in the right lower lobe on the lateral view and
a CAT scan was recommended. He was also given the diagnosis
of pyelonephritis and as he was extremely febrile with a
temperature of 103 and appeared quite lethargic he was
admitted to the Medical Service.
Apparently the patient was seen at [**Hospital 2725**] Hospital on
[**6-27**] with similar symptoms and was also admitted at that
time. Blood cultures from that hospital admission revealed
beta hemolytic strep in one out of two bottles obtained. It
is unclear as to how the diagnosis of pyelonephritis was made
other then physical examination as no urinalysis was
performed in the Emergency Room.
The patient was admitted and started on intravenous
antibiotics, which included Levaquin 500 mg q.d. At the time
of his admission and evaluation in the Emergency Room his
vital signs revealed an elevated temperature, which came down
to 97.4, heart rate 95, blood pressure 120/70 with an O2 sat
of 97%. His laboratories at the time revealed an elevated
white blood cell count at 18.2, hemoglobin 13.4, hematocrit
41, platelet count 387, sodium 130, potassium 4.2, chloride
91, bicarb 26, BUN 20, creatinine .7.
After the patient was admitted he still began to show signs
of increased abdominal distention as well as flank pain and
showed no signs of improvement with antibiotics. A CAT scan
with contrast of his chest, abdomen and pelvis was performed
shortly later on that evening at approximately 11:00. This
revealed a large infrarenal abdominal aortic aneurysm that
extended approximately from the level of the renal arteries
to approximately 1.5 cm above the bifurcation of the common
iliac arteries. The maximum diameter was noted to be 7 cm.
There was noted to be high density contrast fluids
surrounding the aorta and extending down into the
retroperitoneum into the pelvis. Apparently this was called
to the house officer at the time of the [**Location (un) 1131**] ___________
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 20352**]
MEDQUIST36
D: [**2132-8-29**] 10:13
T: [**2132-8-29**] 11:11
JOB#: [**Job Number 35248**]
Name: [**Known lastname 6269**], [**Known firstname 6270**] Unit No: [**Numeric Identifier 6271**]
Admission Date: [**2132-7-3**] Discharge Date: [**2132-9-3**]
Date of Birth: [**2056-10-19**] Sex: M
Service:
ADDENDUM: The patient continues to do well on Far 9. He was
seen by [**Hospital 616**] Clinic for management of his outpatient
diabetes as it was unclear whether he should be discharged on
the insulin he was receiving at 10 units per day rather than
oral agents. Prior to his hospitalization he was managed on
just a diet. They recommended the use of Glyburide 1.25 mg
po q d rather than the use of NPH and had subsequently
discontinued his NPH. He was also seen by the Diabetes
Learning Center for instruction on how to manage his diabetes
and how to check his blood sugar. Physical therapy and
occupational therapy have worked extensively with this
patient in order to facilitate his move home. He must go
home as he is Venezuelan and has no insurance in the United
States. He is qualified for a free VNA at this time. He
will receive home physical therapy. Donations have been
given to him by surrounding physical therapy facilities for
the use of a walker with wheels. He will be advised to
follow-up with Dr. [**Last Name (STitle) **] in 10 days and with the [**Hospital 616**]
Clinic in two weeks for a more thorough evaluation and
work-up for his chronic diabetes mellitus. He will be
discharged on the following medications which include
Glyburide 1.25 mg po q d, Glutamine 10 mg po bid, Serevent 2
puffs by meter dose inhaler [**Hospital1 **], Lasix 40 mg po q d, Colace
100 mg po bid, Niferex 150 mg po bid and Dulcolax suppository
10 mg prn q d.
Of note is the fact that he was evaluated one final time by
the swallowing technician that suggested that he go home on
soft solids and thickened liquids. He and his daughter were
educated on how to purchase and use the thickening solution
that can be found in pharmacies. They have agreed to this
and demonstrated a clear understanding of the use of this
product.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], M.D. [**MD Number(1) 1549**]
Dictated By:[**Last Name (NamePattern1) 6272**]
MEDQUIST36
D: [**2132-9-3**] 11:40
T: [**2132-9-4**] 11:43
JOB#: [**Job Number 6273**]
Name: [**Known lastname 6269**], [**Known firstname 6270**] Unit No: [**Numeric Identifier 6271**]
Admission Date: [**2132-7-3**] Discharge Date: [**2132-9-3**]
Date of Birth: [**2056-10-19**] Sex: M
Service:
ADDENDUM: The patient was then taken emergently to the
operating room on [**2132-7-4**] for repair of the ruptured
abdominal aortic aneurysm. This was performed by Dr. [**First Name4 (NamePattern1) 255**]
[**Last Name (NamePattern1) **] with details of the operation dictated in a
separate operative note. The patient was transferred to the
Intensive Care Unit intubated, paralyzed and in critical
condition, hemodynamically unstable due to the amount of
blood loss and the difficulty in the operating room.
The patient then had a prolonged hospital course in the
Intensive Care Unit. Due to multiple chart reviews and
thinnings, the chart is not complete at this time. Some of
the events in the Intensive Care Unit involved acute renal
failure secondary to hypovolemia as well as ATN. This
subsequently resolved and the patient continued to make
urine. This lasted over a period of several weeks. The
patient remained in the Intensive Care Unit for approximately
45 days. Other events in the Intensive Care Unit revealed
him to have MRSA growing in his sputum with subsequent
respiratory failure and ventilator dependence. A
tracheostomy was then performed approximately 20 days after
his arrival in the Intensive Care Unit. It should also be
noted that the patient's abdomen was not closed immediately
postoperatively from his aneurysm repair due to the extent of
edema and hematoma present. He was subsequently brought back
by the general surgery team for closure of his abdomen on
postoperative day #2. He was started on IV Vancomycin for
treatment of his MRSA in his sputum but continued to have [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 6274**] hospitalization due to bacteremia, acute renal failure,
respiratory failure and malnutrition. A gastrostomy tube was
also placed in patient on postoperative day #20 for
initiation of tube feeds. This was done as the patient was
not able to swallow, remained on the ventilator and had poor
mentation. He began to improve slowly around postoperative
day #45 and was able to begin speaking and maintaining his
input and output balanced due to aggressive diuresis with
Lasix and Diamox. Speech and swallow was subsequently
consulted and he failed multiple times and continued on his
tube feeds. Nutrition consult was also obtained to manage
the patient's nutritional needs. On postoperative day #49
the patient looked very well, was tolerating his tube feeds
without difficulty, was mentating and speaking with use of a
fenestrated trach. He was off all pressors at this time.
His acute renal failure had resolved and he was no longer on
IV Vancomycin for his MRSA. It was decided by both the
vascular staff and the Intensive Care Unit that he would be
able to be transferred up to the vascular Intensive Care Unit
on the [**Location (un) **].
Once he was on Far 9, the patient made rapid recovery. He
was started on trach collar trials and did quite well. His
trach was eventually capped off and he showed no signs of any
respiratory distress. His trach was subsequently removed on
postoperative day #54 without any evidence of respiratory
failure. Currently he is doing quite well, he is still
having difficulty with his oral intake and nutrition service
has started a calorie count on him. He is taking in
approximately 1200 calories a day and this will need to be
increased prior to his discharge. Also the patient is being
seen by physical therapy and is currently unable to go home
due to low endurance and general debilitation. He has made
remarkable recovery despite his diagnosis and operative
procedure and will continue to be followed.
Discharge summary will be continued at time of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], M.D. [**MD Number(1) 1549**]
Dictated By:[**Last Name (NamePattern1) 6272**]
MEDQUIST36
D: [**2132-9-1**] 11:16
T: [**2132-9-5**] 20:32
JOB#: [**Job Number 6275**]
|
[
"482.41",
"263.9",
"590.80",
"518.81",
"584.9",
"285.1",
"250.00",
"441.3",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44",
"31.1",
"89.64",
"39.55",
"43.11",
"54.62"
] |
icd9pcs
|
[
[
[]
]
] |
167, 235
|
264, 9822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,960
| 155,668
|
41952
|
Discharge summary
|
report
|
Admission Date: [**2196-3-30**] Discharge Date: [**2196-4-7**]
Date of Birth: [**2113-3-21**] Sex: M
Service: MEDICINE
Allergies:
Pradaxa / OxyContin
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
hip fracture s/p fall
Major Surgical or Invasive Procedure:
left hip hemiarthroplasty
History of Present Illness:
Mr. [**Known lastname 406**] is a 82M with a history of atrial fibrillation
on coumadin, EtOH Cirrhosis complicated by portal hypertension,
TIAs and s/p TKA of LLE, septic arthritis s/p washout [**2-29**],
discharged to rehab on [**2196-3-18**], presents back to the hospital s/p
fall with new left hip fracture.
.
Per patient, he received sleeping pill last night for insomnia
(rehab facility confirmed trazadone 25mg), felt groggy this
morning, got up to go to the bureau, slipped and fell landing on
his side. He experienced severe pain in his groin and was
unable to get up from the floor. Rehab staff found him on the
floor. He was responsive, and there was no evidence of seizure,
no notable weakness, and no urinary or fecal incontinence.
Patient denies hitting his head, and there was no evidence of
trauma. He denies chest pain, palpitations, dizziness,
lightheadedness. Patient was taken to the hospital.
.
Of note, patient was noted to syncopize while working with
physical therapy the day prior to presentation. He was noted to
be conversant while eating lunch. Immediately thereafter, he
was walking with PT and just feel over and became unresponsive.
A Code Blue was called, but prior to resuscitation, staff hit
him hard on the chest, and patient "woke up," asking why he was
being hit. Per nursing home staff, patient endorsed a prior
episode similar to this at home several months ago, but patient
was unable to confirm this today.
.
Patient is at rehab recovering from left knee washout, culture
grew staph lugdunensis, and he was on vancomycin, as nafcillin
was implicated in AIN. He is followed in OPAT and his abx
should finish [**2196-4-12**]. Last dose of vancomycin was on [**3-29**], when
he received 750mg q2d. AT rehab, nurses noted that he was
recovering well, regaining range of motion in his knee and
regaining strength, able to walk around the floor.
.
In the ED, initial vitals were 97.5 119 145/110 22 98%. EKG
showed a. fib at 99, NA, TWI laterally. Lab work revealed INR
6.4, Cr 1.7 (baseline), Hct 35 (higher than baseline at recent
discharge). Head CT was negative for bleed. Patient was given
morphine 5mg x2 for pain. Hip films showed nondisplaced
impaction fracture of the left femoral neck. Patient was seen
by ortho team, who recommended surgical fixation after medical
stabilization. Patient was transferred to the medical floor.
Vitals prior to transfer were: 96.8 ax HR: 99-107 a. fib. RR: 11
O2: 100 BP: 165/98 Pain: 0/10.
.
On the floor, VS: 97.2 149/97 112 20 98(RA). Patient was
very somnolent, but was arousable and can answer questions,
although responses were slow and patient endorses significant
gaps in his memory. Daughter states that this is his usual
state when he receives pain medication. He denies pain or
discomfort.
Past Medical History:
- [**2-29**] I&D and linear exchange L knee
- [**3-14**] ERCP
- TIA [**11-22**]
- Atrial Fibrillation on Coumadin
- C. Cath for STEMI found to have non-occlusive CAD
- Alcoholic cirrhosis s/p portal shunt in [**2154**] (TIPS?)
- CKD - baseline Cr of 1.5-2.3
- Gout
- prior etoh abuse, sober for 24 years
- TKR '[**88**]
Social History:
He has been at rehab since discharge in early [**Month (only) 547**]. Prior to
[**Month (only) **] when he was admitted for NSTEMI, lived at home in
[**Hospital1 **] by himself but has had 24 hour care and VNA since his
discharge from rehab in [**Month (only) **]. He still works as geneologist
and finds missing heirs to estates. He smoked for 10 years quit
40 years ago, etoh abuse, quit 24 years ago has been in AA
since.
Family History:
- Non-contributory to acute presentation
- Brother had TIAs is 86, mother and father both lived
to old age.
Physical Exam:
Physical Exam On Admission:
Vitals: Tc 97.2 BP 149/97 HR 112 RR 20 O2sat 98(RA)
General: Somnolent but arousable and appropriately answers
questions, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: normoactive bowel sounds, soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding
GU: foley for urinary obstruction
Ext: warm, faintly palpable pulses, evidence of venous stasis
changes b/l shins, left knee surgical site is c/d/i with mild
erythema, skin tear at the left wrist in ulnar dorsal aspect,
skin tear right elbow
Neuro: somnolent, intermittently follows commands, able to move
all extremities, difficult if he's 4/5 strength b/l upper
extremities or if he's not trying hard enough, no asterixis
Physical Exam on Discharge:
VS: 98 122/72 96 20 99% RA
Gen: No acute distress
HEENT: Anicteric sclerae. moist mucous membranes.
Resp: Faint bibasilar crackles
CV: Tachycardic and irregular. Normal s1, s2. No M/G/R.
Abd: +BS. Soft. NT/ND.
Ext: Left hip with clean dressing in place. No edema.
Neuro: A+O X3
Pertinent Results:
Labs on Admission:
[**2196-3-30**] 06:50AM BLOOD WBC-9.6# RBC-3.18*# Hgb-10.5*# Hct-35.3*#
MCV-111* MCH-33.1* MCHC-29.9* RDW-21.7* Plt Ct-315
[**2196-3-30**] 06:50AM BLOOD Neuts-79.4* Lymphs-13.0* Monos-3.3
Eos-3.7 Baso-0.6
[**2196-3-30**] 06:50AM BLOOD PT-63.9* PTT-54.6* INR(PT)-6.4*
[**2196-3-30**] 06:50AM BLOOD Glucose-129* UreaN-33* Creat-1.7* Na-137
K-4.6 Cl-105 HCO3-22 AnGap-15
[**2196-3-30**] 06:50AM BLOOD ALT-26 AST-49* CK(CPK)-88 AlkPhos-166*
TotBili-1.7*
[**2196-3-31**] 04:43AM BLOOD Albumin-PND Calcium-9.4 Phos-3.9 Mg-2.0
[**2196-3-31**] 04:43AM BLOOD Vanco-22.2*
Cardiac Enzymes:
[**2196-3-30**] 06:50AM BLOOD CK-MB-8
[**2196-3-30**] 06:50AM BLOOD cTropnT-0.10*
[**2196-3-30**] 09:45PM BLOOD CK-MB-5 cTropnT-0.10*
[**2196-3-31**] 04:43AM BLOOD cTropnT-0.12*
INR trend:
[**2196-3-30**] 06:50AM BLOOD PT-63.9* PTT-54.6* INR(PT)-6.4*
[**2196-3-30**] 09:45PM BLOOD PT-31.6* PTT-49.8* INR(PT)-3.1*
[**2196-3-31**] 04:43AM BLOOD PT-23.3* PTT-42.9* INR(PT)-2.2*
[**2196-3-31**] 10:53AM BLOOD PT-22.2* PTT-42.7* INR(PT)-2.1*
Imaging:
TTE [**2195-11-25**]:
The left atrial volume is severely increased. The right atrium
is moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild to moderate
regional left ventricular systolic dysfunction with basal to mid
inferior and inferolateral hypokinesis. Doppler parameters are
indeterminate for left ventricular diastolic function. 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 are mildly thickened (?#). There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild focal LV systolic dysfunction. Mild mitral
regurgitation, likely due to leaflet tethering. Mild aortic
regurgitation. Biatrial enlargement.
Cardiac Cath [**2195-10-15**]:
1) Selective angiography of this right-dominant system
demonstrated
non-obstructive coronary artery disease. The LMCA was normal.
The LAD had minor lumen irregularities in the mid and distal
portions of the vessel; the proximal diagonal branch had 40-50%
stenosis. The LCx had minor irregularities. The RCA had 30-40%
stenosis at the distal posterolateral segment artery.
2) Limited resting hemodynamics revealed moderate-to-severe
systemic
arterial hypertension, with a central aortic pressure of 161/97
mmHg.
pMIBI [**2195-9-2**] ([**Hospital1 **]): No evidence of infarct or ischemia;
normal wall motion; calculated EF 53%; TID 0.97.
CT Head [**2196-3-30**]:
IMPRESSION:
No acute intracranial process. Age-related involutional changes.
Hip Unilateral 2 views [**2196-3-30**]:
IMPRESSION: Nondisplaced impaction fracture of the left femoral
neck
Chest Xray [**2196-3-30**]:
IMPRESSION:
1. No acute cardiopulmonary process.
2. Stable mild cardiomegaly.
3. Mild vascular engorgement.
3. Left PICC terminating in the low SVC.
Femur [**2196-3-30**]:
1. Grossly unchanged appearance of left femoral neck fracture
with mild
foreshortening, but no displacement in the interim.
2. Changes of a prior left total knee arthroplasty with
orthopedic hardware in place and intact.
3. Calcified atherosclerotic vascular disease of the superficial
femoral
artery.
HIP [**3-30**]:
The patient is status post left hemiarthroplasty in overall
anatomic alignment on this single AP view. No periarticular
fracture is detected. Subcutaneous emphysema and staples are
consistent with recent surgery.
CXR [**4-6**]:
In comparison with the study of [**3-31**], there is increased
opacification at both bases with obscuration of the
hemidiaphragms, consistent with layering pleural effusions, more
prominent on the right. Compressive atelectasis is seen at both
bases. Cardiac silhouette is at the upper limits of normal in
size or slightly enlarged. There may be mild pulmonary vascular
congestion.
Little change in the appearance of the PICC line.
DISCHARGE LABS:
[**2196-4-7**] 04:46AM BLOOD WBC-6.7 RBC-2.75* Hgb-9.0* Hct-29.8*
MCV-108* MCH-32.7* MCHC-30.2* RDW-19.3* Plt Ct-261
[**2196-4-7**] 04:46AM BLOOD PT-28.3* PTT-39.8* INR(PT)-2.7*
[**2196-4-7**] 04:46AM BLOOD Glucose-116* UreaN-39* Creat-1.4* Na-137
K-5.1 Cl-108 HCO3-22 AnGap-12
[**2196-4-7**] 04:46AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname 406**] is a 82M with a history of atrial fibrillation on
coumadin, EtOH cirrhosis complicated by portal hypertension,
TIAs and s/p TKA of LLE, septic arthritis s/p washout [**2196-2-29**],
discharged to rehab on [**2196-3-18**], presents back to the hospital s/p
fall with new left hip fracture, s/p arthoplasty of left femoral
neck, course complicated by hypotnesion, UTI, atrial
fibrillation, and supertherapuetic INR.
Active Issues:
# Surgical Repair of Left femoral neck fracture: S/p mechanical
fall. He underwent hemiarthroplasty of the affected hip with
1300cc of blood loss and rec'd a unit of blood and platelets in
the OR. He was relatively hypotensive in the [**Name (NI) 13042**] requiring
moderate pressor support while on propofol which was weaned
following extubation. He was monitored overnight in the MICU
without any significant events and called back out to the floor.
The orthopedic service continued to follow the wound. A wound
vac was placed by the team on [**4-5**]. It did not drain any fluid
and wound vac was removed on [**4-7**]. Per ortho, staples should be
removed on post - op day 14, 7 days from discharge. An
appointment should be made for him to follow - up in the ortho
clinic in 2 weeks (phone number in discharge -planning).
# Hypotension: Once patient was transferred back to the floor,
he had several episodes of transient asymptomatic hypotension to
SBPs 60 - 70s. The first episode was on [**4-3**]. At this point,
his Hct was stable and there was no evidence of acute bleed.
Patient was orthostatic with ambulation. Both the orthostasis
and the hypotension resolved with 1 L bolus NS. At this point
in time, both his metoprolol and tamsulosin were held.
Metoprolol was restarted on [**4-5**] once BPs had stabilized and
uptitrated for control of atrial fibrillation while tamsulosin
continued to be held. On the AM of [**4-6**], patient again had a
hypotensive episode to SBPs in the 60s, asymptomatic which
resolved with 1 L NS bolus. At this point, he had a low grade
temp to 100.4 and was mildly confused. Urinalysis returned
positive and patient was started on IV ceftriaxone for presumed
UTI, urine cultures pending at time of discharge. He had no
further hypotensive episodes. Still unclear if etiology
dehydration versus infection, likely combination of both.
# Urinary Tract infection: As described above, patient had a
hypotensive episode on AM of [**4-6**] associated with confusion and
low grade fever. Urinalysis showed + leuk esterase, 14 WBCs, few
bacteria, thus, he was started on 1 g IV ceftriaxone q24 for
treatment of complicated UTI. He currently has an indwelling
foley catheter to treat urinary retention (see below). His
urine cultures were pending at the time of discharge.
# Confusion: Beginning on the AM of [**4-6**], patient began to have
short intermittent periods of confusion, but would be quickly
reoriented. Thought to be secondary to urinary tract infection.
On day of discharge, patient was still have brief periods of
confusion, but much less frequent, and again, was able to be
reoriented.
# Urinary Retention and BPH: Patient with long history of BPH
and urinary retention treated with tamsulosin. Tamsulosin was
held following hypotensive episode on [**4-3**] and had not yet been
retstarted. Patient failed voiding trial on [**4-3**] and foley
placed while off tamsulosin. No that his blood pressures have
normalized, plan should be to restart tamsulosin, discontinue
foley, and give patient another voiding trial, especially given
UTI as above.
# Atrial Fibrillation: Patient has chronic atrial fibrillation,
rate controlled on metoprolol succinate 50 once a day.
Metoprolol was discontinued when patient became hypotensive as
above. Once patient's blood pressures stabilized, his heart
rates returned to th 120s-130s. Metorpolol tartrate was started
on [**4-5**] and uptitrated to the current dose of 37.5 mg TID. His
rates have now stabilized at 90s-110s; metoprolol can be
uptitrated as needed at MACU. Anticoagulation as below.
# Elevated INR. Patient's INR was 6.4 on admission. He was
given vitamin K IV 2mg x 2 for reversal. His INR trended down
pre-op. Received one dose of warfarin following repair, INR rose
to 5.1, and was given vitamin K for reversal to prevent post-op
hemorrhage. INR trended down to 2.1 on [**4-4**], thus coumadin was
restarted at 1 mg once a day, which he was continued on through
discharge. INR 2.7 on day of discharge.
# Syncope/Fall: Patient states that fall morning prior to
admission was purely mechanical and he remembered the entire
episode. On the contrary, at rehab, patient was noted to
syncopized, be unresponsive, and then arousable after
stimulation. He had just eaten, so unlikely was hypoglycemic,
has not had problems with hypoxia. Staff noted pulse of 83,
irregular, so not in RVR or bradycardic. As patient had just
eaten and gotten up, could have vasovagaled. Likely also an
element of orthostatic hypotension per above. Patient had no
further syncopal episodes while in house. Please place patient
on fall precuations at rehab as he poses a significant fall
risk.
# L Knee Septic Arthritis: S/p washout on [**2-29**], wound cultures
grew STAPHYLOCOCCUS LUGDUNENSIS, thought likely bacteremic
seeding s/p podiatric procedure. Was initially on IV nafcillin,
switched to IV vancomycin due to concern for AIN as above. He
is scheduled for a 6 week course of vancomycin to finish [**4-12**].
He followed in the Infectious Disease [**Hospital 4898**] clinic. He remained
on vancomycin at a dose of 750mg q48h; trough of 18 on [**4-2**] so
remained on same dose.
# OPAT Labs while on Vancomycin:
Patient needs Weekly:
CBC w/diff
BUN/Ct
ESR CRP and
Vanco Trough
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed
to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] or to on [**Name8 (MD) 138**]
MD in when clinic is closed.
Patient's antibiotic course to complete [**4-12**]. He needs to be
scheduled in the [**Hospital **] clinic for follow - up. Please call [**Telephone/Fax (1) 91063**] to schedule patient to see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Inactive issues:
# Alcoholic Cirrhosis: Complicated by portal vein thrombosis and
encephalopathy during last hospitalization after undergoing TKA,
was started on rifaximin and lactulose, continued at rehab, and
patient remains on these medications. Patient is s/p portocaval
shunting in [**2153**]. Patient's MELD score on admission was 34.
Was continued on lactulose and rifampin.
# CAD: [**10-23**] cath showed non-occlusive CAD to 40-50% stenosis,
but [**11-22**] TTE showed EF 30%, so likely have intervening event
during that month. Patient is not currently in decompensated
heart failure. At rehab recently, he was diuresed for pleural
effusions, but CXR from today shows no evidence of pulm edema,
effusions, and patient is satting 97(RA). Patient was continued
on Aspirin 81 mg PO/NG DAILY, Metoprolol as above, rosuvastatn
40 qhs.
# HTN: Metoprolol as above.
# CKD: Baseline Cr of 1.5-2.3, currently 1.4. All medications
were renally dosed.
# Gout: Stable, currently asymptomatic. Patient was continued
on allopurinol.
Transitional issues:
- Wound vac in place, needs orthopedics follow - up
- Foley catheter removal and voiding trial as above
- Continue treatment of UTI
- OPAT Labs faxed to [**Hospital **] clinic and OPAT appointments as above
Medications on Admission:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. -
recent held
2. metoprolol succcinate 50 mg daily
3. sodium bicarbonate 325mg [**Hospital1 **]
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. pravastatin 40mg qPM
7. zofran 4mg q8h
8. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) mL
PO three times a day: Titrate to [**2-14**] bowel movements daily, hold
if pt having >4 bowel movements daily.
9. warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: Not to exceed 2g daily.
11. vancomycin 750mg q48h
12. mirtazapine 15mg qhs
13. tamsulosin 0.4mg qhs
14. omeprazole 40mg daily
15. rifaximin 400mg tid
16. allopurinol 1000mg
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Vancomycin 750 mg IV Q48H
3. sodium bicarbonate 325 mg Tablet Sig: One (1) Tablet PO twice
a day.
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): titrate to 3 BMs daily.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
15. tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day)
as needed for pain.
16. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
17. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
18. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
left proximal femur fracture s/p left hip hemiarthroplasty
Secondary Diagnosis:
Septic left knee
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 406**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted after a fall at your
rehabilitation center and found to have a left hip fracture. You
went for a left hip repair and did well. You were continued on
antibiotics to help manage your knee infection. We also started
you on antibiotics for a urinary tract infection. We continued
your medications for atrial fibrillation and your coumadin.
The following changes were made to your medications:
STOP metoprolol succinate
START metoprolol tartrate
DECREASE Coumadin to 1 mg daily
START IV ceftriaxone for treatment of UTI
STOP Tamsulosin
START Ultram as needed for pain
Please see below for your follow up appointments.
Followup Instructions:
Will need to reschedule OPAT appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] per discharge summary
Department: LIVER CENTER
When: FRIDAY [**2196-4-15**] 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
Please have your staples removed at your rehabilitation facility
at post-operative day 14.
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**9-25**] days
post-operation for evaluation. Call [**Telephone/Fax (1) 1228**] to schedule
appointment upon discharge.
|
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icd9cm
|
[
[
[]
]
] |
[
"00.77",
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
19947, 20013
|
9855, 10299
|
301, 329
|
20194, 20194
|
5321, 5326
|
21128, 21981
|
3965, 4075
|
18405, 19924
|
20034, 20034
|
17526, 18382
|
20370, 21105
|
9496, 9832
|
4090, 4104
|
5022, 5302
|
17292, 17500
|
5920, 9479
|
240, 263
|
10314, 16232
|
357, 3161
|
20134, 20173
|
16249, 17271
|
20053, 20113
|
5340, 5903
|
20209, 20346
|
3183, 3504
|
3520, 3949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,395
| 129,721
|
46670
|
Discharge summary
|
report
|
Admission Date: [**2119-10-9**] Discharge Date: [**2119-11-11**]
Date of Birth: [**2063-10-9**] Sex: M
Service: SURGERY
Allergies:
Detrol / Ibuprofen,Micronized / Lactose
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
renal transplant [**2119-10-10**]
ureteral stent removed [**2119-10-30**]
renal transplant biopsy [**2119-10-31**]
History of Present Illness:
Mr. [**Known lastname 2816**] is a 55 y/o male w/ a h/o HIV, Hep C, diabetes,
HTN and CKD stage IV-V. Admitted for transplant. H/o CKD never
on
dialysis, although AVF placed. Not anuric. Denies sxs of
infection, including: fevers, chills, shortness of breath,
cough,
chest pain, abdominal pain, nausea, vomiting, and dysuria. Has
chronic diarrhea due to antiretrovirals.
Past Medical History:
PMHx:
1) CKD: stage IV-V, kidney biopsy [**2118-6-6**] with severe diabetic
glomerulosclerosis
2) DM since 40s, now insulin-dependent
3) HIV: on tritherapy, no sxs per patient or detectable viral
loads, viral load undetectable on [**2119-4-3**]
4) Hep C: untreated, bx on [**2119-6-6**]: grade 2 inflammation, stage
1
fibrosis
5) CVA with right-sided weakness [**2115**]
6) congestive heart failure (? due to irregular heartbeat,
resolved): recent cardaic tests wnl
7) childhood asthma, resolved
normal stress test11/09
echo: mild LVH, EF 65%, trace TR
nl colonoscopy (internal hemorrhoids)
upper endoscopy: hiatal hernia
essentially nl cystoscopy: (BPH, ? incomplete voiding)
CMV positive per [**2119-3-23**] note
PSurgHx:
L arm AVF
L rotator cuff surgery
L shoulder lipoma excision
partial parathyroidectomy [**2115**]
Social History:
lives in [**Hospital1 1559**] with wife
on disability due to stroke, former heavy equipment operator
no tobacco, EtOH, or drug use since stroke
IVDU until mid [**2089**]
Family History:
significant for diabetes, HTN, and heart disease
no kidney disease or transplant history
Physical Exam:
vitals:T 97.9, HR 92, BP 130/70, RR 20, sat 99% RA
gen: NAD, AXO, dysarthric
HEENT: EOMI, PERRLA, anicteric, R-sided facial droop, R tongue
deviation
cardiac: RRR, no M/R/G
resp: CTAB
abd: soft, nontender, nondistended, +BS; surgical incision
clean, dry and intact; staples in situ.
ext: wwp; pitting edema to mid-shin; +femoral, DPs, and PTs b/l,
L upper arm palpable thrill and audible bruit over AVF
neuro: R upper and lower extremity weakness, sensation intact.
Pertinent Results:
[**2119-10-9**] 03:59PM BLOOD WBC-6.0 RBC-3.48* Hgb-10.9* Hct-30.7*
MCV-88 MCH-31.3 MCHC-35.5* RDW-15.3 Plt Ct-115*
[**2119-10-9**] 03:59PM BLOOD PT-12.9 PTT-26.9 INR(PT)-1.1
[**2119-10-9**] 03:59PM BLOOD Glucose-73 UreaN-73* Creat-5.8*# Na-141
K-3.0* Cl-107 HCO3-24 AnGap-13
[**2119-10-9**] 03:59PM BLOOD ALT-26 AST-52*
[**2119-10-9**] 03:59PM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.2 Mg-2.0
[**2119-10-10**] 11:38AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.6
[**2119-10-10**] 11:38AM BLOOD Glucose-110* UreaN-64* Creat-4.5*# Na-145
K-2.8* Cl-111* HCO3-23 AnGap-14
[**2119-10-10**] 11:38AM BLOOD WBC-2.0*# RBC-3.11* Hgb-9.6* Hct-28.7*
MCV-92 MCH-30.8 MCHC-33.4 RDW-15.2 Plt Ct-99*
[**2119-10-11**] 04:52AM BLOOD Glucose-213* UreaN-68* Creat-5.5* Na-145
K-4.0 Cl-108 HCO3-22 AnGap-19
[**2119-10-13**] 04:51AM BLOOD Glucose-99 UreaN-90* Creat-7.2* Na-137
K-3.8 Cl-103 HCO3-20* AnGap-18
[**2119-10-16**] 03:01AM BLOOD Glucose-200* UreaN-94* Creat-6.9* Na-137
K-3.7 Cl-99 HCO3-19* AnGap-23*
[**2119-10-19**] 02:35AM BLOOD Glucose-232* UreaN-85* Creat-7.0*# Na-136
K-3.2* Cl-99 HCO3-21* AnGap-19
[**2119-10-19**] 04:51PM BLOOD Glucose-193* UreaN-65* Creat-4.7*# Na-134
K-4.0 Cl-101 HCO3-18* AnGap-19
[**2119-10-19**] 02:35AM BLOOD ALT-12 AST-48* LD(LDH)-463* AlkPhos-41
TotBili-1.5
[**2119-10-19**] 04:51PM BLOOD Calcium-7.4* Phos-4.1# Mg-2.2
[**2119-11-11**] 06:30AM BLOOD WBC-7.7 RBC-2.99* Hgb-9.0* Hct-27.3*
MCV-91 MCH-30.1 MCHC-33.0 RDW-18.7* Plt Ct-566*
[**2119-11-11**] 06:30AM BLOOD Glucose-109* UreaN-47* Creat-2.6* Na-145
K-3.8 Cl-117* HCO3-20* AnGap-12
[**2119-11-10**] 05:35AM BLOOD tacro FK-11.9
[**2119-11-5**] Blood Culture, Routine (Final [**2119-11-11**]):
VIRIDANS STREPTOCOCCI. ISOLATED FROM ONE SET ONLY.
ECH ([**2119-11-10**]):Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic valve sclerosis. Valsalva inducible LVOT gradient.
Compared with the prior study (images reviewed) of [**2119-10-20**], the
severity of mitral regurgitation is reduced and no resting LVOT
gradient is now identified.
Brief Hospital Course:
On [**2119-10-10**], he underwent renal transplant into left iliac fossa.
Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Ureteral stent and JP were placed.
Intraop, urine was produced. Urine output was 1 liter for the
day 0. Urine output gradually decreased and fluid replacements
were stopped as urine output diminished. Creatinine increased.
Hct decreased to 22.5 on postop day 4. A renal duplex was done
to assess for perinephric hematoma. Findings demonstrated new
hydronephrosis of the transplant kidney, mildly elevated
resistive indices, unchanged, from immediately postop. There was
a small 3.5-cm perinephric fluid collection anterior and
inferior to the transplant kidney. PRBC were given.
On [**10-14**] the RIJ TL line was exchanged for an HD line; HD was
started for delayed graft function. Left leg was noted to be
larger than the right leg. LENIS were done noting partial
occlusive LLE SFV & calf v thrombi.
He was transferred to SICU on [**10-15**] after MRV pf pelvis
demonstrated large heterogeneous fluid collection (likely
hematoma) medial and posterior to the transplant kidney
extending into pelvis w/ bladder compression (7.2 x 17.6 x 7.4
cm). The left common iliac and external iliac veins demonstrate
luminal compression by the pelvic collection but are noted to
have flow and left common femoral vein was of normal caliber and
had flow.
Transplant renal u/s showed no hydronephrosis; increased size of
perinephric collections from [**2119-10-14**] along w/ high resistance
flow in all of the intraparenchymal arteries likely due to the
presence of large collection. The main renal vein was patent.
LLE duplex confirmed extremely slow flow seen within the vessels
of the left leg, but no deep vein thrombosis was demonstrated.
He was transfused with 1 unit PRBCs for drop in Hct to 24.8 from
28.3. Dialysis was performed.
On [**10-17**], he was dialyzed, but became hypotensive post HD. Got 1U
pRBCs for hypotension with MAPs of 50s. Overnight did not
tolerate po's and vomited brownish content with +occult blood.
At 3 am dropped BP, with adequate response to NS bolus
On [**10-18**]: Patient refused to go to the OR for washout of
hematoma. He experienced an acute change in mental status (more
confused, refusing PO, tugging at dressings/lines). Psychiatry
consult deemed him not competent to make his own medical
decisions at this time and recommended haldol for agitation and
not benzos. CT head w/o contrast did not demonstrate new acute
cerebral insults. Neurology consult recommended seroquel for
severe agitation. Renal service recommended an echocardiogram
to eval his persistent hypotension. Transplant renal u/s showed
no change from prior.
On [**2119-10-19**] he was taken to the OR for evacuation of hematoma
(~2L), no active source of bleeding observed. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**10-20**]: Transfused 1 unit PRBC, R PICC ordered. Insulin adjusted
[**First Name8 (NamePattern2) **] [**Last Name (un) **]. Cortisol stimulation test results were not overly
impressive and so no stress dose steroids were administered
(cortisol level: pre-cosyntropin 27.2, 30-min 37.6; 60-min
39.9). Echo returned w/ hyperdynamic LV with outflow
obstruction. Metoprolol 5mg IV Q6H started. Tacro [**1-20**]. Hematoma
from evacuation growing sparse enterococcus IV linezolid was
started for 7 days. Agitated and refusing meds and PICC.
[**10-21**]: CVVH filter clogged. Holding on CVVH until Monday for HD.
Patient agreed for right PICC line. Overnight with BS in the
450s, started on insulin gtt. Increasing in b-blockers for high
BPs. Cards recommending to switch to verapamil.
[**10-22**]: Lop increased to 15 IV Q 6H for HTN. Cont insulin gtt, pt
continues to refuse meds, lab draws, and vital monitoring
intermittently but did take his tacro and MMF. A-line d/c'ed,
continued TPN. Regular diet (though not taking much). JP drain
Cr = 3.
URETERAL STENT d/c'd [**2119-10-30**]
[**2119-10-23**]: Evaluated by psych and deemed competent. Insulin
glargine was started at night in addition to the 60 U regular
insulin in TPN. He was transferred to the floor.
[**2119-10-24**]: creatinine stable at 3.3. The renal biopsy from [**2119-10-19**]
demonstrated no evidence of rejection. Lantus 25 U given in the
night and the regular insulin in the TPN was increased to 85U.
insulin gtt continued. The JP output sample Creatinine was 3.0.
[**2119-10-25**]: TPN was discontinued and he was put on a regular low
sodium diet. Lopressor dose was increased and norvasc was added
for BP control. he refused to take his meds including
immunosuppressants.
[**2119-10-26**]: PT consult was obtained. Had an episode of eyelid
flutter on standing. Psych recommended avoiding benzodiazepines
and haldol for severe agitation. Sliding scale insulin was
increased.
Over the next few days, PT was consulted and the patient was
assisted out of bed and walked a little bit. He had a low grade
temperature and blood cultures, urine cultures were sent. The
blood culture sent on [**2119-11-5**] was positive for Strep.Viridans.
He was started on Vancomycin initially and then changed over to
ceftriaxone and will continue the same till [**2119-11-19**]. An ECHO
was done on 10//22/10 which showed no evidence of vegetations. A
PICC line was inserted on [**2119-11-10**] and the position of the tip
was confirmed on the CXR.he is been doing well and tolerating a
regular diet well.
He is now being sent to an extended care facility.
Medications on Admission:
metoprolol 12.5 mg [**Hospital1 **], Epogen 10,000 units SC weekly,
diltiazem ER 360 mg daily, valsartan 80 mg daily, Bactrim DS
twice weekly, furosemide 80 mg [**Hospital1 **], Novolog 12 units [**Hospital1 **],
ranitidine 150 mg [**Hospital1 **], calcitriol 0.5 mcg every other day,
divalproex TBEC 500 mg [**Hospital1 **], Kaletra 2 tabs [**Hospital1 **], etravirine 200
mg
[**Hospital1 **], raltegravir 400 mg [**Hospital1 **], ferrous sulfate 325 daily,
multivit,
eucerin [**Hospital1 **]
Discharge Medications:
1. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
5. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO 2X/WEEK (TU,SA).
7. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: Three
(3) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold for sbp <110 or HR <60.
13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
17. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
18. mycophenolate sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Four (4) Tablet, Delayed Release (E.C.) PO BID (2 times a
day) as needed for immunosuppression.
19. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
20. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for Pain.
21. loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
22. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
23. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours): to be continued till
[**2119-11-19**].
24. 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.
25. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous once a day.
26. insulin glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
27. insulin lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous four times a day: see printed scale.
28. Outpatient Lab Work
Labs: every Monday and Thursday
cbc, chem 10, ast, t.bili, ua, and trough prograf level
fax to [**Telephone/Fax (1) 697**] attn: Transplant Coordinator
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**] - [**Location (un) **]
Discharge Diagnosis:
esrd
DM
HIV
h/o cva
s/p renal transplant with delayed graft function
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 will be transferred to [**Hospital **] Rehab in [**Doctor First Name 3094**] MA
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the warning signs listed below:
fever, chills, nausea, vomiting, shortness of breath, increased
abdominal pain, decreased urine output, edema, weight gain of 3
pounds in a day, abdominal incision appears red or has
bleeding/drainage
You will have blood drawn every Monday and Thursday for labs.
Labs should be fax'd to [**Hospital1 18**] Transplant Office 6[**Telephone/Fax (1) 99075**]
attn: Transplant Coordinator
You may shower, no tub baths/swimming
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2119-11-17**] 8:50.
[**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: [**Telephone/Fax (1) 99076**] Date / time : [**2119-11-13**] at
9:30 am
Completed by:[**2119-11-11**]
|
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icd9cm
|
[
[
[]
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] |
[
"39.95",
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,705
| 117,398
|
51452
|
Discharge summary
|
report
|
Admission Date: [**2114-2-21**] Discharge Date: [**2114-3-21**]
Date of Birth: [**2036-5-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Abdominal pain and distension
Major Surgical or Invasive Procedure:
[**2113-2-21**] exploratory laparotomy, appendectomy, and needle
decompression of large bowel
.
[**3-17**]: intubation
History of Present Illness:
77 M last discharged from [**Hospital1 18**] on [**2114-2-3**] with the diagnosis of
pneumonia and CHF exacerbation presents with progressive
abdominal pain fo rthe last week, denies flatus or bowel
movements for 3 weeks. Patient denies fever, chills, nausea or
vomitting. Patient never had a colonoscopy in the past.
Past Medical History:
* COPD: no PFTs on record, on home O2 3L/m for past 2 weeks
* Interstitial lung disease
* atrial fibrillation (formerly on coumadin; stopped during last
admission)
* CHF: last echo [**12-31**] with LVEF >55%, 2+ MR, 3+ TR, mild AV
stenosis, severe pulm art HTN
* severe pulm art HTN by echo
* DM type II
* CRI: baseline creat 1.6
* BPH
* known bladder mass since [**2108**]
* ? lung mass
* anemia
Social History:
lives with his wife in a 2 story house but is now at a [**Hospital1 1501**] since
recent hospitalization; smoked 150 pack-years, quit 7 years ago;
formerly worked in a battery factory and may have been exposed
to hazardous chemicals during this time; has a h/o asbestos
exposure; no alcohol or illicit drug use. One daughter lives
down the street.
Family History:
Father with CAD.
Physical Exam:
Admission Examination:
T=97.5 HR=87 BP=109/63 RR=31 95% RA
Chest: wheezes B/L
Heart: RRR
ABD: very distended, no rebound tenderness
Ext: no edema
Rectal: no blood or masses, profuse diarrhea provoked by exam
Pertinent Results:
Admission Labs
[**2114-2-21**] 01:55AM PT-12.2 PTT-24.9 INR(PT)-1.0
[**2114-2-21**] 01:55AM NEUTS-90.0* BANDS-0 LYMPHS-4.1* MONOS-4.6
EOS-1.1 BASOS-0.1
[**2114-2-21**] 01:55AM WBC-12.9* RBC-3.11* HGB-9.5* HCT-27.7* MCV-89
MCH-30.4 MCHC-34.1 RDW-19.7*
[**2114-2-21**] 01:55AM ALBUMIN-3.4 CALCIUM-9.2 PHOSPHATE-3.8
MAGNESIUM-2.3
[**2114-2-21**] 01:55AM LIPASE-26
[**2114-2-21**] 01:55AM ALT(SGPT)-20 AST(SGOT)-18 LD(LDH)-314* ALK
PHOS-113 AMYLASE-71 TOT BILI-0.8
[**2114-2-21**] 01:55AM GLUCOSE-126* UREA N-65* CREAT-1.9*
SODIUM-129* POTASSIUM-4.2 CHLORIDE-88* TOTAL CO2-30 ANION GAP-15
[**2-21**] KUB: large bowel obstruction
[**2-21**] CT ABD/PELVIS:
IMPRESSION:
1. Dilated fluid-filled distal appendix with periappendiceal
stranding concerning for tip appendicitis in the proper clinical
setting.
2. Ill-defined nodular opacities in the right lower lobe
consistent with infectious process.
3. Small bilateral pleural effusions.
4. Calcified pleural plaques consistent with asbestosis
exposure.
5. Dilated large bowel without evidence of obstruction. These
findings are consistent with [**Last Name (un) **] syndrome.
6. Fat-containing right inguinal hernia.
[**2-27**] CT ABD/PELVIS/ CHEST CTA:
IMPRESSION:
1. Compared to [**2114-2-21**], there is improvement in the
previously described multifocal patchy opacities in the
bilateral lungs. There remains mild ground glass opacities
within the lung apices.
2. There is diffuse colonic wall thickening with mural
enhancement, concerning for infectious colitis; however, in the
setting of recent abdominal surgery, ischemia cannot be totally
excluded. There is no other finding suggestive of ischemia such
as portal venous air or pneumatosis.
3. Small bilateral pleural effusions.
4. Diverticulosis without evidence of diverticulitis.
5. Soft tissue mass adjacent to the Foley catheter in the
bladder, for which further evaluation with ultrasound with full
bladder is recommended. This may represent asymmetric
hypertrophy of the prosatate gland, however a neoplasm of the
bladder is included in the differential diagnosis.
6. Small amount of ascites.
7. No evidence of pulmonary embolus or thoracic aortic
dissection.
[**3-1**] Renal Ultrasound: no hydronephrosis
[**3-6**] ABD 2 views:
There are gas-filled loops of prominent transverse colon
overlying the mid abdomen with slight thickening of haustral
folds. Though nonspecific, this may be seen due to infectious
etiology such as C. diff colitis. There is no gross evidence for
free air or signs specific for obstruction. Pleural
calcifications are evident in the visualized portions of the
lower chest as better demonstrated on a recent chest CT.
________
MICU:
Echocardiogram:
Conclusions: Overall left ventricular systolic function is low
normal (LVEF 50%). There is no ventricular septal defect. The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated. Right ventricular systolic
function appears depressed. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery
systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade. Echocardiographic signs
of tamponade may be absent in the presence of elevated right
sided pressures. Compared with the findings of the prior study
(images reviewed) of [**2114-1-16**], multiple major
abnormalities as noted above persist without significant
change.
[**2114-3-21**] 02:47AM BUN: 96* Creatinine: 4.0*
Brief Hospital Course:
Patient was admitted to surgery under Dr. [**Last Name (STitle) **]. Patient was
brought directly to the OR for exploratory laparotomy,
appendectomy and decompression of the large bowel. There were
no complications and the patient was transferred to the SICU
intubated. The patient received peri-op Kefzol and Flagyl.
Cardiology was consulted and recommended beta blockage to keep
HR<110, and to keep Hct>30%. On POD1, patient was manually
decompressed, extubated, and received 1u PRBCs. On POD3, patient
remained hemodynamically stable, still a-fib, afebrile, had
formed stools, and soft, non-tender abdomen. Patient was
transferred to the floor, NGT was d/c'ed. Patient was kept NPO
for minor abdominal distention. On POD3, patient had hematuria
and a continuous bladder irrigation was started. Urology was
consulted and recommended CBI (titrate to light pink. Patient
remained on IV hydrocortisone to cover his chronic prednisone
therpay. A steroid taper was started. On POD4, stool was found
to be positive for C. Diff. The patient was continued on IV
Flagyl and oral vancomycin was started. On the evening of POD5,
patient complained of severe chest and back pain. EKG, cardiac
enzymes, and CTA chest were all negative. Pain was not relieved
on SL nitroglycerin. Arterial blood gas showed an O2 of 81.
The patient was tranferred back to the SCIU for hemodynamic
monitoring. Cardiology was reconsulted. Cycled cardiac enzymes
were negative. He remained stable in the ICU with a mild O2
requirement (3L). Amylase and lipase were noted to be elevated
the morning following this event and he was diagnosed with
pancreatitis. He remained NPO for 2days however never had a
recurrence of pain and his amylase and lipase trended to normal
over the next 4 days. TPN was initiated given his prolonged
status without significant oral intake. This was continued and
calorie counts are currently being recorded to assess his
caloric intake. His creatinine was noted to rise significantly
on POD7-10 accompanied by an abrupt decline in urine output.
This has currently peaked and his urine as well as creatinine
have improved. Renal was consulted during this time and felt
that contrast nephropathy vs ATN from other etiologies was the
cause. He remains up approximately 10kg and is now successfully
being diuresed on high doses of lasix. He currently has 3+
peripheral edema as well as mild plural edema. His FSBG began
to increase requiring an insulin gtt on POD11. Insulin was
increased in his TPN to 40units (dex 300). On POD13 his TPN was
cut in half due to moderate oral intake and he was noted to wean
off of the insulin gtt overnight.
.
S/p MICU transfer [**3-6**] for management of multiple post-operative
complications.
.
***MICU Course***
.
Mr. [**Known lastname 4427**] was transferred to the Medical ICU in the setting of
worsening renal function, anemia, respiratory decline. His
respiratory status continued to decline, with acute worsening on
[**3-17**] requiring intubation, likely secondary to persistant
and significant pulmonary edema. Though diuresis was attempted
during MICU stay, it has to be discontinued in the setting of
worsening renal function and hypotension. Discussions were held
with nephrology and the patient's family regarding the role of
hemodialysis to remove excess fluid; the patient had explicitly
stated to family previously that he would not want to be on
hemodialysis. His renal function continued to decline, and the
patient's family chose to make Mr. [**Known lastname 4427**] [**Last Name (Titles) **] measures only.
He was extubated on [**3-21**] and expired within one hour of
extubation from respiratory arrest.
.
# Hypercarbic respiratory failure - initially felt secondary to
increased work of breathing in setting of volume overload.
Nosocomial pneumonia also potential contributor. On [**3-17**],
required intubation for obtundation and acidemia in setting of
hypercarbia, as he did not seem to be responding to NIPPV.
Bilateral pleural effusions may be contributing to respiratory
difficulties
- treated with zosyn and vancomycin for possible nosocomial
pneumonia without improvement
-unable to diurese given diminished U/O, ARF
-per family, no HD at patient's wishes
-per family no thoracentesis
-extubated [**3-21**] and ceased spontaneous respiration within
one hour.
.
# Acute renal failure: Creatinine has increased from 1.3 to 3 in
the setting of hypotension. Pre-renal and likely now a component
of intrinsic renal failure. [**Month (only) 116**] be obstructive component with
hematuria and decreased urine output, but no evidence of this on
ultrasound or CT.
- followed by renal service throughout MICU course
-given worsening pulmonary edema and renal failure, discussed
role of HD with family and renal service, however in accordance
with patient's wishes, HD declined by family.
.
# Hypotension: felt secondary to CHF or sepsis. No improvement
with antiboitics or hydrocortisone. Likely component of
decreased cardiac output in setting of volume overload from
renal failure, but unable to diurese as discussed above.
.
# anemia: Likely combination of GI and GU losses, and possibly
decreased production secondary to poor nutritional status. GI
recommends conservative management at present, as endoscopy
would be moderate risk procedure given patient's recent surgery
and comorbidities. CT obtained - no RP bleed, likely hematoma in
bladder.
- treated with [**Hospital1 **] pantoprazole and transfused to maintain
hematocrit > 25
.
# ID - Increasing leukocytosis and hypotension as above. Wound
culture demonstrating ESBL Klebsiella and Enterococcus. Previous
cultures showed VRE. Also with LUE cellulitis and C. difficile
positive on [**2114-2-25**].
- Linezolid -Started [**2114-3-11**] for rash; d/c [**3-19**] given
improvement in rash
- pip-tazo started [**2114-3-17**] for broad-spectrum coverage of
possible pna - to complete 8 day course
-started vancomycin [**3-19**] for potential nosocomial pna for 8 day
course.
- PO Vanco and metronidazole continued during administration of
antibiotics for C. difficile.
.
# Rapid afib: intially with HR in the 120s; has independently
become more bradycardic. Held metoprolol in setting of
hypotension and digoxin as spontaneously rate decreased
- no anticoagulation given active hematuria and GI bleed, and
anemia
.
# DM: Initially difficult to control during this
hospitalization, currently stable on current regimen of NPH AM
and PM. Treated with standing NPH and sliding scale insulin in
ED.
.
# CHF: Clearly total body volume overloaded but unable to
diurese as discussed above. No HD per family
.
# Rash on trunk: Initially felt to be due to irritation from
lying on trunk as was only on dependent areas of body, but
became more diffuse. Initially seemed to improved w/ linezolid
which was continued for approximately 1 week course. No temporal
relation to new medications.
.
# [**Last Name (un) **] syndrome: s/p decompression [**2-21**] as discussed in
surgerical course above.
.
#Urologic: Known history of bladder mass, with prolonged course
of hematuria. Evaluated by urology service who performed
cystoscopy, revealing large hematoma within the bladder, but no
active bleeding; the removed large portions of the clot during
the cystoscopy. Despite this intervention and continuous bladder
irrigation for most of his MICU course, hematuria persisted.
Eventually urine output declined as renal function worsened.
.
# FEN: initially on TPN, then transition to tube feeds.
Medications on Admission:
Ipratropium
Senna/Colace
Levalbuterol
Prednisone 20mg until [**1-27**]
Furosemide 40mg qMWF
ASA 325 mg qd
Lisinopril 2.5 mg qd
Diltiazem 240 qd
Tamulosin 0.4 mg qhs
Insulin SS
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Congestive Heart Failure
Respiratory Failure
Pulmonary Edema
Renal Failure
[**Last Name (un) 3696**] Syndrome
Atrial Fibrillation
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Completed by:[**2114-3-29**]
|
[
"V58.65",
"038.9",
"707.03",
"V58.67",
"995.92",
"583.81",
"250.42",
"008.45",
"427.31",
"403.91",
"577.0",
"998.59",
"600.01",
"560.89",
"782.1",
"486",
"518.81",
"428.0",
"599.7",
"540.9",
"584.5",
"112.2",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"47.09",
"96.6",
"45.03",
"99.04",
"96.72",
"96.48",
"96.04",
"99.15",
"00.14",
"57.0",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13727, 13736
|
5954, 13473
|
345, 465
|
13909, 13919
|
1877, 5931
|
1616, 1634
|
13699, 13704
|
13757, 13888
|
13499, 13676
|
13943, 13977
|
1649, 1858
|
276, 307
|
493, 813
|
835, 1233
|
1249, 1600
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,560
| 182,407
|
33909
|
Discharge summary
|
report
|
Admission Date: [**2124-7-27**] Discharge Date: [**2124-8-8**]
Date of Birth: [**2056-1-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Indocin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain/Fatigue/DOE
Major Surgical or Invasive Procedure:
[**2124-7-27**] - Redosternotomy, CABGx3(Saphenous vein graft
(SVG)->Diagonal artery, SVG->Ramus artery, SVG->Posterior left
ventricular artery), MVR(33mm St. [**Male First Name (un) 923**] 33mm Porcine Valve)
[**7-29**] - Reexploration for bleeding
[**8-1**] - Permenant pacemaker placement.
History of Present Illness:
The patient is a 68-year-old gentleman who underwent coronary
artery bypass grafting for critical symptomatic congestive heart
failure symptoms back
in [**2124-1-15**] up in [**Location (un) 5450**], [**Location (un) 3844**]. The patient
re-presented with a bout of congestive heart failure and Dr.
[**Last Name (STitle) 78250**] worked the patient up, which showed that all of his vein
grafts were occluded. His mammary artery was
patent to the LAD and there was severe native vessel progression
as well. This degree of mitral regurgitation had significantly
increased as well between [**Month (only) 1096**] and this point. The patient
was therefore referred for redo coronary
artery bypass grafting as well as mitral valve repair or
replacement.
Past Medical History:
CAD s/p CABGx6 in [**1-/2124**]
CVD
COPD
Hyperlipidemia
HTN
AAA
PNA
MI
DJD
Gout
CRI
h/o alcohol abuse
Renal cell cancer s/p nephrectomy
CHF
CVD s/p (B) CEA
Social History:
Lives with wife in [**Name (NI) **]. Quit smoking two weeks ago. Former heavy
drinker, currently drinks three beers daily.
Family History:
Unremarkable
Physical Exam:
74 112/62 67" 188lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM. (B) CEA incisions.
LUNGS: CTA bilaterally
HEART: RRR, No R/G, I/VI systolic late blowing murmur, well
healed sternotomy
ABD: Soft, ND/NT/NABS. well healed right nephrectomy incision.
EXT:warm, well perfused, no bruits, no varicosities, L GSV
harvested Right appears suitable. Mild peripheral edema
NEURO: No focal deficits. Uses cane for walking d/t left hip
arthritis.
Pertinent Results:
[**2124-7-27**] - ECHO
Pre Bypass: The left atrium is markedly dilated and elongated.
Color-flow imaging of the interatrial septum raises the
suspicion of an atrial septal defect, but this could not be
confirmed on the basis of this study. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is an inferobasal left ventricular
aneurysm. There is severe regional left ventricular systolic
dysfunction with an inferior basal aneurysm with akinesis of the
basal inferior and inferior-septal walls. There is also severe
hypokineis of the entire lateral and remaing portions of the
inferior and septal walls, and mild hypokinesis of the anterior
and anteroseptal walls. LVEF 20%, but given severity of MR, this
is likely an overestimation of actual LV function. Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the aortic arch. There are three
aortic valve leaflets. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. Moderate to severe (3+) mitral regurgitation is seen.
The mitral regurgitation vena contracta is >=0.7cm (0.8 cm).
There is no pericardial effusion.
Post Bypass: No change in Biventricular function. There is a
bioprosthetic mitral valve in place, no paravalvular leaks.
Aortic contours intact. Remaing exam is unchanged. All finidngs
discussed with surgeons at the time of the exam.
PROCEDURE: Chest PA and lateral on [**2124-8-7**].
COMPARISON: [**2124-8-3**].
HISTORY: 68-year-old man with status post MVR and CABG, rule out
effusion.
FINDINGS: The loculated right hemithorax effusion including the
fissures have
remained stable. The small present left pleural effusion has
decreased in
size on today's examination. Persistent cardiomegaly is
moderate. The left
subclavian dual-lead pacemaker is unchanged in location. Left
retrocardiac
atelectasis is more pronounced on today's examination. The
pulmonary
vasculature is slightly prominent but no definite edema is seen.
IMPRESSION:
1. Loculated right small to moderate pleural effusion, stable.
2. Improvement of the small left pleural effusion.
3. Moderate cardiomegaly.
[**2124-8-7**] 01:43AM BLOOD WBC-12.2* RBC-3.00* Hgb-8.6* Hct-26.8*
MCV-90 MCH-28.6 MCHC-31.9 RDW-15.2 Plt Ct-611*#
[**2124-8-6**] 04:35AM BLOOD Hct-27.7*
[**2124-8-2**] 02:20AM BLOOD PT-12.9 PTT-22.6 INR(PT)-1.1
[**2124-8-7**] 01:43AM BLOOD Glucose-94 UreaN-23* Creat-1.0 Na-133
K-4.6 Cl-97 HCO3-29 AnGap-12
Brief Hospital Course:
Mr. [**Known lastname 6164**] was admitted to the [**Hospital1 18**] on [**2124-7-27**] for surgical
management of his coronary artery and vein graft disease. He was
taken directly to the operating room where he underwent a
redosternotomy with coronary artery bypass grafting to three
vessels and a mitral valve replacement using a 33mm St. [**Male First Name (un) 923**]
porcine valve. Please see operative note for details.
Postoperatively Mr. [**Known lastname 6164**] was transferred to the intensive care
unit for monitoring. He initially required inotropes and packed
red blood cells for pressure support and anemia. Complete heart
block was noted under his temporary pacemaker and the EP service
was consulted. A pacemaker was likely needed. He was
successfully extubated on postoperative day one. On
postoperative day two, he developed high output from his chest
tubes and was reintubated. He was taken to the operating room
where he was re-explored for bleeding and hemostasis was
acheived of a bleeding branch of a vein graft. He was then
returned to the intensive care unit for monitoring. The next
morning he awoke neurologically intact and was extubated. He
remained pacer dependent. Plavix, aspirin and a statin were
resumed. As it was unlikely his conduction system would recover,
the electrophysiology service placed a permenant pacemaker on
[**2124-8-1**] without complication. The hematology service was
consulted for thrombocytopenia. Although his HIT assay was
negative, it was recommended to treat as if he was HIT positive.
Thus, all heparin products were avoided and a serotonin release
HIT assay was sent and if positive, it is recommended he be
treated with argatroban and coumadin. His platelets recovered.
On [**2124-8-2**], he was transferred to the step down unit for further
recovery. The physical therapy service was consulted for
assistance with his postoperative strength and mobility.Plavix
was resumed. He required agressive diuresis and remained in the
hospital for diuresis. Repeat HIT antibody was negative. SRA is
still pending. His pacemaker was interrogated on [**8-8**], adn wsa
found to be functioning correctly. He was noted to have 3 5
minute episodes of atrial fibrillation, he was switched to a
full aspirin. He will follow up with the device clinic in 6
weeks. He was ready for discharge home on POD #12.
Medications on Admission:
Aspirin 325'
Crestor 20'
Iron 325'
MVI
Plavix 75'
Digoxin 0.25'
Lisinopril 5'
Lopressor 50"
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. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*20 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. 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*
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]
Discharge Diagnosis:
CAD s/p Redo CABGx3/MVR
CHB s/p PPM
H/O CABGx6 [**1-/2124**]
CVD s/p Bilat CEA
COPD
Hyperlipidemia
HTN
AAA
PNA
MI in past
CRI
Gout
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:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 2 weeks. ([**Telephone/Fax (1) 1504**]
Please call for appt.
Please follow-up with Dr. [**Last Name (STitle) 78250**] in 4 weeks.
Please follow-up with Dr. [**Known firstname **] in 6 weeks. [**Telephone/Fax (1) 78347**]
Please follow-up with the device clinic on [**9-18**] at 9:00, [**Hospital Ward Name 23**]
Building [**Location (un) 436**], [**Telephone/Fax (1) 62**].
Completed by:[**2124-8-8**]
|
[
"287.4",
"998.0",
"997.1",
"423.1",
"414.02",
"V45.73",
"998.11",
"518.5",
"428.20",
"412",
"274.0",
"305.1",
"V10.52",
"427.31",
"272.4",
"428.0",
"426.0",
"438.9",
"441.4",
"424.0",
"414.01",
"303.91",
"496",
"401.9",
"E934.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.1",
"34.04",
"37.72",
"37.83",
"99.07",
"35.23",
"39.31",
"99.05",
"99.04",
"38.93",
"37.12",
"96.71",
"39.64",
"88.72",
"89.45",
"36.13",
"96.04",
"39.61",
"34.03"
] |
icd9pcs
|
[
[
[]
]
] |
8478, 8525
|
4886, 7242
|
294, 589
|
8700, 8709
|
2278, 4863
|
9451, 9913
|
1706, 1720
|
7385, 8455
|
8546, 8679
|
7268, 7362
|
8733, 9428
|
1735, 2259
|
232, 256
|
617, 1371
|
1393, 1550
|
1566, 1690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,764
| 178,319
|
35817
|
Discharge summary
|
report
|
Admission Date: [**2160-2-22**] Discharge Date: [**2160-3-5**]
Date of Birth: [**2088-12-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Cold Left Lower Extremity
Major Surgical or Invasive Procedure:
Left iliac, femoral, superficial femoral artery, profunda
embolectomy, 4-compartment fasciotomy.
History of Present Illness:
73y/o female admitted to [**First Name9 (NamePattern2) 81456**] [**Doctor First Name **] [**2-16**] for 6 month history
of intermittent abdominal distention and flatus associated with
diminished appetite. Denies post pranial abdominal pain.
Admitting physical abdominal acities and distention. Patient was
to under go expl lab today but develope acute left
foot ischemia. The patient was evaluated by Dr. [**Last Name (STitle) 1391**] and
patient was transfered here for further evaluation. When she
arrived, her IV heparin was running at 850U/hr. Patient denies
any history of cardiac problems, asthma, stroke, arrythmia's,
PUD, bowel changes, melena or bloody stools.
Past Medical History:
no acute illness or surgical history
Social History:
Married, lives at home w/husband and daughter. [**Name (NI) 4906**]
recovering from recent hospitalization for perforated bowel. +
Tobacco use, 1ppd, though recently cut down 1 month ago. + ETOH,
approx 1 drink/day.
Family History:
not assessed
Physical Exam:
At admission:
VS: T 98.0 HR 124 B/P 117/81 RR 22 O2sat 95% @4L
Gen: no acute distress, anxious mild dyspena with speech
HEENT: no JVD, no carotid bruits, pulses 1+
Lungs: diffuse wheezing
Heart: irregular, irregular no mumur, gallop or rub.
ABD: mid distention with diminshed bowel sounds and mild RLQ
tenderness. No bruits
PV: left foot pale, cold, nonsensate, can not wiggle toes of
dorsiflex foot. temperature change extends to below left knee.
Rt. foot cool with good capillary rfill and motor/sensory
intact.
Pulse exam: 1+ femorals bilaterally with bruits, [**Doctor Last Name **] absent
bilaterally, rt. DP/PT dopperable monophasic .lt. pedal pulses
absent.
Neuro: oriented to time,place and person. non focal exam except
for left foot findings.
At discharge:
expired
Pertinent Results:
[**2160-2-22**] 05:53PM BLOOD WBC-21.6* RBC-4.26 Hgb-13.3 Hct-37.4
MCV-88 MCH-31.4 MCHC-35.6* RDW-13.1 Plt Ct-272
[**2160-2-23**] 04:50AM BLOOD WBC-18.5* RBC-3.75* Hgb-11.9* Hct-32.7*
MCV-87 MCH-31.8 MCHC-36.5* RDW-13.3 Plt Ct-256
[**2160-2-24**] 03:11AM BLOOD WBC-12.7* RBC-3.86* Hgb-11.9* Hct-34.2*
MCV-89 MCH-30.9 MCHC-34.9 RDW-13.3 Plt Ct-250
[**2160-3-3**] 12:51AM BLOOD WBC-7.1 RBC-2.45* Hgb-7.5* Hct-21.4*
MCV-87 MCH-30.7 MCHC-35.3* RDW-15.7* Plt Ct-364
[**2160-3-4**] 02:53AM BLOOD WBC-10.9# RBC-2.67* Hgb-8.2* Hct-23.2*
MCV-87 MCH-30.6 MCHC-35.1* RDW-15.4 Plt Ct-506*
[**2160-3-5**] 12:12AM BLOOD WBC-10.6 RBC-3.63*# Hgb-11.0*# Hct-31.3*#
MCV-86 MCH-30.4 MCHC-35.2* RDW-15.0 Plt Ct-250#
[**2160-2-22**] 05:53PM BLOOD PT-15.5* PTT-53.8* INR(PT)-1.4*
[**2160-2-22**] 10:29PM BLOOD PT-17.1* PTT->150 INR(PT)-1.5*
[**2160-2-23**] 04:50AM BLOOD PT-15.0* PTT-71.0* INR(PT)-1.3*
[**2160-3-3**] 12:51AM BLOOD PT-15.8* PTT-101.1* INR(PT)-1.4*
[**2160-3-4**] 11:04PM BLOOD PT-15.6* PTT-62.8* INR(PT)-1.4*
[**2160-2-22**] 05:53PM BLOOD Glucose-80 UreaN-23* Creat-0.9 Na-131*
K-5.2* Cl-97 HCO3-23 AnGap-16
[**2160-2-22**] 10:29PM BLOOD Glucose-83 UreaN-22* Creat-0.8 Na-140
K-4.8 Cl-105 HCO3-27 AnGap-13
[**2160-2-23**] 04:50AM BLOOD Glucose-92 UreaN-21* Creat-0.9 Na-136
K-4.4 Cl-104 HCO3-24 AnGap-12
[**2160-3-2**] 12:59AM BLOOD Glucose-84 UreaN-34* Creat-2.1* Na-137
K-3.8 Cl-102 HCO3-25 AnGap-14
[**2160-3-3**] 12:51AM BLOOD Glucose-145* UreaN-41* Creat-2.2* Na-136
K-3.9 Cl-101 HCO3-27 AnGap-12
[**2160-3-4**] 02:53AM BLOOD Glucose-120* UreaN-53* Creat-2.1* Na-138
K-4.5 Cl-103 HCO3-26 AnGap-14
[**2160-2-22**] 05:53PM BLOOD ALT-133* AST-196* AlkPhos-134*
TotBili-0.5
[**2160-2-23**] 04:50AM BLOOD ALT-132* AST-297* CK(CPK)-[**Numeric Identifier 81457**]*
AlkPhos-108 TotBili-0.4
[**2160-2-25**] 01:30AM BLOOD ALT-129* AST-147* CK(CPK)-1632*
AlkPhos-119* TotBili-0.2
[**2160-3-3**] 12:51AM BLOOD ALT-32 AST-17 AlkPhos-127* TotBili-0.4
[**2160-2-25**] 03:00PM BLOOD CK-MB-26* MB Indx-2.1
[**2160-2-26**] 02:41AM BLOOD CK-MB-21* MB Indx-2.0
[**2160-2-27**] 11:29AM BLOOD CK-MB-16* MB Indx-2.8
[**2160-2-22**] 10:29PM BLOOD Calcium-5.6* Phos-4.1 Mg-1.3*
[**2160-2-23**] 04:50AM BLOOD Albumin-1.7* Calcium-6.6* Phos-3.5
Mg-1.3*
[**2160-3-3**] 12:51AM BLOOD Albumin-2.1* Phos-5.4* Mg-2.5
[**2160-3-4**] 02:53AM BLOOD Calcium-8.6 Phos-5.1* Mg-2.4
[**2160-2-24**] 03:11AM BLOOD calTIBC-66* Ferritn-469* TRF-51*
[**2160-3-3**] 09:37AM BLOOD calTIBC-100* TRF-77*
[**2160-2-24**] 07:13PM BLOOD %HbA1c-5.9
[**2160-2-24**] 07:13PM BLOOD Triglyc-152* HDL-9 CHOL/HD-9.9 LDLcalc-50
[**2160-2-24**] 07:20PM BLOOD Ammonia-27
[**2160-2-24**] 07:13PM BLOOD TSH-2.6
[**2-22**] ECG: Sinus tachycardia (119). Diffuse ST-T wave abnormality.
Cannot rule out myocardial ischemia. Low QRS voltage in the limb
leads. No previous tracing available for comparison.
[**2-23**] TTE: The left atrium is normal in size. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The estimated right atrial pressure is
0-10mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is severe regional left ventricular systolic
dysfunction with basal to mid septal and anterior
hypokinesis/akinesis and mid inferior akinesis. No masses or
thrombi are seen in the left ventricle. Overall left ventricular
systolic function is severely depressed (LVEF= 20-30 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Severe regional left ventricular systolic
dysfunction consistent with multivessel coronary artery disease.
Mild (1+) mitral regurgitation. Moderate to severe [3+]
tricuspid regurgitation with moderate pulmonary artery systolic
hypertension.
[**2-23**] CT abd/pelvis: 1. Findings poorly evaluated without
intravenous contrast but potentially suspicious for peritoneal
carcinomatosis, including ascites and probable peritoneal and
serosal thickening. If there is an outside hospital CT with
intravenous contrast, then this can be scanned into the system
for comparison. 2. Partial small-bowel obstruction, with
transition point in the distal ileum. Contrast does pass into
the colon. 3. Moderate ascites. 4. Moderate bilateral pleural
effusions and adjacent atelectasis. 5. Small hiatal hernia. 6.
Tiny non-obstructing left nephrolithiasis. 7. Anasarca.
[**2-23**] CT Head: FINDINGS: There is a moderate-sized area of
hypodensity in the watershed territory between the right MCA and
PCA territory, consistent with reported history of subacute
infarction. There is no sign of hemorrhagic transformation
within this area. There is no other intracranial hemorrhage.
There is no mass, mass effect, or evidence of other area of
infarction.
There is moderate sulcal prominence in the bilateral frontal
lobes, most
consistent with atrophy, slightly out of proportion to
ventricular size. Basal cisterns are normal. There is mild
mucosal thickening in the ethmoid air cells, and nasal passages.
Paranasal sinuses and mastoid air cells are
otherwise normally aerated.
IMPRESSION: Evolving area of infarction in the watershed
territory between
the right MCA and PCA distributions. No sign of intracranial
hemorrhage, or hemorrhagic transformation of this infarct.
[**3-1**] cytology: Pleural fluid: ATYPICAL. Atypical epithelioid
cells present: Rare clusters of atypical epithelioid cells are
present, but degeneration precludes definitive classification.
[**3-5**] TTE: Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality, however, [**Hospital1 **]-ventricular
systolic function appears to be preserved.
Brief Hospital Course:
The patient was admitted on [**2160-2-22**]. After initial evaluation,
she was taken to the OR emergently for LLE thrombectomy. She
underwent a left iliac, femoral, superficial femoral artery,
profunda embolectomy, 4-compartment fasciotomy.
Post-operatively, her pulses were pulses (DP and PT) were
monophasic. She was taken to the CVICU, intubated and sedated
and on pressors, and on a heparin drip. She remained on pressor
support, as her pressures could not tolerate her pain/sedation
drips.
She had new onset atrial fibrillation which was rate controlled.
She was aggressively treated for rhabdomyolysis and ARF with
hydration. She had a bedside ECHO which showed: severe regional
LV systolic dysfunction (EF 20-30%) consistent with multivessel
CAD. Mild (1+) MR. Moderate to severe [3+] TR with moderate PA
systolic hypertension. She had a head CT which showed right
parieto-occipital infarct. The patient remained intubated. She
could not be weaned off the ventilator - she would thrash about
in the bed, and was unresponsive to commands. She would move her
upper extremities, and right lower extremity; muscle twitches
were noted in her left lower extremity. Attempts to extubate
were not successful - she would hypertensive and very highly
aggitated when these attempts were made. She was switched to TPN
and made NPO when she vomitted tube feeds - this may have been
due to extensive carcinomatosis causing pSBO.
She was seen by gyn/onc for her ascites and distension, as well
as CT scan, which were concerning for ovarian cancer. She had a
CT scan of her abdomen and pelvis on [**2-23**]; this was concerning
for peritoneal carcinomatous, including ascites and probable;
pSBO; moderate bilateral pleural effusions and adjacent
atelectasis; small hiatal hernia; tiny non-obstructing left
nephrolithiasis; anasarca. Peritoneal ascites came back positive
for adenocarcinoma, suspicious for ovarian cancer. Pleural fluid
cytology, from a right thoracentesis on [**3-1**], came back positive
for malignant cells. She was not deemed to be a surgical
candidate, though may be a chemotherapy candidate; however,
discussing these options were deffered as the patient could not
be extubated to participate in these discussions.
The patient was made DNR/DNI [**2-26**]. On the morning of [**3-5**], the
patient became acutely hypotensive and was treated with blood
(for postoperative blood loss and intravascular depletion),
fluids and pressors. Her heparin drip was discontinued. A
femoral artery line was placed when the radial line stopped
working. The patient's lower extremity and abdomen became
mottled, her abdomen tense, and it became more difficult to
ventilate her; she became increasingly acidotic. Her family was
made aware. The decision was made to make her CMO. Time of death
was 0528 on [**2160-3-5**].
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2160-3-14**]
|
[
"434.91",
"518.81",
"291.81",
"789.51",
"197.2",
"998.11",
"433.10",
"444.81",
"496",
"428.0",
"729.72",
"183.0",
"584.9",
"728.88",
"197.6",
"428.21",
"599.0",
"427.31",
"560.9",
"401.1",
"444.22",
"511.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"83.14",
"96.72",
"38.06",
"96.6",
"99.15",
"38.08"
] |
icd9pcs
|
[
[
[]
]
] |
11386, 11395
|
8482, 11302
|
339, 437
|
11446, 11455
|
2276, 7001
|
11508, 11543
|
1447, 1461
|
11357, 11363
|
11416, 11425
|
11328, 11334
|
11479, 11485
|
1476, 2234
|
2248, 2257
|
274, 301
|
465, 1137
|
7010, 8459
|
1159, 1197
|
1213, 1431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,801
| 166,827
|
36862
|
Discharge summary
|
report
|
Admission Date: [**2116-8-27**] Discharge Date: [**2116-9-3**]
Date of Birth: [**2067-5-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
headache, visual changes
Major Surgical or Invasive Procedure:
[**8-31**]: Left frontal craniotomy for tumor resection
History of Present Illness:
49yo female with 1 month history of headaches, shooting lights
in visual fields, and tearing eyes of increasing frequency.
Presented to [**Hospital **] Hospital for evaluation of these symptoms
and noted on CT scan to have left frontal mass. Patient
transferred to [**Hospital1 18**] for further evaluation and treatment. She
denied any symptoms other than those above.
Past Medical History:
s/p excision of fibroid cyst L breast ([**6-/2116**]), s/p
appendectomy (childhood)
Social History:
lives at home alone
Family History:
no notable family history
Physical Exam:
Exam upon admission:
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Pupils: 5 to 3mm bilaterally EOM: full and intact
Neck: Supple.
Lungs: not examined
Cardiac: not examined
Abd: not examined
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-18**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors. Notable
difficulty with spelling and serial 7s.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-19**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 3+ 3+ 3+ 3+ 3+
Left 3+ 3+ 3+ 3+ 3+
Toes downgoing bilaterally, no clonus
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Exam upon discharge:
Alert, oriented to person, place and date. PERRL bilaterally.
EMOI without nystagmus. Face is symmetric, tongue is midline. No
prontator drift or dysmetria. Full strength and sensation
throughout upper and lower extremities. Wound is clean, dry and
intact without erythema or drainage. There is resolving left
periorbital ecchymosis.
Pertinent Results:
Labs on admission:
[**2116-8-26**] 10:45PM GLUCOSE-100 UREA N-10 CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
[**2116-8-26**] 10:45PM WBC-10.3 RBC-4.48 HGB-13.1 HCT-38.7 MCV-86
MCH-29.2 MCHC-33.9 RDW-12.8
[**2116-8-26**] 10:45PM PLT COUNT-311
[**2116-8-26**] 10:45PM PT-12.8 PTT-28.8 INR(PT)-1.1
[**2116-8-27**] 11:20AM URINE UCG-NEGATIVE
CT HEAD W/O CONTRAST Study Date of [**2116-8-26**]:
FINDINGS: There is a heterogeteous, poorly defined left frontal
intraxial
mass with surrounding vasogenic edema. It measures approximately
3.5 x 2.8 cm. An MRI with [**Date Range **] would be better in further
evaluation. There are no other lesions or masses. There is
significant mass effect causing left sulcal effacement and
compression of the frontal [**Doctor Last Name 534**] of the left lateral ventricle.
There is a 7.6 mm rightward subfalcine herniation. There is no
evidence of hydrocephalus or ventricular entrapment. The [**Doctor Last Name 352**]
and white matter differentiation in remainder of the brain is
maintained. The osseous and soft tissue structures are
unremarkable.
IMPRESSION: Left frontal lobe poorly defined mass with vasogenic
edema and 7.6 mm rightward subfalcine herniation. Findings are
concerning for a primary glial neoplasm and further correlation
with MR [**First Name (Titles) 151**] [**Last Name (Titles) **] is recommended.
MR HEAD W & W/O CONTRAST [**2116-8-27**]:
FINDINGS: As seen on the recent CT examination, there is a mass
identified in the left frontal lobe region. The mass
demonstrates irregular shape and
measures approximately 4 cm in size. Following [**Month/Day/Year **],
irregular areas of enhancement are seen with rim enhancement in
the components of the mass. The mass extends from the left
frontal lobe region to the subcortical region. Extensive
surrounding edema is seen with mass effect on the left lateral
ventricle and midline shift. No restricted diffusion seen within
the mass. There are no other areas of abnormal enhancement
identified within the brain. Few scattered foci of T2
hyperintensity are seen in the brain.
IMPRESSION: Large, approximately 4 cm mass in the left frontal
lobe with rim enhancement and surrounding edema with midline
shift and mass effect on the left lateral ventricle. Foci of low
signal on susceptibility images in the mass indicate prior
hemorrhage. The appearances of the mass are suggestive of a
primary neoplasms such as a glioma. There is no hydrocephalus or
acute infarct seen.
PFI: Left frontal lobe mass with surrounding edema and midline
shift. The
appearances are suggestive of a primary brain neoplasm such as
glioma.
Cardiology Report ECG Study Date of [**2116-8-28**] 12:28:30 PM
Sinus rhythm. Normal tracing. No previous tracing available for
comparison. Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 142 74 396/415 60 52 50
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2116-8-28**]
7:14 AM
IMPRESSION: Unchanged left frontal mass lesion with persistent
effacement of the sulci and mass effect. The functional MRI
demonstrated the expected activation areas during the movement
of the hand and feet, language and also movement of tongue at
more than 1 cm from the lesion.
Final Report CT TORSO WITH CONTRAST [**2116-8-28**] 5:33 PM
FINDINGS: CT CHEST: There is no axillary, hilar, or mediastinal
lymphadenopathy. The heart and great vessels are unremarkable.
There is no pericardial or pleural effusion. The lungs are
clear. The airways are patent to the subsegmental level. There
is no focal consolidation or pneumothorax.
CT OF THE ABDOMEN: The spleen, pancreas, adrenal glands,
kidneys, and liver are unremarkable. There is focal fatty
infiltration adjacent to the
ligamentum teres (3, 54). Minimal gallbladder wall thickening is
likely
attributable to adenomyomatosis. There is no mesenteric or
retroperitoneal
lymphadenopathy. The adrenal glands are unremarkable. The small
bowel loops are normal in caliber and without focal wall
thickening. There is no evidence of free air or free fluid.
CT OF THE PELVIS: The rectum, sigmoid colon, bladder is
unremarkable. The
uterus is unremarkable. Multiple dilated veins along the left
pelvic side
wall, including the left gonadal vein is noted (3, 104). There
is no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic lesions
identified.
IMPRESSION: 1. No CT evidence of primary malignant tumor or
distant metastases. 2. Prominent pelvic veins along the left
pelvic sidewall and dilated left gonadal vein, a frequent
incidental finding. However, in the setting of chronic pelvic
pain, the appearance can sometimes reflect pelvic congestion
syndrome.
Pathology Report
Procedure Date [**2116-8-31**], Report Date [**2116-9-1**]
DIAGNOSIS:
I. Left frontal tumor is frozen section #1 (A-B):
Necrotic tissue with rare atypical cells.
II. Left frontal tumor for frozen section #2 (C-D):
Malignant neoplasm consistent with glioma.
III. Left frontal tumor for permanent section (E-H):
Glioblastoma (WHO grade IV), See Note.
Note: Severe cytologic atypia, numerous and atypical mitotic
figures, microvascular proliferation, and necrosis (extensive)
are seen.
HEAD CT WITHOUT IV CONTRAST [**2116-8-31**]: There has been interval
left frontal craniectomy and excision of a previously 3.5-cm
mass in the left frontal lobe. There is expected pneumocephalus.
Although the degree of vasogenic edema is similar, there has
been a decrease in the degree of shift of midline structures,
previously 10 mm shift to the right, and now 5 mm shift to the
right (2:15). There is again compression of the frontal [**Doctor Last Name 534**] of
the left lateral ventricle, but this appears somewhat less
severe than in the prior study. The right lateral ventricle
demonstrates improvement in the degree of mass effect. There has
been no interval development of hydrocephalus, and the basal
cisterns appear intact. There is no evidence of transtentorial
herniation. The small amount of hemorrhage in the postoperative
bed is expected. There is overlying subgaleal hematoma, and the
craniectomy site is well opposed. The visualized paranasal
sinuses and remainder of soft tissues appear unremarkable.
IMPRESSION: Expected appearance following resection of left
frontal lobe
mass, with continued, but somewhat decreased mass effect and
right shift of midline structures.
MRI [**2116-9-1**]:
FINDINGS: The patient is status post left frontal craniotomy and
resection of a previously identified neoplastic process
involving the left frontal lobe, there is evidence of residual
blood products within the surgical area, persistent and
unchanged vasogenic edema and mild mass effect along the sulci
in the right frontal ventricular [**Doctor Last Name 534**]. After administration of
[**Doctor Last Name **] contrast, there is no evidence of significant
abnormal enhancement, however, possibly it is too early to
discriminate abnormal enhancement, correlation with a followup
MRI once the blood product has been reabsorbed, is recommended
for further assessment. On the axial T2-weighted sequence, the
arterial flow voids, demonstrates a possible vascular loop at
the junction of the left A1 segment, and the anterior
communicating artery (5:11), formally a small aneurysm cannot be
completely excluded, followup with MRA is recommended. The
visualized paranasal sinuses are normal as well as the orbits,
there is evidence of patchy opacities at the mastoid air cells
bilaterally.
IMPRESSION:
1. The patient is status post left frontal mass resection and
left frontal craniotomy, there is persistent vasogenic edema,
blood products in the surgical bed.
2. The previously described left frontal lobe mass lesion
apparently has been resected, and the blood at the surgical
cavity obscures the pattern of enhancement, followup after the
reabsorption of the blood products is
recommended.
3. Possible prominent vascular loop versus a small aneurysm is
identified at the junction of the A1 and anterior communicating
segment on the left.
CTA HEAD W&W/O C & RECONS([**9-2**]):
On non-contrast, decreasing pneumocephalus, otherwise unchanged
post-left-
frontal-mass resection appearance; no new hemorrhage. On CTA, no
aneurysm or vascular occlusion. Area at the A1 segment
bifurcation with acomm not aneurysm, likely infandibulum
Brief Hospital Course:
The patient was admitted to the neurosurgery service on [**2116-8-27**]
after her CT scan revealed a new brain mass in the left frontal
lobe. She was started on steroids for the large amount of edema
surrounding the mass as well as dilantin for seizure
prophylaxis. Her MRI of the brain revealved irregular areas of
enhancement with rim enhancement in components of the mass. The
was also mass effect on the left lateral ventricle. On [**2116-8-28**]
the patient had a functional MRI in preparation for surgery.
She went to the OR for tumor resection on [**8-31**]. The patient
tolerated the procedure well and the procedure was without
complications. The patient went to the ICU post-operatively for
Q 1 hour neuro checks. Her neuro exam was stable
post-operatively. Physical therapy evaluated her and felt that
she was safe to ambulate on her own and did not require any
additional visits. She was tranferred to the neurosurgical floor
on [**9-1**].
Her MRI showed a gross total resection however there was a
question of a small aneurysm seen at the junction of the ACOMM
at A1 on the left. Therefore the patient had a CTA to further
evaulate this on [**9-2**]. The CTA showed that this area of concern
to be an infandibulum and not an aneurysm. Occupational therapy
evaluated the patient on [**9-2**] and felt that she would benefit
from outpatient therapy to assist with cognitive training. The
final pathology for the mass was Glioblastoma - WHO grade IV.
She was ultimately discharged to home as above([**9-3**]), with
follow up scheduled in the brain tumor clinic. The patient
remained neurologically intact at the time of discharge.
Medications on Admission:
None
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
3. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): make sure to take as long as you require narcotic
pain medication.
Disp:*30 Capsule(s)* Refills:*0*
5. Outpatient Occupational Therapy
Please assist this patient with cognitive training.
6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Headache.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left frontal Glioblastoma (WHO grade IV)
Discharge Condition:
Neurologically stable
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.
??????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.
??????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**].
??????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:
??????Please return to the office in [**7-24**] days (from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2116-9-28**]
at 11:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], on [**Hospital Ward Name 23**] 8. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your acute hospitalization
Completed by:[**2116-9-3**]
|
[
"E878.8",
"V10.3",
"191.1",
"997.91",
"348.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
14013, 14019
|
11170, 12815
|
342, 400
|
14104, 14128
|
2807, 2812
|
15863, 16599
|
964, 992
|
12870, 13990
|
14040, 14083
|
12841, 12847
|
14152, 15840
|
1007, 1014
|
278, 304
|
428, 802
|
1597, 2432
|
2826, 11147
|
1271, 1581
|
824, 910
|
926, 948
|
2453, 2788
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,696
| 172,954
|
20016
|
Discharge summary
|
report
|
Admission Date: [**2152-1-9**] Discharge Date: [**2152-1-16**]
Service: Surgery, Green Team
HISTORY OF PRESENT ILLNESS: Briefly, the patient is a
79-year-old gentleman who presented with bright red blood per
rectum. He has had multiple episodes of this prior to
admission and presented slightly tachycardic.
The patient was admitted to the Medical Intensive Care Unit
and large bore IV access was obtained and resuscitation was
begun.
PAST MEDICAL HISTORY:
1. Peptic ulcer disease.
2. Coronary artery disease.
3. Hypertension.
4. Arthritis.
PAST SURGICAL HISTORY:
1. He is status post a total gastrectomy and Billroth II
reconstruction.
2. He is also status post revision of his Billroth II to a
Roux-en-Y in [**2151-10-18**] for biliary reflux.
3. He is also status post coronary artery bypass graft in
[**2141**].
MEDICATIONS ON ADMISSION: (His medications on admission
included)
1. Toprol-XL 100 mg by mouth once per day.
2. Aspirin 81 mg by mouth once per day.
3. Accupril 20 mg by mouth once per day.
4. Imdur 60 mg by mouth once per day.
5. Protonix 40 mg by mouth once per day.
6. Pravachol 10 mg by mouth once per day.
7. Hydrochlorothiazide 25 mg by mouth three times per day.
8. Vioxx by mouth as needed.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's physical
examination revealed he was afebrile. He was tachycardic and
mildly hypotensive. The patient was in mild distress. His
lungs were clear. His heart was regular. His abdomen was
soft, nontender, and nondistended. Bowel sounds were
present. His rectal examination was guaiac-positive.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the Medicine Service. He was transfused multiple units
and sent to tagged red cell scan. The tagged red cell scan
was positive for a bleed in a question of the duodenum. He
was taken to angio at that time. After a 3-vessel angio it
was found that he had bleeding of the hepatic flexure, and
this was coiled successfully. The patient was then taken
back to the Intensive Care Unit, and hematocrit levels were
cycled, and he was stable from this standpoint.
The patient was examined on hospital day two and was found to
have peritoneal signs. He was taken emergently to the
operating room for an exploratory laparotomy and right
colectomy. Please see the Operative Report for further
details.
Postoperatively, the patient was transferred to the Intensive
Care Unit and slowly improved. His hematocrit was
stabilized. He was making good urine, and the patient was
able to do well.
He was transferred to the floor, and after return of bowel
function his diet was slowly advanced. He was able to
tolerate a regular diet before the time of discharge.
Physical Therapy was also consulted, and the patient began
ambulating and did well from a Physical Therapy standpoint.
It was felt that he could go home and follow up with for a
home safety evaluation.
The patient continued to improve. His intravenous fluids
were Heplocked. His diet was advanced, and the patient was
tolerating regular food. He was slowly restarted on all of
his medications including his antihypertensive medications.
The patient was doing well on postoperative day five. The
patient was discharged to home. His staples were removed,
and Steri-Strips were placed prior to discharge. The patient
was tolerating a regular diet at this time.
DISCHARGE STATUS: The patient was discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
PRIMARY DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed.
2. Status post tagged red cell scan.
3. Status post angio coiling of the left colon complicated
by right colonic ischemia.
4. Status post exploratory laparotomy and right colectomy.
SECONDARY DISCHARGE DIAGNOSES:
1. Peptic ulcer disease.
2. Coronary artery disease.
3. Hypertension.
4. Arthritis.
5. Status post subtotal gastrectomy and Billroth II
reconstruction.
6. Status post revision of his Billroth II to a Roux-en-Y
for biliary reflux.
7. Status post coronary artery bypass graft.
MEDICATIONS ON DISCHARGE: He was given prescriptions for
Percocet and Colace as well as to continue all of his home
medications.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one to two weeks for a
wound check.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Known firstname **]
MEDQUIST36
D: [**2152-1-16**] 07:28
T: [**2152-1-16**] 09:37
JOB#: [**Job Number 53924**]
|
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icd9cm
|
[
[
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[
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3785, 4068
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|
866, 1606
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4233, 4653
|
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|
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|
3469, 3513
|
131, 449
|
471, 560
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,693
| 177,173
|
49882
|
Discharge summary
|
report
|
Admission Date: [**2195-10-14**] Discharge Date: [**2195-10-23**]
Date of Birth: [**2133-8-29**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Left parietal mass removal
History of Present Illness:
Patient is a 62 year old woman who presents to [**Hospital1 18**] for
evaluation after having a 2 minute witnessed tonic clonic
seizure
while at work. She was post-ictal upon EMS arrival and was not
reponding to any commands but was protecting her airway. She was
trasnferred to [**Hospital1 18**] for further care and in the ER while being
evaluated she had another seizure. She had a CT of the head that
showed a left parietal brain lesion and neurosurgery was
consulted. Prior to arriving to consult on the patient she was
intubated and sedated for airway protection. Unable to obtain
review of systems given patients recent intubation and no family
available to dicuss.
Past Medical History:
Poorly differentiated Nodular Lymphoma, >20years ago in pelvis,
s/p XRT, in remission
Hypertension
Hyperlipidemia
CKD, baseline creat 1.2-.14
Anemia, unclear etiology (extensive w/u with labs, BMB, GI w/u
neg, may be [**3-11**] CKD)
s/p TAH/BSO for pelvic mass/metrorrhagia '[**85**]
Thyroiditis
Social History:
The patient lives in [**Location 669**] with her Husband and son. She is
employed in the Cafeteria of the [**Location (un) 86**] Public School.
Tobacco: [**6-12**] cigarettes daily x 20 years
Family History:
Mother - Died age 86 from CAD
Father - Died in 80s from "poisoned ETOH"
- no family history of Gastrointestinal disease
Physical Exam:
PHYSICAL EXAM:
Gen: intubated, sedated
HEENT: Pupils: PERRL EOMs unable to obtain
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intuabted, sedated, no commands
Orientation: unable to obtain
Language: unable to assess
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally.
III, IV, VI: unable to assess
V, VII: unable to assess
VIII: unable to assess
IX, X: unable to assess
[**Doctor First Name 81**]: unable to assess
XII: unable to assess
Motor: MAE
Sensation: unable to assess
Toes downgoing bilaterally
Coordination: unable to assess
Pertinent Results:
[**10-14**] CT head noncontrast: 2-cm rounded hypodensity in the left
parietooccipital region concerning for underlying intra-axial
mass with edema
[**10-14**] MRI with and without contrast: 3 x 2.8 cm cystic mass with
internal enhancing mural nodule
[**10-15**] CT Torso with and without contrast: Scattered enlarged and
necrotic lymph nodes
[**10-15**] CTA head: Hypoattenuating left parietal lesion is
redemonstrated,
suspicious for neoplasm. Narrowing of left supraclinoid ICA.
[**10-16**] Postop CT head: 1. Post-surgical changes from left parietal
craniotomy including mild frontoparietal pneumocephalus,
post-operative hemorrhage and subcutaneous air. 2. Minimal
subfalcine herniation. No sign of transtentorial or tonsillar
herniation. 3. No hemorrhage outside of the surgical bed or
evidence of acute large territorial infarction.
[**10-17**] Postop MRI with and without contrast: 1. Two small foci of
contrast enhancement along the inferior margin of the left
occipitoparietal surgical cavity. Recommend continued follow-up.
2. Stable 4-mm enhancing lesion in the left precentral cortex
with slow diffusion, which has similar signal characteristics to
the resected larger mass.
Discharge Labs: [**2195-10-21**] 06:00AM
WBC-9.5 RBC-3.04* Hgb-9.2* Hct-27.3* MCV-90 Plt Ct-184
Glucose-88 UreaN-20 Creat-0.9 Na-138 K-3.8 Cl-105 HCO3-24
AnGap-13
Brief Hospital Course:
[**Known firstname **] [**Known lastname 104205**] was intubated in the emergency department for
seizure control and admitted to the Neurosurgery service for Q1
hour neuro checks. She was continued on Dilantin for seizures.
MRI with and without contrast was performed and demonstrated a
large cystic lesion in the left posterior temporal lobe. CT
torso performed for metastatic work up demonstrated multiple
enlarged scattered and necrotic lymph nodes. On [**10-16**] she remained
intubated and was prepared to be taken to the OR for resection
of her lesion. She had an MRI WAND study and CTA for operative
planning and was taken to the operating room for resection on
the afternoon of [**10-16**]. Post-operatively she was transferred
intubated to the ICU.
Her post operative course was notable for agitation, controlled
with propofol, and then extubation on [**10-18**], with mild post
extubation confusion. She developed hyponatremia which resolved
with PO fluid intake. She was then transferred to the general
medicine service. She had no further seizures throughout the
remainder of her hospital stay.
The patient's biopsy results were consistent with metastatic
carcinoma, likely of lung origin. Given she was already seen at
the [**Hospital3 328**] for her prior lymphoma and her anemia, she
preferred to pursue further evaluation and treatment there. She
was scheduled to see Dr.[**Last Name (STitle) **] one week after discharge at the
recommendation of Dr.[**Last Name (STitle) 3315**]. She will have a phenytoin level
checked prior to this appointment. She was instructed to pick up
a CD with all of her imaging results on the [**Location (un) **] of the
[**Hospital Ward Name 23**] building next week prior to her follow-up appointments;
arrangements were made for her pathology slides to be sent to
Dr[**Last Name (STitle) 104206**] office. She was continued on Phenytoin and Decadron
for seizure prophylaxis and instructed not to drive or return to
work until seen by Dr.[**Last Name (STitle) **].
The patient was also noted to have a new thyroid nodule which
will need to be followed-up as an outpatient. She was maintained
on half of her home dose of Atenolol and her Lisinopril was
held; she maintained good blood pressures on this regimen and
was instructed to follow-up with her PCP for repeat blood
pressure checks.
Medications on Admission:
Lisinopril 20 mg po daily
Omeprazole 20 mg po daily
Atenolol 100 mg po bid
Levothyroxine 50 mcg po daily (last filled in [**8-17**])
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day): Please have a phenytoin level
checked at your visit with Dr.[**Last Name (STitle) 724**].
Disp:*180 Tablet, Chewable(s)* Refills:*0*
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): This is a lower dose than you were taking previously.
Disp:*60 Tablet(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Continue this
medication whie you are taking Decadron (your steroid).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Please have a dilantin level checked on Tuesday, [**10-27**]
prior to your visit with Dr.[**Last Name (STitle) **].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left Parietal Tumor
Metastatic Carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with seizures and were found
to have a brain mass that is thought to be a metastatic
carcinoma that may have originated in your lung. You underwent
resection of the mass and were started on two new medications,
Dilantin and Decadron, to prevent further seizures. You will
need to follow-up with a neuro-oncologist at [**Hospital3 328**] for
further management of these medications and your underlying
cancer.
The following instructions are related to your recent surgery:
Exercise should be limited to walking; no lifting, straining, or
excessive bending.
You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine. Please take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at
Dr.[**Last Name (STitle) **] office at 08:30 on the [**Location (un) **] in the [**Hospital3 328**]
Yawkey Building.
You are being sent home on a steroid medication. 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
office visit with your neuro-oncologist.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Please follow-up with your new neuro-oncologist, Dr.[**Last Name (STitle) 53939**]
[**Name (STitle) **], at the [**Hospital3 328**] on Thursday, [**10-29**] at 9:00AM.
You should have a Dilantin level checked 30 minutes before this
visit as noted above. Please also keep the following appointment
with your primary care doctor.
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Specialty: Internal Medicine
When: Wednesday [**10-28**] at 9:30am
Location: [**Hospital6 9657**] PHYSICIAN GROUP
Address: [**Location (un) **] [**Apartment Address(1) 25389**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 24396**]
|
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13,666
| 186,885
|
21286
|
Discharge summary
|
report
|
Admission Date: [**2175-11-3**] Discharge Date: [**2175-11-8**]
Date of Birth: [**2124-8-12**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
Unresponsiveness, rigidity
Major Surgical or Invasive Procedure:
Intubation/Extubation
Lumbar Puncture
History of Present Illness:
51 year-old woman with history of seizures since [**2171**], the first
of which occurred in the setting of polysubstance (Wellbutrin
and Buspar) overdose, with resultant right temporal subdural and
subarachnoid hemorrhages, also with depression, panic disorder,
alcohol abuse, dyslipidemia, and hypothyroidism, who presents
with "unresponsiveness." According to her husband, the patient
was doing well until Saturday when she fell and struck her left
forehead while walking a dog. Her husband states that she
sustained an abrasion to the area and had headaches, but was
otherwise herself until Monday around noon. At that time, he
noted that she had slurred speech and unsteady gait for a period
of approximately 3 hours. He states that it seemed as if she
had been drinking alcohol, though she denied so. He suggested
that they go to the hospital, but the patient refused. By 6 pm,
she had returned to her baseline and was in her usual state of
health on Tuesday and Wednesday.
However, he came home this evening around 5 pm, and noted
shortly afterward that she seemed sluggish, with slurred speech.
She was agitated, and again walking unsteadily. He helped her
upstairs to bed, though she fell and hit the back of her head.
She gradually became more confused and lost consciousness over
next half-hour. He noted her breathing to be "abnormal."
Shortly thereafter, she was noted to be rigid. He decided to
drive her himself, and had difficulty getting her into the car
given the rigidity.
On arrival at [**Hospital3 1280**] Hospital, she had what was described as
a "rigid seizure." Her arms and legs were extended and rigid
with hands open and feet plantarflexed. She was initially
unresponsive and not withdrawing to noxious, though at one point
she was reported to be lightly squeezing her hands on command.
She received Narcan, lorazepam 2 mg IV x 2, and was intubated
with succinylcholine and etomidate. She was sedated on
Propofol, then switched to Versed given hypotension (SBP 70s).
She was also apparently hypothermic and placed under a warming
device. The patient was loaded with Cerebyx 25 mg/kg at the
advice of Neurology. Urinalysis showed 15 ketones and serum
aspirin level was within normal limits at 72. CBC, coagulation
studies, urine toxicology (including benzodiazepines, cocaine,
amphetamines, cannabinoids, opiates, and barbiturates), serum
toxicology (including acetaminophen and alcohol), CT head and
neck, and chest x-ray were all reportedly unremarkable. A
nasogastric tube placed to suction found "coffee ground emesis"
and possibly several pill fragments.
The patient was started on Neo-Synephrine en route to [**Hospital1 18**] for
persistent hypotension. The patient was reportedly diffusely
rigid on presentation here. A Neurology consult was urgently
called.
Review of Systems: Unable to provide. Her husband reports an
unintentional 20 pound weight loss in recent months. She had
been evaluated with no clear etiology yet identified.
Past Medical History:
-Generalized tonic-clonic seizures, history per recent note by
Dr. [**Last Name (STitle) **] from [**2175-9-12**]: "First seizure in [**2171**] in the
setting of an intentional Wellbutrin overdose and fall resulting
in a right temporal lobe contusion. She was event free until
[**4-19**] when she had several episodes of loss of consciousness and
confusion after a minor head trauma. She was placed on Keppra
at that time. She had one event in [**2173-2-14**] and a series of
alcohol related seizures in [**5-21**] for which she was admitted to
[**Hospital3 1280**] Hospital. At that time, she had several, back to
back seizures consisting of unresponsiveness and left head and
eye version. Her last seizure occurred three weeks ago. As
usual, it was preceded by overwhelming anxiety and fear. She
felt warm and diaphoretic. She called her husband at work to
tell him what was happening and, while on the phone with him,
became unresponsive. Her husband called EMS who apparently
found her lying on the floor at home. She was confused for
about thirty minutes after the event. She was taken to [**Hospital 3856**] where she received Valium in the ED and was discharged
home. She called us last week to report this episode and we
increased her Keppra dose to 1500 mg [**Hospital1 **] (from 1000/1500)."
Precipitants for seizures reportedly include alcohol, sleep
deprivation and missed medication doses. Head trauma may be
another. Had not had seizure in over one year.
-s/p small subdural and subarachnoid hemorrhages in right
frontal lobe with small intraventricular hemorrhage with initial
seizure in [**2171-6-15**]
-Muscle tension headaches in setting of cervical spondylosis
-Dyslipidemia
-Hypothyroidism
-Depression
-Panic disorder
-Alcohol abuse
-s/p right shoulder repair repeated multiple dislocations with
possible residual right arm weakness
Social History:
Lives with husband, has 2 children, recently gained job at Stop
n' Shop and resumed driving after clearance of seizures for over
a year. Reportedly a recovering alcoholic. Has had extensive
smoking history. Has denied a history of drug abuse in the
past.
Family History:
No seizures per review of records. By report, mother with
coronary artery disease and diabetes, died at age 56. Brother
with diabetes. Sister and her daughter with asthma. Daughter
with frequent headaches.
Physical Exam:
Vitals: T 98.4 F BP 112/76 P 92 RR 16 SaO2 100 on
ventilator
General: NAD, appears thin
HEENT: abrasion over left forehead, sclerae anicteric, orally
intubated, NGT tube with dark material to suction, appears as
coffee grounds
Neck: C-collar in place
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen: soft, thin, non-tender, non-distended, bowel sounds
present
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes
Neurologic Examination:
Performed several minutes after Versed stopped
Mental Status:
Sedated, not opening eyes even to sternal rub, but
intermittently gagging spontaneously on ETT, not following
commands
Cranial Nerves:
Optic disc margins sharp; no blink to threat bilaterally. Pupils
equally round and reactive to light, 5 to 4 mm bilaterally.
Eyes midline, no nystagmus, OCR not performed given collar. No
corneals. Face appears grossly symmetric. Brisk gag.
Motor:
Normal bulk throughout. Essentially rigid at first, with all
four extremities fully extended and feet plantarflexed. Then
appeared to have decerebrate-type posturing. Tone in arms then
decreased somewhat to allow some flexion and extension at
elbows. Later noted rhythmic clonic movement at feet. No
purposeful movement.
Sensation: No withdrawal to noxious in extremities.
Reflexes:
DTRs could not be elicited due to rigidity.
Toes were downgoing on the left and equivocal on the right.
Coordination and Gait:
Could not be assessed
Pertinent Results:
[**2175-11-3**] 08:23AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-5* POLYS-0
LYMPHS-100 MONOS-0
[**2175-11-3**] 08:22AM CEREBROSPINAL FLUID (CSF) PROTEIN-57*
GLUCOSE-101
[**2175-11-3**] 11:56AM PHENYTOIN-14.0
[**2175-11-3**] 12:27AM LACTATE-2.9*
[**2175-11-3**] 12:20AM WBC-7.8 RBC-4.63 HGB-14.4 HCT-43.1 MCV-93
MCH-31.2 MCHC-33.5 RDW-13.1
[**2175-11-3**] 12:20AM LIPASE-48
[**2175-11-3**] 12:20AM ALT(SGPT)-13 AST(SGOT)-29 CK(CPK)-132 TOT
BILI-0.2
[**2175-11-3**] 09:01AM LACTATE-0.9
Brief Hospital Course:
51 year-old woman with history of seizures since [**2171**], the first
of which occurred in the setting of polysubstance (Wellbutrin
and Buspar) overdose, with resultant right temporal subdual and
subarachnoid hemorrhages, also with depression, panic disorder,
alcohol abuse, dyslipidemia, and hypothyroidism, who presents
with "unresponsiveness" and tonic clonic movements concerning
for a seizure. Limited examination at this time is notable for
possible for rigidity and abnormal movements that may represent
generalized tonic-clonic activity versus decerebrate posturing.
Initial laboratory studies are notable only for an elevated
lactate, which may be secondary to ictal activity or
hypotension, and hypocalcemia. EKG shows right bundle branch
block. Head CT shows an old posterior right temporal
hypodensity, likely encephalomalacia from her prior contusion.
The possible seizures could be due to recent recurrent head
trauma or medication non-compliance. Given her history,
medication overdose or substance abuse should be considered.
Hypocalcemia, while unlikely should be in the differential. An
infectious process, such as meningitis, still should be excluded
emergently. The discordance between the clinical picture and
imaging could suggest diffuse axonal injury.
1. Neuro
-LP showed protein 57, glucose 101, WBC 1, 100% lymph, RBC 5,
gram stain showed no microorganisms, bacterial culture showed no
growth, f/u HSV PCR and Lyme
-Discontinued Vancomycin, Ceftriaxone, and Acyclovir given LP
results
-CT Head showed no acute intracranial process, stable
encephalomalacia in the right temporal lobe.
-MRI/MRA of the head showed right temporal encephalomalacia and
small areas of encephalomalacia in the subcortical white matter
of right frontal and parietal lobes which have evolved since the
previous MRI of [**2171-7-2**], no acute infarct seen, mass effect, or
hydrocephalus identified, somewhat artifact-limited normal MRA
of the head
-EEG showed slow background and occasional suppressive bursts.
These findings suggest a widespread encephalopathy affecting
both cortical and subcortical structures. There were no clearly
epileptiform features.
-Keppra increased from 1500 mg PO bid to 2000mg [**Hospital1 **], weaned off
Dilantin
-Ativan IV prn seizure cluster
-urine tox positive for benzos, serum tox ASA 6
-CT C-spine showed no acute fracture or malalignment, multilevel
degenerative changes, C-collar removed
2. Cards
-Initially on pressors (likely hypotension after Propofol
bolus), have been weaned off
-CEs: CK 132, TropT <0.01
-Cardiac telemetry
-Cont. Simvastatin 40 mg daily
- Lisinopril added for elevated BP's
3. Respiratory
-Extubated [**11-4**]
-CTA chest: no evidence of PE
- Stable while on floor
4. ID
- blood cultures negative
-CXR showed no consolidation
-UA showed 50 ketones, neg leuk/nitr, f/u urine culture
-CSF culture showed no growth
-Lactate 2.9->0.9
- HSV CSF pending at d/c
- Afebrile while on floor
5. FEN/GI
-Prelim read of CT abd/pelvis showed early SBO, attending read
showed marked distention of the distal duodenum and jejunum with
thickening of the mucosal wall concerning for ischemia, though
could represnet shock bowel. There is no evidence for vascular
insufficiency. There is no evidence for small bowel obstruction
and distal loops of small
and large bowel are normal in appearance.
-She also had coffee grounds emesis out of NG tube, Surgery
consulted: no evidence of obstruction upon attending review but
finding c/w hypotensive ischemia
-LFTs, lipase normal
-f/u stool guaiac
-Regular diet
-IVF standing
-Cont. MVI, thiamine, folate
-Cont. Ca/Vit D
- No evidence of GI bleeding while on floor
6. Psych
-Cont. Klonopin 0.5 mg PO QID
-Cont. Sertraline 200 mg PO daily
-Recommended a dual diagnosis program as outpt
7. Endo
-TSH 3.2
-Cont. Levothyroxine 25 mcg DAILY
8. PT/OT evaluated and recommended outpt therapy
Medications on Admission:
-CLONAZEPAM 0.5 mg QID
-LEVETIRACETAM 1500 mg [**Hospital1 **]
-LEVOTHYROXINE 25 mcg daily
-SERTRALINE 200 mg daily
-SIMVASTATIN 40 mg daily
-CALCIUM-CHOLECALCIFEROL (D3) [CALCIUM 600 + D]
-CYANOCOBALAMIN [VITAMIN B-12]
-MV, IRON,MIN-FA-CO Q10-LYC-LUT
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day).
7. Levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
Disp:*240 Tablet(s)* Refills:*2*
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
11. Outpatient Physical Therapy
for gait steadiness
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure vs. post-concussive seizure vs. seritonin syndrome vs.
non epileptic seizure
Discharge Condition:
Good. Patient back to baseline.
Discharge Instructions:
Please follow up with all appointments as below. Abstain from
alcholol. Note changes to medications as below.
Followup Instructions:
Psychiatrist: MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6929**], MD Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2175-12-5**] 4:30
Neurologist: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 540**] MD Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2176-1-9**] 2:30
Neuropsych Testing: [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**MD Number(3) 56301**]:[**Telephone/Fax (1) 1047**] Date/Time:[**2176-1-9**] 9:00. [**Hospital **] [**Hospital **]
Medical Center [**Hospital Ward Name 516**], [**Hospital Ward Name 860**] Building [**Location (un) **].
Nutritionist appointment set through office of PCP,[**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 6051**],MD,[**Telephone/Fax (1) **]. Appointment is with Dr.
[**Last Name (STitle) 56302**],nutritionist,[**Hospital1 56303**],[**Location (un) 47**],for [**2177-11-29**]:30 AM,[**2175**].
An appointment has been scheduled for dual diagnosis treatment
at
[**Hospital1 **],[**Last Name (NamePattern1) 56304**]., [**Last Name (un) 17679**],[**Telephone/Fax (1) 56305**],for Friday,
[**11-10**] at 10 am.
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79,578
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36689
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Discharge summary
|
report
|
Admission Date: [**2114-8-23**] Discharge Date: [**2114-9-7**]
Date of Birth: [**2075-5-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatitis
Major Surgical or Invasive Procedure:
Right IJ Central line placement [**2114-8-24**] at [**Hospital1 18**] with removal of
(L) subclavian placed at OSH; intubation at OSH [**8-14**] and [**8-16**];
extubated [**2114-8-29**].
History of Present Illness:
Mr. [**Known lastname 82971**] is a 39 year old man with diabetes,
hypertriglyceridemia, and alcoholism who presented to an OSH on
[**8-11**] with abdominal pain in the setting of increased EtOH use
over the last month.
.
There, admission labs were notable for lipase 1687, WBC 11 with
24% bands, Hct 50, AST 125, ALT 99, Na 125, gap of 17.
Cholesterol was approximately 3000. CT scan on admission showed
evidence of pancreatitis, pancreatic edema with free fluid in
the pelvis. He was admitted to the ICU for close monitoring and
fluid resuscitation.
.
At the OSH ICU, he became progressively confused despite
treatment with lorazepam per CIWA. He developed respiratory
distress on [**8-14**] and was intubated. He self extubated on [**8-16**] and
did well initially, though had to be reintubated later that day
for respiratory distress and altered mental status. He has
undergone multiple attempts at weaning from the vent apparently
complicated by increased hypercapnia and hypoxia.
.
He remained febrile throughout his hospital course. He was
started on ceftriaxone and vancomycin empirically on [**8-14**]. Flagyl
was added subsequently, and then ceftrixone was changed to
levofloxacin. Oral vancomycin was added on [**8-19**]. His antibiotics
were again modified to doripenem on [**8-20**] with improvement of his
WBC from 25 to 12k by [**8-21**]. A RIJ had been placed on [**8-14**] and was
removed on [**8-21**]. Cultures of blood, urine, and lines have been
negative as have C diff toxin assays.
.
On evaluation in the [**Hospital Unit Name 153**], he is intubated and unable to provide
any history.
Past Medical History:
Familial hypertriglyceridemia, Alcohol abuse, HTN, Anxiety, DM,
Gout, MVA s/p ankle fracture
Social History:
Married. Daily drinker 6 beers/day. Uses marijuana and cocaine.
No tobacco.
Family History:
Other family members with Diabetes
Physical Exam:
On [**Hospital Unit Name 153**] admission:
Vitals 102.2 112 139/81 23 100% on AC
General Young man intubated and sedated
HEENT Sclera anicteric, conjunctiva slightly injected on right
Neck Supple
Pulm Diminished at right base
CV Tachycardic regular S1 S2 no m/r/g
Abd Mildly distended, diminished bowel sounds, grimaces with
palpation
Extrem Warm no edema palpable distal pulses. legs symmetric
Neuro Opens eyes to voice, squeezes hands and wiggles toes to
command
Derm No rash or jaundice
Lines/tubes/drains foley yellow urine left subclavian
.
On [**Hospital Unit Name 153**] transfer:
Vitals: T98.6 P97 BP 144/93 RR19 SaO2 96% RA
General: Calm, asks appropriate questions, oriented to person,
hospital
Pulm Decreased breath sounds L base, otherwise CTA
CV Tachycardic, nl S1 S2, no m/r/g
Abd: s/nt, mildly distended, active bowel sounds
Extrem Warm, 2+ distal pulses. legs symmetric, no /c/c/e
.
At Discharge:
VS: 98.9 PO, 92, 144/82, 20, 94% RA
GEN: In NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **].
LUNGS: CTA(B).
COR: RRR
ABD: BSx4. Soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
Pertinent Results:
On [**Hospital Unit Name 153**] admission [**2114-8-23**]:
WBC-14.0* RBC-2.48* Hgb-8.1* Hct-24.0* MCV-97 MCH-32.5*
MCHC-33.6 RDW-13.7 Plt Ct-690*
Neuts-71* Bands-1 Lymphs-14* Monos-7 Eos-3 Baso-1 Atyps-0
Metas-0 Myelos-2* Plasma-1*
PT-12.6 PTT-24.7 INR(PT)-1.1
Glucose-95 UreaN-19 Creat-0.6 Na-149* K-4.1 Cl-111* HCO3-29
AnGap-13
ALT-18 AST-46* LD(LDH)-474* AlkPhos-67 Amylase-13 TotBili-0.5
Lipase-94* Hapto-613* Triglyc-259* Lactate-0.8
Albumin-2.8* Calcium-8.4 Phos-3.9 Mg-2.1
.
Labs at transfer [**2114-9-2**]:
WBC-18.3* RBC-2.82* Hgb-8.7* Hct-25.2* MCV-89 MCH-30.9 MCHC-34.6
RDW-14.2 Plt Ct-762*
PT-15.2* PTT-67.7* INR(PT)-1.3*
Glucose-94 UreaN-11 Creat-0.5 Na-138 K-3.0* Cl-101 HCO3-24
AnGap-16
Calcium-8.7 Phos-3.8 Mg-1.8
.
VitB12-633
Folate-14.0
.
OSH Imaging:
[**8-11**] CT abd/pelvis:
severe pancreatitis no necrosis, pseudocyst, or organized fluid
collection. fatty liver.
.
[**8-17**] CT abd/pelvis:
increased ascites and RP effusions, no organized collection
bilateral pleural effusions
.
[**Hospital1 18**] Imaging:
[**8-23**] EKG: Sinus rhythm. Early R wave progression. No previous
tracing available for comparison.
.
[**8-23**] CT head: Normal study.
.
[**8-23**] CT Abd/pelvis:
1. Extensive peripancreatic fluid collections extending from the
greater
curvature of the stomach into the deep pelvis in the presacral
area. Areas of hypoenhancement within the pancreas, particularly
within the body and neck are identified and concerning for
possible necrosis, although artifact from interdigitating fluid
cannot be excluded.
2. Small bilateral pleural effusions with associated
atelectasis.
3. Air within the bladder likely due to recent Foley
catheterization.
Clinical correlation is recommended.
4. Diffuse anasarca.
.
[**2114-8-28**] CT Abdomen/pelvis:
1. No CT evidence of pancreatic necrosis.
2. Grossly unchanged appearance of very large peripancreatic
fluid
collections, with largest collection adjacent to the greater
curvature of the stomach slightly more organized and increased
in size than seen previously.
3. Increased bilateral pleural effusions and bibasilar
atelectasis
.
[**8-30**] Lower extremity doppler ultrasound:
1. Deep venous thrombosis involving the calf veins, including
both peroneal veins and one of the paired right posterior tibial
veins.
.
[**8-30**] CTA Chest:
1)Left Lower lobe subsegmental pulmonary embolism.
2)Large left pleural effusion with near-complete collapse of the
left lower lobe and right lower lobe atelectasis and small
pleural effusion.
3)Large pseudocyst has slightly decreased in size since the
previous abdominal study and now measures 6.9 x 10 cm.
.
[**9-2**] CXR:
Compared to [**8-30**], the general haziness of the left hemithorax is
substantially less, suggesting improvement in the pleural
effusion. The right central catheter has been removed and the
nasogastric tube remains coiled in the upper stomach. No
evidence of acute pneumonia or vascular congestion.
.
[**2114-9-5**] Gallbladder U/S:
1. No gallstones identified within the gallbladder.
2. Mild right hydronephrosis possibly related to right ureter
passing through post-pancreatitis phlegmonous change from prior
recent CT scan.
3. Pseudocyst/inflammatory change incompletely evaluated in the
region of the distal pancreatic body and tail as noted on CT
scan from [**2114-8-11**].
.
Micro
[**8-23**], [**8-24**], [**8-25**], [**8-26**] BCx - no growth
[**8-30**], [**8-31**] Bx- pending
[**8-29**] BCx - STAPHYLOCOCCUS, COAGULASE NEGATIVE from central and
peripheral sites
[**8-25**], [**8-26**], [**8-29**], [**8-30**] UCx - negative
[**8-28**] Sputum Cx- sparse growth oropharyngeal flora
[**8-31**] IJ catheter tip cx- no significant growth
[**8-31**] Blood Cx - No Growth
[**8-31**] Stool C.diff - negative
Brief Hospital Course:
[**Hospital Unit Name 153**] Course [**2114-8-23**] - [**2114-9-2**]:
Mr. [**Known lastname 82971**] is a 39M with h/o DM and alcoholism and pancreatitis
who is transferred to [**Hospital1 18**] for a higher level of care.
.
* Pancreatitis - Based on admission labs, pt with pancreatitis
on presentation. No evidence of necrosis on OSH imaging and
[**Hospital1 18**] imaging. Most likely precipitated by drinking binge. HCTZ
can also be associated with pancreatitis though less likely.
Triglycerides 259 here but approx 3000 per report at OSH,
suggesting there may also be some component of hyperlipidemia as
cause. Surgery was consulted who recommended supportive care
with fluids and fever management. Pt's increased abdominal
pressure may have contributed to his respiratory failure by
increasing bibasilar atelectasis and pain leading to spliting.
Bladder pressure 11 at transfer and abdomen soft. Once stable,
pt was transferred to surgery for further management and
evaluation given possible need for resection of pseudocyst.
.
* Respiratory distress: Pt was intubated at OSH on [**8-14**] for
respiratory distress. He has no h/o lung disease. Respiratory
distress attributed to increased abdominal pressure exerting
pressure on lungs and increasing atelectasis with bilateral
pleural effusions as well as pulmonary edema. Also some
component of spliting due to pain/pancreatitis. Esophageal
balloon demonstrated pressure of 8, suggesting that large
plateau pressures were most likely due to non-compliant chest
wall rather than intrinsic lung disease. Pt was diuresed without
problems and was extubated [**2114-8-29**] without complications. Given
that small left PE was on same side as pleural effusion, there
was concern that thoracentesis may increase VQ mismatch vs
continued effusion leading to lung trapping. IP evaluated
pleural effusion and determined thoracentesis could be performed
after pt stable 1-2 weeks on anticoagulation regimen; however,
pleural effusion on CXR [**2114-9-2**] had significantly decreased. Pt
was saturating 96% RA at transfer.
.
* Pulmonary embolus: Bilateral deep vein thrombi were found on
doppler ultrasound on [**8-30**] and a small PE was found chest CTA.
A heparin drip was started without bolus for concern about
precipitating hemorrhagic transformation of his pancreatitis. No
transition to coumadin given need for possible procedures.
.
* Fever and leukocytosis - Pt spiked intermittent fevers up to
103-104 during acute phase of illness. Tm on transfer was 100.2.
This was attributed to pancreatitis. Due to concern for necrosis
as cause of fever, pt had repeat CT abdomen/pelvis [**8-28**] with
results above. Cultures remained negative and empiric
antibiotics were stopped. However, blood cultures from [**8-29**]
demonstrated coagulase negative Staph aureus, pan sensitive.
Vancomycin (started [**2114-8-30**]) was changed to nafcillin on
[**2114-9-1**]. WBC continues to be elevated (18.3 at transfer),
possibly due to pancreatitis vs PE vs bacteremia. C. diff
negative x2.
.
* Agitation - Patient 10+ days out from last drink, therefore
delirium tremens less likely. [**Month (only) 116**] be delirious from acute
illness, medications, prolongued ICU stay. Head CT here
negative. His neurontin (on med list from OSH transfer) was
held. Also concern for benzo withdrawal as he required heavy
sedation with midazolam during intubation. Agitation responded
well to ativan PRN and patient was calm and appropriate on
transfer.
.
* Anemia - Hct was very concentrated at initial presentation to
OSH (Hct 50) likely [**2-12**] third spacing. Hct on presentation here
was 24. Pt was transfused 1 unit cells for Hct 23 -> 28.
Haptoglobin 613 making hemolysis unlikely. B12 and folate were
normal. There was concern for hemorrhagic pancreatitis given Hct
has been slowly decreasing throughout hospital stay with Hct
25.2 at transfer.
.
* Alcohol and substance abuse - Patient received thiamine,
folate and multivitamin. Social work was consulted.
.
* DM - patient intially on insulin drip given pancreatitis,
which was transitioned to ISS.
.
* HTN - Patient remained hypertensive (SBP 130s-160s) even after
home meds of cozaar and HCTZ were restarted. Continued HTN
attributed to pain, agitation.
.
FEN - Patient restarted on tube feeds via NGT prior to transfer.
Following transfer to the Surgical floor, his nasogastric tube
was removed and he was started on a clear liquid diet, which was
gradually advanced to regular. Coumadin was started for his
DVT/PE to maintain an INR 2.5-3.0 with background heparin. His
foley was discontinued as well; he was able to void without
problem.
He was evaluated by Physical Therapy due to his prolonged
hospitalization and deconditioned state, but after working with
him for a few days he was steady on his feet and walking short
distances without difficulty.
Blood cultures were negative from [**2114-8-30**] and [**2114-8-31**], and
Nafcillin was discontinued on [**2114-9-7**]. He remained afebrile and
his WBC 10K.
On [**2114-9-7**], the Heparin infusion was discontinued. As the
patient's INR was 1.7 that morning and close to therapeutic goal
of [**2-13**], it was determined that a Lovenox-Coumadin bridge was not
indicated. INR goal is 2.5; therapeutic range 2-3.
At the time of discharge on [**2114-9-7**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. He was discharged home without services,
and will follow-up with his new PCP on [**Name9 (PRE) 766**], [**2114-9-10**] for
further management of Coumadin. Generally, it is recommended
that anticoagulation therapy with Coumadin be continued for
6months for an initial PE. Follow-up with a Pancreatologist was
also recommended. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Medications at home:
Cozaar 100mg PO daily
Lipitor 80mg PO daily
HCTZ 25mg Po QAM
Allopurinol 100mg PO Daily
.
Medications on transfer from outside hospital:
Versed @ 6/hr
Fentanyl @ 150/hr
Doripenem 500mg IV q8h
Clonidine patch 0.3mg q7d
Neurontin 400mg q8h
Zyprexa SL 10mg q8h
Afrin [**Hospital1 **]
Lovenox 40mg SQ daily
Protonix 40mg IV daily
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
5. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QAM.
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
11. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Warfarin 4 mg Tablet Sig: One (1) Tablet PO QDAY in the
evening: Please take this medication the same time each day.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pancreatitis
2. Alcohol Abuse
3. Lower lobe subsegmental pulmonary embolism
4. HTN
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-20**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
DO NOT DRINK ANY ALCOHOL WHATSOEVER
.
Coumadin (Warfarin):
What is this medicine used for?
This medicine is used to thin the blood so that clots will not
form.
How does it work?
Warfarin changes the body's clotting system. It thins the blood
to prevent clots from forming.
What you should contact your healthcare provider [**Name Initial (PRE) **]:
Signs of a life-threatening reaction. These include wheezing;
chest tightness; fever; itching; bad cough; blue skin color;
fits; or swelling of face, lips, tongue, or throat, severe
dizziness or passing out, falls or accidents, especially if you
hit your head. Talk with healthcare provider even if you feel
fine, significant change in thinking clearly and logically,
severe headache, severe back pain, severe belly pain, black,
tarry, or bloody stools, blood in the urine, nosebleeds,
coughing up blood, vomiting blood, unusual bruising or bleeding,
severe menstrual bleedin, or rash.
Call your doctor if you are unable to eat for several days, for
whatever reason. Also call if you have stomach problems,
vomiting, or diarrhea that lasts more than 1 day. These problems
could affect your Coumadin??????/warfarin dosage.
Coumadin (Warfarin) and diet:
Certain foods and beverages can impair the effect of warfarin.
For this reason, it's important to pay attention to what you eat
while taking this medication.
Until recently, doctors advised [**Name5 (PTitle) **] taking warfarin to avoid
foods high in vitamin K. This is because large amounts of
vitamin K can counteract the benefits of warfarin. However,
recent research shows that rather than eliminating vitamin K
from your diet, it is more important to be consistent in your
dietary vitamin K intake.
These foods contain vitamin K:
Fruits and vegetables, such as: Kiwi, Blueberries, Broccoli,
Cabbage, [**Location (un) 2831**] sprouts, Green onions, Asparagus, Cauliflower,
Peas, Lettuce, Spinach, Turnip, collard, and mustard greens,
Parsley, Kale, Endive. Meats, such as: Beef liver, Pork liver.
Other: Mayonnaise, Margarine, Canola oil, Soybean oil, Vitamins,
Soybeans and Cashews.
Limit alcohol. Alcohol can affect your Coumadin??????/warfarin dosage
but it does not mean you must avoid all alcohol. Serious
problems can occur with alcohol and Coumadin??????/warfarin when you
drink more than 2 drinks a day or when you change your usual
pattern. Binge drinking is not good for you. Be careful on
special occasions or holidays, and drink only what you usually
would on any regular day of the week.
Monitoring:
The doctor decides how much Coumadin??????/warfarin you need by
testing your blood. The test measures how fast your blood is
clotting and lets the doctor know if your dosage should change.
If your blood test is too high, you might be at risk for
bleeding problems. If it is too low, you might be at risk for
forming clots. Your doctor has decided on a range on the blood
test that is right for you. The blood test used for monitoring
is called an INR.
Use of Other medications:
When Coumadin??????/warfarin is taken with other medicines it can
change the way other medicines work. Other medicines can also
change the way Coumadin??????/warfarin works. It is very important to
talk with your doctor about all of the other medicines that you
are taking, including over-the-counter medicines, antibiotics,
vitamins, or herbal products.
Followup Instructions:
Your new PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 82972**] ([**Telephone/Fax (1) 82973**]). You have an
appointment with him on [**Last Name (LF) 766**], [**2114-9-10**] at 1PM. You will
need your PT/INR checked on that day, and Dr. [**Last Name (STitle) 82972**] will tell
you how much Coumadin to take.
It is recommended that you follow-up with a Gastroenterologist
specializing in Pancreatitis. Your new PCP can refer you to a
local Gastroenterologist. If you prefer to see a
Gastroenterologist at [**Hospital1 18**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] is recommended.
Phone: ([**Telephone/Fax (1) 82974**]. Location: [**Hospital Ward Name 452**] Rose 101, [**Hospital Ward Name 516**].
Completed by:[**2114-9-7**]
|
[
"285.9",
"518.0",
"789.59",
"999.31",
"276.4",
"995.94",
"272.1",
"577.2",
"349.82",
"415.19",
"303.91",
"300.00",
"518.81",
"305.20",
"518.89",
"577.0",
"453.42",
"305.60",
"293.0",
"274.9",
"401.9",
"511.9",
"790.7",
"250.00",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"44.93",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14827, 14833
|
7364, 13313
|
325, 514
|
14963, 14972
|
3596, 4741
|
19840, 20660
|
2378, 2414
|
13710, 14804
|
14854, 14942
|
13339, 13339
|
14996, 19817
|
13360, 13687
|
2429, 3328
|
3342, 3577
|
273, 287
|
542, 2152
|
4750, 7341
|
2174, 2269
|
2285, 2362
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,570
| 186,188
|
12925
|
Discharge summary
|
report
|
Admission Date: [**2179-11-2**] Discharge Date: [**2179-11-9**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Decreasing exercise tolerance
Major Surgical or Invasive Procedure:
[**2179-11-3**] Four Vessel Coronary artery bypass grafting utilizing
the left internal mammary to left anterior descending, vein
grafts to diagonal, obtuse marginal and posterior descending
artery.
[**2179-11-2**] Cardiac catheterization
History of Present Illness:
This is an 83 year old male with history of aortic stenosis. He
is normally quite active, walking between three and five miles
every day. He has recently been complaining of fatigue and a
decrease in exercise tolerance. He also notes occasional
shortness of breath when he is walking, occurring with various
amounts of activity. He denies chest discomfort, palpitations or
any prior syncopal episodes. A recent stress ECHO in [**Month (only) 359**]
[**2178**] was stopped due to complaints of dyspnea. EKG was notable
for ST-T wave depressions. ECHO post exercise revealed a new
lateral wall abnormality. The peak aortic gradient was 27 mmHg
with a mean of 13 mmhg. Based on the above results, he was
referred for cardiac catheterization.
Past Medical History:
Aortic Stenosis; Chronic thrombocytopenia; Anemia; Chronic Renal
Insufficiency; GERD; Gout; Arthritis; s/p Hernia repair; s/p
Cataract Surgery
Social History:
Prior heavy ETOH abuse - quit [**2156**]. Admits to about 25 pack year
history of tobacco but quit over 20 years ago. Patient is
married with five children. he previously worked as a police
officer in [**Location (un) 86**].
Family History:
Denies premature coronary artery disease
Physical Exam:
Vitals: BP 140-150/60-70, HR 60, RR 14, SAT 96% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign, poor dental health
Neck: supple, no JVD, transmitted murmur to carotid noted
Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2179-11-8**] 06:30AM BLOOD WBC-7.1 RBC-3.27* Hgb-10.3* Hct-29.5*
MCV-90 MCH-31.5 MCHC-34.8 RDW-15.6* Plt Ct-120*
[**2179-11-2**] 01:20PM BLOOD WBC-3.9* RBC-3.28* Hgb-10.9* Hct-31.6*
MCV-96 MCH-33.3* MCHC-34.5 RDW-13.7 Plt Ct-96*
[**2179-11-8**] 06:30AM BLOOD Glucose-182* UreaN-70* Creat-2.4* Na-134
K-3.9 Cl-100 HCO3-21* AnGap-17
[**2179-11-2**] 01:20PM BLOOD Glucose-147* UreaN-23* Creat-1.2 Na-141
K-3.5 Cl-107 HCO3-28 AnGap-10
[**2179-11-8**] 06:30AM BLOOD Calcium-8.1* Phos-4.5 Mg-2.2
[**2179-11-2**] 01:20PM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE
Brief Hospital Course:
Mr. [**Known lastname 46**] was admitted and underwent cardiac catheterization on
[**11-2**]. Selective coronary angiography revealed a right
dominant system with severe three vessel coronary artery
disease. The LMCA had a severe 90% left main stenosis. The LAD
had moderate diffuse disease. It gave off a large diagonal
branch with
an 80% proximal stenosis. The LCx had mild diffuse disease while
the RCA had a tubular 80% mid vessel stenosis. Assessment of the
aortic valve revealed a peak to peak gradient of only 9 mmHg.
The calculated valve area was 1.7cm2. Left ventriculography was
not performed. Based on the above results, cardiac surgery was
consulted for surgical revascularization and further evaluation
was performed. A carotid ultrasound showed a moderate
plaque(40-59% stenosis) in the right internal carotid artery
while the left internal carotid artery had less than 40% lesion.
Workup was otherwise unremarkable and he was cleared for
surgery.
On [**11-3**], Dr. [**Last Name (STitle) **] performed four vessel coronary
artery bypass grafting. For operative details - see op note.
Following the procedure, he was brought to the CSRU in stable
condition. Within 24 hours, he awoke neurologically intact and
was extubated. He weaned from inotropic support without
difficulty. He initially experienced some confusion,
disorientation and agitation which intermittently required
Haldol. Over several days, his mental status improved. He
otherwise maintained stable hemodynamics as beta blockade was
resumed. Amiodarone was started for brief episodes of paroxsymal
atrial fibrillation. On postoperative day three, he transferred
to the floor. He remained in a normal sinus rhythm without
further episodes of atrial fibrillation. His platelet count
dropped as low as 81K but remained relatively stable throughout
his hospital stay. Over his remaining days, he continued to make
clinical improvements with diuresis and medical therapy.
Amiodarone and beta blockade were titrated accordingly. By
discharge, he was near his preoperative weight with oxygen
saturations of 95% on room air. He was ambulating without
difficulty. His discharge chest x-ray was notable for only small
bilateral pleural effusions. All wounds were clean and his
mental status returned to baseline. He was eventually cleared
for discharge to home on postoperative day six. Appropriate
follow up appointments have been made.
Medications on Admission:
Metoprolol 25 mg qd, Allopurinol 100 mg qd, Aspirin 500 mg qd,
Cod Liver Oil, Prevacid and Pepcid prn
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. 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*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
8. Sucralfate 1 g Tablet Sig: One (1) Tablet PO twice a day.
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease - s/p coronary artery bypass grafting;
Hypertension; Aortic Stenosis; Chronic thrombocytopenia; Anemia;
Chronic Renal Insufficiency; GERD; Gout; Arthritis; s/p Hernia
repair; s/p Cataract Surgery; Brief Postoperative Atrial
Fibrillation
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for one month. Monitor wounds for signs of
infections. Call with any questions.
Followup Instructions:
Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**3-23**] weeks
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-21**] weeks
Dr. [**First Name8 (NamePattern2) 4768**] [**Last Name (NamePattern1) 5456**] in [**1-21**] weeks
Completed by:[**2180-1-19**]
|
[
"585.9",
"401.9",
"274.9",
"285.9",
"530.81",
"413.9",
"414.01",
"424.1",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"37.23",
"88.56",
"39.61",
"36.15",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
6613, 6671
|
2814, 5226
|
298, 539
|
6976, 6983
|
2234, 2791
|
7198, 7489
|
1732, 1774
|
5378, 6590
|
6692, 6955
|
5252, 5355
|
7007, 7175
|
1789, 2215
|
229, 260
|
567, 1308
|
1330, 1474
|
1490, 1716
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,035
| 101,276
|
23895
|
Discharge summary
|
report
|
Admission Date: [**2120-10-4**] Discharge Date: [**2120-10-23**]
Date of Birth: [**2059-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 yo man w/ h/o rectal CA and HTN who presents c/o diarrhea x 5
days (started on [**9-30**]). Patient reports persistent, non-bloody,
watery diarrhea every 10-30 minutes. Denies abdominal pain,
fever, chills, N/V, cough, rash, dysuria, sick contacts, or
recent travel. No recent medication changes, no antibiotics
recently. Has not eaten in restaraunts recently. H/o similar
diarrhea in the past which he says was due to chemo.
.
In the ED, patient's lactate was initially 4.0 and he was
tachycardic at 110. Normotensive at 124/80. Apparently, he
refused central line (sepsis protocol). Received IVF through
peripheral IV, and repeat lactate was 2.4. His HR also
stabilized in the 80's. BP remained normal. While in the ED,
he spiked to 101.3 so he was given Cefepime, vanco, and flagyl.
CT of the abdomen and he was admitted to OMED for further
observation.
.
Past Medical History:
1. Rectal metastatic adenocarcinoma with A lytic lesion in T11
dx in [**2120-3-22**], CEA was elevated at 329--->1207 ([**2120-8-20**]).
s/p 13 XRT therapies. Treated with Avastin (bevacizumab), 5FU,
and Leucovorin. Last treatment [**2120-9-25**]. Oncologist: Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]
2. Hypertension
Social History:
Originally from [**Location (un) 6847**], moved to USA about 30 years ago.
Married. Former restaurant worker, not working presently. Has
a 35 pack year smoking history, quit ~[**2118**]. Rarely drinks
alcohol.
Family History:
Non-contributory
Physical Exam:
VS: T=98.6 (Tm=101.3); BP=155/82; HR=88; RR=11; O2=98% (RA)
GEN: elderly asian man, NAD
HEENT: PERRL OU, MMM, OP clear, no icterus
NECK: no JVD
CV: RRR, NL S1/S2, no murmurs appreciated on exam, no S3/S4
heard
RESP: CTA, no W/R/R
ABD: NABS, soft, NT, ND, no masses
EXT: no edema
RECTAL: guaiac negative per ED
NEURO: A&Ox3, CN II-XII intact bilat, motor/sensory exam intact
bilat
Pertinent Results:
GLUCOSE-153 UREA N-16 CREAT-0.7 SODIUM-135 POTASSIUM-3.0
CHLORIDE-107 TOTAL CO2-20 ANION GAP-11
CALCIUM-6.9 PHOSPHATE-1.4 MAGNESIUM-2.3
.
WBC-1.2 RBC-4.07 HGB-11.8 HCT-33.0 MCV-81 MCH-29.0 MCHC-35.7
RDW-18.3 PLT COUNT-153
.
PT-15.6 PTT-27.9 INR(PT)-1.7
.
GRAN CT-780
.
LACTATE-1.7
.
URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG RBC-0 WBC-0-2
BACTERIA-RARE YEAST-NONE EPI-0-2
Brief Hospital Course:
61 y/o male with metastatic rectal ca diagnosed [**3-26**] s/p xrt
(last [**6-25**]) and chemo (last [**2120-9-25**]) who was admitted with
diarrhea, fever, and neutropenia who developed hypoxemia, lactic
acidosis, and confusion. Since his admission, the patient's
diarrhea and fevers had progressively improved on cefepime,
vancomycin, and metronidazole as well as Lomotil. Since then
his course has been complicated by a steadily declining
hematocrit (33 to 25 over the admission), worsening
thrombocytopenia, and a new coagulopathy (INR up to 5.4). On
[**10-12**], he was noted to be hypoxemic and had chest x-ray showing
only a distended stomach and a CTA with no PE (but also a
distended stomach and known liver mets). ABG was 7.44/25/63
then 7.32/21/84 that afternoon. His oxygen requirement waxed
and waned, from mid 80's on room air to mid 90's on room air.
His hypoxemia persisted and the patient became increasingly
tired, confused, and tachypneic. A repeat ABG was 7.3/19/75 but
his lactate had climbed from 3.5 to 8.0. He was transferred to
the ICU at which time he was fatigued and appeared disoriented.
In this setting, he denied pain (including abdominal) as well as
dyspnea despite obvious tachypnea and mild accessory muscle use.
He was started on IVF with 3 amps bicarb, lactate trended down,
acidosis resolving. CT abdomen showed SBO with no obvious cut
off for obstruction a NGT placed and medical management
recommeneded by surgery. Primary oncologist Dr. [**Last Name (STitle) **]
continued to follow.
In the ICU he was found to have guiaic positive NGT
secretions. He was transfused PRBCs for a dropping HCT. In
addition he was noted to have an elevated INR for which he was
treated with FFP. He was evaluated by surgery who felt him to
be a poor surgical candidate. For his confusion a CT of his
head was performed which was negative for bleed or other change.
His hypoxia resolved and was felt to be due to aspiration
initially. He was treated with TPN given his poor nutritional
status. He was treated with octroetide per surgery recs with no
improvement. On [**2120-10-18**] a family meeting was held at which
time it was decided that the goal of care was maximal comfort.
At that meeting it was decided to continue with fluids and
analgesia but to limit other medications and TPN. The family
will provide Chinese herbs and prayer.
.
# GI: Diarrhea was believed to be chemo-induced diarrhea. The
patient was covered with cefepime, vancomycin, and flagyl given
neutropenic fever. The CT of abdomen on admission did not show
any inflammatory processes in the abdomen. The patient was given
supportive care with IVF and Lomotil once obtained stool samples
for cultures which were negative and his diarrhea improved with
lomotil. However, patient became acidotic and CT abdomen was
repeated and revealed SBO. NGT was placed and surgey was
consulted but did not feel that the patient was a good surgical
candidate. Patient was continued on medical management.
Octreotide was added to his regimen to help to relieve
obstruction. His lactate continued to trend down and NGT outout
began to slow. Patient denied any abdominal pain.
However, while in the ICU he developed bloody stools in the
setting of coagulopathy. This was felt to be likely secondary to
his rectal cancer. He was tranfused pRBCs and FFP. After several
bloody stools and rectal tube placement his bloody bowel
movements slowed, his coags improved and his hematocrit was
stable.
.
Coagulopathy: Likely DIC secondary to cancer. He devloped GI
bleed as mentioned above and was transfused several units of FFP
and pRBCs and 1 unit of platelets. By tranfer from the ICU his
HCT and INR was stable but platelets were 34. The patient and
family did not want any further transfusions as their goal was
comfort and this would require daily monitoring of his CBC and
coags.
.
# NEUTROPENIC FEVER: The patient was started on cefepime, vanco,
and flagyl on admission. He had some fevers early in his
hospitalization but remained afebrile for the rest of his
admission. He because hypoxic and acidotic and a CT chest was
otained which revealed likely aspiration/pneumonia. He was
continue on his antibiotics to complete a 14 day course and
received daily neupogen injections. By the 11th day of his
antibiotic course he was no longer neutropenic. His neupogen was
discontinued and he remained afebrile.
# AG METABOLIC ACIDOSIS: concerning for lactic acidosis [**1-24**] to
hypovolemia. Patient refused central line/sepsis protocol in
ED. He was hemodynamically stable on transfer to the floor.
Lactate normalized after IVF. Then the patient continued to have
non-anion gap acidosis [**1-24**] to diarrhea. ABG was obtained and
the patient appropriately compensated with decreased CO2 (25)
with normal pH 7.4-7.44. He then became more hypoxic and acidotc
and was tranferred to the ICU. In the ICU it was discoved that
he had an extremely dilated stomach and SBO. It was felt that
the lactic acidosis ,may have been secondary to the extreme
distension of his stomach given the rapid decline in his lactate
on decompression with NGT. His gap closed and his lactate
conitnued to tened down.
.
# RECTAL CANCER: Last chemotherapy was last avastin/5FU on [**9-25**].
Given that he did not tolerate this well, no further
chemotherapy was planned. He also developed what is believed to
be lower GI bleed, SBO and DIC during admission all which were
thaough to be related to his metastatic disease. Due to his poor
prognosis and worsening medical condition a family meeting was
held and the family and patient agreed that comfort was the most
important goal at this point. He was continued on IVF and the
NGGT was kept in place to prevent worsening pain from his SBO.
It was decided that no further blood products would be given.
.
FEN: Patient was actively hydrated in the setting of diarrhea
and acidosis. He was continued on IVF given his SBO. Given his
poor prognosis and that comfort was the goal, he was not started
on TPN, but rather hydrated with IVF in the setting of SBO.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Atenolol 50 mg PO once a day.
3. Buspirone
4. Compazine prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
7. Morphine 2 mg/mL Syringe Sig: [**12-24**] Injection Q4H (every 4
hours) as needed.
8. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Metastatic rectal cancer.
Small bowel obstruction.
Hypertension.
Discharge Condition:
Stable. He is appropriate and interactive. The goal of care is
comfort.
Discharge Instructions:
Please take all medications as prescribed. The goal of care is
comfort.
Followup Instructions:
You have the following follow-up appointments
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2120-10-30**] 10:00
Provider: [**Name Initial (NameIs) 4426**] 22 Date/Time:[**2120-10-30**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2120-10-30**] 10:30
Completed by:[**2120-10-23**]
|
[
"507.0",
"276.51",
"560.89",
"198.89",
"284.8",
"112.0",
"276.2",
"578.9",
"154.8",
"707.03",
"518.82",
"V15.3",
"197.7",
"787.91",
"286.6",
"288.0",
"276.8",
"E933.1",
"401.9",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"96.09",
"96.07",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9774, 9844
|
2808, 8884
|
324, 330
|
9953, 10029
|
2281, 2785
|
10150, 10610
|
1848, 1866
|
9025, 9751
|
9865, 9932
|
8910, 9002
|
10053, 10127
|
1881, 2262
|
276, 286
|
358, 1232
|
1254, 1603
|
1619, 1832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,460
| 119,351
|
8768
|
Discharge summary
|
report
|
Admission Date: [**2147-5-26**] Discharge Date: [**2147-6-15**]
Date of Birth: [**2079-1-26**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
Admitted for liver transplant on [**2147-5-27**]
Major Surgical or Invasive Procedure:
OLT [**2147-5-27**]
Portal [**Month/Day/Year **] Thrombolysis with TPA [**2147-6-6**]
History of Present Illness:
Patient is a 68-year-old gentleman with end-stage liver disease
and HCC in the setting of primary sclerosing cholangitis. He had
a prior liver resection or
bile duct excision and has also had a prior splenorenal shunt.
He has also undergone RF ablation of his HCC. Recently patient
has been in his usual state of health and has undergone liver
transplant workup/evaluation. No recent flares of ulcerative
colitis.
Past Medical History:
Ulcerative colitis
PCS
HCC
Social History:
Lives in [**Location **] NY with wife
Denies use of ETOH, tobacco or IVD
Family History:
Non-contrib
Physical Exam:
On Admission:
VSS
In NAD, A+O x3
Anicteric
Lungs: CTA bilaterally
Card: RRR, no murmur noted
Abd: Soft, NT,ND, BS+. Normal tone, no guarding. Several scars
on abdomen
Extr: No edema
Pertinent Results:
Labs on Admission [**2147-5-26**] 09:39PM:
GLUCOSE-75 UREA N-11 CREAT-0.7
SODIUM-142 POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-24 ANION GAP-13
ALT(SGPT)-38 AST(SGOT)-56* ALK PHOS-103 TOT BILI-0.9
AMYLASE-46 LIPASE-26
CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-1.9
CHOLEST-162 TRIGLYCER-51
WBC-6.5 RBC-3.78* HGB-13.8* HCT-40.0 MCV-106* MCH-36.6*
MCHC-34.6 RDW-13.5
PLT COUNT-242
PT-14.9* PTT-27.8 INR(PT)-1.3* FIBRINOGEN-219
Labs on [**2147-6-14**]
FK506: 5.8 on [**1-5**]
Na: 135 K: 4.4 Cl: 103 CO2 23
BUN: 9 Creat: 0.7 Gluc: 94
ALT: AST: 23 79 AP: 247 Tbili: 2.4 Alb: 3.0
PT: 21.7 PTT: 32.1 INR: 2.1 On Coumadin 2.5 mg
Brief Hospital Course:
Pt admitted for OLT [**5-27**] Post transplant: liver tx U/S showed
low RI's
Extubated on POD 1. [**5-28**] a-fib, rate controlled, coverted back
into sinus [**5-30**] Transferred to [**Hospital Ward Name 121**] 10 and continued to improve
until [**6-5**] when he developed elevated WBC, fevers. CT abd showed
a thrombosed portal [**Last Name (LF) 5703**], [**First Name3 (LF) **] patient taken back to SICU for
portal [**First Name3 (LF) 5703**] thrombolysis and infusion catheter left in place for
TPA infusion overnight. FIB=318, INR= 1.4 PTT 34.
On [**6-7**] there was improvement in thrombus, IMV remains occluded.
s/p repositioning portal [**Month/Day (1) 5703**] infusion catheter, now extending
into IMV. Portal pressure gradient 10 mmHg. hematuria,
hemodynamic stable. TPA infusion stopped.
On [**6-8**] the catheters were removed, venogram looks better with
residual clot in SMV/IMV. Patient started on heparin drip, and
by [**6-10**] a Duplex US shows patent HA, small improved thrombus in
PV. Started on coumadin on [**6-10**] and by [**6-14**] patient therapeutic
on coumadin and heparin has been stopped.
Other items are tremors possibly attributable to the Prograf
which was held from [**6-6**] -[**6-8**] and then slowly restarted. PT
evaluation states need for rehab for strengthening, transfers,
gait and balance., also unable to attempt stairs. Appetite has
been fair, using supplements. To be discharged to [**Hospital1 **] for
short term rehab.
Medications on Admission:
azulfidine 1'', actigall 300'', aldactone 25', prednisone 4',
MVI, mycelex troches 10'''''
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
s/p Orthotopic Liver Transplant
thrombus (improving) in PV: On coumadin
Discharge Condition:
Stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] If you experience nausea, vomiting, diarrhea,
increased abdominal tenderness,fever, chills or any other
symptomes concerning to you.
Transplant labs to be drawn and results faxed every Monday and
Thursday to the Transplant office at [**Telephone/Fax (1) 697**]. Please draw
CBC, Chem 10, AST, ALT, ALk phos, albumin, T Bili and Trough
Prograf level. Also PT/INR
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2147-6-15**] 2:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2147-6-19**] 4:00
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2147-6-22**] 2:00
Completed by:[**2147-6-15**]
|
[
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"557.0",
"570",
"571.5",
"452",
"599.7",
"155.2",
"V58.61",
"427.31",
"E933.1",
"333.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.05",
"99.29",
"00.93",
"88.64",
"50.59",
"54.59",
"00.40",
"86.05",
"39.50",
"38.86",
"99.04",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
3532, 3611
|
1921, 3390
|
363, 451
|
3727, 3736
|
1282, 1898
|
4179, 4597
|
1052, 1065
|
3632, 3706
|
3416, 3509
|
3760, 4156
|
1080, 1080
|
275, 325
|
479, 895
|
1094, 1263
|
917, 946
|
962, 1036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,212
| 190,127
|
34222
|
Discharge summary
|
report
|
Admission Date: [**2108-6-8**] Discharge Date: [**2108-6-28**]
Date of Birth: [**2026-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Right subclavian artery pseudo aa, CHF exacerbation.
Major Surgical or Invasive Procedure:
repair of right subclavian artery aa and hematoma evacuation
with right clavicular wedge resection [**2108-6-9**]
History of Present Illness:
81M LVEF 25%, mult CABG, MVR, DM, AF on coumadin, [**Hospital 78816**]
transferred from [**Hospital **] [**Hospital6 5016**] with R.SC artery
pseudoaneurysm after attempted R.SC CVL. Pt was initially
admitted to OSH with abdominal and chest discomfort. Found to
have temperature 101.7F BP 86/40. At [**Name (NI) **] [**Name (NI) **], pt was given
inhalers and one dose Rocephin, IV fluids. An attempt to enter R
subclavian vein for central line placement resulted in R
subclavian artery puncture. He was transferred here for
evacuation of pseudoaneurysm. He is s/p R sublclav exploration,
arteriotomy closure, clavicle rsxn, & hematoma evac on [**6-9**]. He
has been continued on vancomycin, flagyl and cipro from [**6-9**] to
[**6-12**] for sepsis of unclear source of infection. Urinalysis and
blood cxs are negative to date here. No leukocytosis and
afebrile here. He is being transferred to the medicine service
due to persistent O2 requirement, thought to be secondary to
congestive heart failure. His baseline weight is 170 lbs; he
currently weighs 190 lbs. He had been on 20 Lasix PO bid at
home. Received here 20 IV daily, yesterday 40 IV x2 and this AM
80 IV x1. Currently denies SOB, CP, palpitations, n/v/d,
abdominal pain, fevers, and chills.
Past Medical History:
PMH:
- CAD s/p CABG [**2088**], re-do CABG [**2101**] with MV bioprosthetic
replacement [**2-25**] bacterial endocarditis
- Dilated cardiomyopathy with EF 30%
- Chronic AFib with permenent pacemaker (VVI type).
- HTN
- DMII (insulin dependent, uncontrolled)
- CKD Stage 3-4 (no L kidney)
- Anemia
- Arthritis
.
PSx:
- CABG [**2088**], [**2101**]
- s/p laparotomy for bowel perforation
- s/p herniorrhaphy
Social History:
married, lives with spouse
retired
habits: former smoker
Family History:
unknown
Physical Exam:
Vital signs: 97.7-63-18 O2 94% room air b/p 138/62
GEN: lying in bed on side c/o severe rt. shoulder and arm pain
[**11-2**]
Skin: ecchmosis of rt. neck anterior chest, back rt side and arm
and hand with 3-4 + swelling
HEENT: pin point pupuls, sluggish but reactive, no JVD, no
carotid bruits
Lungs: crackles @ left base
Heart: RRR, no mumur, gallop ,rub
ABD; protuberant, nontender, nodistended BS active
EXT: RUE larger than left.rt. supraclavicular area full but
soft. large area of ecchmosis of rt. neck/chest and extending to
all of rt. arm. right hand swollen, warm with good capillary
refill. sensory intact rt. hand grasp diminished but able to
wiggle fingers. ( later on rexamination unable to move arm or
feel his hand)
Neuro: orient to time,place ,person, mild disoriention secondary
to narcotic effect and pain, not able to participate in full
neuro exam.
pulse exam: intact pulses upper and lower extremities
Pertinent Results:
[**2108-6-8**] 06:37PM URINE MUCOUS-RARE
[**2108-6-8**] 06:37PM URINE RBC-14* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2108-6-8**] 06:37PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2108-6-8**] 06:37PM URINE GR HOLD-HOLD
[**2108-6-8**] 06:37PM URINE HOURS-RANDOM
[**2108-6-8**] 08:45PM WBC-5.2 RBC-3.72* HGB-9.3* HCT-31.1* MCV-84
MCH-25.0* MCHC-29.9* RDW-16.4*
[**2108-6-8**] 08:45PM CALCIUM-8.6 PHOSPHATE-4.0 MAGNESIUM-2.5
[**2108-6-8**] 08:45PM CK-MB-NotDone cTropnT-0.03*
[**2108-6-8**] 10:40PM TYPE-ART PO2-104 PCO2-79* PH-7.31* TOTAL
CO2-42* BASE XS-9
.
R.UE U/S: [**6-8**] IMPRESSION:
2 cm pseudoaneurysm off of the right subclavian artery, within
the large hematoma in this region.
.
[**2108-6-8**]: EKG Regular ventricular pacing with ventricular ectopy.
No previous tracing available for comparison.
.
CXR [**2108-6-12**]:
IMPRESSION: Unchanged moderate bilateral pleural effusions with
stable severe cardiomegaly. No pneumonia or pulmonary edema.
Unchanged bibasilar atelectasis.
.
RUE U/S [**2108-6-13**]: IMPRESSION: Thrombus surrounding the PICC line
involving the proximal basilic and extending into the axillary
vein.
.
[**2108-6-14**]:FINDINGS: In comparison with the study of [**6-12**], there is
little overall change. Again there is enlargement of the cardiac
silhouette with bilateral pleural effusions. Some indistinctness
of pulmonary vessels suggests increased pulmonary venous
pressure. Pacemaker leads persist in this patient with midline
sternal sutures and CABG.
.
ECHO [**2108-6-14**]:The left atrium is markedly dilated. The right
atrium is markedly dilated. The estimated right atrial pressure
is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is moderate global left ventricular hypokinesis (LVEF =
30-40 %). There is no ventricular septal defect. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with depressed free wall contractility. There
is abnormal systolic septal motion/position consistent with
right ventricular pressure overload. The aortic root is
moderately dilated at the sinus level. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The prosthetic mitral valve leaflets are thickened.
The transmitral gradient is normal for this prosthesis. Trivial
(intravalvar) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
[**2108-6-15**]: U/S RUQ-IMPRESSION:
1. The common bile duct has normal diameter for the patient age
.
2. Cholelithiasis with no evidence of cholecystitis.
3. Small amount of ascites and right-sided pleural effusion.
4. Moderate splenomegaly.
5. Simple cyst of the left lobe of the liver.
.
EKG [**6-17**]:Regular ventricular pacing with underlying atrial
fibrillation. Frequent ventricular ectopy. Compared to the
previous tracing ventricular ectopy is new.
.
[**2108-6-18**] Renal U/S: IMPRESSION:
1. Single right kidney, with renal cortical thinning but normal
echogenicity.
2. Multiple simple renal cysts.
.
CXR [**2108-6-24**]:FINDINGS:
Cardiomegaly and bilateral effusions are again noted. Accounting
for some positioning differences, I see no significant interval
change. Upper lungs remain clear, and the pulmonary vasculature
is unchanged.
.
all BCX: no growth.
Brief Hospital Course:
A/P:Mr. [**Known lastname **] is a 81yo male with LVEF 25%, mult CABG, MVR, DM,
AF on coumadin, s/p PPM, s/p evacuation of iatrogenic
pseudoaneurysm, RUE DVT-on coumadin, called out of MICU. Pt
initially transferred to [**Hospital1 18**] for R subclavian pseudoaneurysm
repair, transferred to the MICU for hypotension, somnolence, and
increasing oxygen requirement. Diuresed and transferred out to
the floor.
.
1)Hypoxia: likely secondary to CHF exacerbation in the setting
of chronic co2 retention. S/p significant diuresis with lasix
gtt, stopped on [**6-22**]. Now continues to diurese on his own.
Torsemide was restarted at low doses, but became dehydrated so
was held as of [**6-25**]. Diamox was added along with torsemide for
high bicarb, but studies have shown that this does not add any
benefit in heart failure patients so it was stopped. He was
found to be [**Last Name (un) **]-[**Doctor Last Name 6056**] breathing at night, so we have
maintained him on BiPAP 12/8 with moderate benefit. He can
continue to be maintained on CPAP 8 on the floor. He does
continue to have continued O2 requirement however, possibly due
to atelectasis vs continued volume overload and hypercapnea. He
was ruled out for aspiration by speech and swallow on [**6-25**], and
although he has improved from initial MICU transfer, respiratory
status will still need to be addressed. On the floor, pt's 02
requirement became much less, sating anywhere from 92-98% on
2L-RA.
.
2)Hypotension secondary to hypovolemia: brief and now resolved.
No evidence of sepsis, thought to be secondary to diuresis.
Because of pt's acute systolic CHF, he required diuresis.
However, he had been difficult to diurese as boluses of
diuretics transiently had caused hypotension. Pt's BP has been
stable since transfer out of the MICU on the new regimen.
.
3)Acute on chronic renal failure: Patient has stage 3 CKD at
baseline. s/p diuresis and now auto-diuresis, patient's
creatinine continues to improve and is now below his baseline.
Holding acei. Restarted torsemide and added diamox briefly but
holding in the setting of dehdyration by labs.
.
4)Acute on chronic systolic heart failure: Likely exacerbated by
significant amount of fluids he received during peri-operative
period. Repeat ECHO with global systolic hypokinesis with LVEF
30-40%. ACE held due to renal failure, then restarted. S/P
lasix gtt for diuresis which was stopped on [**6-23**] and torsemide
readded. Low dose beta blocker added on AM of [**6-25**].
.
5)Right upper extremity weakness: Likely brachial plexus injury
in the setting of recent R subclavian pseudoaneurysm repair. MRI
not possible at this time due to pacemaker. Pt has been seen by
physical and occupational therapy who should continue to work
with him in the rehab setting. In addition, pt has a volar
split that should remain in place during the night and for 2
hours/off/on during the daytime hours. If weakness persists, pt
should have further evaluation by neurology with perhaps and
EMG.
.
6)Right upper extremity DVT: In setting of PICC line. Patient is
already on Coumadin for atrial fibrillation. INR is 2.3 today.
PICC line replaced on [**6-14**] (now in LUE).
.
# Pseudoaneurysm: Iatrogenic R axillary artery PSA and hematoma
from OSH in setting of central line placement. Transferred on
[**6-8**], s/p R sublclav exploration, arteriotomy closure, clavicle
rsxn, & hematoma evac [**6-9**]. Vascular surgery following and
arrangement is made for pt to f/u in 2 weeks with Dr. [**Last Name (STitle) 1391**].
Staples and sutures were removed on [**2108-6-28**], day of discharge.
Wound evaluated by vascular surgery.
.
7)Hyperbilirubinemia: With mixed hyperbilirubinemia (both direct
and indirect). With e/o cholelithiasis, no abdominal pain. Pt
underwent RUQ u/s for further evaluation which found no cause.
Bilirubin trended down.
.
8)Diabetes type 2 uncontrolled: Pt was continued glargine 20 qhs
and a regular insulin SS was added.
.
9)CAD: PT was continued on ASA. His ACEI and BB were restarted
upon discharge from the MICU>
.
# Delirium: Per pt's wife this is not new and often occurs at
home and in the hospital setting. Pt was given frequent
reorientation and lines and tubes were minimized. In addition,
wife states pt tends to be sleepy during the day and this is not
new. Pt on occasion has become confused in the evenings.
Seroquel may be given prn.
.
9)FEN: dysphagia diet, speech and swallow cleared.
.
Medications on Admission:
Medications at Home:
lasix 20 daily
aspirin 81 mg daily
Flomax 0.4 mg daily
Lescol 80 mg daily
lantus 20 units bedtime, novolog 40 units with meals.
Coumadin
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours).
2. Ipratropium Bromide 0.02 % Solution Sig: [**1-25**] Inhalation Q6H
(every 6 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Torsemide 20 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day): Hold for SBP <95.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID PRN as needed
for agitation/delerium.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO daily PRN: PRN for
weight gain or leg swelling. Hold for SBP <95.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
14. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: see
sliding scale Subcutaneous QIDACHS: SEE SLIDING SCALE.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Major:
right subclavian artery pseudoaneurysm - iatrogenic
right axillary hematoma - iatrogenic
right axillary-brachial plexus injury - iatrogenic
history of ischemic heart disease
acute on chronic systolic heart failure
upper extremity, catheter-related deep vein thrombosis
delirium
.
Minor:
bioprothetic mitral valve replacement [**2-25**] bacterial endocarditis
history of chronic AF s/p VVI pacer, anticoagulated
history of hypertension
histroy of DM2, insulin dependant uncontrolled
history of systolic CHF, ? type, chronic with acute CHF postop
history of chronic kidney disease stage 3, absent left kidney
history of anemia of chronic disease
history of arthritis
history of bowel perforation s/p lap
s/p herniorraphy
postop blood loss anemia, transfused
Discharge Condition:
stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] for repair of an aneurysm that was
found in your R.arm. You were followed by vascular surgery for
this. You also had an exacerbation of your heart failure while
you were here. For this, you were given medications to remove
fluid.
.
If you develop fevers/chills, pain/bleeding/drainage at your
R.shoulder wound, chest pain/shortness of breath please contact
your doctor or go to the emergency room.
.
Please take your medications as prescribed and follow up with
the appointments below.
Followup Instructions:
Dr. [**Last Name (STitle) 1391**] vascular surgery. Wed [**7-11**]. 9:45am.
[**Telephone/Fax (1) 1393**]
-followup with neurolgist if rt. arm motor/sensory does not
return to normal for further evaluation. You may call ([**Telephone/Fax (1) 78817**] for this appointment.
.
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 70836**] to be seen
within 2 weeks of discharge.
|
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"V45.81",
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icd9cm
|
[
[
[]
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] |
[
"77.81",
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"38.02",
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icd9pcs
|
[
[
[]
]
] |
12911, 12958
|
7026, 11463
|
368, 484
|
13766, 13775
|
3254, 7003
|
14350, 14818
|
2287, 2296
|
11672, 12888
|
12979, 13745
|
11489, 11489
|
13799, 14327
|
11510, 11649
|
2311, 3235
|
276, 330
|
512, 1768
|
1790, 2197
|
2213, 2271
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,387
| 168,262
|
9808
|
Discharge summary
|
report
|
Admission Date: [**2131-6-23**] Discharge Date: [**2131-7-5**]
Date of Birth: [**2081-7-23**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Ankle Pain
Major Surgical or Invasive Procedure:
[**2131-6-25**] Intubation by MICU team
[**2131-6-26**] Self-extubation
History of Present Illness:
Mr. [**Known lastname **] is a 49 year old man with past medical history of Type 2
diabetes (complicated by nephropathy and neuropathy) and
peripheral vascular disease status post right superficial
femoral artery stent with dry gangrene of the right 5th
metatarsal and subsequent amputation 2 months ago, who presented
on [**2131-6-23**] with nontraumatic acute pain of the right ankle and
fevers.
When he was in the ED he had fevers to 103, and was admitted
given concern for septic arthritis. At the metatarsal site, he
had noticed intermittent increased drainage of the wound with
mild odor. An ankle arthrocentesis was attempted; however an
appreciable amount of fluid could not be obtained. Lower
extremity ultrasound was negative for deep venous thrombosis.
Orthopedics was consulted who recommended IV
vancomycin/ceftazadime for empiric coverage of probable
cellulitis given hyperpigmentation of right lower extremity.
On [**2131-6-24**], the patient awoke from a nap with chest discomfort,
acute tachycardia, and new onset acute hypoxia. Saturations
were reported to be as low as 70% on room air, with increase to
low 90's on 100% nonrebreather mask. Pulmonary exam was not
significant for wheezes or crackles. EKG showed new sinus
tachycardia to 127, with lateral ST depressions in V5/6 but
otherwise no other evidence of acute ischemic changes. Chest X
ray was not concerning for new pulmonary effusions,
pneumothorax, or pneumonia. Troponins were positive at 0.28.
with CK-MB of 5. He was started on an empiric heparin drip and
transferred to the ICU for further monitoring.
Past Medical History:
Type 2 diabetes complicated by retinopathy, nephropathy,
neuropathy
Chronic Kidney disease
Hypertension
Hyperlipidemia
Peripheral Vascular disease
Tobacco abuse
History of tibial fracture
Right superficial femoral artery stent and angioplasty [**1-/2131**]
Social History:
He is not currently working. He has worked as
a painter in recent years. He is actively smoking and has done
so for 20 years. He drinks alcohol in moderation.
Married, lives with wife. Independent in ADLs
Family History:
His mother is in the 70s, has "problems with her legs". His
father is in good health. He has 3 sisters and 2 brothers who
are in good health. He has one daughter 28 and one son 15, who
are in good health.
Physical Exam:
ADMISSION EXAM
Vitals: T:102.6 BP: 145/74 P:124 R:34 O2:92% NRB
General: Alert, oriented, respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple,no LAD
CV: Tachycardic with sinus 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. RLE with missing 5th
metatarsal. Granulation tissue and mild purulence present at
site. Tenderness to palpation up to mid calf. RLE appears
hyperpigmented compared to left.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact.
DISCHARGE EXAM
98.3 136/68 71 18 100 RA
GENERAL - Well-appearing man in NAD, comfortable, appropriate
LUNGS - No adventitious sounds
HEART - Nl S1-S2, no murmurs.
ABDOMEN - Nontender, nondistended, no masses or HSM, no
rebound/guarding
EXTREMITIES - R ankle swollen compared to left, hyperpigmented
compared to Left. Some limitation in movement of R ankle [**12-21**]
pain. Prior amputation site on R 5th toe w/o any drainage.
Pertinent Results:
ADMISSION LABS:
[**2131-6-23**] 08:00PM WBC-11.6*# RBC-3.13* HGB-9.8* HCT-29.4*
MCV-94 MCH-31.3 MCHC-33.3 RDW-13.5
[**2131-6-23**] 08:00PM CRP-15.5*
[**2131-6-23**] 08:00PM GLUCOSE-98 UREA N-50* CREAT-2.2* SODIUM-141
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-22 ANION GAP-18
[**2131-6-23**] 08:20PM LACTATE-1.4
[**2131-6-23**] 08:30PM URINE RBC-7* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2131-6-23**] 08:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2131-6-23**] 08:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2131-6-23**] 11:07PM LACTATE-1.0
RELEVANT LABS:
[**2131-6-23**] 08:00PM BLOOD WBC-11.6*# RBC-3.13* Hgb-9.8* Hct-29.4*
MCV-94 MCH-31.3 MCHC-33.3 RDW-13.5 Plt Ct-288
[**2131-7-5**] 07:05AM BLOOD WBC-9.0 RBC-3.19* Hgb-9.6* Hct-29.9*
MCV-94 MCH-30.2 MCHC-32.2 RDW-13.8 Plt Ct-479*
[**2131-6-23**] 08:00PM BLOOD Neuts-90.5* Lymphs-5.1* Monos-3.4 Eos-0.7
Baso-0.2
[**2131-7-5**] 07:05AM BLOOD Neuts-71.2* Lymphs-18.9 Monos-5.5 Eos-4.0
Baso-0.3
[**2131-7-5**] 07:05AM BLOOD Glucose-162* UreaN-49* Creat-2.5* Na-141
K-4.8 Cl-104 HCO3-29 AnGap-13
[**2131-6-24**] 03:13PM BLOOD CK-MB-5 cTropnT-0.28*
[**2131-7-3**] 09:10AM BLOOD CK-MB-1 cTropnT-0.06*
[**2131-6-30**] 06:15AM BLOOD calTIBC-215* Hapto-442* Ferritn-843*
TRF-165*
[**2131-6-23**] 08:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2131-6-23**] 08:30PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2131-6-23**] 08:30PM URINE RBC-7* WBC-1 Bacteri-FEW Yeast-NONE Epi-0
DISCHARGE LABS
[**2131-7-5**] 07:05AM BLOOD WBC-9.0 RBC-3.19* Hgb-9.6* Hct-29.9*
MCV-94 MCH-30.2 MCHC-32.2 RDW-13.8 Plt Ct-479*
[**2131-7-5**] 07:05AM BLOOD Neuts-71.2* Lymphs-18.9 Monos-5.5 Eos-4.0
Baso-0.3
[**2131-7-5**] 07:05AM BLOOD Plt Ct-479*
[**2131-7-5**] 07:05AM BLOOD Glucose-162* UreaN-49* Creat-2.5* Na-141
K-4.8 Cl-104 HCO3-29 AnGap-13
[**2131-7-5**] 07:05AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.0
MICROBIOLOGY:
Blood cultures 8/4, [**6-24**], [**6-26**], [**6-29**]: no growth.
Lyme serology negative
Urine culture [**6-23**] negative
Wound swab from R amputated toe [**6-30**]: no growth, no
microorganisms on gram stain
IMAGING:
TTE [**2131-6-25**]
The left atrium and right atrium are normal in cavity size. The
patient is mechanically ventilated. The IVC is small, consistent
with an RA pressure of <10mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (?#) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and low normal global left ventricular systolic
function. No valvular pathology identified. Dilated ascending
aorta.
Compared with the prior study (images reviewed) of [**2131-5-10**],
global left ventricular sysotlic function is now slightly
reduced with preserved systolic function. The heart rate is also
now tachycardic.
CT CHEST [**2131-6-25**]:
FINDINGS: Normal appearance of the visualized thyroid. No lower
cervical adenopathy. Heart size within normal limits. Limited,
non-contrast evaluation of the upper abdomen reveals no gross
abnormality. Blood pool is hypodense relative to myocardium
suggesting anemia.
Evaluation of the lungs demonstrates normal overall parenchymal
pattern with focal areas of scattered ground-glass opacity in
the bilateral upper and lower lobes, most prominent in the left
upper lobe. Confluent opacification in the bilateral lower
lobes in a dependent distribution with small bilateral pleural
effusions are noted. In the right lower lobe subpleural space,
there is a 7-mm calcification which along with mediastinal lymph
node calcifications suggests granulomatous disease.
No acute osseous abnormality. Vasculature is normal in caliber.
IMPRESSION:
1. Scattered ground-glass opacities with consolidations in the
bilateral
lower lobes. Appearance is nonspecific, but in the appropriate
clinical
setting likely represents pneumonia.
2. Anemia.
3. Stigmata of old granulomatous disease.
4. Lack of IV contrast prevents evaluation of the pulmonarey
vessels for
embolus.
[**2131-6-28**] MRI
MR OF THE LEFT ANKLE WITHOUT THE INTRAVENOUS ADMINISTRATION OF
CONTRAST
FINDINGS: Diffuse prominent subcutaneous edema is present
throughout the distal left lower extremity and imaged portions
of the left foot. Trace tibiotalar joint effusion.
Prominent edema is also present within [**Last Name (un) 22044**] fat pad. Edema is
also present with the sinus tarsi. Edema is present within the
plantar musculature of the mid and hindfoot. No evidence however
for edema extending along fascial planes within the foot and
distal left lower extremity. No subcutaneous or intramuscular
abscess.
Anterior and posterior tibiofibular ligaments are intact and
normal in signal. Anterior and posterior talofibular ligaments
are intact. Calcaneofibular ligament appears grossly intact.
Deltoid and spring ligaments appear intact.
Extensor tendons are normal in signal. Trace fluid is present
with the tendon sheath of the intact tibialis anterior. Small
amount of fluid is present within the tendon sheath of the
intact posterior tibialis. Small amount of fluid is present
within the tendon sheaths of the intact peroneal brevis and
longus.
Achilles tendon is normal in thickness and signal. No evidence
for discrete
fracture nor significant bone marrow edema. No evidence for
osteomyelitis.
IMPRESSION:
1. Prominent subcutaneous edema of the distal left lower
extremity and foot. Although nonspecific, this finding can be
due to cellulitis. Edema also present in the plantar musculature
and could reflect an element of myositis.
2. No MR evidence for osteomyelitis or fasciitis. No focal
fluid collection to suggest abscess.
3. Trace left ankle effusion.
4. Mild tenosynovitis of otherwise intact anterior tibialis,
posterior
tibialis, and peroneus longus and brevis tendons.
[**2131-6-28**]
EXAM: MRI of the right foot without contrast.
FINDINGS: There are expected post-surgical changes from prior
amputation of the fifth toe and mid-to-distal fifth metatarsal
bone. There is mild soft tissue edema and enhancement
surrounding the amputated fifth toe, as well as subcutaneous
edema (mild) surrounding the entire forefoot. However, there
are no obvious fluid collections to suggest abscess. The
visualized residual fifth metatarsal bone as well as the rest of
the visualized bones demonstrates no gross abnormal bone marrow
edema and no cortical destruction to suggest osteomyelitis.
There are diffuse abnormal T2 signal involving the intrinsic
muscles of the foot. Evaluation of the extensor and flexor
tendons as well as limited evaluation of the intrinsic ligaments
of the foot demonstrates no acute abnormality. Limited
evaluation of the mid foot also demonstrates no acute pathology.
IMPRESSION:
1. Post-surgical changes involving previously amputated fifth
metatarsal and toe, without evidence of osteomyelitis.
2. Assessment for abscess limited by absence of IV contrast,
but no obviuos soft tissue abscess identified.
3. Diffuse subcutaneous soft tissue edema (mild), likely due to
cellulitis.
4. Diffuse intrinsic muscle edema, nonspecific in appearance.
The
differential diagnosis includes changes secondary to neurogenic
disease from underlying diabetes and myositis.
Brief Hospital Course:
49 y/o man with DMII who initially presented with ankle pain
consistent with cellulitis, with hospital course complicated by
sepsis, acute hypoxia requiring intubation in the medical ICU,
progression of chronic kidney disease, and troponinemia.
ACTIVE ISSUES:
# Right lower extremity pain due to leg cellulitis.
Upon admission, Mr. [**Known lastname **] was empirically started on vancomycin
and ceftazadime on [**2131-6-24**] for coverage of a presumed infection.
Although initial concern was for septic arthritis, tap by
orthopedics only showed a few drops of bloody fluid that was not
sent for lab evaluation. He had minimal improvement in symptoms,
so decision was made to obtain right ankle MRI to look for deep
wound infection on [**2131-6-28**] that was negative for osteomyelitis,
although did show edema that could be evidence of cellulitis.
Reportedly in the MICU he was still spiking fevers to 103 at
night before being transferred to the Medicine floor on [**2131-6-29**].
After being transferred to the floor however, patient remained
afebrile. Flagyl was started on [**2131-6-30**] per Infectious Disease
recommendations. Another MRI was obtained on [**2131-7-2**] that
included all portions of the right foot, as parts of the foot,
notably the amputated 5th metatarsal, were not obtained on the
prior MRI, which was again negative for osteomyelitis.
Rheumatology was also consulted who did not believe that his
right lower extremity pain was due to a rheumatological issue.
Mr. [**Known lastname 33020**] pain improved by time of discharge and all antibiotics
were discontinued on [**2131-7-3**]. He remained afebrile after
discontinuation. Blood cultures 8/4, [**6-24**], [**6-26**], and [**6-29**] and
urine culture [**6-23**] showed no growth. Lyme serology was also
negative.
# Acute Hypoxemia:
Soon after admission, Mr. [**Known lastname **] was saturating in mid to high 90s
on nasal cannula; however, on [**2131-6-25**], patient was reported to
have desaturations to mid 80s, and placed on non-rebreather
without improvement in O2 saturation. He was tachypneic and
tachycardic, and decision was made to intubate and provide
mechanical ventilation. His presumed cause is likely flash
pulmonary edema (secondary to sepsis) as he responded well to
diuresis with IV lasix. He self extubated on [**2131-6-26**], and
required minimal supplemental O2 afterwards, ultimately
transferred to the floor on [**2131-6-29**]. Of note while he was
intubated and sedated, he required vasopressor support with
norepinephrine, however this was discontinued as he was
extubated and weaned off sedation.
# CKD Stage 3:
Mr. [**Known lastname **] has underlying chronic kidney disease that has been
acutely worsening over the past few months. His creatinine level
was around ~1.7 a few months ago, but hovered around ~2.5 for
much of his admission. Renal team was consulted, and felt that
his declining kidney function was simply a natural progression
of his chronic kidney disease. Of note Mr. [**Known lastname **] also had a low
hematocrit throughout much of admission (~29). His labs were
consistent with anemia of chronic disease, with no evidence of
hemolysis. Renal did not believe there was any role for
inpatient management of his anemia.
# Elevated Troponin (Not NSTEMI):
While in the MICU, Mr. [**Known lastname 33020**] cardiac enzymes revealed a mildly
elevated Tn-T in the setting of CKD, but his CM-MB was normal.
Cardiology was consulted, and believed this was consistent with
some "demand" ischemia in the setting of the patient's acute
illness. A TTE was performed that demonstrated normal LV
function without any regional wall motion abnormalities.
CHRONIC ISSUES:
# Type 2 Diabetes controlled with complications:
Mr. [**Known lastname **] was started on insulin sliding scale while in house, and
did not have any complications. He was continued on his home
glipizide after discharge.
# Superior femoral artery stent/Peripheral vascular disease:
Vascular surgery was consulted for possibility of vascular
optimization for healing purposes as well
as a question of an infected right superior femoral artery
stent. They did ankle brachial index measurements and an
ultrasound of his right superior femoral artery stent which
showed satisfactory bloodflow.
# Benign Hypertension:
Patient was continued on his home amlodipine. Labetolol was
added to help with his blood pressure control.
# Hyperlipidemia:
Home simvastatin was continued.
TRANSITIONAL ISSUES:
- Follow up final read of ultrasound of right superior femoral
artery graft from [**2131-7-2**] and final read of ankle brachial index
studies from [**2131-7-2**]. These were reviewed with primary team in
conjunction with vascular surgery, but the final report has not
been updated yet.
- Patient will have close follow-up with Vascular Surgery.
- Due to progression of chronic kidney disease, dialysis or
transplant may need to be pursued within the next year. Mr. [**Known lastname **]
is currently transitioning outpatient renal providers, who will
continue to follow closely.
- Full code
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
2. Clopidogrel 75 mg PO DAILY
3. Collagenase Ointment 1 Appl TP DAILY
4. Viagra *NF* (sildenafil) 100 mg Oral PRN
5. Amlodipine 10 mg PO DAILY
6. GlipiZIDE 5 mg PO DAILY
7. Simvastatin 10 mg PO DAILY
8. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Collagenase Ointment 1 Appl TP DAILY
4. Simvastatin 10 mg PO DAILY
5. Torsemide 20 mg PO DAILY
6. Labetalol 300 mg PO BID
hold for sbp<100 or hr<60
RX *labetalol 300 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
7. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**11-20**] tablet(s) by mouth every four hours Disp
#*12 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*30 Packet Refills:*0
9. GlipiZIDE 5 mg PO DAILY
10. Viagra *NF* (sildenafil) 100 mg Oral PRN
11. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Cellulitis
Secondary diagnoses:
Peripheral vascular disease s/p right SFA stent
Diabetes
Hypertension
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted for infection on your right leg. We treated
your infection with intravenous antibiotics. While you were
here, you were transferred to the Intensive Care Unit for
trouble breathing secondary to fluid in your lungs. This
improved with removing fluid with diuretic medications.
Medications started:
Oxycodone (for pain)
Labetolol (for blood pressure)
Miralax (for constipation)
Medications stopped:
None
Please see below for your follow-up appointments.
Followup Instructions:
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
**APPOINTMENT TUESDAY [**2131-7-10**] at 1:15 PM**
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2131-7-16**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2131-7-19**] at 2:45 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2131-7-19**] at 3:30 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"357.2",
"V49.72",
"995.92",
"682.6",
"250.50",
"585.3",
"584.9",
"272.4",
"443.81",
"518.81",
"305.1",
"518.4",
"583.81",
"038.9",
"427.89",
"250.60",
"362.01",
"250.40",
"411.89",
"403.10",
"285.21",
"250.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"96.71",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
18051, 18057
|
11777, 12023
|
278, 351
|
18246, 18246
|
3965, 3965
|
18961, 20033
|
2500, 2707
|
17302, 18028
|
18078, 18078
|
16883, 17279
|
18429, 18938
|
2722, 3946
|
18130, 18225
|
16263, 16857
|
228, 240
|
12038, 15453
|
379, 1977
|
3981, 11754
|
18097, 18109
|
18261, 18405
|
15469, 16242
|
1999, 2257
|
2273, 2484
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,345
| 180,713
|
9912
|
Discharge summary
|
report
|
Admission Date: [**2121-3-28**] Discharge Date: [**2121-4-2**]
Date of Birth: [**2078-2-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
nausea and vomitting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43yo M with hx of alcohol abuse, withdrawal and ?DT in past
(found out later during hospital course) and hx of BRBPR (nml
EGD and colonoscopy as per pt) who presents with 12days of n/v.
Pt reports he ate some home delivery chinese food 12 days ago
with a friend. At the time he only ate fried rice with pork (no
sea food, shrimp, beef, chicken) and five minutes later on the
way to the car he had projectile vomiting. The vomitus consisted
entirely of undigested food and he does not believe it contained
blood or bile but difficult to assess as the fried rice was red.
He subseqeuntly got in his car and left so is unsure if his
friend also got sick at the time (friend does not have a phone
and he has not been in contact with him since). Since that time
he has had persistent n/v with either solids or liquids. He
reports nausea with even the smell of food. These episode of
vomiting all are precede by an indescribable "funny feeling",
cough and shaking. After several coughing fits he invariably
vomits which is followed by head ached described as "head
bursting", eyes teraing, and chills. However he denies
subjective fevers at any point in time. These all occurr [**6-10**]
minutes after eating. He denies any abd fullness or bloating. He
denies any difficulty or pain with swallowing. He reports his
last BM was approximately 10 days ago and was "nml". Since these
episodes began he has lost his appetite and is unable to hold
down any food leaving him weak with cramping and a 25lb weight
loss. Although he is from [**Country 2559**], he denies any recent travel or
visitors from outside MA or from [**Name (NI) 6687**], or [**Location (un) **]. He last visited [**Country 2559**] 3 years previous. He denies HA
(aside from when it occurs after his vomiting), pruritis, change
in skin color, change in sleep wake cycle, CP, palpitations,
SOB.
In the ED, the patient was given approximately 4L of IVF with
KCl, magnesium, and anzemet. During his stay in the ED, he
began exhibiting signs of alcohol withdrawal. Although he
denied excessive alcohol use, previous hx of withdrawal, DT,
hospitalizations for alcohol abuse, his previous record revealed
extensive alcohol history and as well as an admission to [**Hospital1 18**]
for intoxication and subsequent withdrawal requiring large doses
of benzodiazepine.
Past Medical History:
1. "Gastroenteritis" in '[**15**] diagnosed by EGD/colonscopy when he
presented to OSH ([**Location (un) **], MA) with BRBPR.
2. Benign tremor
3. s/p appy at age 8
4. Alcohol abuse with withdrawals
5. pancreatitis
6. pancreatic cyst vs. pseudocyst
7. depression.
Social History:
Patient moved from [**Location (un) 20338**], [**Country 2559**] in [**2106**] with his wife and
kids to to [**Name (NI) 33228**], NY to work for his in-laws family
restaurant. He subsequently had a successful cheese
distributory business until [**10-12**] when his business went
bankrupt. After that, his wife left him with his 2 children and
he has been depressed since. He moved to [**Location (un) 86**] in '[**17**] where he
opened a deli in the [**Hospital3 4414**]. He sold the deli and has since
worked at [**Last Name (un) 33229**] Farmer's Market in [**Location 4288**] and now sells
Neopolitan Italian Ice.
.
He currently lives by himself in an apartment without pets, but
previousy he lived for many years at his girlfriend's apartment
where there were two cats.
Pt denies use of tobacco or illicit drugs.
.
Pt. changes history about alcohol use from 2 glasses a day to
bottles a day to being sober for 20 years which cannot be true
given that he was admitted last year for alcohol intoxication
and subsequent withdrawal.
Family History:
1. Father - deceased from prostate CA
2. Mother - deceased from lymphoma
3. No history of HTN, DM, or liver disease in family.
Physical Exam:
VS: Afebrile HR: 80 BP: 130/90 RR: 12 SaO2: 100% RA
Gen: middle aged M, lying in bed, in NAD. conversing fluently in
Italian with broken English.
Skin: no jaundice or easy bruising
HEENT: EOMI, anicteric, ?normal disk margins on fundoscopic
exam.
Neck: no LAD, supple
CV: RRR, S1, S2, no murmurs rubs, gallops
Chest: CTA bilaterally
Abd: soft, NT, ND, BS+, liver span approximatley 8-10cm. No
spleen palpable.
Ext: wwp, no c/c/e
Rectal: Guaiac negative (as per ED note)
Pertinent Results:
[**2121-3-28**] 09:00AM URINE HOURS-RANDOM
[**2121-3-28**] 09:00AM URINE UHOLD-HOLD
[**2121-3-28**] 09:00AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2121-3-28**] 09:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-12* PH-7.0 LEUK-NEG
[**2121-3-28**] 09:00AM URINE RBC-0 WBC-0 BACTERIA-0 YEAST-NONE EPI-0
[**2121-3-28**] 07:36AM GLUCOSE-94 UREA N-4* CREAT-0.6 SODIUM-141
POTASSIUM-2.8* CHLORIDE-108 TOTAL CO2-24 ANION GAP-12
[**2121-3-28**] 07:36AM CALCIUM-8.1* PHOSPHATE-1.8* MAGNESIUM-1.5*
[**2121-3-28**] 07:36AM WBC-2.5* RBC-3.77* HGB-13.0* HCT-37.5*
MCV-100* MCH-34.6* MCHC-34.8 RDW-13.0
[**2121-3-28**] 07:36AM NEUTS-75.5* LYMPHS-19.5 MONOS-3.5 EOS-1.0
BASOS-0.6
[**2121-3-28**] 07:36AM MACROCYT-1+
[**2121-3-28**] 07:36AM PLT COUNT-58*
[**2121-3-27**] 06:15PM GLUCOSE-97 UREA N-4* CREAT-0.6 SODIUM-137
POTASSIUM-3.5 CHLORIDE-99 TOTAL CO2-27 ANION GAP-15
[**2121-3-27**] 06:15PM CALCIUM-8.8 PHOSPHATE-2.1* MAGNESIUM-1.6
[**2121-3-27**] 06:15PM WBC-3.8* RBC-4.51* HGB-16.0 HCT-45.4 MCV-101*
MCH-35.4* MCHC-35.2* RDW-13.0
[**2121-3-27**] 06:15PM NEUTS-71.6* LYMPHS-22.5 MONOS-4.5 EOS-0.8
BASOS-0.6
[**2121-3-27**] 06:15PM MACROCYT-1+
[**2121-3-27**] 06:15PM PLT COUNT-73*
[**2121-3-27**] 06:00AM GLUCOSE-98 UREA N-4* CREAT-0.5 SODIUM-137
POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-28 ANION GAP-11
[**2121-3-27**] 06:00AM ALT(SGPT)-43* AST(SGOT)-98* ALK PHOS-84 TOT
BILI-3.8*
[**2121-3-27**] 06:00AM GGT-2842*
[**2121-3-27**] 06:00AM CALCIUM-8.1* PHOSPHATE-2.1* MAGNESIUM-1.7
[**2121-3-27**] 06:00AM IRON-195*
[**2121-3-27**] 06:00AM calTIBC-212* VIT B12-706 HAPTOGLOB-22*
FERRITIN-1365* TRF-163*
[**2121-3-27**] 06:00AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HAV
Ab-POSITIVE IgM HAV-NEGATIVE
[**2121-3-27**] 06:00AM HCV Ab-NEGATIVE
[**2121-3-27**] 06:00AM WBC-3.2* RBC-4.03* HGB-14.3 HCT-40.1 MCV-100*
MCH-35.6* MCHC-35.8* RDW-12.6
[**2121-3-27**] 06:00AM NEUTS-60.6 LYMPHS-32.1 MONOS-5.6 EOS-0.9
BASOS-0.7
[**2121-3-27**] 06:00AM MACROCYT-1+
[**2121-3-27**] 06:00AM PT-14.2* PTT-28.1 INR(PT)-1.3
[**2121-3-27**] 06:00AM PLT SMR-VERY LOW PLT COUNT-57*
.
.
-[**2121-3-27**] Serum and urine tox negative
-[**2121-3-27**] UA: trace protein, occasional bacteria
-[**2121-3-26**] KUB: nml
-[**2121-3-26**] Liver US: "Gallstones and sludge without evidence of
cholecystitis. Echogenic liver consistent with fatty
infiltration. Other forms of liver disease, including more
significant hepatic fibrosis or cirrhosis, cannot be excluded on
the basis of this examination."
-[**2121-3-27**] CT of abd/pelvis: "Nonenlarged, periportal and
peripancreatic lymph nodes. 4 mm hypodensity within the
pancreas, a nonspecific finding that could represent a dilated
duct or pancreatic pseudocyst or cystic lesion. This could also
possibly relate to prior pancreatitis. Tiny, rounded, hypodense
lesion within the right kidney, too small to accurately
characterize but likely representing a cyst."
.
Brief Hospital Course:
1. Withdrawal/N/V: On HD#1, the patient was initially worked
up for possible GI causes of n/v including gastroparesis,
pancreatic disease, liver disease, infectious and obstruction.
He was also scheduled for a head CT to evaluate possible central
causes of persistant n/v (including raised intracranial
pressure). While awaiting the head CT on the evening of HD#1,
the patient developed symptoms consistent with alcohol
withdrawal. He was initially considered low risk for withdrawal
as his tox screen was negative and he reported he had not had a
drink for >10days secondary to n/v. (this was all prior to
availability of previous medical records). He then became
tachycardic, diaphoretic with marked tremors and agitated. The
patient was given 40mg po valium without much effect. He
subsequently received multiple doses of valium IV without any
effect. In sum, he recieved 430mg of valium IV/PO and required
a versed gtt to stabilize his symptoms of withdrawal. Due to
his signficant withdrawal symptoms the patient was maintained on
a versed gtt. He was subsequently transferred to the MICU where
he was given more valium and observed for signs of respiratory
depression. He was stabilized in the MICU and transferred back
to the floor off the versed gtt. Lab values on admission were
consistent with significant alcohol abuse (elevated GGT, with
AST>ALT at 2:1 ratio), therefore most of the symptoms of n/v may
very well be due to alcohol withdrawal.
On the floor, he was continued on an alcohol withdrawal
protocol. He immediately received 50mg librium PO x1 upon
transfer. Subsequently he was given librium 75mg PO QID for the
first day followed by 50mg QID We will give librium 100mg
Q6hours for the 1st day and then 50mg Q6hours on the 2nd day.
The librium taper was discontinued after this, for the patient
was very sedated. His CIWA's were very low at this time (0-5),
and he was not requiring additional Ativan. He was stable with
respect to his alcohol withdrawal at time of discharge. He was
seen by the addiction service while in-house. He will follow up
in [**Company 191**]. He declined outpatient substance abuse counselling.
2. Pancreatic hypodensity: given the presenting symptoms of n/v
as well as his history of ?pancreatitis - pancreatitis was on
the differential, however, the patient has normal amylase and
lipase in addition to a benign abd on physical exam. This make
pancreatitis less likely. However the incidental finding of a
hypodensity is concerning for a possible pancreatic CA. He will
follow up as an outpatient for this ?pancreatic mass.
3. Hematology: Pt with elevated total bili (mostly indirect) as
well as elevated LDH suggesting he may be hemolyzing. However
he has had a stable Hct of 35-37. ?superficial hemolysis in
setting of stress. His hematocrit remained stable while
in-house while bilirubin trended down. He will follow up as an
outpatient should he need further workup for ?low grade
hemolysis (G6PD deficiency a possibility given his Italian
background).
4. Disposition: He was discharged in stable position. He will
follow up in hepatology for follow up of his abnormal LFT's. He
will also follow up in [**Company 191**] with his new PCP after discharge
(appointments scheduled).
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Alcohol Withdrawal/Delirium Tremens
2. Gastroenteritis
Secondary Diagnoses:
1. Liver enzyme abnormalities
2. Pancreatic lesion
Discharge Condition:
Good
Discharge Instructions:
1. Please take all your medications as prescribed and described
in this discharge paperwork. We made the following changes to
your medication regimen:
- We added Colace and Senna, medications to help with
constipation. Use them as needed and as described to have
regular bowel movements.
- We added Thiamine, Folic Acid, and Cyanocobalamin. These
are vitamins that should be taken once daily
- We added ambien, a medication to help with insomnia. Take
one tablet before bed ONLY if you are having difficulty
sleeping. You should not be taking this on a nightly basis.
2. Please follow up with your new PCP and the [**Hospital 3585**] clinic
as described below.
3. Please call your doctor if you are experiencing fever,
chills, abdominal pain, chest pain, shortness of breath, or with
any other concerns
Followup Instructions:
1. Please follow up with your new primary care physician.
[**Name Initial (NameIs) 2169**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26**] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2121-4-16**] 2:00
2. Please follow up in the Liver clinic:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2121-4-21**] 9:20
You may need an outpatient workup for the pancreatic lesion seen
on your imaging. Your hematocrit should also be monitored to
ensure that it remains stable.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"291.0",
"305.01",
"276.5",
"558.9",
"571.2",
"571.1",
"284.8",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11780, 11786
|
7705, 10976
|
334, 340
|
11982, 11988
|
4690, 7682
|
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|
4056, 4185
|
11031, 11757
|
11807, 11886
|
11002, 11008
|
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4200, 4671
|
11907, 11961
|
274, 296
|
371, 2696
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2718, 2983
|
3002, 4040
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,826
| 175,744
|
49502
|
Discharge summary
|
report
|
Admission Date: [**2100-9-5**] Discharge Date: [**2100-9-22**]
Date of Birth: [**2019-7-19**] Sex: M
Service: MEDICINE
Allergies:
Tetanus&Diphtheria Toxoid / Amoxicillin / Vicodin / Levaquin
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
right colon cancer
Major Surgical or Invasive Procedure:
[**2100-9-5**] open R colectomy
History of Present Illness:
Mr. [**Known lastname 103570**] is an 81 y/o M w/h/o renal transplant, 5-vessel
CABG, AAA repair, sigmoid colectomy, anemia, DVT/PE on coumadin
who p/w fungating circumferential non-bleeding 5 cm mass of
malignant appearance in the hepatic flexure noted on colonscopy
[**6-/2100**] for R open colectomy tomorrow. He currently notes no
symptoms from his colon cancer, no abd pain, no change in bowel
habits, no hematochezia, no melena. He had a CT torso in w/u
showing no metastatic disease, but a thyroid nodule which, on
u/s was shown to be a simple cyst. He does, however note chronic
leg swelling, and over the last 6 months to a year has noted
worsening fatigue on excertion, currently he is able to walk 40
feet without fatigue. He had a nuclear stress test in [**3-12**]
showing a fixed, severe perfusion defect in mid and basal
inferior wall and basal inferoseptum, and
basal inferior wall hypokinesis with normal systolic function.
He has a note from Dr. [**Last Name (STitle) **] stating that he should be
lovenox bridged post op. He stopped his coumadin 6 days ago.
His baseline creatinine is 1.1. He has a note from Dr. [**Last Name (STitle) **]
advising NS at 100cc/hr preoperatively. Of note he has two skin
cancers (basal cell) that were removed from his legs in [**Month (only) **]
and [**Month (only) 596**] which are not healing. He has daily dressing changes
with antibiotic ointment per his dermatologist.
Past Medical History:
PMH:
Hypertension
Hyperlipidemia
Coronary Artery Disease
Hiatal hernia per wife
gout
h/o DVT, PE (on coumadin)
Hemorrhoids
PSH:
renal transplant [**2077**]
h/o diverticulitis s/p sigmoid colectomy [**2087**]
CABG [**2086**] ([**Doctor Last Name 14714**])
EVAR [**3-/2092**] ([**Doctor Last Name **])
Revision of aortic stent graft [**1-/2096**] ([**Doctor Last Name **])
Social History:
Nonsmoker. Occassional drinker. He used to be employed by the
utility company but is currently retired. Mr. [**Known lastname 103570**] lives
with his wife- no home services.
Family History:
Noncontributory.
Physical Exam:
On admissioN:
Vitals: T:97.7 HR:59 BP:141/73 RR:20 Sat:100%RA
Gen: NAD
HEENT: NC/AT
CV: RRR, no m,r,g
Resp: CTA, old well healed median sternotomy
Abd: S, NT/ND, multiple well healed abdominal incisions
Ext: 2+ edema b/l LE, nonhealing wounds with fibrinous base on
both R and L anterior legs.
Pertinent Results:
[**2100-9-5**] 03:00PM WBC-7.7 RBC-3.83* HGB-8.3* HCT-27.5* MCV-72*
MCH-21.8* MCHC-30.3* RDW-19.0*
[**2100-9-5**] 03:00PM GLUCOSE-156* UREA N-21* CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-20* ANION GAP-17
[**2100-9-5**] 03:00PM CALCIUM-8.5 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2100-9-8**] 04:42AM BLOOD WBC-13.5* RBC-3.92* Hgb-9.6* Hct-29.3*
MCV-75* MCH-24.6* MCHC-32.9 RDW-20.4* Plt Ct-132*
[**2100-9-8**] 04:42AM BLOOD Neuts-65 Bands-30* Lymphs-3* Monos-0
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**9-7**] CXR: FINDINGS: As compared to the previous radiograph, the
monitoring and support devices are in unchanged position. There
are newly developed bilateral mild-to-moderate pleural effusions
with subsequent atelectasis. However, the signs indicative of
pulmonary edema have slightly improved. Unchanged size of the
cardiac silhouette
[**9-8**] CT head:
FINDINGS: Evaluation is limited by streak artifact from
overlying wires.
There is no extra-axial collection, intracranial hemorrhage, or
mass effect. Streak artifact passes through the region of the
left central sulcus. There is subtle hypodensity in the left
caudate, as well as basal ganglia and insular ribbon(series 2;
images 14-17). There is mild prominence of the extra-axial
spaces consistent with atrophy, with a predominantly frontal
distribution. The ventricles are slightly enlarged likely the
result of atrophy.
The orbits are unremarkable. The visualized soft tissues are
normal.
Incidental note is made of a lipoma along the anterior falx. The
visualized paranasal sinuses demonstrate minimal mucosal
thickening of the right maxillary sinus as well as several
ethmoid air cells, the remainder are clear.
IMPRESSION: Hypodensity in the region of the left thalamus, and
insular
ribbon. If clinically indicated, this might be further evaluated
with MRI to exclude stroke.
[**9-9**] Echo:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%) secondary to inferior hypokinesis and posterior
dyskinesis; the other walls are hyperdynamic. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**9-9**] CT chest:
FINDINGS: The airways are patent to the segmental level. In the
right lobe
of the thyroid gland a hypodense lesion measuring aprox. 29x24
mm is
unchanged. Patient is status post CABG. Native coronary arteries
have dense calcifications. Hypodensity of the cardiac [**Doctor Last Name 1754**]
compared to the myocardium suggests anemia. There is no
pericardial effusion. Mild-to-moderate bilateral pleural
effusions are increasing from [**9-6**]. Mediastinal lymph nodes
are unchanged. The ascending aorta measures AP 44 mm was 41 mm
in [**Month (only) 205**], the descending and visualized portion of the proximal
abdominal aorta show dense wall ateromatous calcifications, and
probably stable focal mural thrombus at the level of the
diaphragm. Abdominal aorta aneurism is incomplety imaged.
Right central line tip is in mid to lower SVC. There is large
bibasilar
atelectasis in lower lobes bilaterally and in the right middle
lobe, which is almost collapsed.
The aorta is very tortuous and has extensive diffuse
atherosclerotic plaques.
This examination is not tailored for subdiaphragmatic
evaluation. There are gallstones. The kidneys are atrophic with
a hypodense exophytic lesion from the left upper pole kidney
unchanged from study. The pancreas is atrophic. The adrenal
glands are normal. Hypodense lesion in the left lobe of the
liver is barely visualized.
There are no bone findings of malignancy. There are stable
sclerotic changes in the vertebral body of T9.
IMPRESSION: Bilateral pleural effusions associated with large
bibasilar
atelectasis and almost collapse of the right middle lobe. No
evidence of CHF or pneumothorax.
Lesion in the right lobe of the thyroid gland. If ultrasound has
not been
performed, it is recommended for further evaluation.
1-cm lesion in the left kidney is unchanged.
.
[**9-15**] Hand:
IMPRESSION:
1. Findings concerning for osteomyelitis in the carpus, proximal
radiocarpal
joint and distal radioulnar joint as questioned. Further
evaluation with
arthrocentesis may be helpful.
2. Degenerative changes as above.
.
[**9-15**] Renal ultrasound:
IMPRESSION:
1. Patent vasculature with resistive indices in the upper, mid
and lower pole of the transplant kidney ranging from 0.74 to
0.83 somewhat increased from [**2092**].
2. No hydronephrosis or perinephric fluid collection.
.
[**9-16**] CXR:
FINDINGS: In comparison with the study of [**9-9**], there are low
lung volumes in
this patient with intact midline sternal wires. Left subclavian
catheter
extends to about the lower SVC or cavoatrial junction. The
hemidiaphragms are now sharply seen, with mild atelectatic
changes at the bases. No evidence of acute focal pneumonia.
...
LABS ON DISCHARGE:
[**2100-9-22**] 09:45AM BLOOD WBC-9.0 RBC-3.29* Hgb-7.9* Hct-25.6*
MCV-78* MCH-24.1* MCHC-30.9* RDW-21.5* Plt Ct-498*
[**2100-9-15**] 06:03AM BLOOD Neuts-78* Bands-1 Lymphs-10* Monos-5
Eos-3 Baso-1 Atyps-0 Metas-2* Myelos-0
[**2100-9-22**] 09:45AM BLOOD PT-18.7* PTT-31.7 INR(PT)-1.7*
[**2100-9-22**] 09:45AM BLOOD Glucose-82 UreaN-40* Creat-1.7* Na-138
K-4.1 Cl-105 HCO3-23 AnGap-14
[**2100-9-22**] 09:45AM BLOOD Calcium-8.6 Mg-1.9
[**2100-9-17**] 04:30AM BLOOD CRP-140.8*
Brief Hospital Course:
81 yo M with hypertension, CAD s/p CABG, prior DVT/PE, prior
renal transplant (due to polycystic kidney disease) and prior
AAA repair admitted for right hemicolectomy for colon cancer
with complications of hypoxia, A Fib, altered mental status as
well as left wrist pseudogout.
.
The patient was admitted for right hemicolectomy for colon
cancer. Pre-op he received FFP and 2 units PRBC's for an
elevated INR and chronic anemia. He underwent the procedure on
[**2100-9-6**]. With conservative management he had return of bowel
function and his diet was slowly advanced. At the time of
discharge he was tolerating a normal diet. Most of his staples
were removed at the time of discharge but a few were left in.
He will need to follow-up with Dr. [**Last Name (STitle) 1120**] within two weeks of
discharge. This was explained to the patient.
.
Post-operatively, the patient developed acute hypoxia. This was
felt to be multifactorial - from a component of fluid overload
(he was several liters positive during and after surgery),
probable hospital acquired aspiration pneumonia (with new
bandemia and fever) and compressive atelectasis. The patient was
transferred to the ICU, started on a lasix drip and empiric
Vanc/Cefepime. He clinically improved. At the time of
discharge, he was euvolemic and had excellent oxygen saturations
on room air. He completed an 8-day course of Vancomycin and
Cefepime on [**2100-9-17**].
.
On transfer to the ICU, the patient was hypotensive. He
transiently required pressor support. He then developed rapid a
fib. He was started on a diltiazem drip and transitioned to oral
diltiazem with good rate control but intermittent a fib/flutter.
He was started on a heparin drip as a bridge to coumadin. His
diltiazem was slowly converted to a beta blocker given his
history of coronary artery disease as well as some runs of
nonsustained ventricular tachycardia noted on telemetry. His
heart rate was well controlled on the beta blocker. Of note,
his rhythm was predominantly atrial flutter. He was discharged
on Toprol XL of 200 mg daily, an increased dose compared to his
beta blocker on admission.
.
The patient did have new findings on echocardiogram of posterior
LV dyskinesia but negative cardiac enzymes and he was felt NOT
to have suffered any ischemic cardiac injury.
.
The patient developed profound altered mental status while in
the ICU. A head CT found possible hypodensity in the left
thalamus. With conservative therapy and limiting of sedating
medications, the patient's mental status returned to [**Location 213**] and
he had no apparent neurologic deficits. The CT scan finding was
not further worked up as it was unlikely to change management.
He may need a MRI of his head in the future. His mental status
was at his baseline at the time of discharge.
.
The patient developed acute onset left wrist pain on [**2100-9-14**].
Rheumatology was consulted and his wrist was tapped. This
revealed CPPD crystals. The white count was borderline however,
and as such orthopedic hand surgery took the patient for a wash
out. Cultures were followed carefully and these were no growth.
Infectious diesease was consulted and they agreed that
antibiotics were not warranted. Once the cultures were
negative, he was started on a brief prednisone taper. At the
time of discharge, he was not having any left wrist pain. He
has sutures in place that will need to be removed by the hand
surgery team. He will need to follow-up with them on Tuesday
[**9-28**]. The number for their clinic was given to him and
the need to follow-up was explained.
.
The patient has a history of renal transplant due to
complications of polycystic kidney disease. He was followed
throughout his hospitalization by the nephrology consult
service. He was continued on immunosuppressives throughout his
course. His creatinine did increase to 1.6 two days after his
foley catheter was discontinued. It was possible that he has a
component of post-obstructive renal failure. Creatinine improved
to 1.4, then worsened to 1.6. Renal felt as though pt may be
intravascularly dry and recommended a fluid bolus as well as
checking cyclosporine levels. Despite several fluid challenges,
his creatinine remained between 1.6 and 1.7. His outpatient
nephrologist, Dr. [**Last Name (STitle) **] was consulted. He preferred to not
pursue any further diagnostic procedures and recommended
watchful waiting. He was fine with the patient being
discharged. He recommended that Mr. [**Known lastname 103570**] receive feraheme
prior to discharge and be set-up to have a repeat injection on
Monday [**9-27**]. He planned on seeing the patient at that
visit, having repeat labs and managing his renal function from
there. His ACE-I was held during his hospitalization and was
NOT restarted on discharge. This should be discussed at the
time of his renal follow-up. He was instructed to continue his
immunosuppressants including prednisone at 5 mg daily until he
sees Dr. [**Last Name (STitle) **]. Of note, his foley catheter was removed
prior to discharge with a post-void residual of only 40 cc.
.
For his iron deficiency anemia, he received one dose of IV
ferrlecit and one dose of feraheme. He is [**Last Name (STitle) 1988**] to receive
another injection of feraheme.
.
For his colon cancer, he will follow-up as an outpatient for
ongoing care.
.
The patient has a history of HTN, CAD, DVT/PE on coumadin,
chronic anemia and AAA repair. These issues were stable
throughout his hospitalization.
.
Incidental: CT chest on [**2100-9-9**] showed a lesion in the right
lobe of the thyroid gland. If ultrasound has not been performed,
it was recommended for further evaluation.
***
TRANSITIONAL ISSUES:
- thyroid ultrasound if not performed in past
- consideration of head MRI if clinically warranted
- consideration of restarting ACE-inhibitor
- follow-up of his creatinine
Medications on Admission:
Azathioprine 25', Cyclosporine 100', Fluticasone 50mcg 1-2 puffs
nasal daily, Folic Acid 1', Metoprolol 25'',Mupirocin 2% to
wound daily, Nitroglycerin 0.4 PRN, Ramipril 2.5', Ranitidine
150'', triamcinolone 0.1% to wound daily, Warfarin 5', ASA 81'
Discharge Medications:
1. azathioprine 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. cyclosporine 100 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: please take 1.5 pills on [**9-22**] and [**9-23**], have your INR
checked on [**9-24**] and then follow instructions from your primary
care doctor.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Itch.
7. prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day:
take four tablets on [**9-23**], then take two tablets on [**9-24**] and
[**9-25**] and then take 5 mg daily until you see your kidney doctor.
[**Last Name (Titles) **]:*40 Tablet(s)* Refills:*0*
8. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
[**Last Name (Titles) **]:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Outpatient Lab Work
Check INR, PTT, basic metabolic panel on [**2100-9-24**] and send
results to pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7790**] at [**Telephone/Fax (1) 6443**] (fax number).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Colon cancer s/p right hemicolectomy
Hypoxia due to fluid overload, hospital-acquired aspiration
pneumonia and compressive atelectasis
A Fib
Altered mental status
Hypertension
CAD
DVT/PE, in the past
AAA
Anemia
Prior renal transplant
Pseudogout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for surgery to remove colon cancer.
You suffered several complications including atrial flutter and
fibrillation, pneumonia, left wrist pseudogout. You were started
on prednisone with improvement in your wrist symptoms. You
should take 20 mg through [**2100-9-23**] and then 10 mg from [**9-24**]
through [**9-25**] and then 5 mg daily. You should discuss this dose
with your nephrologist when you see him on [**2100-9-27**].
Your kidney suffered some damage during your hospitalization.
It is crucial that you follow-up with your kidney doctor. At
that time, please confirm with him your medications.
Specifically, please confirm with him your prednisone dose.
Finally, we recommended that you have skilled nursing placement
for more intensive physical therapy. However you refused. You
stated understanding the risks of leaving deconditioned, which
includes fall, hip fracture and death.
You need to follow-up with the doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
Additionally, you should follow-up with the hand surgery service
next week. Please call to schedule. You also need to call to
schedule your general surgery follow-up within the next two
weeks to get the remainder of your staples removed.
***
MEDICATION CHANGES:
- take 7.5 mg of coumadin daily, have INR checked [**9-24**] and then
follow instructions from your primary care doctor
- stop taking metoprolol 25 mg twice daily and START Toprol XL
200 mg daily
- stop Ramipril until otherwise instructed by your doctors
Followup Instructions:
Please call Dr.[**Name (NI) 3377**] office to schedule follow-up within two
weeks of discharge. Her number is [**Telephone/Fax (1) 160**].
Please call the Hand surgery office at [**Telephone/Fax (1) 3009**] to schedule
follow-up for Tuesday [**2100-9-28**] to have your staples
removed.
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: WEDNESDAY [**2100-9-29**] at 10:10 PM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Infusion/[**Hospital **] Clinic
[**2100-9-27**] at 11:15 AM. However, please arrive 30 minutes
in advance to be seen by your nephrologist.
[**Location (un) 830**]
[**Hospital Ward Name 2104**] [**Location (un) 442**]
[**Location (un) 86**], [**Telephone/Fax (1) 103571**]
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2100-10-5**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: Cardiology
Name: Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]
When: Wednesday [**2100-10-20**] at 2 PM
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
|
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icd9cm
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[
[]
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[
"99.77",
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icd9pcs
|
[
[
[]
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16375, 16437
|
8743, 14443
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339, 372
|
16726, 16726
|
2789, 3655
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2441, 2459
|
14938, 16352
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16458, 16705
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14663, 14915
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16909, 18168
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2474, 2474
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14464, 14637
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18188, 18446
|
281, 301
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8245, 8720
|
400, 1833
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3664, 8226
|
2488, 2770
|
16741, 16885
|
1855, 2229
|
2245, 2425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,504
| 149,115
|
4966
|
Discharge summary
|
report
|
Admission Date: [**2120-9-13**] Discharge Date: [**2120-10-4**]
Date of Birth: [**2046-6-15**] Sex: M
Service: MEDICINE
Allergies:
Pneumovax 23 / Allopurinol / Hydralazine
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
percutaneous drain at the gallbadder
History of Present Illness:
Mr [**Known lastname 20608**] is a 74-year-old male who originally presented to an
OSH with on [**2120-8-4**] with cholecystitis and ascending cholangitis
as well as an NSTEMI; he was transferred urgently to [**Hospital1 18**] for
an ERCP. ERCP demonstrated gross pus in the stomach and spilling
from the papilla; a biliary stent was placed. He was treated
with Zosyn x 7 days. (8/12/008-8/19/08). A cholecystostomy tube
was placed percutaneously, and elective cholecystectomy was
deferred by general surgery until the near future. His LFTs
trended down throughout his stay.
.
The patient was discharged on [**2120-8-15**], and the tube fell out on
[**2120-8-16**] at [**Hospital3 **] facility. Per the patient and
his family, he began feeling ill 1-2 weeks prior to
presentation, with malaise and intermittant RUQ pain. He was
seen at [**Hospital3 15054**] [**Hospital1 107**] 5 days ago; per his family and the
surgical note, both an ultrasound and CT scan were unrevealing
for gallbladder disease. He was treated for hypoglycemia and
released.
.
On the day of admission he developed increasing abdominal pain
and erratic behavior per his wife. She did not note fevers at
home. Otherwise, he did not have chest pain, difficulty
breathing, increased lower extremity edema, vomiting, or
diarrhea at home. He did have nausea per his wife.
.
In the ED: initial vitals were: T 99.3, HR 86, BP 126/73, RR 20,
95% on RA. In the [**Last Name (LF) **], [**First Name3 (LF) **] U/S was concerning for acute
cholecystitis; perforated gallbladder or abscess could not be
excluded. Surgery was consulted; it was felt the patient was not
a surgical candidate, recommended perc drainage and admission to
MICU. Code sepsis was called; he was intubated for airway
protection (with etomidate and rocuronium), a central line was
placed for access. He was given vancomycin and Zosyn. He was
placed on propofol. He is admitted to the MICU for further
management.
.
Past Medical History:
cholecystitis with ascending cholangitis [**8-2**]
CAD s/p CABG [**2095**], redo CABG [**2105**]
s/p AAA repair
IDDM
CKD
gout
chronic systolic CHF
h/o GIB
Social History:
Retired managment consultant. Has 5 children. Nonsmoker, quit
over 20 years ago. No alcohol use.
Family History:
NC
Physical Exam:
VS: T 101.6 rectal, HR 95, BP 100/42, RR 20, 100% on vent
GEN: intubated, sedated. opens eyes to voice. does not follow
commands.
HEENT: pupils small but reactive bilaterally, sclerae anicteric,
tonuge slightly dry, tongue midline
CV: RRR, 2/6 systolic murmur at LUSB
PULM: coarse breath sounds at right base, no wheeze
ABD: distended but soft, midline surgical scar extending from
sternum to pubis, + [**Doctor Last Name **] on exam, abd otherwise nontender
EXT: dp pulses 1+ bilaterally, no edema
Pertinent Results:
[**2120-9-13**] 10:35PM TYPE-ART PO2-128* PCO2-38 PH-7.26* TOTAL
CO2-18* BASE XS--9
[**2120-9-13**] 10:35PM GLUCOSE-229*
[**2120-9-13**] 10:35PM freeCa-1.10*
[**2120-9-13**] 09:58PM COMMENTS-GREEN TOP
[**2120-9-13**] 09:58PM GLUCOSE-220* LACTATE-1.7 NA+-135 K+-5.0
CL--106 TCO2-17*
[**2120-9-13**] 09:45PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2120-9-13**] 09:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2120-9-13**] 09:45PM URINE RBC-0-2 WBC-[**2-28**] BACTERIA-MANY YEAST-NONE
EPI-0-2
[**2120-9-13**] 09:45PM URINE AMORPH-MANY
[**2120-9-13**] 07:56PM LACTATE-7.1* K+-5.8*
[**2120-9-13**] 05:53PM COMMENTS-GREEN TOP
[**2120-9-13**] 05:53PM LACTATE-1.2
[**2120-9-13**] 05:42PM GLUCOSE-178* UREA N-62* CREAT-2.8* SODIUM-134
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-21* ANION GAP-17
[**2120-9-13**] 05:42PM estGFR-Using this
[**2120-9-13**] 05:42PM ALT(SGPT)-27 AST(SGOT)-27 LD(LDH)-161 ALK
PHOS-266* TOT BILI-0.7
[**2120-9-13**] 05:42PM LIPASE-40
[**2120-9-13**] 05:42PM ALBUMIN-2.6* CALCIUM-8.8 PHOSPHATE-4.6*
MAGNESIUM-2.3
[**2120-9-13**] 05:42PM WBC-15.7* RBC-3.21* HGB-9.1* HCT-28.9* MCV-90
MCH-28.3 MCHC-31.4 RDW-14.0
[**2120-9-13**] 05:42PM NEUTS-85.1* LYMPHS-10.1* MONOS-4.1 EOS-0.6
BASOS-0.1
[**2120-9-13**] 05:42PM PLT COUNT-425
[**2120-9-13**] 05:42PM PT-16.4* PTT-32.0 INR(PT)-1.5*
[**2120-10-3**] 05:44AM BLOOD WBC-5.9 RBC-2.68* Hgb-7.7* Hct-24.5*
MCV-91 MCH-28.9 MCHC-31.6 RDW-15.0 Plt Ct-322
[**2120-9-21**] 04:30AM BLOOD Neuts-81.2* Lymphs-11.6* Monos-4.3
Eos-2.6 Baso-0.4
[**2120-10-3**] 05:44AM BLOOD Plt Ct-322
[**2120-10-3**] 05:44AM BLOOD PT-14.3* PTT-32.1 INR(PT)-1.2*
[**2120-10-3**] 05:44AM BLOOD Glucose-135* UreaN-26* Creat-1.4* Na-141
K-4.0 Cl-109* HCO3-28 AnGap-8
[**2120-10-3**] 05:44AM BLOOD Glucose-135* UreaN-26* Creat-1.4* Na-141
K-4.0 Cl-109* HCO3-28 AnGap-8
[**2120-10-3**] 05:44AM BLOOD ALT-10 AST-17 LD(LDH)-172 AlkPhos-116
Amylase-41 TotBili-0.5
[**2120-10-1**] 09:08PM BLOOD CK-MB-7 cTropnT-0.80*
[**2120-10-1**] 09:11AM BLOOD CK-MB-6 cTropnT-0.78*
[**2120-9-30**] 10:29AM BLOOD CK-MB-NotDone cTropnT-0.65*
[**2120-9-26**] 06:26AM BLOOD CK-MB-NotDone cTropnT-0.74*
[**2120-9-26**] 01:12AM BLOOD CK-MB-NotDone cTropnT-0.82*
[**2120-9-25**] 01:31PM BLOOD CK-MB-NotDone cTropnT-0.82*
[**2120-9-15**] 03:17AM BLOOD CK-MB-22* MB Indx-5.0 cTropnT-1.48*
[**2120-9-14**] 07:25PM BLOOD CK-MB-8 cTropnT-1.90*
[**2120-9-14**] 03:23PM BLOOD CK-MB-7 cTropnT-1.93*
[**2120-9-14**] 06:08AM BLOOD CK-MB-NotDone cTropnT-0.98*
[**2120-10-3**] 05:44AM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.2 Mg-1.9
[**2120-9-14**] 08:29AM BLOOD Cortsol-39.3*
[**2120-9-14**] 12:49AM BLOOD Hapto-420*
[**2120-10-3**] 09:35PM BLOOD Vanco-26.7*
[**2120-10-3**] 05:44AM BLOOD Vanco-33.8*
[**2120-10-2**] 09:37AM BLOOD Type-ART FiO2-35 pO2-112* pCO2-40 pH-7.45
calTCO2-29 Base XS-3 Intubat-NOT INTUBA Comment-NEBULIZER
Brief Hospital Course:
74M with recent admission for cholecystitis and ascending
cholangitis s/p perc tube placement with
Lactobacillus/Citrobacter sepsis now with resolved sepsis
# Cholecystitis/Septic shock: Signs and symptoms of septic shock
resolved. Has defervesced on Vanco/Meropenem. Cholecystitis is
most likely source of sepsis given improvement on antibiotics.
Blood cultures showing lactobacillus and Citrobacter Freundii
with repeat blood cx NGTD and wound cx from gallbladder grwoing
Citrobacter and Enteroccoccus. Hemodynamically stable.
Percutaneous cholecystostomy tube was not draining anymore so
was replaced for 12 gauge but still not draining. Repeat US on
[**9-26**] again shows increasing distension and no change in debris
collection despite larger drain. IR was unable to offer any
additional therapy. Two surgical attendings have been consulted
regarding surgery and determined that he is too high risk, and
should be managed conservatively although surgery could be
performed if very aggressive care was wanted by family and
patient with understanding he had high intra op mortality risk.
Ultimately patient and family decided he would like to go home
with VNA and bridge towards hospice. This was arranged for him.
# Poor mental status and neurological deficits: Pt w/ multiple
CNS deficits in brain, and spinal cord, unclear etiology though
Neurology suggests that the spinal lesions are likely infarcts
[**1-27**] hypoperfusion, whereas some of the brain lesions are most
likely embolic. mental status improved during hospitalization
and he had capacity and alertness by time of discharge.
# Chest Pain: Pt had previous complaints of CP similar to CP he
has at home. He has recent h/o NSTEMI. Possibly etiologies
include UA, GI etiologies such as DES, GERD, PTX, PE. He was
given Nitro with good effect, resolution. CP now resolved.
Biomarkers trending down. No PTX on CXR. No further CP.
Continued beta [**Last Name (LF) 7005**], [**First Name3 (LF) **]. Likely recurrent NSTEMI in setting
of demand ischemia.
# Acute renal failure s/p CVVH for hyperkalemia: Creatinine has
been stable at 1.5-1.6, unclear baseline.
# RUE Swelling: Some RUE swelling noted on [**9-28**] with 2+ pitting
edema in the right hand. RUE US to assess for DVT negative.
Swelling improved on [**9-28**]
Medications on Admission:
Metoprolol 25 mg TID
Zolpidem 5 mg HS
Aspirin 325 mg daily
Lipitor 10 mg daily
Prazosin 5 mg daily
Pantoprazole 40 mg daily
Tylenol-Codeine #3 300-30 mg Tq6H PRN
Bisacodyl PRN
Insulin Lispro sliding scale
Heparin SC
Docusate
Senna
Lisinopril 5 mg daily
Amlodipine 5 mg daily
Lasix 20 mg [**Hospital1 **]
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Morphine Concentrate 20 mg/mL Solution Sig: 5 - 20mg PO q2h
as needed for pain or dyspnea.
Disp:*qs for 4 wks * Refills:*0*
5. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain/fever .
6. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY
(Daily) as needed for constipation.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous every
twenty-four(24) hours.
Disp:*qs for 1 month* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
16. equipment
1 full electric hospital bed
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
18. equipment
1 air mattress
19. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
20. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: [**12-27**]
Sublingual every four (4) hours as needed for secretions.
Disp:*qs 1 mo supply* Refills:*0*
21. Haloperidol 0.5 mg Tablet Sig: 1 - 4 Tablet PO every four
(4) hours as needed for anxiety, delerium.
Disp:*qs for 1 mo Tablet(s)* Refills:*0*
22. Ativan 0.5 mg Tablet Sig: 1 -4 Tablets PO every four (4)
hours as needed for anxiety.
Disp:*qs for 1 mo supply Tablet(s)* Refills:*0*
23. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1)
Transdermal once a day.
Disp:*15 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 4485**] Home Care
Discharge Diagnosis:
Primary Diagnosis:
- Cholangitis
- Sepsis
- Stroke to brain and thoracic spine
Secondary Diagnosis:
- CAD s/p CABG [**2095**], redo CABG [**2105**]
- AAA repair
- Diabetes
- Chronic kidney disease
- gout
- chronic systolic CHF
Discharge Condition:
afebrile, vitals stable, A&Ox3
Discharge Instructions:
You had sepsis and cholangitis, which is infection of the
gallbladder, and also developed a stroke while inpatient. Your
infection was treated with antibiotics. You will be discharged
with home services, and with a transition to hospise.
Followup Instructions:
If you have any questions/concerns please call your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] ([**Telephone/Fax (1) 250**]).
Completed by:[**2120-10-24**]
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icd9pcs
|
[
[
[]
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11125, 11186
|
6158, 8452
|
316, 355
|
11458, 11491
|
3183, 6135
|
11778, 11957
|
2642, 2647
|
8807, 11102
|
11207, 11207
|
8478, 8784
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11515, 11755
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2662, 3164
|
262, 278
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383, 2332
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11308, 11437
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11226, 11287
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2354, 2511
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2527, 2626
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,643
| 194,605
|
4429
|
Discharge summary
|
report
|
Admission Date: [**2107-7-20**] Discharge Date: [**2107-7-24**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Shortness of [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68 yo M with COPD (home O2 requirement= 4LNC) requiring multiple
ICU admissions (three in the last 2 months) and intubations,
hypertension, coronary artery disease, GERD and diverticulosis
with hospitalization in [**2-14**] for presumed diverticular bleed p/w
hematochezia this morning. He was discharged most recently on
[**7-12**] after COPD flare was treated with short burst of steroids
before dropping down to his home dose of 20mg prednisone. He
reports 1 episode of crampy abdominal pain with 2-3 episodes
BRBPR this morning around 4-6am precipitating presentation to
ED.
.
In the ED, initial vs were: 98.5, 90/50, 96, 16, 97% on RA. His
lowest BP [**Location (un) 1131**] was 84/50. He received 1L NS and had one
peripheral IV and a triple lumen CVL placed in the right IJ.
His Hct was elevated from baseline of 30-33 at 39. GI was called
in the ED; planned to admit to MICU for serial HCTs and
potentially a scope. Two units of blood were crossmatched.
Vitals prior to transfer were 98.7 80 95/47 24 100% 4L NC.
.
On arrival to the MICU pt denied any pain. He stated his
breathing was at baseline. No chest pain. No lightheadedness
with ambulation. Abdominal pain resolved. He did have 1 further
small episode of BRBPR in the ICU. He reported eating West
Indian food yesterday which he notes will sometimes upset his
stomach. Eats multiple seeded fruits as well. Typically is
constipated, had diarrhea this am. He denies EtOH or NSAID use.
Otherwise ROS unremarkable. NGL performed at bedside with 200cc
instilled, bilious gastic contents removed, no blood or coffee
grounds.
Past Medical History:
- NSTEMI with Troponin 12 ([**2101**]); cath ([**2103**]), however, showed
normal coronaries. TTE ([**8-/2103**]) showed mild RV enlargement and
preserved BiV function
- ?Pulmonary HTN (not documented on TTE or cath)
- COPD, 4L NC at home with nightly BiPAP 12/5
- Hypertension
- Hyperlipidemia (but last cholesterol in [**2105**] showed
HDL 62, LDL 58)
- Iron-deficiency anemia (baseline Hct 29-31)
- GERD
- Diverticulosis
- Hemorrhoids
- UTIs with VRE and Pseudomonas
- Chronic low back pain s/p L1-L2 laminectomy
- s/p bilateral cataract surgery
- Benign prostatic hyperplasia s/p TURP
- h/o pseudomonas and MRSA infections
Social History:
Originally from [**Country 7936**]. Lives with his wife in [**Location (un) 686**]; her
health is good. Has children who live in the area. Retired
mechanic.
T - 20 pack year history, quit at age 37
A - Occasional
D - Prior marijuana use
Family History:
Father with [**Name2 (NI) 499**] cancer diagnosed in his 70s. Mother with
[**Name (NI) 2481**].
Physical Exam:
On admission to MICU
Vitals: T:98.1 BP:113/50 P:91 R:19 O2:93% 4L
General: Somnolent but easily arousable. Oriented. Pleasant.
NAD. Pursed lip breathing which per pt is his baseline.
HEENT: Sclera anicteric, MMM, oropharynx clear.
Neck: supple, JVP not elevated, no LAD. RIJ in place.
Lungs: Decreased air exchange. No wheezes or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. External
rectal exam with skin tag at 6o'clock and fresh blood in
perirectal area.
Ext: Thin. Warm. No edema. Skin tear on dorsum of right hand.
On admission to CC7
PE:
VS T98.4 HR95 BP120/58-128/62 RR20-28 99%4L (4L at baseline)
Gen: NAD, pleasant, A&OX3
Neck: Soft, supple
CV: RRR, no m/g/r, nl S1/S2
Pulm: CTAB, decreased [**Name (NI) 1440**] sounds, poor inspiratory effort
GI: nt/nd, soft, +BS
Ext: no cyanosis/ecchymosis/edema, =DP/PT pulses
Pertinent Results:
[**2107-3-2**] Colonoscopy:
Impression: Diverticulosis of the whole [**Month/Day/Year 499**]
Otherwise normal colonoscopy to cecum
Recommendations: No identifiable bleeding diverticulum.
If bleeding recurs, consider tagged red blood scan, angiogram,
discuss with Surgery.
.
CXR: (My read) Hyperinflated lungs, no infiltrate or effusion.
No PTX. Flattened diaphragms. R CVL in SVC.
.
LABS ON ADMISSION to MICU:
[**2107-7-20**] 06:55AM BLOOD WBC-15.5* RBC-4.56*# Hgb-12.0*#
Hct-39.5*# MCV-87 MCH-26.4* MCHC-30.4* RDW-14.7 Plt Ct-371
[**2107-7-21**] 03:20AM BLOOD WBC-13.0* RBC-3.17*# Hgb-8.3*# Hct-27.6*
MCV-87 MCH-26.3* MCHC-30.2* RDW-14.7 Plt Ct-287
.
[**2107-7-20**] 06:55AM BLOOD PT-11.4 PTT-26.8 INR(PT)-0.9
.
[**2107-7-21**] 03:20AM BLOOD Glucose-108* UreaN-13 Creat-0.6 Na-142
K-4.5 Cl-109* HCO3-27 AnGap-11
.
[**2107-7-20**] 06:55AM BLOOD CK(CPK)-46
[**2107-7-20**] 06:55AM BLOOD cTropnT-<0.01
[**2107-7-20**] 06:55AM BLOOD CK-MB-NotDone proBNP-140
.
[**2107-7-21**] 03:20AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.9
.
LABS ON ADMISSION TO FLOOR:
CBC:
85
15.8 > 8.6 < 248
26.5 <-- 22.5, 25.6, 23.0, 28.4, 27.6, 29.2, 29.6,...
39.5
.
134 | 95 | 17 /
-------------- 84
4.7 | 34 | 0.6 \
.
CK 130
MB 6
Trop < 0.01
.
Hct 22.5 <-- 25.6 <-- 23.8 <-- 28.4 <-- 27.6 <--39.5 <-- 29.8
(1
week earlier)
Brief Hospital Course:
This is a 68 yo male with extensive history of hospitalizations
for COPD exacerbation as well as multiple lower GI bleeds
admitted for hematochezia.
.
# Hematochezia: likely diverticular bleed given history of
signficant diverticula. He has had 1 prior hospitalization for
a lower GI bleed in [**2-14**] for which only sources identified on
scope were diverticula. Other potential etiologies include
internal hemorrhoids. Colonic mass is less likely given
multiple prior scopes in past 9 years. Upper GI bleed less
likely given absence of [**Date Range **] and clear nasogastric lavage. Is
on chronic steroids so is at risk for gastritis. Given no prior
source definitively identified previously, small bowel sources
are also possible. Was transfused 1 unit pm [**7-22**] for
persistantly low but stable Hct.
Had one episode of maroon stool early morning on [**7-22**]; since
then, he had one episode of "trickling" blood on [**7-23**]. No
bleeding after that. Throughout this hospital course, patient
had one 20G peripheral IV in place. IV PPI was started in the
MICU and patient transitioned to home PPI PO dose upon arrival
to floor. Stool cultures were done [**2-7**] crampy bowel movmements,
which came back negative.
.
-GI was consulted in the MICU, no intervention now due to
patient's known history of diverticulosis, confirmed on recent
colonoscopy ([**2107-3-2**]). Due to recurrent episodes of
hematochezia, colectomy/partial colectomy was discussed in MICU
to reduce future bleeding risk. But given the extensive
distribution of his diverticulosis, a segmental resection may
not be curative and a total colectomy would carry increased
morbidity. Per GI recs, should patient have another bleed, a
bleeding scan should be done (despite relatively poor accuracy)
to better localize soruce of bleeding. This may aide
interventional treatment, guide resection localization. Home
aspirin was held due to the bleed. Patient was hemodynamically
stable in the MICU and transferred out to the floor, where he
remained hemodynamically stable until discharge. Hematocrit
q6hrs per GI in MICU --> q8hrs on CC7. Hematocrit stabilized on
[**2107-7-23**] (26.5 --> 28.7 --> 30.4 --> 27.8 --> 29.2)
.
# sustained VT: Pt had 16 seconds ventricular tachycardia with
mild chest "tightness" and SOB overnight [**7-21**]. When asked where,
pointed more towards his neck. Started on nebulizers and got
EKG, cardiac enzymes and electrolytes. SOB and "tightness"
quickly resolved. Felt not very likely to have an MI. Cardiac
enzymes came back negative X2. Lytes were normal. Patient does
not have a history of VT and last ECHO done in [**2103-8-6**]. No
more episodes of VT in MICU or on the floor. Patient was advised
to follow up on this with an ECHO or stress test as an
outpatient. His PCP is [**Name Initial (PRE) 12309**].
.
# COPD. Remained at baseline (4L O2) throughout this hospital
course. Patient was continued on home dose steroids, tiotropium,
albuterol nembulizers as needed. Continued calcium, vitamin D
and alendronate.
.
Medications on Admission:
Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Q2H as needed for
shortness of [**Name Initial (PRE) 1440**], patient request
Alendronate 70 mg Tablet QMON
Aspirin 325 mg Tablet DAILY
Calcium Carbonate 500mg TID
Camphor-Menthol 0.5-0.5 % Lotion qid prn
Cholecalciferol (Vitamin D3) 400 unit Tablet DAILYDocusate
Sodium 100 mg Capsule twice a day as needed
Lactulose 10 gram/15 mL Syrup 30ML every eight (8) hours as
needed
Lorazepam 0.5 mg Tablet at bedtime as needed for insomnia
Montelukast 10 mg DAILY
Morphine 15 mg Tablet Sustained Release q12
Omeprazole 20 mg Capsule DAILY
Oxycodone-Acetaminophen 5-325 mg Tablet every six (6) hours as
needed
Pravastatin 20 mg Tablet DAILY
Prednisone 20 mg Tablet daily
Sennosides [Senna] 8.6 mg Tablet
Tiotropium Bromide 18 mcg Capsule, DAILY
Trimethoprim-Sulfamethoxazole 160-800 mg Tablet 3X/WEEK
(MO,WE,FR).
.
Allergies: Levofloxacin
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB, wheeze.
2. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
11. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
14. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO
every eight (8) hours as needed for constipation.
15. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Acute Blood Loss Anemia
Lower Gastrointestinal Bleeding
Secondary:
Chronic Obstructive Lung Disease
Iron deficiency anemia
Benign prostatic hypertrophy
Hypertension
Gastroesophageal Reflux Disorder
Discharge Condition:
Improved. Vital signs are stable. Patient is hemodynamically
stable.
Discharge Instructions:
You were admitted with a lower GI bleed. You received one unit
of red blood cells and you stopped bleeding. Your breathing was
at baseline throughout this admission. You had an episode of a
fast heart rhythm which should be followed-up on with your
primary care physician. [**Name10 (NameIs) **] should discuss the need for a stress
test of your heart with him.
.
One of your labs, you white blood cell count, came back
elevated; this may be due to the fact that you take prednisone
for your breathing. You should follow-up on your white blood
cell counts with your primary physician.
.
Your medications were unchanged.
.
If you develop further bleeding, or shortness of [**Name10 (NameIs) 1440**], please
call your doctor and return to the hospital.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"V15.82",
"496",
"562.10",
"285.1",
"724.2",
"562.12",
"V13.02",
"416.8",
"412",
"V58.65",
"512.1",
"280.9",
"427.1",
"530.81",
"414.01",
"V46.2",
"455.6",
"272.4",
"401.9",
"V12.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10734, 10792
|
5293, 8328
|
305, 311
|
11044, 11115
|
3968, 5270
|
2852, 2950
|
9251, 10711
|
10813, 11023
|
8354, 9228
|
11139, 12013
|
2965, 3949
|
229, 267
|
339, 1930
|
1952, 2581
|
2597, 2836
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
534
| 193,417
|
53799
|
Discharge summary
|
report
|
Admission Date: [**2124-1-31**] Discharge Date: [**2124-2-9**]
Date of Birth: [**2056-10-29**] Sex: F
Service:
ADMISSION DIAGNOSIS: Bicuspid aortic valve and aortic
stenosis.
DISCHARGE DIAGNOSES:
1. Bicuspid aortic valve and aortic stenosis.
2. Status post aortic valve replacement with
[**Last Name (un) 3843**]-[**Doctor Last Name **] valve.
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
woman with a known congenital bicuspid aortic valve who has
now developed a critical stenosis. She presents with a
presyncopal episode.
The patient had a transthoracic echocardiogram in [**2123-12-5**] which demonstrated an increased peak aortic gradient of
77 mmHg. Following a second presyncopal episode, the patient
underwent cardiac catheterization in [**2124-1-5**] which
showed a calculated aortic valve area of 0.7 cm2 and a
relatively preserved ejection fraction of 50%.
The patient subjectively reports progressive fatigue and mild
dyspnea on exertion times several months. No shortness of
breath, chest pain, paroxysmal nocturnal dyspnea, or
orthopnea.
PAST MEDICAL HISTORY:
1. Bicuspid aortic valve.
2. Asthma.
3. Factor [**Doctor First Name 81**] deficiency.
4. Hypertension.
5. Hypercholesterolemia.
6. Polymyalgia rheumatica.
7. Osteoarthritis.
8. Status post appendectomy.
9. Status post left knee arthroscopy.
10. Status post left donor nephrectomy.
11. Status post tubal ligation.
12. Status post incisional hernia repair.
13. Left bundle-branch block.
ALLERGIES: PENICILLIN (gives swelling). CONTRAST DYE (gives
hives).
MEDICATIONS ON ADMISSION:
1. Prednisone 6 mg p.o. q.d.
2. Fosamax 70 mg p.o. every Thursday.
3. Singulair 10 mg p.o. q.d.
4. Hydrochlorothiazide 12.5 mg p.o. q.d.
5. Combivent as needed.
6. Advair as needed.
7. Vitamin E.
8. Vitamin C.
9. Calcium.
10. Multivitamin supplement.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was an
elderly woman in no acute distress. Head, eyes, ears, nose,
and throat examination revealed normocephalic and atraumatic.
Pupils were equal, round, and reactive to light. Extraocular
movements were intact. Sclerae were anicteric. The throat
was clear. The neck was supple without lymphadenopathy or
masses. The chest was clear to auscultation bilaterally.
Cardiovascular examination revealed a regular rate and rhythm
with a 3/6 systolic ejection murmur. The abdomen was soft,
nontender, and nondistended, without masses or organomegaly.
Extremities were warm. Not cyanotic and not edematous times
four. Neurologic examination was intact.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission
laboratories revealed complete blood count with a white blood
cell count of 9.1, hematocrit was 35.9, and platelets were
311. Chemistries revealed sodium was 140, potassium was 4,
chloride was 103, bicarbonate was 28, blood urea nitrogen was
16, creatinine was 0.7, and blood glucose was 108. ALT was
37, AST was 26, alkaline phosphatase was 56, total bilirubin
was 0.2. Prothrombin time was 12, INR was 1, and partial
thromboplastin time was 37.3. Urinalysis was negative.
RADIOLOGY/IMAGING: A chest x-ray showed no acute process.
HOSPITAL COURSE: The patient was admitted for semi-elective
aortic stenosis repair.
Preoperatively, the patient was evaluated for her factor [**Doctor First Name 81**]
deficiency and was cleared by the Hematology/Oncology Service
in order for surgery. They investigated the past records
surrounding her past surgeries; including her donor
nephrectomy as well as knee arthroscopy, and made the
suggestion for a bioprosthetic valve to be preferential.
They also remarked that postoperative bleeding may be a
significant complication. They did note, however, that she
had tolerated her past surgeries very well.
On [**2124-2-1**], the patient underwent aortic valve
replacement (minimally invasive) with a 21-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] valve.
The patient tolerated the procedure well and was transferred
to the Postanesthesia Care Unit with Levophed and propofol
drips. There was some bleeding in the case, and the patient
was transfused 9 units of fresh frozen plasma and 1 unit of
packed red blood cells in the operating room.
In the Unit, the patient was started on a nitroglycerin drip
and propofol was increased. The patient was extubated in the
evening on postoperative day zero.
On postoperative day one, the patient had her Nipride drip
weaned off as well as beginning moving to the chair with
assistance. Here, it was noted that she had an approximately
20-beat run of ventricular tachycardia which was asymptomatic
and spontaneously resolved. The patient was sleeping while
this occurred.
On the following days on the floor, the patient continued to
work with Physical Therapy in regaining her strength and
mobility.
On the evening on postoperative day three, the patient had
another short 7-beat run of ventricular tachycardia. Again,
she was sleeping and symptomatic. Cardiology was consulted
for evaluation and had no changes in management to recommend.
The patient stayed on the floor and worked again with
Physical Therapy and was ambulating quite well.
On the evening on postoperative day six, the patient again
had two short runs of ventricular tachycardia of
approximately 6 beats and 4 beats while she was sleeping.
The patient was clinically asymptomatic. The
Electrophysiology Service was consulted and had no further
recommendations. They stressed only continuing beta blockade
with metoprolol as we were doing.
On the evening on postoperative day seven, the patient had a
short run of supraventricular tachycardia. Again, the
patient was asymptomatic.
DISCHARGE DISPOSITION: On postoperative day eight, the
patient was discharged to home tolerating a regular diet,
adequate pain control on oral pain medications, and having no
more presyncopal events.
PHYSICAL EXAMINATION ON DISCHARGE: Physical examination on
discharge revealed the patient was in no acute distress. The
chest was clear to auscultation bilaterally. No sternal
click. No drainage from the incision site. A regular rate
and rhythm without murmurs, rubs, or gallops. There was 1+
pedal edema bilaterally.
PERTINENT LABORATORY VALUES ON DISCHARGE: Laboratories on
discharge revealed complete blood count with white blood cell
count of 11, hematocrit was 31.6, and platelets were 333.
Chemistry panel revealed sodium was 141, potassium was 4.7,
chloride was 100, bicarbonate was 30, blood urea nitrogen was
19, creatinine was 0.9, and blood glucose was 91. Magnesium
was 2.1.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Percocet 5/325 p.o. as needed.
3. Colace 100 mg p.o. b.i.d.
4. Prednisone 6 mg p.o. q.d.
5. Singulair 10 mg p.o. q.h.s.
6. Lasix 20 mg p.o. b.i.d. (times seven days).
7. Potassium chloride 20 mEq p.o. b.i.d. (times seven
days).
8. Lopressor 25 mg p.o. b.i.d.
9. Combivent 1 to 2 puffs inhaled q.4-6h. as needed.
10. Oxazepam 5 mg to 10 mg p.o. q.h.s. as needed.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home with [**Hospital6 3429**].
DISCHARGE DIET: Discharge diet is cardiac.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient should follow up with Cardiology (Dr. [**First Name (STitle) **]
in one to two weeks.
2. The patient should follow up with Dr. [**Last Name (STitle) 1537**] in four weeks;
address the need for diuretics and cardiac medications.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2124-2-9**] 16:22
T: [**2124-2-9**] 16:31
JOB#: [**Job Number 110405**]
|
[
"725",
"401.9",
"286.2",
"V45.73",
"746.4",
"493.90",
"424.1",
"780.2",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"89.68",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
5738, 5937
|
214, 365
|
6641, 7063
|
1620, 3194
|
3212, 5714
|
7266, 7792
|
149, 193
|
7078, 7233
|
6284, 6614
|
394, 1092
|
1115, 1593
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,999
| 127,232
|
4701
|
Discharge summary
|
report
|
Admission Date: [**2164-3-22**] Discharge Date: [**2164-4-4**]
Date of Birth: [**2098-10-3**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Obstructive jaundice
Major Surgical or Invasive Procedure:
1. Pylorus preserving pancreaticoduodenectomy.
2. Staging laparoscopy.
3. Gold seeds fiducial placement for cyber knife
radiotherapy.
History of Present Illness:
This 65-year-old gentleman was
recently referred to me through Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for
treatment of a pancreatic head mass causing obstructive
jaundice. This gentleman is a life long amputee from
childhood who has coronary artery disease and peripheral
vascular disease as well. His cardiac workup preoperatively
showed a near occluded right coronary artery but an open,
left-sided vasculature. He was cleared by his cardiologist to
proceed with a Whipple's pancreaticoduodenectomy that would
be required for his obstructive head mass. Endoscopy and
stenting has occurred already by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Past Medical History:
CAD, s/p MI, angioplasty, stents x3
s/p L AKA w/ prothesis from train accident, age 9; s/p revision
hypercholesterolemia
s/p CCY
s/p appy
s/p double mastoidectomy
HTN
tinnitus
chronic pain
Social History:
Pt lives alone and is unemployed. Smokes one pack per day,
occasional EtOH, marijuana occasionally.
Family History:
no family h/o cancers or pancreatitis
Physical Exam:
On discharge:
96.8 64 116/69 18 98% RA
NAD, A&Ox3
RRR
CTAB
soft, NT/ND
wound- c/d/ismall amount of serous drainage from the lateral
aspect.
no LE edema
Pertinent Results:
[**2164-3-22**] 05:14PM BLOOD WBC-12.7*# RBC-3.63* Hgb-11.7* Hct-33.1*
MCV-91 MCH-32.1* MCHC-35.3* RDW-13.4 Plt Ct-248
[**2164-3-23**] 03:00AM BLOOD WBC-14.5* RBC-3.51* Hgb-11.1* Hct-32.2*
MCV-92 MCH-31.5 MCHC-34.4 RDW-13.4 Plt Ct-228
[**2164-4-2**] 09:56AM BLOOD WBC-10.3 RBC-3.04* Hgb-9.6* Hct-27.6*
MCV-91 MCH-31.6 MCHC-34.8 RDW-13.0 Plt Ct-567*
[**2164-4-3**] 05:10AM BLOOD WBC-11.3* RBC-3.29* Hgb-10.3* Hct-29.5*
MCV-90 MCH-31.3 MCHC-34.8 RDW-13.3 Plt Ct-593*
[**2164-4-4**] 05:25AM BLOOD WBC-9.5 RBC-3.00* Hgb-9.4* Hct-27.5*
MCV-92 MCH-31.5 MCHC-34.4 RDW-13.4 Plt Ct-589*
[**2164-4-4**] 05:25AM BLOOD Plt Ct-589*
[**2164-4-2**] 09:56AM BLOOD PT-11.9 PTT-24.0 INR(PT)-1.0
[**2164-3-22**] 05:14PM BLOOD Glucose-158* UreaN-20 Creat-1.1 Na-141
K-4.8 Cl-109* HCO3-19* AnGap-18
[**2164-3-23**] 03:00AM BLOOD Glucose-240* UreaN-18 Creat-1.0 Na-136
K-3.6 Cl-109* HCO3-19* AnGap-12
[**2164-4-3**] 05:10AM BLOOD Glucose-104 UreaN-13 Creat-0.9 Na-133
K-4.9 Cl-101 HCO3-23 AnGap-14
[**2164-4-4**] 05:25AM BLOOD Glucose-98 UreaN-13 Creat-1.1 Na-135
K-4.6 Cl-100 HCO3-25 AnGap-15
[**2164-3-26**] 09:19AM BLOOD ALT-14 AST-32 CK(CPK)-257* AlkPhos-182*
Amylase-18 TotBili-0.4
[**2164-3-26**] 04:12PM BLOOD CK(CPK)-269*
[**2164-3-30**] 12:33AM BLOOD CK(CPK)-64
[**2164-3-26**] 09:19AM BLOOD Lipase-9
[**2164-3-28**] 01:50AM BLOOD Lipase-9
[**2164-3-26**] 09:19AM BLOOD Albumin-2.6* Calcium-7.8* Phos-2.3*
Mg-1.4*
[**2164-3-27**] 03:45AM BLOOD Calcium-7.6* Phos-2.8 Mg-2.1
[**2164-4-2**] 09:56AM BLOOD Calcium-7.7* Phos-2.9 Mg-1.9
[**2164-4-4**] 05:25AM BLOOD Calcium-8.1* Phos-4.4 Mg-1.9
Brief Hospital Course:
Pt taken to operation on [**2164-3-22**] and tolerated well. Pain
controlled with epidural, had some confusion. POD 1 PO meds
started, on Whipple pathway. POD 5 pt became more confused and
somnolent and had an increasing O2 requirement, had post-op
atelectasis and was transferred to the SICU. Pt started on TPN.
CXR [**3-28**]:
There are low lung volumes and the image taken is supine
lordotic. There is no evidence of vascular congestion. There is
interval development of left basilar atelectasis. Small left
pleural effusion is also seen. The lungs are clear.
Pt had another event of confusion, [**Month (only) **]. O2 and inc. CO2.
Sedated and intubated. Given fluids for post-op hypovolemia
Echo [**3-29**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF 70%). Due to
suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. 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 but aortic
stenosis is not
present. No masses or vegetations are seen on the aortic valve.
No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There
is no mitral valve prolapse. No mass or vegetation is seen on
the mitral
valve. Trivial mitral regurgitation is seen. The pulmonary
artery systolic
pressure could not be determined. No vegetation/mass is seen on
the pulmonic
valve. There is no pericardial effusion. The absence of a
vegetation by 2D
echocardiography does not exclude endocarditis if clinically
suggested.
POD 9 pt extubated. Wound culture +MRSA, Vanc and Zosyn.
POD 12 regular diet, TPN stopped. Rehab screened and cleared
for home w/ PT.
POD 13 pt d/c'd to home.
Medications on Admission:
ASA 325, atenolol 50', duragesic patch 100, percs, lipitor 40',
lisinopril 10', neurontin 900''', secobarbitol 200 hs, valium
40HS, zantac 150"
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
.
Home meds
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
pancreatic adenocarcinoma
Discharge Condition:
Good
Discharge Instructions:
Resume your regular medications. Take all new medications as
directed. Do not drive while taking narcotics.
You may shower. Allow water to run over the wound, but
do not scrub. Pat the wound dry. Leave the steri-strips in
place, they will fall off on their own. Do not take a bath or
swim
until after follow-up appointment. No heavy lifting (> 10 lbs)
for 6 weeks.
Please call your doctor or return to the ER if you experience:
-Fever (> 101.4)
-Inability to eat/drink or persistant vomiting
-Increased pain
-Redness or discharge from your wound
-Other symptoms concerning to you
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in one week. Call his office,
([**Telephone/Fax (1) 2363**], to arrange the appointment.
|
[
"285.1",
"577.1",
"196.2",
"518.0",
"157.0",
"272.0",
"401.9",
"276.52",
"V45.82",
"412",
"414.01",
"V49.76"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"52.7",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5652, 5715
|
3336, 5194
|
286, 422
|
5785, 5792
|
1736, 3313
|
6423, 6568
|
1502, 1541
|
5388, 5629
|
5736, 5764
|
5220, 5365
|
5816, 6400
|
1556, 1556
|
1570, 1717
|
226, 248
|
450, 1156
|
1178, 1368
|
1384, 1486
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,976
| 138,114
|
42876
|
Discharge summary
|
report
|
Admission Date: [**2163-2-8**] Discharge Date: [**2163-3-3**]
Date of Birth: [**2094-10-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2163-2-14**] 1. Aortic valve replacement with a 21-mm St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 4041**] tissue valve. 2. Coronary artery bypass grafting x4
with the left internal mammary artery to the left anterior
descending artery, and reverse saphenous vein graft to the
posterior descending artery, and sequential reverse saphenous
vein graft to the first obtuse marginal artery and the distal
circumflex artery.
History of Present Illness:
68 year old male with severe aortic stenosis was transferred
from [**Hospital6 5016**] for further management of severe
aortic stenosis and three vessel disease. He was admitted to
[**Hospital3 **] in [**12-23**] with symptoms of wheezing and shortness of
breath. Reportedly, he was found to have an STEMI and was in
acute sCHF - cath showed 3VD and TTE with EF 25%. He experienced
Vfib arrest while in the hospital - ICD was subsequently placed.
He was evaluated for possible AVR/CABG but was thought to be too
high risk due to calcified aorta. He was set-up with [**Hospital1 2025**] for
evaluation for percutaneous valve replacement but has not been
evaluated by them yet and states that they were not able to
accomodate him quickly enough. He was readmitted to [**Hospital3 **]
on [**2-6**] with recurrence of wheezing, shortness of breath, cough
- less severe than in [**Month (only) 404**] per him. He was diuresed there
with Lasix 40 mg IV BID with resolution of his symptoms and his
AceI was decreased. He feels back to his usual self now except
for cold symptoms. He is now being referred to cardiac surgery
for surgical evaluation for aortic valve replacement and
revascularization.
Past Medical History:
Coronary artery disease s/p MI, stent to LCx in [**2152**] ([**Hospital3 5097**])
Severe Aortic Stenosis (valve are 0.58 cm, mean gradient 31
mmHg)
Hyperlipidemia
Hypertension
Peripheral vascular disease
Congestive heart failure 25-30%
Diabetes M2 since early [**2140**]
Carotid stenosis
s/p Vfib arrest in [**12-23**]
Glaucoma
s/p repair of R femoral artery pseudoaneurysm after site became
infected in [**2152**]
s/p inguinal hernia repair
s/p cholecytectomy
Social History:
Lives with his wife and son. [**Name (NI) **] 2 children.
tobacco: smoked for ~ 6 months in his youth
EtOH: h/o heavy EtOH in his 50s, none recently
Family History:
brother died age 52 of heart disease
sister died of CHF at age 61
mother died age 77 cirrhosis
father died at 60 w/ DM and heart disease
younger brother also with heart disease
Physical Exam:
Pulse:92 Resp:18 O2 sat:97/RA
B/P 139/89
Height:64" Weight:70.1 kgs
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade II/VI holosystotic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: dop Left: dop
Radial Right: palp Left: palp
Pertinent Results:
ADMISSION LABS
[**2163-2-9**] 03:30AM BLOOD WBC-7.1 RBC-4.66 Hgb-11.6* Hct-34.4*
MCV-74* MCH-24.9* MCHC-33.6 RDW-15.7* Plt Ct-154
[**2163-2-9**] 03:30AM BLOOD PT-12.8* PTT-30.6 INR(PT)-1.2*
[**2163-2-9**] 03:30AM BLOOD Glucose-131* UreaN-20 Creat-0.8 Na-136
K-4.0 Cl-98 HCO3-29 AnGap-13
[**2163-2-9**] 03:30AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.2
.
OTHER PERTINENT LABS
[**2163-2-10**] 04:20AM BLOOD ALT-12 AST-27 LD(LDH)-282* AlkPhos-105
TotBili-0.8
[**2163-2-10**] 04:20AM BLOOD %HbA1c-5.9 eAG-123
[**2163-2-12**] 09:08PM BLOOD TSH-4.1
.
MICRO
[**2163-2-10**] 01:36PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2163-2-10**] 01:36PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.0 Leuks-NEG
.
IMAGING
[**1-/2080**] PANOREX
No peri-apical lucency to suggest dental infection. Clear
maxillary sinuses.
.
[**1-/2080**] CXR
FINDINGS: No previous images. The heart is normal in size and
there is no substantial vascular congestion or acute focal
pneumonia or pleural effusion.
Single channel ICD line extends to the region of the apex of the
right ventricle.
.
[**1-/2080**] CT TORSO
CHEST CT: In the left upper lobe, there is a 6-mm pulmonary
nodule (2:15). An additional 4-mm nodule is seen in the right
lower lobe (2:28). More inferiorly in the right lower lobe,
there is a tiny calcified granuloma (2:39). There is minimal
bibasilar atelectasis, left greater than right.
There are no pleural effusions. The airways are patent to the
subsegmental levels bilaterally.
There is extensive calcification throughout the thoracic aorta,
denser in the ascending portion and along the arch. Marked
aortic valve calcifications are seen. There is severe
calcification of the coronary arteries. The visualized portion
of the thyroid gland is unremarkable. Small calcified left hilar
lymph nodes measure up to 7 mm (2:23), consistent with prior
granulomatous disease. There are no pathologically enlarged
mediastinal, hilar, or axillary lymph nodes. There is no
pericardial effusion. Note is made of a left-sided pacemaker
with a right ventricular lead.
ABDOMEN CT: Lack of intravenous contrast material limits
assessment of the abdominal organs. The liver is grossly
unremarkable. The patient is status post cholecystectomy. The
spleen, pancreas, adrenal glands, and kidneys are unremarkable.
The stomach, small bowel, colon, and appendix are grossly
normal. There are extensive calcifications throughout the
abdominal aorta, including at the origins of the celiac axis,
SMA, renal arteries, and [**Female First Name (un) 899**].
Calcifications are also seen throughout the iliac arteries
bilaterally. The abdominal aorta is normal in caliber. There is
no free fluid or free air in the abdomen. No pathologically
enlarged abdominal lymph nodes are seen.
PELVIS CT: The bladder is unremarkable. The prostate gland is
markedly enlarged, indenting the bladder at its base. There is
no free fluid in the abdomen. No pathologically enlarged
abdominal lymph nodes are seen. In the right inguinal region, in
continuity with or just anterior to the right common Femoral
artery, there is a rim calcified 3.6 x 3.0 x 3.5 cm structure,
incompletely characterized on this non-contrast study, but
possibly an aneurysm or pseudoaneurysm of the right common
femoral artery or old calcified hematoma (2:116, 300B:26).
BONE WINDOW: No suspicious lytic or blastic lesions are
identified.
Multilevel degenerative changes of the thoracolumbar spine are
seen.
IMPRESSION:
1. Extensive widespread atherosclerotic disease including
calcifcations thoughout the entire aorta, specifically the
ascending aorta and aortic arch.
Severe coronary artery calcifications.
2. Left upper lobe 6-mm pulmonary nodule and right lower lobe
4-mm pulmonary nodule. If this patient has no history of smoking
or malignancy, followup CT in 12 months is recommended.
Otherwise, followup CT in 6 months is recommended.
3. Rim-calcified 3.6-cm structure in continuity with or just
anterior to the right common femoral artery could be a
pseudoaneurysm of the adjacent artery or may represent a
calcified hematoma. Further evaluation with ultrasound or prior
imaging could provide additional information.
.
[**1-/2080**] CAROTID SERIES
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On
the right there is mild heterogeneous plaque seen in the ICA. On
the left
there is mild heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 98/22, 100/36, 91/25 cm/sec. CCA peak
systolic
velocity is 97 cm/sec. ECA peak systolic velocity is 116 cm/sec.
The ICA/CCA ratio is 1.0. These findings are consistent with
<40% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 87/23, 88/36, 77/26 cm/sec. CCA peak
systolic
velocity is 87 cm/sec. ECA peak systolic velocity is 128 cm/sec.
The ICA/CCA ratio is 1.0. These findings are consistent with
<40% stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
.
[**2-10**] TTE
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. There is severe regional left
ventricular systolic dysfunction with akinesis of the septum and
anterior wall. There is an anteroapical left ventricular
aneurysm. No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Mild to
moderate ([**12-13**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Severe regional LV systolic dysfunction consistent
with prior LAD infarction. Anteroapical aneurysm with mild
hypokinesis of the other segments. Critical calcific aortic
stenosis with mild to moderate aortic regurgitation. Mild
pulmonary artery systolic hypertension.
Brief Hospital Course:
MEDICAL COURSE:
68M with 2nd MI/Vfib arrest 1 mo ago now s/p ICD placement with
known severe AS and sCHF (EF25-30%) felt too risky for CABG
previously, now transferred from [**Hospital6 5016**] for AVR
and 3-vessel CABG.
.
# Severe AS:
Easily audible on exam, valve area 0.58 demonstrated on cath
[**2162-12-17**] per OSH records. Outpatient cardiologist recommends
urgent intervention, felt awaiting scheduled [**2163-2-21**] perc AVR at
[**Hospital1 2025**] too long given clinical picture, recurrent dyspnea.
Pre-operative evaluation included CT torso (demonstrating
extensive arterial calcification), carotid ultrasounds, & dental
extractions. TTE demonstrated [**Location (un) 109**] 0.8.
.
# sCHF s/p ICD: EF 25%
On admission he was euvolemic and free of CHF symptoms, an
improvement since initiating lasix at OSH 1 week prior to
admission. Continued lisinopril 10 mg qday, metoprolol 50 mg
[**Hospital1 **], lasix QD. TTE demonstrated "severe regional left
ventricular systolic dysfunction with akinesis of the septum and
anterior wall."
.
# 3-vessel CAD:
Pt had a STEMI on [**2161-12-17**] per records; urgent cardiac
cath at that time demonstrated extensive 3VD including 50%
stenosis ostial L main, 100% occluded LAD, and 50% stenosis in
proximal and distal RCA. Pt was CP free during this admission;
no hx anginal CP. Continued aspirin 324 mg qday, pravastatin 80
mg qday, metoprolol 50 mg [**Hospital1 **]. Plavix held peri-operatively.
Underwent CABG.
.
SURGICAL COURSE:
The patient was brought to the Operating Room on [**2163-2-14**] where
the patient underwent Aortic Valve Replacement, CABG x 4 with
Dr. [**Last Name (STitle) **]. He received Linezolid and Cefazolin for peri-op
antibiotics per ID recommendations given his history of VRE and
MRSA. Post-operatively was transferred to the CVICU on Epi,
milrinone and neo in stable condition for recovery and invasive
monitoring.
He was coagulopathic post-operatively and received numerous
blood products. He developed seizures in the immediate post-op
period. Neurology was consulted and the patient was stabilized
on a regimen of Dilantin and Keppra. There was concern for
embolic stroke given the extent of aortic calcification. Head
CT was negative initially for hemorrhage or infarct.
The patient's permanent pacemaker was interrogated and temporary
pacing wires were discontinued without complication. Chest
tubes were discontinued. Tube feeds were initiated. He
remained intubated several days as he was slow to wake up and
unable to clear secretions effectively. E.coli UTI developed and
he was started on Cipro. Thrombocytopenia developed and HIT was
negative. Platelets would recover. Hemodynamics stabilized and
pressors were discontinued.
He was extubated on POD7. He developed supraglottic edema,
requiring re-intubation several hours later. He was started on
steroids for this.
He developed post-op AFib which converted to sinus rhythm with
amiodarone. He was anti-coagulated briefly, but Warfarin was
discontinued following a prolonged period of stable sinus
rhythm.
He was extubated again. Speech and swallow followed the patient
and advanced his diet as appropriate per evaluation. The
patient remained A&Ox1. He developed visual disturbances/loss
of vision on POD 15. Head CT revealed watershed emboli.
Neurology recommended increasing aspirin to full strength.
The patient was transferred to the telemetry floor for further
recovery. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 17 the patient was very deconditioned, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged on post-operative day 17 to [**Hospital 8323**] in [**Hospital1 3597**] in good condition with appropriate follow up
instructions.
Medications on Admission:
Metformin 500 mg qAM/ 1000mg qPM
ASA 325 mg qday
Enalapril 20 mg [**Hospital1 **] --> 10 lisinopril qday 2d ago
Pravastatin 80 mg qday
Glipizide 10 mg qday
Plavix 75 mg qday
Metoprolol 50 mg [**Hospital1 **]
Lasix 40 mg PO qday (started 2d prior to admission)
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
2. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 400mg daily for one week, then taper to 200mg daily
ongoing.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days: titrate per clinical condition.
9. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
10. metformin 500 mg Tablet Sig: One (1) Tablet PO qAM.
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO qPM.
12. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO once a day: give at 100mg dose at 2AM daily along
with 150mg dose at both 10AM and 6PM goal level 15-20, monitor
levels every 2-3 days with serum albumin.
13. phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO twice a day: give 150mg dose at both 10AM and 6PM
along with 100mg dose at 2AM daily. goal level 15-20, monitor
levels every 2-3 days with serum albumin.
14. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.
15. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p Aortic Valve
Replacement and Coronary artery bypas graft x 4
Past medical history:
Prior Myocardial Infarction, stent to LCx in [**2152**] ([**Hospital 2586**])
Hyperlipidemia
Hypertension
Peripheral vascular disease
Chronic Systolic Congestive Heart Failure, LVEF 25-30%
Diabetes Mellitus Type II
Carotid Disease
History of Vfib arrest in [**2162-12-12**]
Discharge Condition:
Alert and oriented x 1, visual deficit
Deconditioned
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2163-3-24**] at 2:45p in the [**Hospital Unit Name **],
[**Hospital Unit Name **]
Cardiologist: [**First Name8 (NamePattern2) 29069**] [**Doctor Last Name 29070**] [**Telephone/Fax (1) 37284**] [**2163-3-21**] at 2:45
([**Hospital1 3597**] office [**Telephone/Fax (1) 5424**])
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 66039**] in [**3-17**] weeks
[**Hospital 4038**] Clinic: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 12195**] option #2 in two
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:[**2163-3-3**]
|
[
"250.00",
"369.9",
"V45.82",
"518.51",
"410.92",
"414.01",
"780.09",
"293.0",
"780.39",
"564.00",
"599.0",
"997.1",
"401.9",
"272.4",
"434.11",
"424.1",
"428.22",
"427.31",
"997.02",
"440.0",
"V12.04",
"V12.53",
"041.49",
"478.6",
"287.5",
"428.0",
"V45.02",
"433.10",
"E878.2",
"286.9",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.14",
"39.61",
"36.15",
"96.72",
"33.24",
"96.71",
"96.6",
"35.21",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
15550, 15597
|
9815, 13655
|
328, 776
|
16044, 16255
|
3497, 9792
|
17178, 18108
|
2664, 2842
|
13965, 15527
|
15618, 15726
|
13681, 13942
|
16279, 17155
|
2857, 3478
|
269, 290
|
804, 1998
|
15748, 16023
|
2498, 2648
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,091
| 127,768
|
6498
|
Discharge summary
|
report
|
Admission Date: [**2173-6-18**] Discharge Date: [**2173-7-29**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Right foot infection
Major Surgical or Invasive Procedure:
s/p [**6-25**] open ray amputation of right great toe
s/p [**7-3**] debridement of right ray amp
s/p [**7-23**] right TMA
History of Present Illness:
This is an 86-year-old gentleman with an ischemic right leg, who
underwent angioplasty and stenting and subsequently had osteo.
of his right great toe. He
presented with infection extending up the tendon sheath, with
involvement of his metatarsal head.
Past Medical History:
- DM2 on insulin
- CRI (baseline Cr 1.8-2.0)
- CAD s/p CABG
- CHF EF
- s/p AICD /pacemaker
- BPH
- Hypercholesterolemia
- Afib on anti-coagulation
- H/o SDH- stable per last CT head
- s/p L. [**Month/Year (2) 1793**] stent [**7-2**]
- s/p L. PT stent/angioplasty w/tPA of distal embolization to
plantar arch [**2172-11-3**]
- s/p L. TMA
- Chronic epidiymitis- s/p recent rt orchiectomy for necrotic
testes
- Anemia (Baseline 26-30) on epogen
Social History:
Former tobacco use. No ETOH use. Living at [**Last Name (un) 15685**].
Family History:
NC
Physical Exam:
Physical Exam
Vitals: T:[**2163-4-28**] BP: 130/80 P:88 R: 24 SaO2: 97%RA
General: eldery, frail gentelman, Awake, alert, NAD.
HEENT: MMM,PERRL, EOMI without nystagmus, no lesions noted in OP
Neck: no lymphadenopathy, supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, 1/6 SEM at apex, no JVD
Abdomen:soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted, + umbilical hernia, Suprapubic catheter in
place with dressing, no purulence or erythema at catheter site
Extremities: no pain to palpation of lt posterior arm/shoulder,
no bruising, no deformity, lt foot amputation, right TMA stump
is healing well, no erythema, no discharge, no edema.
GU: s/p orchiectomy, no erythema, no ulceration, no penile
discharge, no rash, suprapubic tube
Skin: supple, no tenting, normal temp, no sweating
Neurologic: mental status: alert, following commands sluggishly.
Pertinent Results:
[**2173-7-27**] 06:17AM BLOOD
WBC-7.7 RBC-3.26* Hgb-8.5* Hct-27.6* MCV-85 MCH-26.2* MCHC-31.0
RDW-18.3* Plt Ct-418
[**2173-7-25**] 04:14AM BLOOD
PT-13.3* PTT-35.6* INR(PT)-1.2*
[**2173-7-27**] 06:17AM BLOOD
Plt Ct-418
[**2173-7-27**] 06:17AM BLOOD
Glucose-213* UreaN-36* Creat-1.5* Na-144 K-4.4 Cl-109* HCO3-24
AnGap-15
[**2173-7-23**] 06:48AM BLOOD
ALT-38 AST-38 LD(LDH)-223 AlkPhos-439* Amylase-58 TotBili-0.3
[**2173-7-27**] 06:17AM BLOOD
Calcium-8.4 Phos-3.2 Mg-2.2
[**2173-7-28**] 12:52PM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-3* WBC-5 Bacteri-NONE Yeast-NONE Epi-0
[**2173-7-28**] 12:52PM
[**2173-7-3**] 9:30 am TISSUE Site: FOOT RIGHT FOOT.
GRAM STAIN (Final [**2173-7-3**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND
CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
WOUND CULTURE (Final [**2173-7-6**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE GROWTH.
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
Pt transfered from [**Last Name (un) 15685**] for left arm pain w/ known UTI.
In ED, found to have confusion, UTI, ARF w/ Cr 2.5 (baseline
1.8-2.0), given fluid bolus.
Pt's left arm pain had been evaluated w/ X-ray at [**Last Name (un) 15685**] w/o
fx; was ruled out for MI w/ neg Troponins x3; lt arm pain
decreased during hospital stay.
PT was started on Ceftriaxone 1g IV qDialy on [**2173-6-19**] and his
mental status improved.
Pt's renal failure as evaluated with Ulytes, FENA and urine eos.
Pt was found to have both prerenal failure due to dehydration
and Acute Interstial Nephritis (AIN, w/ many urine eosinophils)
though to be due to Macrobid.
During hospital stay, pt's suprapubic catheter was replaced; pt
received fluids and Cr remained stable from 2.5-3.0. It is
anticipated that pt's acute renal failure due to AIN will
resolve slowly over several weeks.
Pt also developed a rt foot cellulits [**1-29**] rt toe ulcer, was
started on Vancomycin 1g q48hrs (renal dosing) with improvement.
Pt's coumadin was held for INR of 4.0. Coumadin restartedd on
DC.
In addition, during hospital stay, pt developed hypoglycemia
(blood sugar 40's), hypothermia w/ temp 88F and altered mental
status w/o change in BP or HR. Pt's hypothermia and altered
mental status were thought to be due to hypoglycemia and poor
personal temperature regulation. Pt was evaluated, sepsis ruled
out with CXR (neg), blood cultures (pending), CBC (no
leukocytosis), ABG and lactate (lactate 2.0) and received IV
dextrose with resolution of symptoms. Pt's temperature rose to
97.0 axillary, blood sugar 138 and normal mental status after
blankets and dextrose.
Pt was also found to have hypothyroidism and was started on
Levothyroxine 25mcg qD started.
[**6-24**] - patient's right foot in pain and noted to be erythematous
and warm. [**Month/Year (2) **] proceeded with a right first toe open ray amp
on [**6-25**].
The patient was brought back to the OR on [**2173-7-3**] for debridement
of infected R great toe amp site.
On [**2173-7-14**] pt in respiratory distress and became unresponsive
and intubated on the floor. Abdomen firmly distended, lactate
5.6. Pt transferred to SICU, a line and central line placed.
Pt extubated on [**2173-7-16**] and transferred to VICU on [**2173-7-18**] in
stable condition.
The patient was tolerating a PO diet and moved to floor status
on [**7-19**].
Pt underwent a right TMA on [**2173-7-23**].
The patient was transferred to the floor on [**2173-7-26**] in stable
condition and more mentally alert.
Geriatrics consult was obtained / medications were adjusted.
Also [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 387**] consult was obtained. for persistant low blood
sugars. His hyperglycemic meds were adjusted
The patient is to be discharged to a rehab facility [**2173-7-30**] in
stable condition.
Medications on Admission:
Digoxin 125 mcg Qday
Atorvastatin 20 mg Qday
Ferrous Sulfate 325 mg Qday
Prilosec 20 mg Qday
Senna 8.6 mg [**Hospital1 **]
Epoetin Alfa 2,000 unit/mL M-W-F.
Calcitriol 0.25 mcg QOD
Aspirin 81 mg Qday
Bisacodyl 5 mg prn
Furosemide 60 mg Qday
Insulin 75/25 30) units Subcutaneous QAM.
Insulin 75/25 (Hum) (12) units Subcutaneous QPM.
Exelon 1.5 mg [**Hospital1 **]
Metoprolol Succinate 200 mg Qday
Docusate Sodium 100 mg prn
Hydralazine 25 mg Q6hrs
Coumadin 4.5 mg Tablet Qday
Metolazone 2.5mg QMon/Thurs
Lisinopril 10mg Qday
MVI, Vit C
Macrobid 100mg [**Hospital1 **] x 7 days
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): moniter INR [**1-30**] goal.
Disp:*90 Tablet(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 doses* Refills:*2*
10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
Disp:*20 Capsule(s)* Refills:*2*
11. Rivastigmine 1.5 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
13. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*2*
15. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
18. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
19. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
20. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
21. Losartan 25 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
22. Losartan 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
23. INSULIN
Insulin SC Sliding Scale
Bedtime NPH 3 Units
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-60 mg/dL [**12-29**] amp D50
61-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 1 Units 1 Units 1 Units 0 Units
161-200 mg/dL 2 Units 2 Units 2 Units 0 Units
201-240 mg/dL 3 Units 3 Units 3 Units 0 Units
241-280 mg/dL 4 Units 4 Units 4 Units 2 Units
281-320 mg/dL 5 Units 5 Units 5 Units 4 Units
321-360 mg/dL 6 Units 6 Units 6 Units 6 Units
361-401 mg/dL 7 Units 7 Units 7 Units 8 Units
> 401 mg/dL Notify M.D.
24. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed.
25. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 14 days.
26. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
27. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day for 14
days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Urinary tract infection, Right foot cellulits, Acute Renal
Failure
The patient was admitted with cellulitis of the right leg. He
is diabetic, has chronic renal failure, hypertension and had
a CABG and long history of peripheral [**Location (un) 1106**] disease with a
previous TMA on the left side. The patient is s/p right TMA
([**2173-7-23**])
Discharge Condition:
stable
Discharge Instructions:
Please return to emergency department if you have fever, chills,
dysuria, or if the leg wound becomes increasingly red, swollen,
hot or excessive discharge.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2173-9-6**]
11:15Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2173-8-26**] 11:15
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**], ([**Telephone/Fax (1) 24953**] [**Hospital1 1426**] Urology, please make an
appointment for 1-2 weeks.
Please follow up with Dr [**Last Name (STitle) 24954**] in two weeks. He can be
reached at [**Telephone/Fax (1) 543**].
Completed by:[**2173-7-29**]
|
[
"427.31",
"293.0",
"584.9",
"038.10",
"585.9",
"730.27",
"250.80",
"403.90",
"285.21",
"518.81",
"729.5",
"244.9",
"428.0",
"440.23",
"997.62",
"682.7",
"V45.81",
"V45.02",
"599.0",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"84.11",
"93.59",
"84.12",
"38.93",
"99.07",
"99.04",
"77.68",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10587, 10664
|
3746, 6603
|
282, 406
|
11056, 11065
|
2171, 3723
|
11270, 11853
|
1257, 1261
|
7230, 10564
|
10685, 11035
|
6629, 7206
|
11089, 11247
|
1276, 2098
|
222, 244
|
434, 688
|
2113, 2152
|
710, 1153
|
1169, 1241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,198
| 167,708
|
9238+9239
|
Discharge summary
|
report+report
|
Admission Date: [**2165-8-26**] Discharge Date: [**2165-8-27**]
Date of Birth: [**2104-10-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
black stool x1 day
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
60yo M hx NSTEMI s/p stent [**2159**] and [**1-2**] who presented with
melena x1. Pt states he has been taking [**Month/Year (2) 4532**] and aspirin for
>5y and never had a problem. Today he noticed a black tarry
stool. Denies epigastric pain, reflux, abdominal pain,
n/v/diarrhea. He does endorse increased alcohol intake x3 nights
this past weeks, drinking a cocktail and half bottle of wine. He
also admits to taking a few advil a week ago. The patient was
concerned about the black stool and called his PCP who told him
to come in. He denied SOB, CP, lightheadedness.
.
In the ED, initial vs were: Temp:98 HR:59 BP:111/64 Resp:12
Sat:100% RA. Patient was given IV protonix and NG lavage which
was negative for active bleeding.
.
On the floor, he was stable, nad, no complaints, no further
episodes of melena.
Past Medical History:
HL
PTCA '[**58**], '05x2, '[**64**] (with NSTEMI)
Social History:
Is a lawyer, lives at home with wife, has 3 grown children. From
[**Location (un) 745**].
-Tobacco history: None
-ETOH: Social
-Illicit drugs: None
Family History:
Father--bypass at 50yo, alive
Mother--No serious condition, alive
Physical Exam:
Vitals: T: 98.6 BP: 94/56 P:82 R: 18 O2: 100%RA
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, +S4, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
[**2165-8-26**] 11:08AM GLUCOSE-105* UREA N-47* CREAT-1.1 SODIUM-137
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-30 ANION GAP-10
[**2165-8-26**] 11:08AM estGFR-Using this
[**2165-8-26**] 11:08AM WBC-9.2 RBC-4.48* HGB-13.9* HCT-41.6 MCV-93
MCH-31.1 MCHC-33.5 RDW-14.1
[**2165-8-26**] 11:08AM NEUTS-69.4 LYMPHS-22.2 MONOS-5.3 EOS-1.6
BASOS-1.5
[**2165-8-26**] 11:08AM PLT COUNT-149*
[**2165-8-26**] 11:08AM PT-13.2 PTT-22.8 INR(PT)-1.1
Brief Hospital Course:
60M hx of NSTEMI s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 5175**] on [**Last Name (Prefixes) 4532**] and [**Last Name (Prefixes) **] p/w 1
episode melena.
.
# Melena: The patient presented with one episode of melena after
years on [**Last Name (Prefixes) 4532**] and recent episodes of increased etoh use. He
denied any sob, lightheadedness, dizziness, but did endorse mild
fatigue. Vital signs were stable and NG lavage showed no signs
of acute bleed. Given hemodynamic stability, patient was
continued on [**Last Name (LF) 4532**], [**First Name3 (LF) **]. The patient was made NPO overnight
without IVF. Did not report any other episodes of melena. In the
AM he underwent endoscopy with GI which revealed a 1cm gastric
ulcer in the antrum, cratered but clean based without active
bleeding or visible vessel. No intevention was performed. Per ID
he was given 1 dose IV pantoprazole and then dced with order for
Omeprazole 40mg [**Hospital1 **]. The patient was also found to have a HCT
drop from 41.6 to 33.6 overnight. HCT was repeated 7hrs later
and was found to be stable at 33.0. Patient continued to be
asymptomatic besides fatigue and was discharged with follow-up
with PCP and instructions to return if he became symptomatic.
.
# CAD with [**Hospital1 **]: continued [**Hospital1 4532**] and [**Hospital1 **]. continued diovan,
metop, lipitor, niaspan.
The attending on the patient had communicated with the patient's
outpatient cardiologist and PCP regarding the fact that both
protonix and plaxix would be given at the same time putting the
patient at least at a theoretical risk for decreased
effectiveness of [**Hospital1 4532**]. GI attending was also involved in the
discussions. It was decided that in the setting of a relatively
significant size ulcer that protonix was going [**Last Name (un) **] continued.
[**Last Name (un) **] and [**Last Name (un) **] would also stay on to prevent [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **].
.
FEN: No IVF, replete electrolytes, regular diet, NPO after
midnight.
.
Prophylaxis: subcutaneous heparin
.
Medications on Admission:
[**Last Name (Prefixes) **]
[**Last Name (Prefixes) **]
Metoprolol
Diovan
Lipitor
Niaspan
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*4*
7. Niaspan 1,000 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
gastric ulcer/Upper GI Bleed
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 participating in your care. You were
admitted for an episode of black, tarry stool signifying a GI
bleed. On admission you were found to have stable blood pressure
and blood counts, however your blood pressures decreased
slightly overnight and your blood count dropped. You underwent
endoscopy showing a gastric ulcer likely responsible for your
bleed. You were given an IV proton pump inhibitor (gastric acid
blocker) and will be discharged with a prescription for an oral
gastric acid blocker. You also have a blood test pending for a
bacteria that can cause ulcers. You were given IV fluids to
increase your BP and had a repeat blood check which showed your
blood counts to be stable.
You will likely have some dark stools for the next few days,
but please call or come back to the hospital if you develop
frank bleeding, shortness of breath, chest pain,
lightheadedness, or dizziness.
*************
Please continue your home medications as before admission.
Please START the following medication:
- Omeprazole 40mg one tablet, every 12h.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Address: [**Street Address(2) **], 2 WEST, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 14148**]
Appointment: Tuesday [**2165-9-3**] 1:00pm
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Admission Date: [**2165-8-28**] Discharge Date: [**2165-8-31**]
Date of Birth: [**2104-10-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 60 yr old male with a history of CAD s/p [**First Name3 (LF) **] to RCA in
[**2164-12-24**], LAD, and mid LCx in [**2158**], on [**Year (4 digits) **] and [**Year (4 digits) **] who
presented to OSH with abdominal pain and melena for the past 3
days.
Patient was just admitted from [**Date range (1) 31715**] with 1 day of melena
and abdominal pain. At that time he had guaiac + black stool,
with a negative NG lavage. GI was consulted. EGD showed gastric
ulcer in antrum 1 cm without active bleeding or visible vessel.
No intevention was performed. Patient was discharged with [**Hospital1 **]
PPI. [**Hospital1 **] and [**Hospital1 **] were continued. Patient admitted to having
used Advil about 7-10 days prior. Notably his H. pylori serology
was positive on discharge. HCT on discharge was 33.
Since discharge, patient complains that he's felt lightheaded,
fatigued, and pale. He's had 1 black stool Monday, Tuesday, and
2 tarry stools on Wednesday. The patient had lightheadedness
when going from sitting to standing position, which was new, and
the reason he came in. He also had some mild nausea.
In the ED, initial VS 98.8 100 108/57 14 99%. NG lavage was not
performed as patient declined, and patient had guaiac positive
black stool. HCT was 25.7. Two days prior HCT was 41.6. Patient
was type and crossed for 2 units. Patient was given 40mg IV
Pantoprazole, 1u PRBCs, and IV fluids. GI was consulted who
recommended ICU admission, repeat HCT after 1u PRBCs. If HCT
continues to fall, they would rescope.
Currently, that patient feels well, but thinks that if he stood
up he would probably feel light headed. Denies BRBPR,
hematemesis, or coffee ground emesis. No fevers or chills. He
has never had GI bleeding in the past.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2159**] mid RCA [**Year (4 digits) **]. LCX
stent.
-PACING/ICD: None.
3. OTHER PAST MEDICAL HISTORY:
PAST MEDICAL HISTORY:
-hyperlipidemia
-UGI bleed history (recent admission 2 weeks ago: EGD with
gastritis/PUD)
-H.pylori
-GERD
-PUD/gastritis
-NSTEMI with CAD: s/p cardiac stent placements in [**2159**] and [**1-2**]
( mid-RCA [**Month/Year (2) **] placed in [**Month (only) 956**] with Dr. [**Last Name (STitle) **], older stent was
in LCX
Social History:
Is a lawyer, lives at home with wife, has 3 grown children. From
[**Location (un) 745**].
-Tobacco history: None
-ETOH: Social -approximately 2 drinks/week
-Illicit drugs: None
Family History:
Father--bypass at 50yo, alive
Mother--No serious condition, alive
Physical Exam:
VS: Temp: BP: 131/63 HR: 95 RR: 15 O2sat 95% on RA
GEN: pleasant, pale, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, 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, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
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
Pertinent Results:
Admission Labs:
[**2165-8-27**] 06:55AM WBC-7.2 RBC-3.66* HGB-11.6* HCT-33.6* MCV-92
MCH-31.5 MCHC-34.4 RDW-14.2
[**2165-8-27**] 06:55AM PLT COUNT-122*
[**2165-8-27**] 06:55AM PT-14.6* PTT-28.9 INR(PT)-1.3*
[**2165-8-27**] 06:55AM CALCIUM-8.2* PHOSPHATE-2.7 MAGNESIUM-1.7
[**2165-8-27**] 06:55AM GLUCOSE-115* UREA N-27* CREAT-1.0 SODIUM-141
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-29 ANION GAP-10
[**2165-8-27**] 01:00PM HCT-33.0*
Imaging:
[**2165-8-29**] CXR: NG tube tip is in the stomach. Cardiomediastinal
contours are normal. There is a nodular opacity in the left
lower lobe, measuring 7 mm. This should be confirmed with a
repeat radiograph, PA and lateral views of the chest.
Otherwise, the lungs are clear. There is no pneumothorax or
pleural effusion.
[**2165-8-29**] EGD: Mild erythema in the whole stomach compatible with
gastritis,
Ulcer in the antrum (endoclip). Otherwise normal EGD to second
part of the duodenum. Recommendations: Ulcer with pigmented
center. Unclear whether this is the source of bleeding.
Endoclips placed. Given question regarding source of bleeding
recommend prep for colonoscopy in AM. Continue on PPI gtt,
discussion with Cardiology regarding anticoagulation given
recent stent placement.
Brief Hospital Course:
60 yo M with CAD s/p [**Month/Day/Year **] to RCA in [**2164-12-24**] with known 1cm
antral ulcer who presents with fatigue, HCT drop, and guaiac +
black stool.
#. GI Bleed: He presented with melena and a 7 point hematocrit
drop from the day prior. EGD on a previous admission showed
gastritis and an antral ulcer. He was placed on a protonix
drip, and given 5 units of PRBC's in the first 24 hours. Repeat
EGD in the MICU again showed his antral ulcer without obvious
evidence of active bleeding but ulcer was clipped this time. He
then underwent colonoscopy which showed no source of bleeding
though it showed 2 polyps. Hct stabilized in high 20's prior to
transfer to floor. He was given a capsule study which will be
interpreted after discharge. He was switched to pantoprazole IV
BID and then changed to PO BID. H.pylori had previously been
foudn positive so treatment was initiated. Patient's HCT
remained stable x24h and he tolerated advancing diet so he was
discharged.
#. CAD: He had a [**Year (4 digits) **] to RCA placed in [**2164-12-24**]. Multiple
other [**Year (4 digits) **] to LAD and LCx in the past. His [**Year (4 digits) **] was initially
held due to concern for bleeding. His other cardiac medications
were also held. In discussion with Dr. [**Last Name (STitle) **] it was agreed to
hold [**Last Name (STitle) **] x2-3wks until follow-up. He was continued on diovan,
metoprolol, lipitor. [**Last Name (STitle) **] was decreased to 162mg daily.
# Colonic Polyps: Seen on colonscopy but not removed given GI
bleed. Will need repeat in [**1-26**] months for removal.
Medications on Admission:
1. Clopidogrel 75 mg po daily
2. Aspirin 325 mg po daily
3. Atorvastatin 40 mg po daily
4. Metoprolol Tartrate 25 mg po bid
5. Lisinopril 5 mg po daily
6. Pantoprazole 40mg po bid
7. Diovan
8. Nyaspan
Discharge Medications:
1. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 13 days.
Disp:*56 Tablet(s)* Refills:*0*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 13 days.
Disp:*104 Capsule(s)* Refills:*0*
7. niacin 500 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted after developing increasing fatigue,
dizziness and signs of GI bleeding. You were found to have
anemia due to a GI bleed and were transfused 4 units of blood
over the course of your admission. Your [**Known lastname 4532**] was also held out
of concern for increasing your bleeding and your aspirin was
decreased to 162mg daily. You underwent endoscopy which
redemonstrated an ulcer that was clipped by the gastroenterology
team. You were also started on treatment for h. pylori, a
bacteria that may be responsible for the ulcer. You then
underwent a colonoscopy which demonstrated two polyps but no
evidence of bleeding. You will need a followup colonoscopy in
3-6mos to remove those polyps. Lastly, a capsule swallow study
was done to assess the portion of the bowel not able to be
visualized in egd or colonoscopy. After these procedures, your
hematocrit continued to be checked and was stable. You also
remained asymptomatic.
Please call or return to the hospital if you develop frank
bleeding with bowel movements, sob, dizziness, chest pain,
lightheadedness, any symptoms that concern you.
***********
STOP taking the following medications:
[**Known lastname **] has been stopped until follow-up with Dr. [**Last Name (STitle) **]
.
The following medications have been CHANGED:
[**Last Name (STitle) **] 162mg daily
.
Please START the following medications:
Clarithromycin 500mg twice daily
Amoxicillin 1g twice daily
Omeprazole 40mg twice daily
Followup Instructions:
Dr. [**Last Name (STitle) 1728**] [**2165-9-3**] at 1pm
Please call to schedule an appointment with Dr. [**Last Name (STitle) **]
(interventional cardiologist) at [**Telephone/Fax (1) 62**], he wants to see
you in 2-3wks to assess whether or not you can restart your
[**Telephone/Fax (1) 4532**].
Please call to schedule a follow-up appointment with
Gastroenterology at [**Telephone/Fax (1) 11048**].
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
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14593, 14599
|
12038, 13639
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7462, 7467
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14652, 14742
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10773, 10773
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10069, 10136
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13890, 14570
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14620, 14631
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13665, 13867
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14803, 16313
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9357, 9481
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7415, 7424
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10789, 12015
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14757, 14779
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9513, 9513
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9535, 9857
|
9873, 10053
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,031
| 153,060
|
11541
|
Discharge summary
|
report
|
Admission Date: [**2173-11-16**] Discharge Date: [**2173-12-1**]
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old,
Cantonese speaking man with a past history of hypertension,
past stroke in [**2172-9-8**] of the left MCA distribution,
who presented with an aphasia and right-sided weakness that
was evaluated at [**Hospital 4415**] which resolved
also with a history of atrial fibrillation and high
cholesterol and history of diabetes. He was admitted on
[**11-16**] to the [**Hospital6 256**] for
syncopal episode with a fall. At the time of admission he
denied head trauma, focal weakness, or chest pain. He was
admitted to the Medicine Team
day prior to admission and did not eat or drink much that day
and then had the fall. His daughter on admission also
reported that he was "not acting himself" for two days prior
to admission. He was found to have electrocardiogram changes
with ST elevations in V2, V3. First set of enzymes were
negative with a CK of 116, MB 2, negative troponin. He was
admitted at that time for rule out myocardial infarction.
Early on the morning of [**11-17**], he was found to have an
increase in CPK and MB and was started on Heparin by the Medicine
team. Soon thereafter, he was noted to have new left-sided
weakness. Heparin was discontinued and reversed with Protamine. A
head CT was obtained that showed an acute right frontal
intraparenchymal hemorrhage with extension into the right
lateral ventricle and blood in all the ventricles, as well as
a subacute right ACA infarct. He was seen by Neurosurgery,
no surgical intervention was done. He was transferred to the
Intensive Care Unit at that time. Eventually myocardial
infarction was ruled out by enzymes.
A repeat head CT was done later on [**11-17**] in the evening
to evaluate for decreased level of arousal which showed no
hydrocephalus and no significant change from the initial CT
showing the bleed. He was then transferred on [**11-18**] to
the Neurology Service. The thought was that he possibly had
a right ACA infarct prior to admission with subsequent
hemorrhagic conversion. He was transferred to the Neurology
Floor for neurologic monitoring for increase intracranial
pressure and for further evaluation.
On [**11-19**] he was noted to have some episodes of
seizure-like movement of the left arm and left facial
twisting. He had a repeat head CT that showed no significant
change once again on [**11-19**]. He also had an EEG done on
[**11-24**] that showed slow and disorganized background with
occasional bursts of generalized flowing indicating a mild
encephalopathy but no areas of persistent focal slowing and
no epileptiform seizures. He had been empirically started on
Dilantin when the seizure-like movements were noted.
When he was initially transferred to the Neurologic Service,
his neurologic exam showed him to awaken to voice. He did
repeat words in Chinese that were said to him, although he
did no answer questions secondary to language. At that time,
he was unable to be assessed, as he did not follow commands.
He has some flattening of the left nasolabial fold and
flaccid tone of the left arm and left leg. His right leg and
right arm were moving spontaneously, lifting of both the
right arm and leg. He withdrew to noxious stimuli on the
right. He did not have withdrawal on the left. His reflexes
were brisk bilaterally with an upgoing left toe and downgoing
right toe. His pupils were equal, round and reactive. He had
a gaze preference to the right but could cross the midline.
His level or arousal did not change significantly through his
hospital stay. He sometimes was responding a little bit more
in the presence of family members, although never really
speaking or following commands and was usually leaning his
head over towards the right.
He developed a fever up to 102?????? with no obvious source found.
He had multiple sets of blood cultures that were negative.
Urine culture was negative. Chest x-rays were clear, and he
did have an LP that showed in tube #1 111 white cells and
[**Pager number **] red cells, and tube #4 had 300 white cells and [**Pager number **] red
blood cells with moderate Xanthochromia and a glucose of 139
and a protein of 67, no organisms on gram stain and negative
culture. The increased white cells were thought to be likely
due to inflammation from intraventricular blood, but as he
had no other source for fever at that time, he was started on
antibiotics in the form of Ceftriaxone and Vancomycin
coverage for meningeal coverage.
His fevers resolved after starting antibiotics. When the
final culture of CSF came back negative, these antibiotics
were stopped, and he has remained afebrile. He had multiple
swallow evaluations and had a PEG tube placed on [**12-4**].
His other issues include persistently high fingersticks. He
is on an Insulin sliding scale that we have increased. He
has also been started on Glucotrol which we raised to 10 mg
q.d., although he still has high fingersticks. He also has
developed mild hyponatremia over the last few days. He now
has a sodium of 131. We have fluid restricted him just to
PEG tube feeds.
He also has had rising platelet counts over the last few days
with platelets up to 614 today. We spoke with Hematology who
felt that the increase in the platelets were most likely
reactive and would not work that up unless they go above 1
million.
As stated above, the patient's neurologic exam has remained
stable. He is generally awake and alert, crosses midline
with his eyes, usually with a right gaze preference but does
not speak and does not follow commands. His left arm and leg
have remained plegic, and his right arm and leg are move
fully. He does withdraw to pain on his right arm and leg,
and on the left side he responds with his right leg to
noxious stimuli.
IMPRESSION: He had another repeat head CT to rule out
hydrocephalus on [**11-23**], and this showed no interval
change and no hydrocephalus.
In summary, the patient is a 78-year-old man with a history
of hypertension, atrial fibrillation, undiagnosed diabetes,
hypercholesterolemia, past cerebrovascular accident with no
residual deficits, now status post right frontal bleed with
intraventricular blood, with left hemiplegia, and decreased
level of responsiveness.
He is now stable for discharge to rehabilitation. His
remaining issues are:
1. Possible seizures: He has remained on Dilantin with
therapeutic levels. His EEG showed encephalopathy but no
epileptiform activity. We recommend that he should remain on
Dilantin for one month, and if no seizures are seen during
that time, his Dilantin should slowly be tapered off.
2. Increase in platelets: His platelets have gradually been
increasing now to 600. This is likely reactive in etiology.
Continue to monitor, and if platelets go above 1 million,
would work this up.
3. Hyponatremia/SIADH: He has had mild hyponatremia with
sodium now at 131. He should not get any free water flushes
or normal saline flushes but only the PEG tube feeds at this
time. Continue to monitor sodium and treat accordingly. His
SIADH is likely secondary to his intracranial hemorrhage.
4. Diabetes: His fingersticks have been persistently high.
We have increased his Glucotrol and increased his Insulin
sliding scale. Would continue to closely monitor and
consider adding further agents.
DISCHARGE MEDICATIONS: Dilantin 300 per G-tube q.d., Flomax
0.4 mg per G-tube q.d., Lopressor 100 mg b.i.d., Zantac
elixir 150 mg b.i.d., Glucotrol 10 mg q.d., Tylenol 650 mg
p.r.n., Lipitor 10 mg q.d., Neutra-Phos 1 packet t.i.d.,
Colace 100 mg t.i.d., regular Insulin sliding scale.
FOLLOW-UP: The patient should follow-up with the [**Hospital 4038**]
Clinic at [**Hospital6 256**] in
approximately three months.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**First Name3 (LF) 25362**]
MEDQUIST36
D: [**2173-12-1**] 12:48
T: [**2173-12-1**] 12:38
JOB#: [**Job Number 13052**]
1
1
1
R
|
[
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"780.6",
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"401.9",
"250.00",
"434.91",
"431",
"V12.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.32",
"96.6",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
7438, 8076
|
124, 7414
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
357
| 101,651
|
29358
|
Discharge summary
|
report
|
Admission Date: [**2199-10-20**] Discharge Date: [**2199-10-23**]
Date of Birth: [**2135-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Mr. [**Known lastname **] is 64-year-old man with liver cirrhosis [**1-19**] NASH, DM,
HTN, CHF EF 40%, CAD, Sizure disorder who p/w cough. Per report
from his nursing home, he has had cough, low grade fever x 3
days. Today, he had an episode of likely aspiration while using
mouth wash, had a coughing fit and during this episode desat'ed
to 80's. His family reports that he has been on small amounts of
oxygen at the nursing home, which he has been on chronically
since [**Hospital 671**] Rehab for unclear reasons. They state that he has
had a ratteling cough for several days but has not appeared
unwell. They also note that he has normally waxing and [**Doctor Last Name 688**]
mental status, that he is not "chatty" normally and that his
mental status appears to be at baseline. Per the patient, he
feels relatively well and denies SOB. He was BIBA from his NH,
enroute EMS had a difficult time obtaining a good pleth/sats and
reported variable O2 sats in high 80's.
.
In the ED: The patient was thought to be ill appearing and
"dry". His vital signs were temp 100.0, HR 107, BP 120/80's, RR
22-26, Sa 96% 2LNC. EKG unchanged, trop 0.06.CXR was noted to
have hazy RLL and LLL. He received Vanc and CTX.
Past Medical History:
1. Seizure disorder with history of status epilepticus with
recent admission for recurrent seizures & 2 prior admission in
[**2197**] & [**2199-1-18**] for status requiring intubation. He has been on
multiple antiepileptic drugs
2. NASH, cirrhosis, hepatocellular carcinoma, recently removed
from [**Year (4 digits) **] list [**1-19**] chronic illness
3. Diabetes.
4. Hypothyroidism.
5. Hypertension.
6. CHF with ejection fraction of 40% on an echo in [**2198-7-18**].
7. Coronary artery disease status post cardiac catheterization
in [**2187**] w/o stenting.
8. History of upper GI bleed status post tips in [**2197**].
9. Stage IV sacral decubitus ulcer.
Social History:
Prior to his illness, he was living with wife; remote tobacco,
no EtOH or drug use. He now resides at [**Hospital 1820**] Nursing Home.
Family History:
Non-contributory.
Physical Exam:
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally
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 and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: sacral ulcer, heel ulcers
Neurologic:
-mental status: waxing and [**Doctor Last Name 688**] between, persistently alert
but oriented to person only at times and occasionally a&ox3.
-contractures in hands and arms.
Pertinent Results:
Labwork on admission:
[**2199-10-20**] 09:45AM BLOOD WBC-5.2 RBC-3.63* Hgb-12.5* Hct-37.6*
MCV-104*# MCH-34.4* MCHC-33.2 RDW-15.1 Plt Ct-65*
[**2199-10-20**] 09:45AM BLOOD Neuts-81.1* Lymphs-12.2* Monos-5.2
Eos-1.4 Baso-0.2
[**2199-10-20**] 09:45AM BLOOD Glucose-178* UreaN-50* Creat-1.1 Na-150*
K-4.1 Cl-110* HCO3-34* AnGap-10
[**2199-10-20**] 09:45AM BLOOD ALT-27 AST-23 CK(CPK)-53 AlkPhos-124*
TotBili-0.3
[**2199-10-20**] 10:35AM BLOOD Ammonia-73*
[**2199-10-20**] 09:45AM BLOOD TSH-0.77
[**2199-10-20**] 09:45AM BLOOD Free T4-1.9*
.
Labwork on discharge:
[**2199-10-23**] 07:45AM BLOOD WBC-2.2* RBC-2.95* Hgb-9.9* Hct-30.7*
MCV-104* MCH-33.7* MCHC-32.4 RDW-14.6 Plt Ct-59*
[**2199-10-23**] 07:45AM BLOOD Glucose-72 UreaN-22* Creat-0.8 Na-146*
K-3.9 Cl-109* HCO3-34* AnGap-7*
.
CHEST (PORTABLE AP) Study Date of [**2199-10-20**]
Formal report pending, but right upper and lower lobe
consolidations present.
.
CHEST PORT. LINE PLACEMENT Study Date of [**2199-10-23**]
Preliminary Report !! PFI !!
Tip of PICC catheter 8 cm from SVC will need to be withdrawn.
Brief Hospital Course:
64 year-old man with cirrhosis, type 2 diabetes, coronary artery
disease, hypertension, congestive heart failure with EF 40%, and
seizure disorder presenting with cough, fevers, and
consolidations on chest x-ray consistent with pneumonia.
.
1. Pneumonia: Chest x-ray from admission showed right middle
and lower lobe consolidations. His oxygen saturations remained
above 92% on room air. He was monitored in the intensive care
unit overnight and transferred to a general medical floor the
morning after admission. He was started on vancomycin and
ampicillin-sulbactam to complete a two-week course for
hospital-acquired versus aspiration pneumonia. A PICC line was
placed [**2199-10-23**] for intravenous access to complete the course of
antibiotics, ending [**2199-11-4**].
.
2. Hypernatremia: Asymptomatic and due to free water depletion.
His free water flushes were increased to 400 cc q4h with
improvement in sodium. His sodium should be monitored
intermittently and his free water flushes should be adjusted
accordingly for hypernatremia.
.
3. Question urinary tract infection from nursing home: The
patient was on nitrofurantoin on admission, and it is unclear
whether this was for treatment or prophylaxis of urinary tract
infection. This was discontinued when the above antibiotics
were started for pneumonia. He can restart nitrofurantoin if
this was being given for prophylaxis when the course of
vancomycin and unasyn is complete.
.
4. Mental status: It was believed that the patient was delirious
on admission, however, after discussion with the patient's wife
and the nursing home his mental status was thought to be at
baseline. He was treated for pneumonia as above. He was
frequently redirected.
.
5. History of nonacloholic steatohepatitis/cirrhosis: The
patient is status post TIPS. He is not [**Month/Day/Year **] candidate
currently due to his multiple comorbiditis. His MELD score was 5
on admission. He was continued on rifamixin and lactulose.
.
6. Chronic systolic congestive heart failure: EF is 40%. His
metoprolol was continued during admission. The patient was
hypovolemic on admission and lasix was held. Lasix was
restarted prior to discharge.
.
7. Seizure disorder: No active issues. The patient was
continued on keppra, topomax and zonisamide. There was initial
confusion regarding his dose of keppra, and the patient was
initially given 2250 mg on admission, however, this was
subsequently changed to his home dose of 500 mg twice daily.
.
8. Type 2 diabetes: No active issues. The patient was continued
on glargine 100 units twice daily as per his outpatient regimen.
He received humalog sliding scale insulin as needed.
.
9. Coronary artery disease: No active issues. The patient was
continued on metoprolol. He is not on aspirin or statin at
baseline, likely due to his liver disease, and this can be
readdressed as an outpatient.
10. Hypothyroidism: The patient was continued on his outpatietn
dose of levothyroxine 400 mcg daily. During admission, his T4
was elevated to 1.9 with normal TSH. His laboratories should be
checked after resolution of this acute illness and his dose of
levothyroxine adjusted accordingly.
.
11. Sacral decubitus ulcer: The patient was followed by the
[**Month/Day/Year **] care nurse.
.
12. Pancytopenia: His blood counts were at baseline during
admission. His pancytopenia is believed secondary to liver
disease. This should be monitored intermittently.
Medications on Admission:
Topiramate 100 mg PO BID
Metoprolol 25 mg PO BID
Levetiracetam PO BID
Zonisamide 500 mg DAILY
Levothyroxine PO DAILY
Fluocinolone 0.025 % Cream
Lactulose 10 gram/15 mL Syrup
Rifaximin PO TID
Lorazepam 0.5 mg PO DAILY
Furosemide 40 mg PO DAILY
Heparin (Porcine) 5,000 unit/mL
Multivitamin PO DAILY
Folic Acid 1 mg PO DAILY
Lansoprazole 30 mg
Thiamine HCl 100 mg PO DAILY
Polyvinyl Alcohol 1.4 % Drops
Discharge Medications:
1. Topiramate 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times
a day).
2. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO BID (2
times a day).
3. Levetiracetam 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2
times a day).
4. Zonisamide 100 mg Capsule [**Month/Day/Year **]: Five (5) Capsule PO DAILY
(Daily).
5. Levothyroxine 100 mcg Tablet [**Month/Day/Year **]: Four (4) Tablet PO DAILY
(Daily).
6. Lactulose 10 gram/15 mL Syrup [**Month/Day/Year **]: Thirty (30) ML PO TID (3
times a day).
7. Rifaximin 200 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2 times a
day).
8. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
9. Furosemide 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
10. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: One (1)
Injection TID (3 times a day).
11. Multivitamin Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
12. Folic Acid 1 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
13. Omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Thiamine HCl 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Day/Year **]: [**12-19**]
Drops Ophthalmic Q6H (every 6 hours).
16. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Month/Day (2) **]: One (1)
Tablet PO DAILY (Daily).
17. Insulin Glargine 300 unit/3 mL Insulin Pen [**Month/Day (2) **]: One Hundred
(100) units Subcutaneous twice a day: plus novolin sliding
scale.
18. Tramadol 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO three times a
day: hold for oversedation and confusion.
19. Scopolamine Base 1.5 mg Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
20. Ascorbic Acid 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2
times a day).
21. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) Inhalation Q4H (every 4 hours).
22. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q4H (every 4 hours).
23. Nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Five (5) ML PO TID
(3 times a day).
24. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day (2) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
25. Ampicillin-Sulbactam 3 gram Recon Soln [**Month/Day (2) **]: One (1) Recon
Soln Injection Q6H (every 6 hours): continue until [**2199-11-4**].
26. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1)
Intravenous Q 12H (Every 12 Hours): continue until [**2199-11-4**].
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) 731**]
Discharge Diagnosis:
Primary diagnoses:
Pneumonia (hospital acquired versus. aspiration)
Hypernatremia
Delirium
Secondary diagnoses:
1. Seizure disorder with history of status epilepticus with
recent admission for recurrent seizures & two prior admission in
[**2197**] & [**2199-1-18**] for status requiring intubation. He has been on
multiple antiepileptic drugs
2. Nonalcholic steatohepatitis, cirrhosis, hepatocellular
carcinoma, recently removed from [**Year (4 digits) **] list due chronic
illness
3. Diabetes - insulin dependent
4. Hypothyroidism
5. Hypertension
6. Congestive heart failure with ejection fraction of 40% on an
echo in [**2198-7-18**]
7. Coronary artery disease status post cardiac catheterization
in [**2187**] w/o stenting
8. History of upper GI bleed status post tips in [**2197**]
9. Stage IV sacral decubitus ulcer
Discharge Condition:
Afebrile, vital signs stable
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were transferred to the hospital with fevers and a cough.
You were found to have a pneumonia and PICC line was placed in
your arm so that you can complete a two week course of
antibiotics (12 more days).
You were also noted to have high levels of sodium in your blood,
and this is probably because you were not getting enough water
in your diet. You are being given more water with your tube
feeds.
We did not change any of your medications (except adding those
two antibiotics for two weeks). Your thyroid levels were high,
and they should be re-checked and the dose of your thyroid
medicine may need to be adjusted.
If you develop increased difficulty breathing or any other
symptoms which seriously concerns you, please return to the
hospital.
Followup Instructions:
Previously scheduled appointments:
Provider: [**Name10 (NameIs) 2841**] LABORATORY Phone:[**Telephone/Fax (1) 2846**] Date/Time:[**2199-11-5**]
10:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 19105**] Date/Time:[**2199-11-5**] 1:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2199-11-27**] 10:20
.
You should try to see your Primary care Provider [**Name Initial (PRE) 176**] 2 weeks.
PCP: [**Name10 (NameIs) **],[**Known firstname **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 70526**]
Completed by:[**2199-10-29**]
|
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"428.22",
"571.5",
"414.01",
"428.0",
"571.8",
"276.0",
"244.9",
"707.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10973, 11072
|
4288, 5743
|
323, 345
|
11940, 11971
|
3201, 3209
|
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|
2441, 2461
|
8189, 10950
|
11093, 11185
|
7764, 8166
|
11995, 12785
|
2476, 3006
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11206, 11919
|
3761, 4265
|
278, 285
|
373, 1583
|
3223, 3747
|
5758, 7738
|
1605, 2272
|
2288, 2425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,225
| 193,661
|
44100+58686+58687
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2144-11-6**] Discharge Date: [**2144-11-15**]
Date of Birth: [**2070-9-6**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
Intubation x2
Stereotactic brain biopsy
History of Present Illness:
The patient is a 74yo R-handed man with a history of MI,
hyperlipidemia and melanoma, who is transferred from OSH for an
ICH.
The patient was at home watching TV, when he suddenly became
unable to speak. He walked to his wife who was in another room
(normal giat, no facial droop noticed), and was only able to get
a few words out ([**Last Name (un) 46536**], [**Last Name (un) 46536**]). He could not give his wife the
name of his children or the date, and at that point she decided
to call 911.
At the OSH, he continued to be unable to speak, but otherwise he
seemed intact. A CT head revealed an ICH in the L-frontotemporal
region, with some edema, possibly underlying mass. He received
decadron 10mg iv before he was transferred to [**Hospital1 18**].
When he arrived in the ED, he was still unable to speak. He was
unable to follow commands per nursing staff. Otherwise he still
appeared intact. Around 20.00 he had a seizure. He turned his
head and eyes to the R and then the seizure generalized. It
lasted a few minutes and he received ativan 1mg iv. He was
postictal for some 5 minutes, hardly responsive, but then seemed
to recover some. He was still not speaking. Then he became very
combatative and was intubated.
ROS: per wife he did not complain of any fever, chills,
headache, neck pain, nausea, vomiting, weakness, chest pain.
Past Medical History:
-NSTEMI [**2129**] with OM1 PTCA
-Dyslipidemia
-Previous epistaxis r/t ASA
-Asthma
-denies HTN
-melanoma x2 (chest, first superficial then recurred deeper with
negative axillary lymphnodes
Social History:
Occupation: toy salesman.
married for 35 years
Son who lives in the area and another lives in [**Doctor First Name 5256**]
and is a Neurosurgery PA.
Family History:
CAD: Brother had CABG in his 60's.
Physical Exam:
VITALS: Tafebrile HR87 BP102/58 (162/83) RR11 sO2 100
GEN: intubated
HEENT: mmm, no scleral icterus
NECK: no LAD; no carotid bruits; neck supple
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema; no
suspicious moles on the chest
MENTAL STATUS:
intubated; not responding to voice; not following commands
CRANIAL NERVES:
II: pupils 0.5mm non-reactive
III, IV, VI: oculocephalics intact
V: corneal and nose tickle intact
VII: Facial movement symmetrical when grimacing
VIII: -
IX: gag intact
XII: -
[**Doctor First Name 81**]: -
MOTOR SYSTEM: Normal bulk and tone bilaterally. Moves all
extremities to noxious: withdrawal on the RUE, RLE; extension on
the LUE and triple flexion in the LLE.
SENSORY SYSTEM: responds to noxious in all 4 extremities (see
above)
REFLEXES:
B T Br Pa Pl
Right 2 2 2 2 1
Left 2 2 2 2 1, reflexes are symmetrically brisk in UE
Toes: downgoing on the R, upgoing on the L
COORDINATION: unable to assess
GAIT: unable to assess
Pertinent Results:
Urine Cocaine Pos
Urine Benzos, Barbs, Opiates, Amphet, Mthdne Negative
Trop-*T*: <0.01
145 104 13 AGap=30
--------------< 133
4.1 15 1.0
CK: 182 MB: Pnd
Ca: 10.4 Mg: 2.4 P: 4.2
Serum ASA, EtOH, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
Serum Acetmnphn Pending
WBC16.2 PLT442 Hct41.7
N:72.9 L:23.4 M:1.4 E:2.0 Bas:0.2
Anisocy: 1+ Microcy: 1+
PT: 12.7 PTT: 21.5 INR: 1.1
CT head: round hyperdense lesion L-frontotemporal region with
some edema
CXR: 2.5cm pulmonary nodule (L middle lobe)
Brief Hospital Course:
The patient is a 74yo R-handed man with a history of MI,
hyperlipidemia and melanoma, who is transferred from OSH for an
ICH with possible underlying mass (L-frontotemporal region). He
presented with inability to speak and follow commands. He had no
symptoms otherwise. After transfer, he had a secondary
generalized seizure, after which he was intubated. On exam after
intubation, his CN were intact, and motor/sensory exam shows
some assymmetries (extension LUE). Tox screen was positive for
cocaine. At the OSH, he received decadron IV and he was loaded
on dilantin
in the ED.
NEURO:
Patient was admitted to Neuro ICU. Continued decadron and
dilantin. MRI showed an intra-parenchymal hemorrhage within the
left temporal lobe which demonstrated surrounding edema
suspicious for an underlying mass. He had a normal portable EEG
in the waking state. There were no areas of persistent focal
slowing, and there were no clearly epileptiform features. Blood
pressure was controlled with IV labetolol as needed and he was
extubated without complications. He was transferred to the floor
on [**11-9**]. On [**11-10**], patient had a seizure with loss of
consciousness, transient hypotension and was intubated for
airway protection. Patient was again transferred to the Neuro
ICU. He received a bolus of dilantin and extubated the following
day. He went for stereotactic brain biopsy on [**2144-11-12**] without
complication. He was transferred to the floor post-operatively.
Prior to discharge, patient was started on Keppra with the plan
continue transitioning from Dilantin to Keppra with appropriate
overlap. He will follow-up with Dr. [**Last Name (STitle) **] in Brain [**Hospital 341**] Clinic
as an outpatient.
CV:
Cycled enzymes which were negative and monitored on caridac
telemetry without events. EKG unchanged. Continued lipitor and
zetia. Held aspirin prior to biopsies. Unclear per notes,
whether patient was taking Plavix as well. He will follow-up
with his primary care physician as an outpatient and may resume
taking aspirin.
PULM/ONC: Lung mass was found on torso CT. There was a left
lower lobe 1.6 x 1.7 cm mass with ground-glass opacity in the
right upper lobe. A nodular peripheral opacity measuring 7 mm in
the left upper lobe, near the lung apex was also seen.
Cardiothoracic surgery was consulted. Patient had CT guided
biopsy on [**11-10**] and developed an asymptomatic small left
pneumothorax that was followed with serial chest x-rays and
treated with O2 nasal cannula. Pathology was pending at time of
discharge. Patient will follow-up with in [**Hospital 94667**] clinic
and get a PET scan per their recs. Of note, pelvic CT on [**11-6**]
noted an enlarged prostate with lobulated appearance, more
prominent on the right, it measures 7.1 x 5.6 cm in axial
dimension. Which will likely need to be monitored and further
evaluated as an outpatient.
FEN: Patient was on decadron and covered with insulin sliding
scale four times daily. He passed a speech and swallow
evaluation and was put on a regular diet.
PPX: Pneumoboots, Tylenol PRN
COMMUNICATION: [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 94668**] (wants to know lung
pathology or brain pathology results IMEDIATELY when it returns)
Medications on Admission:
Lipitor 40mg daily
Gemfibrozil 600mg [**Hospital1 **]
Zetia 10mg daily
ASA 325mg daily
Pepcid 10mg daily
Prevacid 30mg p.r.n.
Advair 1 puff [**Hospital1 **]
Albuterol inhaler p.r.n.
Viagra p.r.n.
Ambien p.r.n.
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
6. Decadron 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours.
Disp:*1 month* Refills:*2*
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Keppra 500 mg Tablet Sig: Two (2) Tablet PO twice a day:
[**Date range (1) 94669**] take 2 tab twice daily. [**Date range (1) **] take 3 tabs in
am and 2 tabs in pm. On [**11-21**] & thereafter, take 3 tabs twice
daily.
Disp:*120 Tablet(s)* Refills:*2*
9. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO twice a day: Take until [**11-21**] then may discontinue
medication.
Disp:*30 Capsule(s)* Refills:*0*
10. Diastat 5 mg Kit Sig: One (1) kit Rectal QD as needed for
seizure lasting >3minutes or >3 seizures per hour: To be used
ONLY in EMERGENCY for prolonged seizure >3 minutes or >3
seizures per hour. Please call PCP if you have to use this kit.
Disp:*3 kits* Refills:*0*
11. Outpatient Physical Therapy
Please perform outpatient physical therapy
12. Outpatient Occupational Therapy
Please perform outpatient occupational therapy
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis:
Left frontotemporal mass
Lung nodules
Secondary diagnosis:
Asthma
Hyperlipidemia
H/o NSTEMI
H/o melanoma
Discharge Condition:
Neurologically stable. Mild fluent aphasia with decreased
comprehension. Motor and sensation exam intact.
Discharge Instructions:
Please take medications as prescribed.
Please keep follow-up appointments.
If you have any fevers/chills, persistent headaches or neck
pain, increasing confusion, numbness or weakness or any other
worrying symptoms, please call your primary care physician [**Last Name (NamePattern4) **].
[**First Name (STitle) 9959**] [**Name (STitle) 9960**] or return to the emergency room.
Followup Instructions:
Please follow-up with in Brain [**Hospital 341**] Clinic. Call [**Telephone/Fax (1) 1844**]
on Monday and schedule an appointment to be seen within [**2-10**]
weeks of discharge.
Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 9959**]
[**Name (STitle) 9960**]. Call [**0-0-**] on Monday to schedule an appointment
to be seen within 1-2 weeks of discharge.
Please follow-up in thoracic surgery [**Hospital 94670**] clinic in
[**2-10**] weeks, [**Telephone/Fax (1) **], with Dr. [**Last Name (STitle) **]. Please call the
office prior to your appointment to schedule a PET CT scan.
Please get this scan before your appointment.
Completed by:[**2144-11-17**] Name: [**Known lastname **],[**Known firstname 1500**] Unit No: [**Numeric Identifier 14972**]
Admission Date: [**2144-11-6**] Discharge Date: [**2144-11-15**]
Date of Birth: [**2070-9-6**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 542**]
Addendum:
Called Mr. [**Known lastname 14973**] family regarding follow-up in [**Hospital 9348**]
clinic at [**Last Name (NamePattern1) 3895**] [**Hospital Unit Name **] [**Location (un) **] on [**2144-11-20**] between
10am to 12pm to get your stitches removed.
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**First Name11 (Name Pattern1) 194**] [**Last Name (NamePattern4) 544**] MD [**MD Number(1) 545**]
Completed by:[**2144-11-18**] Name: [**Known lastname **],[**Known firstname 1500**] Unit No: [**Numeric Identifier 14972**]
Admission Date: [**2144-11-6**] Discharge Date: [**2144-11-15**]
Date of Birth: [**2070-9-6**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 542**]
Addendum:
Was noticed by floating case manager that there are no VNA
services available in the area which Mr. [**Known lastname **] lives. VNA was
arranged for home safety evaluation and to get his dilantin
level checked. I will contact his primary care phyisican [**Name (NI) 14974**]
[**Doctor Last Name 14975**] regarding checking his dilantin level as her transitions
to Keppra and possibly helping set up a home safety evaluation
through her offices.
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**First Name11 (Name Pattern1) 194**] [**Last Name (NamePattern4) 544**] MD [**MD Number(1) 545**]
Completed by:[**2144-11-18**]
|
[
"V45.82",
"512.1",
"493.90",
"198.3",
"412",
"438.11",
"V10.82",
"600.00",
"431",
"518.81",
"780.39",
"V17.3",
"272.4",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.26",
"38.93",
"01.13",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12005, 12212
|
3843, 7097
|
286, 328
|
9089, 9197
|
3284, 3701
|
9625, 10951
|
2099, 2135
|
7357, 8848
|
8941, 8941
|
7123, 7334
|
9221, 9602
|
2150, 2538
|
243, 248
|
356, 1703
|
2629, 3265
|
3710, 3820
|
9020, 9068
|
8960, 8999
|
2553, 2613
|
1725, 1916
|
1932, 2083
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,522
| 143,232
|
52930
|
Discharge summary
|
report
|
Admission Date: [**2199-5-20**] Discharge Date: [**2199-5-26**]
Service: ORTHO [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient with a history of
spinal stenosis. Approximately one year ago he had a fall
which resulted in L1 through L5 compression fractures which
went to right sciatica and right foot numbness. An MRI done
in [**2199-2-17**] showed L4-L5 moderate stenosis, spondylosis of
L5, and severe bilateral stenosis of L5-S1.
PAST MEDICAL HISTORY:
1. Status post myocardial infarction in [**2180**].
2. Coronary artery disease.
3. Hypercholesterolemia.
4. Hypothyroidism.
5. Status post gunshot wound to the arms.
6. Status post kidney stones.
7. Hypertension.
PAST SURGICAL HISTORY:
1. Status post olecranon bursectomy in [**2199-2-17**].
2. Status post cystoscopy and bladder biopsy in [**2196-12-19**].
3. Status post coronary artery bypass graft times four in
[**2195-6-19**].
4. Status post septoplasty in [**2194**].
ADMITTING MEDICATIONS: Aspirin, Lipitor, and Levoxyl.
ALLERGIES: Tetanus, cherries, and sweet potatoes.
SOCIAL HISTORY: Former smoker who has now quit. Alcohol:
approximately two glasses a week.
PHYSICAL EXAMINATION: On admission, blood pressure was
152/81, pulse was 64. The patient is approximately 6 feet
tall and weighs about 210 pounds. In general, he is a well
dressed, well nourished male who is slightly overweight in no
acute distress. His head, eyes, ears, nose and throat
examination revealed him to be normocephalic, atraumatic,
sclerae were anicteric and his neck was without
lymphadenopathy or thyromegaly. His neck was supple and had
full range of motion. His lungs were clear to auscultation
bilaterally. Of note, there was a small scar at the inferior
aspect of his chest which was pink and hypertrophic. His
cardiac examination revealed him to have a regular rate and
rhythm without murmurs, rubs, or gallops. His abdomen was
round, soft, nontender, without hepatosplenomegaly. His gait
was slightly antalgic on the right. He was able to heel-toe
walk. He was able to plantar and dorsiflex bilaterally.
HOSPITAL COURSE: The patient was admitted with a diagnosis
of spinal stenosis and underwent an L3-S1 laminectomy and
fusion by Dr. [**Last Name (STitle) 363**] on [**2199-5-20**]. Of note, during the
operation he had profound bleeding with an estimated blood
loss of approximately four liters. This required transfusion
of eight units of packed red blood cells, four units of fresh
frozen plasma, and one unit of platelets, in addition to five
liters of lactated Ringers. He made only 350 cc of urine
throughout the entire operation.
Postoperatively he was transferred to the Surgical Intensive
Care Unit due to his coagulopathy. Additionally he had some
difficulty with his respiratory status, requiring prolonged
intubation. He was extubated in the Post Anesthesia Care
Unit and failed extubation and reintubation was necessary.
His laboratory studies showed his hematocrit to be 31, PT to
be 13.9, PTT 58.3, and INR 1.3 in the Post Anesthesia Care
Unit. Thus it was felt that he was in DIC. His hematocrit
and coags were continued to be followed and he was transfused
packed red blood cells, platelets, and fresh frozen plasma as
needed.
On postoperative day one, he continued to be intubated and
his creatinine bumped up to 1.5. CKs had been sent off,
which were 399, 4,525, and 4,092 with MBs of 10 and 64. His
electrocardiogram showed normal sinus rhythm without
ST-T-wave changes. He was weaned to extubate on
postoperative day one. His hematocrit was 29.8 and he was
transferred for a hematocrit greater than 30. His
coagulopathy began to resolve and his PT was 13.6, PTT 38.0,
and INR 1.2.
On postoperative day two, he was doing much better, making
good urine, and his hematocrit was stable. On postoperative
day three, he was transferred to the floor due to his stable
condition. His tibialis anterior, extensor hallucis longus,
gastrocnemius, iliopsoas, and quadriceps were all [**3-23**] and his
sensation was intact to light touch. His hematocrit was
stable at 32.9. He continued to have low platelets of 89,000
and was transfused accordingly. His creatinine remained
slightly elevated at 1.6.
On [**5-24**], he was having difficulty with emesis secondary to
his pain medications. His Hemovac continued to put out less
fluid. His laboratory studies showed his hematocrit to be
stable at 33.2, platelets 117,000, and his creatinine fell to
1.3. He was begun back on the IV morphine until he was
taking better po, at which time he was restarted on po pain
medication. He was evaluated by both Physical Therapy and
Occupational Therapy which felt that a rehabilitation stay
would be warranted in him.
He continued to do well and his Hemovac was discontinued.
His diet was advanced as tolerated, and his pain was under
good control. His Foley was discontinued and he was voiding
appropriately.
DISPOSITION: The patient was discharged to rehabilitation in
stable condition on [**2199-5-26**].
DISCHARGE MEDICATIONS: Included Levoxyl 0.05 mg po q day,
Lipitor 10 mg po q day, Vicodin one to two tablets po q four
hours prn pain.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 363**] in
two weeks.
DIET: Regular.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**]
Dictated By:[**Last Name (NamePattern1) 104386**]
MEDQUIST36
D: [**2199-5-24**] 08:14
T: [**2199-5-24**] 09:46
JOB#: [**Job Number 109120**]
|
[
"721.3",
"244.9",
"518.5",
"737.30",
"401.9",
"272.0",
"414.01",
"286.6",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"03.09",
"96.71",
"81.08"
] |
icd9pcs
|
[
[
[]
]
] |
5076, 5576
|
2138, 5052
|
735, 1087
|
1204, 2120
|
148, 469
|
491, 712
|
1104, 1181
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,008
| 156,472
|
11595
|
Discharge summary
|
report
|
Admission Date: [**2132-12-19**] Discharge Date: [**2132-12-22**]
Date of Birth: [**2090-12-29**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 41 year-old white
female with a history of presenting with seizures in the fall
of [**2131**], which led to a workup and an MRI, which showed an
AVM of the right temporal region. She was admitted at that
time for diagnostic angiogram, which confirmed the presence
readmitted now for further angiographic embolization
treatment of the AVM.
PAST MEDICAL HISTORY: Otherwise unremarkable.
MEDICATIONS: Paxil and Prilosec.
SOCIAL HISTORY: She is a nonsmoker with a positive alcohol
intake history.
PHYSICAL EXAMINATION: She was in general a well developed,
well nourished, white female in no acute distress with the
entire general physical examination including head, eyes,
ears, nose, throat, heart, lungs and abdomen are essentially
unremarkable. Neurological examination showed speech to be
fluent. She was awake, alert and oriented times three. FAce
was symmetric. Visual fields were full to confrontation and
she moved all extremities without any evidence of weakness.
Cerebellar examination showed finger to nose to be equal
bilaterally and there was no dysmetria and the remainder of
the neurological examination was unremarkable.
HOSPITAL COURSE: Due to the clinical and previous
angiographic and MRI findings the patient was taken to the
Angiography Suite on the day of admission where under
local anesthetic the patient underwent a repeat diagnostic
cerebral angiogram as well as a coiling of the cerebral AVM of
the right temporal region. The patient tolerated the
procedure well and went to the Neurosurgical Intensive Care
Unit post procedure for recovery. Her post procedure
hospitalization course was essentially unremarkable. She was
subsequently discharged home on the [**2132-12-22**] with
follow up to see Dr. [**Last Name (STitle) 1132**] in the clinic.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Name8 (MD) 5474**]
MEDQUIST36
D: [**2133-3-14**] 15:16
T: [**2133-3-16**] 12:10
JOB#: [**Job Number 36832**]
|
[
"300.01",
"401.9",
"780.39",
"311",
"747.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79"
] |
icd9pcs
|
[
[
[]
]
] |
1334, 2200
|
693, 1316
|
158, 509
|
532, 593
|
610, 670
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,280
| 100,374
|
5323
|
Discharge summary
|
report
|
Admission Date: [**2159-1-25**] Discharge Date: [**2159-2-8**]
Date of Birth: [**2114-8-15**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: Patient is a 44-year-old
gentleman with history of hypertension, diabetes, aortic root
replacement x2 secondary to abscess of the aortic valve
presenting to the Emergency Department on [**1-25**] with upper
gastrointestinal bleed. The patient has vomited blood, had
complaints of low grade temperatures, and was admitted to the
MICU.
The patient had been admitted prior on [**2158-9-24**] to
[**2159-1-23**] for the workup of the aortic root abscess;
but was subsequently discharged to rehabilitation and then
again represented to the Emergency Department on [**1-25**] with
the upper gastrointestinal bleed.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Seizure disorder.
4. Neuropathy.
5. Bilateral pleural effusion.
6. Disseminated fungemia.
7. Renal tubular acidosis x1.
PAST SURGICAL HISTORY:
1. Status post coronary artery bypass graft.
2. PEG placement.
3. Right hemicolectomy.
4. Left thoracotomy.
5. Aortic valve surgery x2.
ALLERGIES: The patient has no known drug allergies.
Upon presentation, patient's vital signs were 99.5, blood
pressure 100/53, heart rate 75, respiratory rate 20. He was
on SIMV mechanical ventilation with pressure support.
PHYSICAL EXAMINATION UPON ADMISSION: In general, he is a
young man in no apparent distress, intubated. Pupils are
midline, equally reactive. Oropharynx was moist. Neck was
supple, no bruits. Lungs: Crackles diffusely, decreased
breath sounds bilaterally. Heart: Regular, rate, and
rhythm. Abdomen is soft, nontender, nondistended. Surgical
incision midline with stables clean, dry, and intact.
Extremities: 3+ pitting edema, significant scrotal edema.
Foley is intact. He has a left subclavian intact.
INITIAL LABORATORIES: White blood cell count 17.2,
hematocrit 27, platelets 183. Chem-7: 144 is the sodium,
potassium 3.7, chloride 114, bicarb 21, BUN 44, and
creatinine of 1, sugar of 154, lactate 1.8, INR 1.3, PTT
35.9. He had multiple blood cultures.
On [**1-30**], he had a left subclavian central line culture that
showed no growth. His MRSA screen on [**2159-1-29**] was negative.
Stool cultures were negative on [**1-27**]. Sputum culture on
[**1-25**] is negative. Blood culture on [**1-15**] negative. Urine
culture on [**1-25**] was negative.
He had an ultrasound of the upper extremity that showed no
deep venous thrombosis on [**2159-1-30**]. During his hospital
course in terms of issues: Gastrointestinal: His upper
gastrointestinal bleeding was evaluated by the
Gastroenterology Service. They initially did not scope the
patient and given that his hematocrit stabilized. During the
last couple days prior to discharge, they scoped him twice,
and both times determined that he had gastritis and
esophagitis in the lower [**12-1**] without any focal hemorrhage.
They recommended supportive care.
In terms of his presentation, a CT scan of his belly was
performed which showed free air as well as bowel wall
thickening around the cecum. Surgery service was consulted,
and they elected to do a right hemicolectomy secondary to
diverticular disease. A postoperative CT scan several days
later showed no anastomotic leak. His GI course was
unremarkable as examination remained nontender, nondistended.
In terms of pulmonary issue, the patient was getting Zosyn
and gentamicin for presumptive pneumonia. He had blood
cultures which had showed sparse growth of Pseudomonas last
month, but he was treated for an 11 day course. In terms of
mechanical ventilation, he was on IMV with pressure support,
and then weaned off to pressure support and PEEP, pressure
support of 20 and PEEP of 10.
Chest x-rays had already showed some failure, i.e., pulmonary
edema. However, the saturations always remained stable.
Cardiovascularly, he has always remained hemodynamically
stable of hypertension, and Lopressor was continued.
Infectious Disease: He has never spiked a fever, though his
white blood cell count has been elevated as high as 30s in
the low 30s. Fever never spiked.
Renal wise, given his fluid status on examination, he had
anasarca, diffuse edema pitting on upper and lower
extremities. Given that he was diuresed with 40 mg of IV
Lasix tid, and he put on -1 to 2 liters negative on the last
several days of admission, and will continue to diurese him
outpatient recommended.
Heme wise, his hematocrit has been stable, most recently.
Though his hematocrit did drop to the low 20s. He was
transfused several units, and has been stable on q6 and q12h
hematocrit checks.
Diabetes: Has been stable. He is on regular insulin-sliding
scale.
Seizure disorder: He has had no apparent seizures so far.
Neurologically, it has been documented that he suffered an
anoxic brain event, brain damage, although he continues not
to be oriented, he occasionally appears to be able to follow
commands. He can track with this eyes, but he does not
follow commands.
Fluids, electrolytes, and nutrition: He is on tube feeds of
Peptamen at 90 cc/hour, and he was full code.
DISPOSITION: Back to nursing home.
DISCHARGE DIAGNOSES:
1. Status post right hemicolectomy.
2. Status post upper gastrointestinal bleed.
3. Diabetes.
4. Hypertension.
5. Anoxic brain damage.
6. Status post aortic valve replacement x2.
7. Neuropathy.
8. History of renal tubular acidosis.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po bid.
2. Epogen 4,000 units subQ two times a week Tuesday and
Friday.
3. Morphine sulfate 2-10 mg IV q2-4h prn pain.
4. Keppra 500 mg po bid.
5. Atrovent 1-2 puffs nebulizer q4h prn wheezing.
6. Bacitracin polymixin ophthalmic ointment apply to each eye
q6h.
7. Tylenol 650 mg po q4-6h.
8. Metoprolol 25 mg po bid.
9. Tube feeds: Peptamen 90 cc/hour.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 19796**]
MEDQUIST36
D: [**2159-2-7**] 13:16
T: [**2159-2-8**] 08:02
JOB#: [**Job Number 21700**]
|
[
"518.83",
"557.0",
"428.0",
"707.0",
"780.39",
"486",
"348.1",
"567.2",
"562.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93",
"96.6",
"96.71",
"45.73",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
5213, 5446
|
5469, 6082
|
972, 1360
|
161, 773
|
1375, 5192
|
795, 949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,087
| 159,446
|
46802+58945
|
Discharge summary
|
report+addendum
|
Admission Date: [**2143-5-6**] Discharge Date: [**2143-5-13**]
Date of Birth: [**2069-10-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hydrochlorothiazide / Sulfonamides / Doxycycline / Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2143-5-6**] Aortic Valve Replacement(23mm St. [**Male First Name (un) 923**] Porcine Valve) and
Four Vessel Coronary Artery Bypass Grafting(left internal
mammary artery to left anterior descending, saphenous vein
grafts to ramus, obtuse marginal, and posterior descending
artery)
History of Present Illness:
Mr. [**Known lastname 5395**] is a 73 year old male with mild symptoms of dyspnea
on exertion over the last 6-12 months. A recent [**Known lastname 461**]
in [**2143-2-1**] revealed severe aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of
0.9cm2 and mean gradient of 49mmHg. His LVEF was estimated at
50-55%. Further evaluation included cardiac catheterization
which revealed three vessel coronary artery disease. Based upon
the above, he was referred for cardiac surgical intervention. He
denies a history of chest pain, syncope and congestive heart
failure.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
Hypertension
Hypercholesterolemia
Type II Diabetes Mellitus
Peripheral Vascular Disease
Splenic Artery Aneurysm, s/p coiling [**2141**]
Squamous Cell Carcinoma Removal
Tonsillectomy
Social History:
Quit tobacco 30 years ago. Admits to very light ETOH
consumption. Currently married and lives with his wife. [**Name (NI) **] is
retired.
Family History:
Denies premature coronary artery disease.
Physical Exam:
PREOP EXAM
Vitals: 130/70, 68, 12
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, 3/6 systolic
ejection murmur which radiates to carotids
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2143-5-6**] Intraop TEE:
PRE-CPB:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic root. The ascending
aorta is mildly dilated. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened and calcified. No masses or
vegetations are seen on the aortic valve. There is moderate to
severe aortic valve stenosis (area 0.8-1.0cm2). Mild to moderate
([**1-2**]+) aortic regurgitation is seen. The annulus measures 2.3
cm.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
POST-CPB:
On infusion of phenylephrine, a-v pacing. Well-seated
bioprosthetic valve in the aortic position. Trivial AI. No
paravalvular leak. Preserved biventricular systolic function.
Trace MR. [**First Name (Titles) **] aortic contour is normal post decannulation.
Brief Hospital Course:
Mr. [**Known lastname 5395**] was admitted and underwent aortic vavle replacement
surgery along with coronary artery bypass grafting by Dr.
[**Last Name (STitle) **]. For surgical details, please see seperate 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. Beta blockade was advanced as tolerated.
Over several days, he continued to make clinical improvements
with diuresis. He remained in a normal sinus rhythm. His chest
tubes, pacing wires and foley were removed without difficulty.
He is voiding abd taking PO on DC. Pt sternum was slightly
cellulitic. Keflex was started. He will continue this for 5
days. Pt recoomended home with vna. Pt DC in stable conditoion.
Medications on Admission:
Aspirin, Amlodipine 10 qd, Lisinopril 5 qd, Metformin 500 [**Hospital1 **],
Atenolol 100 qd, Simvastatin 20 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. 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*
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation: prn.
Disp:*60 Suppository(s)* Refills:*0*
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
Disp:*20 Capsule(s)* Refills:*0*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: prn.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p AVR/CABG
Hypertension
Hypercholesterolemia
Type II Diabetes Mellitus
Peripheral Vascular Disease
History of Splenic Artery Aneurysm, s/p coiling [**2141**]
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 [**4-6**] weeks, call for appt
Dr. [**First Name (STitle) **] in [**2-3**] weeks, call for appt
Dr. [**First Name (STitle) **] in [**2-3**] weeks, call for appt
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2143-7-23**] 1:40
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2143-10-1**]
2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2143-10-1**] 3:00
Completed by:[**2143-5-11**] Name: [**Known lastname 2596**],[**Known firstname **] B Unit No: [**Numeric Identifier 15901**]
Admission Date: [**2143-5-6**] Discharge Date: [**2143-5-13**]
Date of Birth: [**2069-10-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hydrochlorothiazide / Sulfonamides / Doxycycline / Codeine
Attending:[**First Name3 (LF) 741**]
Addendum:
Dsicharge not done on [**5-11**] due to pt. feeling lightheaded in the
shower. Beta blockade was decreased and one unit PRBC
trasnfused, with good response. Cleared for discharge to home on
[**5-13**]. Pt. is to make all followup appts. as per discharge
instructions.
****PLEASE NOTE new discharge medications list dated [**5-13**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
2 weeks.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation: prn.
Disp:*60 Suppository(s)* Refills:*0*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 1 days.
Disp:*4 Capsule(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: prn.
Disp:*60 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*150 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2143-5-13**]
|
[
"427.31",
"250.00",
"682.2",
"272.4",
"443.9",
"285.9",
"E878.2",
"287.5",
"998.59",
"401.9",
"997.1",
"V10.83",
"414.01",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"35.21",
"39.61",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9517, 9694
|
3585, 4481
|
344, 628
|
6428, 6435
|
2164, 3562
|
6771, 8101
|
1665, 1708
|
8124, 9494
|
6202, 6407
|
4507, 4619
|
6459, 6748
|
1723, 2145
|
285, 306
|
656, 1249
|
1271, 1494
|
1510, 1649
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,017
| 167,354
|
21416
|
Discharge summary
|
report
|
Admission Date: [**2168-4-28**] Discharge Date: [**2168-5-22**]
Date of Birth: [**2149-1-27**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
CC:[**CC Contact Info 56552**].
HPI: 19 y/o male with ALL day 176 s/p MUD allogenic stem cell
transplant with GVHD of skin, gut/liver, and now possibly lung.
He was admitted on eweek prior for new onset DOE of about two
weeks now. During workup last admission, CXR was abnormal with
bilateral diffuse patchy infiltrates. High resolution CT showed
tree in [**Male First Name (un) 239**] appearance in lower lobes consistant with infectious
process. Echo showed normal EF. He was seen by Pulmonary, and
bronchoscopy was done. BAL was non contributory, negative for
PCP. [**Name10 (NameIs) 56553**] was negative. He was started on combivent and
his pulmocort was changed to fluticasone. He was started on
azithromycin to cover atypical PNA, atovaquonefor PCP
[**Name Initial (PRE) 1102**]. He had [**Name Initial (PRE) 1570**]'s checked on [**2168-4-26**], which showed FEV1
of 0.95 L. Last bone marrow aspiration and biopsy showed a
hypocellular marrow with a cellularity of less than 10%. No
evidence of leukemia was seen and he was full donor chimerism.
.
He comes in today after being seen in the clinic with continued
SOB. He is being admitted for further workup and possibly open
lung biopsy.
.
Oncology History: He was diagnosed with pre-B-cell ALL in [**2166-6-17**]
after presenting with fatigue, DOE, dizziness, 20lb. weight
loss, lymphadenopathy and splenomegaly. He was found to have
pancytopenia with a Hct of 15. Following diagnosis he underwent
induction therapy on the E-2993 protocol, with intrathecal
methotrexate on day 24 as per protocol. His initial bone marrow
aspiration and biopsy on day +24 showed resolution of most of
his prior abnormal cytogenetics, but persistence of aneuploidy
4. He received phase II of induction chemotherapy with
cyclophosphamide, ARA-C, 6-MP for 28 days. He received
intensification with high-dose MTX, followed by consolidation
therapy with cyclophosphamide and etoposide (EP-16). This was
completed with the addition of dexamethasone and 6-TG in [**Month (only) 958**]
[**2167**]. In [**2167-5-15**], he underwent a repeat bone marrow aspirate
and biopsy. The bone marrow aspirate and biopsy showed karyotype
47,XYY, and no evidence by FISH of the prior mentioned
cytogenetic abnormalities. A recent bone marrow biopsy revealed
mildly hypocellular marrow with maturing trilineage
hematopoiesis and no evidence of ALL, but cytogenetic testing
revealed aneuploidy of chromosome 4 in 12% of cells. He was
admitted on [**2167-8-28**] and began repeat induction with the
ECOG-2993 protocol including Daunarubicin, Vincristine,
Prednisone, and L-Asparaginase with intrathecal methotrexate on
day 10. LP cytology results demonstrated no malignant cells in
sampled CSF. The patient's course of chemotherapy was
complicated by hypomania secondary to high dose prednisone,
hypofibrinogenemia secondary to therapy with L-Asparaginase,
neutropenic fever, and multiple LFT abnormalities. The etiology
of the rise in his transaminases was thought most likely to be
due to a drug reaction. The viral testing was negative. Given
that he was scheduled to undergo an allogeneic transplant with
Cytoxan and TBI conditioning, he did undergo a liver biopsy to
assess the degree of fibrosis as well as inflammation prior to
proceeding with transplant. The liver biopsy showed moderate
microvascular steatosis with mild bile duct injury and
occasional apoptotic hepatocytes, consistent with drug injury.
Special stains for fungi, herpes simplex virus, and CMV were
negative. However, given that his ALT was still at 200, the
transplant planned for [**10-8**] was delayed until [**2167-10-29**] to try
and reduce the risk of VOD. Bone marrow bx from [**10-1**] showed
markedly hypocellular marrow with early recovering trilineage
hemopoesis, no residual ALL identified. Pt was admitted on
[**2167-10-23**] precondition with cytoxan and TBI for an allo transplant.
Last allo transplant complicated by GVH for which he was on
steroids and cyclosporin.
.
Past Medical History:
1. Relapsed Pre B-cell ALL
2. Asthma as a child that resolved by fourth grade.
.
Allergies: Bactrim
.
Medications:
Multivitamin 1 Cap po qd
Folic Acid 1 mg po qd
Prednisone 60 mg po qd
Acyclovir 400 mg po q8
Oxygen 1-2 L/minute as needed while ambulating
Cyclosporine Modified 275 mg po bid
Fluticasone 110 mcg 2 Puff Inh [**Hospital1 **]
Azithromycin 250 mg PO Q24H
Albuterol-Ipratropium 103-18 mcg 2 Puff Inh Q4H
Atovaquone 1500 mg PO QD
Fluconazole 200 mg po qd
pentamidine inh last [**2168-4-25**]
.
Social Hx:
No smoking, occ alcohol, no drugs
.
Fam Hx:
Mother with [**Name (NI) 1932**] Lymphoma
.
PHYSICAL EXAM:
GEN: well appearing male not in respiratory distress
T 98.4 HR 102 BP 118/80 RR 18 Sat 94% RA
HEENT: PERRL, sclera anicteric, evidence of mucosal GVHD
NECK: no cervical LAD
CHEST: lungs with decreased breath sounds aat bases, better at
apecies, bronchial throughout. Small non tender node in right
axilla.
HEART: Mildly tach bur regular, No M/G/R.
ABD: + BS, soft, NT, ND, no masses.
EXT: no C/C/E.
NEURO: intact
.
LABS: see bleow
.
CT SCAN:
1. Diffuse predominantly ground-glass lung opacities with a
predominantly peribronchiolar distribution with sparing of the
lung periphery. This has progressed since [**2168-4-21**].
Differential diagnosis given the time interval since transplant
includes progressive opportunistic infection and noninfectious
entities such as cryptogenic organizing pneumonia.
2. Slight increase in bilateral pleural effusions. Persistent
small
pericardial effusion.
.
ECHO: last admission had normal EF
.
A/P: 19 y/o M day 176 s/p ablative MUD allogenic transplant with
a recent admission for SOB, now presenting with persistent
symptoms for workup.
.
1. DOE: GVHD (peripheral eosinophilia, transaminitis) vs.
Infectious process
- cont azithro, start levofloxacin
- pulm consult
- consider CT surgery consult for open lung biopsy if not
improved
- change fluconazole to voriconazole
- continue prednisone 60mg po qd, cont CSA at 275 mg po bid
(last level 320)
- O2 by nasal cannula to maintain O2>92%
.
2. ALL: He is five months s/p allo transplant. He had GVHD of
skin and liver. His counts are stable.
.
3. Thrombocytopenia: Stable. No evidence of bleeding.
.
4. Anemia: Mild anemia, not requiring transfusion. Stable.
.
5. Transaminitis: Likely due to liver GVHD.
.
6. Eosinophilia: Likely due to GVHD.
.
Eating. Moving bowels without constipation or diarrhea.
Major Surgical or Invasive Procedure:
endotracheal intubation and mechanical ventilation, chest tube x
3, VATS, R tunneled IJ line placed
History of Present Illness:
BMT TRANSFER ACCEPT NOTE
.
CC:[**CC Contact Info 56554**].
HPI: 19 y/o male with ALL several months out from MUD allogenic
stem cell transplant complicated by GVHD of skin, gut/liver. He
was admitted recently for new onset DOE, workup up with
bronchospopy which was negative for infectious cause, and
discharged, on azithromycin for atypical PNA and atovaquone for
PCP prophylaxis, with room air saturation in the mid 90's with
ambulation. He was readmitted after clinic visit showed no
improvement in symptomes. His antibiotics were changed to Vanco,
Cefepime, and Levofloxacin. He underwent VATS procedure for
definitve diagnosis between BOOP/BO vs. Infection. Procedure
went well, but post op course was complicated by chest tube
related pneumothorax.
.
He reports feeling well currently with no SOB, but with some
left sided pain with inspiration, coughing. Pain has been well
controlled with morphine PCA. He denies headache, dysuria,
constipation or diarrhea. He has a good appetite.
.
Oncology History: He was diagnosed with pre-B-cell ALL in [**2166-6-17**]
after presenting with fatigue, DOE, dizziness, 20lb. weight
loss, lymphadenopathy and splenomegaly. He was found to have
pancytopenia with a Hct of 15. Following diagnosis he underwent
induction therapy on the E-2993 protocol, with intrathecal
methotrexate on day 24 as per protocol. His initial bone marrow
aspiration and biopsy on day +24 showed resolution of most of
his prior abnormal cytogenetics, but persistence of aneuploidy
4. He received phase II of induction chemotherapy with
cyclophosphamide, ARA-C, 6-MP for 28 days. He received
intensification with high-dose MTX, followed by consolidation
therapy with cyclophosphamide and etoposide (EP-16). This was
completed with the addition of dexamethasone and 6-TG in [**Month (only) 958**]
[**2167**]. In [**2167-5-15**], he underwent a repeat bone marrow aspirate
and biopsy. The bone marrow aspirate and biopsy showed karyotype
47,XYY, and no evidence by FISH of the prior mentioned
cytogenetic abnormalities. A recent bone marrow biopsy revealed
mildly hypocellular marrow with maturing trilineage
hematopoiesis and no evidence of ALL, but cytogenetic testing
revealed aneuploidy of chromosome 4 in 12% of cells. He was
admitted on [**2167-8-28**] and began repeat induction with the
ECOG-2993 protocol including Daunarubicin, Vincristine,
Prednisone, and L-Asparaginase with intrathecal methotrexate on
day 10. LP cytology results demonstrated no malignant cells in
sampled CSF. The patient's course of chemotherapy was
complicated by hypomania secondary to high dose prednisone,
hypofibrinogenemia secondary to therapy with L-Asparaginase,
neutropenic fever, and multiple LFT abnormalities. The etiology
of the rise in his transaminases was thought most likely to be
due to a drug reaction. The viral testing was negative. Given
that he was scheduled to undergo an allogeneic transplant with
Cytoxan and TBI conditioning, he did undergo a liver biopsy to
assess the degree of fibrosis as well as inflammation prior to
proceeding with transplant. The liver biopsy showed moderate
microvascular steatosis with mild bile duct injury and
occasional apoptotic hepatocytes, consistent with drug injury.
Special stains for fungi, herpes simplex virus, and CMV were
negative. However, given that his ALT was still at 200, the
transplant planned for [**10-8**] was delayed until [**2167-10-29**] to try
and reduce the risk of VOD. Bone marrow bx from [**10-1**] showed
markedly hypocellular marrow with early recovering trilineage
hemopoesis, no residual ALL identified. Pt was admitted on
[**2167-10-23**] precondition with cytoxan and TBI for an allo transplant.
Last allo transplant complicated by GVH for which he was on
steroids and cyclosporin.
.
Past Medical History:
1. Relapsed Pre B-cell ALL
2. Childhood Asthma
.
Allergies: Bactrim
.
Medications:
Multivitamin 1 Cap po qd
Folic Acid 1 mg po qd
Prednisone 60 mg po qd
Acyclovir 400 mg po q8
Cyclosporine Modified 200 mg po bid
Fluticasone 110 mcg 2 Puff Inh [**Hospital1 **]
Albuterol-Ipratropium 103-18 mcg 2 Puff Inh Q4H
Atovaquone 1500 mg PO QD
Fluconazole 200 mg po qd
Cefipime 2g IV Q12hours
Levofloxacin 500 mg PO QD
Morphine Sulfate PCA
Protonix 40 mg PO QD .
Vancomycin 1 g IV Q12
.
PHYSCIAL EXAM:
97.3 94 128/82 22 100%on 4L NC
GEN: well appearing, not tachypneic, left sided chest tube in
place
HEENT: PEERL, EOMI, sclera anicteric
NECK: no LAD
CHEST: crackles on left side ant and posteriorly
HEART: noraml s1/s2. no m/g/r
ABD: NABS, soft, NT, ND, no masses
EXT: no edema or cyanosis
NEURO: intact
.
CT SCAN:
1. Small left apical pneumothorax.
2. Tip of the left chest tube located high within the lung
apex. This tube should be retracted at least 3-4 cm.
3. No evidence of pulmonary embolus.
4. Interval progression of perihilar and bibasilar patchy
consolidation with relative sparing of the lung apices and
periphery. This has significantly progressed since [**2168-4-28**]. Given the time interval since transplant, differential
diagnosis concerning for progressive opportunistic infection and
less likely pulmonary edema.
5. Stable appearance of large right and smaller left pleural
effusion. Moderate pericardial effusion.
.
CXR:
A left-sided chest tube remains in place. A small left
pneumothorax with apical and lateral components is again
demonstrated, with slight decrease in the lateral component.
Cardiac and mediastinal contours are stable. Bilateral alveolar
opacities are without change allowing for differences in lung
volumes.
.
A/P: 19 y/o M s/p ablative MUD allogenic transplant, now s/p
VATS lung Biopsy with Left sided Chest tube in place, getting
worked up for BOOP/BO vs Infection, on Vanco, Cefepime,
Levofloxacin.
.
1. Pulm: GVHD vs. Infectious process.
- Cont levofloxacin, vancomycin, and cefipime
- Cont prednisone at 60 mg PO QD and cont CSA at 200 mg PO BID
(last level 345)
- Cont voriconazole, acyclovir, and atovaqone as prophylaxis po
bid
- O2 by nasal cannula to maintain O2>92%.
- Had chest tube pulled today, watch for SOB
.
2. ALL: He is five months s/p allo transplant. He had GVHD of
skin and liver. His counts are stable.
.
3. Thrombocytopenia: Mild. Stable. No evidence of bleeding.
.
4. Anemia: Mild anemia, not requiring transfusion. Stable.
.
FULL CODE
Social History:
Lives with parents. No Tobacco, no EtOH, no drugs.
Family History:
mother [**Name (NI) 56555**] [**Name (NI) 1932**].
Physical Exam:
99.6/99.6, 105-134, 92-111/60-67, 90-100% 10LNRB
Gen: increased work of breathing, mild respiratory distress,
speaks
in single words, using abdominal muscles for respiration
HEENT: NCAT, PERRL
Cor: tachycardic, s1s2, no r/g/m
Pulm: decreased BS bilaterally, L sided chest tube in place with
serosanguinous fluid draining
Abd: using abdominal muscles as above, soft, NTND, +bs
Ext: no c/c/e, WWP, 2+ pt pulses bilaterally
Pertinent Results:
.
CXR [**5-16**]: Moderate left pneumothorax with interval increase in
size since recent radiograph of one day earlier.
.
CTA chest 4/1:1. No evidence of pulmonary embolism or
dissection. Large right pleural effusion, stable. Bilateral
patchy opacifications appearing slightly more diffuse in
location and less consolidative.
[**5-13**] echo: normal chamber sizes and wall thicknesses, elevated
PA systolic pressure to 36-42. EF 65-70%
.
[**5-2**]: Lung Bx:
I. Lung, left upper lobe, wedge biopsy (A - D):
a. Lung tissue with patchy chronic interstitial pneumonitis
with accumulation of intra-alveolar macrophages. b. No viral
inclusions, granuloma or malignancy identified.
II. Lung, left lower lobe, wedge:
a. Lung tissue with patchy organizing and focally acute
pneumonitis, with accumulation of intra-alveolar macrophages.
b. No viral inclusion, granuloma or malignancy identified.
.
[**4-22**]: BAL negative for PCP, [**Name10 (NameIs) **], influenza or other viral
antigens
.
galactomannan negative
.
[**2168-4-26**] PFTs with FEV1 of 0.95, FVC 1.11 and ratio of 85% which
suggest a restrictive pattern
.
Last bone marrow aspiration and biopsy showed a hypocellular
marrow with a cellularity of less than 10%. No evidence of
leukemia was seen and he was full donor chimerism.
.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 56556**] was hospitalized from [**2168-4-28**] until the time of
his death on [**2168-5-22**]. During this time he was cared for by the
BMT team in the BMT unit, as well as by the [**Hospital Unit Name 153**] team in the
medical ICU. He initially presented wiht tachypnea and dyspnea
of unknown cause. Original infectious workup was negative,
including BAL, and the patient underwent VATS procedure. The
lung biopsy was not pathognomonic but was consistent with GVHD
of the lung, which was the presumed diagnosis. The patient was
kept on steroids as well as cyclosporine to treat his pulmonary
GVHD. VATS was complicated by a left apical pneumothorax for
which chest tube was placed and the patient was transferred to
the [**Hospital Unit Name 153**]. His breathing stabilized with chest tube and
pneumothorax resolved. He was transferred back to the BMT floor,
where he continued to worsen in pulmonary status, becoming
tachypneic even with moving from bed to commode. The decision
was made ot begin photopheresis for his GVHD and right internal
jugular tunneled catheter was placed for this procedure. This
was complicated by a venous air embolus which caused transient
hypotension and hypoxia as well as tachycardia. The patient was
again transferred to the [**Hospital Unit Name 153**], where he remained relatively
stable although he did have an episode of what appeared to be
atrial flutter, which was broken with Valsalva. He was
transferred back to the BMT floor, where his condition continued
to worsen. He was started on treatment for broad infectious
coverage (vanco, cefepime, levofloxacin, pentamidine later
changed to atovaquone, voriconazole), including Pneumocystis
pneumonia treatment, but had no improvement and in fact CXR
showed progression of infiltrates, particularly on the right
side. He was found on the floor to have a spontaneous second
pneumothorax on the left side for which chest tube was placed
again and the patient was transferred back to the MICU.
His tachypnea continued to progress but ABGs showed that the
patient was not tiring for three days of respiratory rate of
40s-50s for most of the day. The running diagnosis at this time
was more likely GVHD of the lung rather than infection and the
patient had been started on cellcept in addition to his steroids
and cyclosporine. He was not able to start photopheresis as he
remained too ill to go to the pheresis lab. Finally, on [**5-20**] the
patient's respiratory status continued to deteriorate, he was
hypoxic to the high 80s and he was developing fatigue, and the
decision was made to intubate the patient. The patient was
extremely difficult to adequately ventillate and required
paralysis in order to work with the ventilator. He went into
rapid afib poorly responsive to beta blockers that lasted
through the night. He also acutely spontaneously desaturated
and was found to have a left tension pneumothorax despite L
sided chest tube that was still in place and had been
demonstrating air leak. The decision was made by the patient's
family that he would not want to continue treatment in this way
and he was extubated on [**2168-5-22**] at approximately 2:15pm. [**Known firstname **]
expired at 2:35pm on [**2168-5-22**]. His parents were in the room with
him at this time. He was pronounced and post-mortem examination
was declined by his family.
Medications on Admission:
Multivitamin 1 Cap po qd
Folic Acid 1 mg po qd
Prednisone 60 mg po qd
Acyclovir 400 mg po q8
Oxygen 1-2 L/minute as needed while ambulating
Cyclosporine Modified 275 mg po bid
Fluticasone 110 mcg 2 Puff Inh [**Hospital1 **]
Azithromycin 250 mg PO Q24H
Albuterol-Ipratropium 103-18 mcg 2 Puff Inh Q4H
Atovaquone 1500 mg PO QD
Fluconazole 200 mg po qd
pentamidine inh last [**2168-4-25**]
Discharge Medications:
pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Progressive pulmonary disease most c/w GVHD of the lung
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2168-5-23**]
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23,365
| 166,419
|
26195
|
Discharge summary
|
report
|
Admission Date: [**2198-8-13**] Discharge Date: [**2198-8-24**]
Date of Birth: [**2147-12-5**] Sex: M
Service: SURGERY
Allergies:
Percocet / Percodan
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Inability to eat, weight loss and sore throat.
Major Surgical or Invasive Procedure:
PEG
Bronchoscopy
Endoscopy
Sigmoidoscopy
History of Present Illness:
The patient is a 50 y/o man s/p liver transplant [**3-12**]. The
patient presented to [**Hospital1 18**] [**6-12**] for a rash with symptoms
concerning for graft versus host disease. His recent coarse has
been complicated by pneumonia, herpes esophagitis and failure to
thrive. He was discharged in [**7-12**] to [**Hospital **] rehab. The patient
returns with similar complaints, febrile, with weight loss and
overall deconditioning.
Past Medical History:
status post liver transplant on [**2198-3-22**] for alcoholic
cirrhosis
multiple failed TIPS with recurrent ascites.
Social History:
The patient is married.
Lives on [**Hospital1 6687**] with wife.
[**Name (NI) 1403**] as a window installer, but currently disabled.
Family History:
Non-contrib
Physical Exam:
101/137/150/79/40/90RA
cachetic, illappearing, aaox3, respiratory distress
tachycardic, regular rhythm, S1S2, no M/G/R
coarse bilateral breath sounds
soft, scaphoid appearing, no rebound, no guarding
no C/C/E
Pertinent Results:
[**2198-8-13**] 06:25PM rapamycin-17.4*
[**2198-8-13**] 09:24PM freeCa-1.25
[**2198-8-13**] 09:24PM TYPE-ART TEMP-37.0 PO2-61* PCO2-33* PH-7.30*
TOTAL CO2-17* BASE XS--8 INTUBATED-NOT INTUBA
[**2198-8-13**] 09:51PM PT-12.5 PTT-24.8 INR(PT)-1.1
[**2198-8-22**] 03:14AM BLOOD Type-ART pO2-128* pCO2-58* pH-7.21*
calTCO2-24 Base XS--5
[**2198-8-22**] 04:50AM BLOOD Type-ART Temp-34.7 pO2-123* pCO2-49*
pH-7.26* calTCO2-23 Base XS--5
[**2198-8-23**] 01:43AM BLOOD Type-ART pO2-87 pCO2-58* pH-7.20*
calTCO2-24 Base XS--5
[**2198-8-23**] 02:38AM BLOOD Type-ART pO2-79* pCO2-62* pH-7.19*
calTCO2-25 Base XS--5
[**2198-8-24**] 12:41AM BLOOD Type-ART pO2-88 pCO2-59* pH-7.20*
calTCO2-24 Base XS--5
[**2198-8-24**] 06:37AM BLOOD Type-ART pO2-82* pCO2-60* pH-7.22*
calTCO2-26 Base XS--4 Intubat-INTUBATED
[**2198-8-23**] 08:05PM BLOOD Type-ART pO2-91 pCO2-62* pH-7.16*
calTCO2-23 Base XS--7
[**2198-8-23**] 04:20PM BLOOD Type-ART pO2-99 pCO2-64* pH-7.19*
calTCO2-26 Base XS--4
[**2198-8-23**] 02:20PM BLOOD Type-ART pO2-79* pCO2-60* pH-7.18*
calTCO2-24 Base XS--6
[**2198-8-22**] 07:06AM BLOOD FK506-4.7*
[**2198-8-23**] 07:38AM BLOOD FK506-7.0
[**2198-8-24**] 08:32AM BLOOD FK506-3.3*
[**2198-8-17**] 08:11AM BLOOD Vanco-6.6*
[**2198-8-18**] 12:27PM BLOOD Vanco-5.0*
[**2198-8-19**] 11:14AM BLOOD Vanco-18.9*
[**2198-8-21**] 07:21PM BLOOD Vanco-20.8*
[**2198-8-24**] 12:23AM BLOOD Vanco-31.6
[**2198-8-15**] 02:08AM BLOOD IgG-344* IgA-94 IgM-21*
[**2198-8-20**] 02:09PM BLOOD Cortsol-32.0*
[**2198-8-23**] 04:10PM BLOOD TSH-0.17*
[**2198-8-21**] 03:16PM BLOOD Triglyc-204*
[**2198-8-22**] 03:02AM BLOOD Triglyc-158*
[**2198-8-13**] 09:51PM BLOOD Albumin-3.2* Calcium-9.0 Phos-3.8 Mg-2.1
[**2198-8-15**] 02:08AM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.1*
Mg-2.0
[**2198-8-16**] 04:06AM BLOOD Calcium-7.8* Phos-1.2* Mg-2.0
[**2198-8-19**] 05:30AM BLOOD Calcium-7.7* Phos-2.0* Mg-1.9
[**2198-8-22**] 03:02AM BLOOD Calcium-7.6* Phos-3.1 Mg-1.8
[**2198-8-23**] 01:20AM BLOOD Calcium-7.8* Phos-3.8 Mg-2.0
[**2198-8-14**] 09:22AM BLOOD CK(CPK)-100
[**2198-8-14**] 05:47PM BLOOD LD(LDH)-286*
[**2198-8-20**] 03:35AM BLOOD ALT-7 AST-8 AlkPhos-48 TotBili-0.5
[**2198-8-24**] 02:30AM BLOOD ALT-6 AST-14 AlkPhos-63 Amylase-53
TotBili-2.9*
[**2198-8-16**] 04:06AM BLOOD Glucose-120* UreaN-13 Creat-0.4* Na-139
K-3.3 Cl-109* HCO3-20* AnGap-13
[**2198-8-17**] 03:39AM BLOOD Glucose-122* UreaN-7 Creat-0.4* Na-142
K-3.0* Cl-113* HCO3-21* AnGap-11
[**2198-8-17**] 03:15PM BLOOD Glucose-112* UreaN-5* Creat-0.4* Na-141
K-3.2* Cl-110* HCO3-22 AnGap-12
[**2198-8-20**] 08:26PM BLOOD K-3.7
[**2198-8-21**] 03:23AM BLOOD Glucose-117* UreaN-16 Creat-1.0 Na-146*
K-3.7 Cl-114* HCO3-23 AnGap-13
[**2198-8-23**] 04:10PM BLOOD Glucose-112* UreaN-34* Creat-1.6* Na-135
K-4.1 Cl-107 HCO3-22 AnGap-10
[**2198-8-16**] 04:06AM BLOOD Plt Ct-119*
[**2198-8-19**] 05:30AM BLOOD Plt Ct-75*
[**2198-8-23**] 04:10PM BLOOD WBC-0.7*# RBC-3.65* Hgb-9.5* Hct-29.4*
MCV-81* MCH-26.1* MCHC-32.4 RDW-19.3* Plt Ct-34*
Brief Hospital Course:
The patient was admitted from clinic directly to the regular
transplant floor for weight loss, fevers, malaise and overall
deconditioning on [**2198-8-13**]. The patient had undergone an OLT on
[**2198-3-12**]. The patient presented after surgery in [**6-12**] was a rash
covering for GVHD. The patient was started on broad spectrum
antibiotics antifungal and IV fluids. Additionally his
immunosuppression were held due to high levels of rapamycin.
Nutrition was consulted to evaluate the patient's nutritional
status and to make recommendation on how to improve his
nutrition. On hospital day two the patient was transferred to
the ICU due to respiratory decompensation while on the regular
floor. Pulmonary medicine team was consulted to assist in the
care of what was believed to be a hospital acquired pneumonia.
The infectious disease team was also consulted, they agreed with
the plan to continue broad spectrum antibiotic and fungal
coverage. The hepatology service was aware of the patient's
presence in the hospital and followed the patient throughout
hospitalization.The patient underwent an echocardiogram to rule
out septic foci of the heart valves that might be seeding his
lungs with septic foci. On [**8-16**] the patient underwent
endoscopy,sigmoidoscopy with biopsies. His sputum cultures from
[**8-14**] grew COAG positive staph, gram positive cocci and gram
positive rods. On [**8-17**] the patient had a PEG tube placed by the
hepatology service which he tolerated without a problem. On [**8-18**]
the patient was stable from a cardiovascular and pulmonary
standpoint. The pulmonary service believed the patient's
pneumonia was under control and that his respiratory status was
improving. Subsequently the patient was transferred back the
floor. Due to tachypnea and tachycardia with new ground glass
opacities on chest xray, the thoracic surgery service was
consulted to obtain biopsy. However, CT findings and the
patient's clinical status deteriorated leading to transfer back
to the ICU. The thoracic and transplant surgery teams did feel
the patient would be able to tolerate a lung biopsy at that
time. Specifically, the CT chest from [**8-19**] demonstrated marked
progression of innumerable bilateral lung opacities involving
all lobes with associated ground glass opacity and cavitation.
While the patient was on the floor he quickly decompensated from
a respiratory standpoint, requiring intubation upon transfer
back the ICU [**8-19**]. The patient underwent bronchoscopy by the ICU
team, however his lung function did not improve. The patient
required pressor support to maintain his blood pressure, his
respiratory status slowly deteriorated until his peak airway
pressure were in the mmHg range. The patient's cell lines were
repleted with Neupogen and multiple blood products to support
his condition. The patient's antibiotics were closely followed
and dosed in order to cover positive cultures per blood, sputum
and urine. Additionally the patient was covered with empiric
fungal medications in the event the he was manifesting sepsis
from a pulmonary fungal source. Ultimately the patient was
unable to overcome overwhelming sepsis from MRSA bacteremia,
Klebsiella pneumonia, C.diff in his stool and diffuse pulmonary
processes for which he was covered with caspofungin. After an
extensive conversation with the patient's wife that occurred on
numerous occasions during his ICU coarse, she decided to
withdraw all supportive measures from her husband's care on
[**2198-8-24**]. The patient died within hours of this decision of
cardiopulmonary arrest.
Discharge Medications:
none
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
death
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none, patient deceased
|
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4390, 7983
|
325, 367
|
8123, 8133
|
1397, 4367
|
8186, 8211
|
1139, 1152
|
8006, 8012
|
8095, 8102
|
8157, 8163
|
1167, 1378
|
239, 287
|
395, 831
|
853, 972
|
988, 1123
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,304
| 109,246
|
1840
|
Discharge summary
|
report
|
Admission Date: [**2142-2-15**] Discharge Date: [**2142-2-22**]
Service: MEDICINE
Allergies:
Tomato / Lorazepam
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 88 yo male with PMH CABG, CHF LVEF 30-35%, metastatic
colon CA who presents with diarrhea and hypotension. He reports
non bloody, yellow diarrhea since [**2-7**], when he was recently
admitted ([**2-7**] to [**2-13**]) for diarrhea thought [**12-20**] chemo meds, c
diff negative, no evidence of colitis on CT. He reports that the
diarrhea had been improving at the time of discharge however, in
the last three days, he has had increasing number of
bowelmovements daily and worsening nausea. He has been unalbe to
tolerate PO x 2days stating that he vomits <30 minutes after a
meal. Yesterday, VNA found him to be weak with BP 94/52
afebrile. The diarrhea continued and he presented to the [**Hospital1 18**]
ED.
.
In the [**Hospital1 18**] ED, intitial VS were: 97.3 86 76/45 20 100% RA. Got
2L IVF, SBP up to 100. EKG with Afib and old Q waves, unchanged
from prior EKG. Labs notable for WBC 3.4, 80%bandemia and
cratinine 3.6 (baseline 1.5-1.7). Given vanc/zosyn, and a total
of 3L IVNS. He had an episode of chest tightnes adn "pressure"
which was different from anginal euqivalant, was given [**Hospital1 **] 325,
2mg IV morphine and pain resolved. EKG unchanged, trop 0.04
which trended to 0.02. CXR showed loss of left heart border and
small left pleural effusion. CT abdomen showed moderately
distended stomach, beyond which oral contrast did not pass
beyond stomach concerning for outlet obstruction. Also with
liver and lung mets which were unchanged. He has been
hemodynamically stable in the ED and was admitted to the ICU for
bandemia, hypotension, [**Last Name (un) **] and possible outlet obstruction.
Admission Vitals: 95([**Last Name (un) 3526**]/[**Last Name (un) 3526**]) 104/50 23 98%.
.
On arrival to the Unit, vitals were 79 100/41 94% 2LNC He
reported mild nausea, hiccups, and chills. Reports breathing
comfortable, denies chest pain, dyspnea. denies abdominal pain,
fever.
Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. Congestive heart failure with previous EF 30% to 35% in [**2140**].
4. Perioperative atrial fibrillation in [**2136**], not on coumadin
now.
5. Basal cell carcinoma.
6. colon cancer dx [**2136**], status post ileocecectomy on [**4-/2137**]
with Dr. [**Last Name (STitle) **]. Mets to liver discovered [**2137**] and now status
post metastatectomy via hepatectomy in 10/[**2137**]. ? Additional
mets discovered [**2139**], s/p cyberknife therapy to liver.
7. Coronary artery disease, status post ST elevation MI in [**2125**]
and three-vessel CABG in [**3-/2128**] (LIMA to the LAD, vein graft to
the first obtuse marginal and to the right PDA)
8. Acute cholecystitis and cholecystectomy in [**2077**].
9. Bladder Cancer [**2139**] followed by Dr. [**Last Name (STitle) 261**]
10. S/p left carotid endarterectomy
Social History:
The patient is a previous mechanical engineer. He smoked
occasionally but quit 35 years ago. He denies any alcohol use.
Lives alone and is independent. No close relatives in the area.
Siblings in [**Location (un) 3156**].
Family History:
Denies family history of cancer, CAD, diabetes.
Physical Exam:
Vitals: T:95.7 BP:100/41 P:79 R:18 O2:99% 2LNC
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: Mildly distended, tympanic to percussion ir LUQ, mild
epigastric tenderness. bowel sounds present, no rebound
tenderness or guarding,
GU: foley in place
Ext: 1+ pitting edema to the ankles BL, warm, well perfused.
Pertinent Results:
ADMISSION LABS
[**2142-2-14**] 08:16PM BLOOD Neuts-36* Bands-20* Lymphs-16* Monos-22*
Eos-1 Baso-0 Atyps-5* Metas-0 Myelos-0
[**2142-2-14**] 08:16PM BLOOD WBC-3.4* RBC-2.58* Hgb-8.5* Hct-26.2*
MCV-101* MCH-33.0* MCHC-32.5 RDW-18.2* Plt Ct-119*
[**2142-2-14**] 08:16PM BLOOD PT-15.2* PTT-25.1 INR(PT)-1.3*
[**2142-2-14**] 08:16PM BLOOD Glucose-134* UreaN-44* Creat-3.6*# Na-141
K-3.8 Cl-111* HCO3-17* AnGap-17
[**2142-2-14**] 10:02PM BLOOD Lactate-2.2*
.
CARDAIC ENZYMES
[**2142-2-14**] 08:16PM BLOOD cTropnT-0.04*
[**2142-2-15**] 01:48AM BLOOD cTropnT-0.02*
[**2142-2-15**] 05:43AM BLOOD CK-MB-12* MB Indx-6.5* cTropnT-0.04*
[**2142-2-15**] 03:35PM BLOOD CK-MB-10 MB Indx-7.8* cTropnT-0.03*
.
=======================IMAGING========================
ABDOMINAL PLAIN FILM
FINDINGS:
Supine and lateral decubitus views of the abdomen demonstrate
small amount of residual barium remaining in the stomach. There
are multiple dilated loops of small and large bowel and
air-fluid levels. There is no pneumatosis or free air.
Visualized osseous structures appear intact.
IMPRESSION:
Multiple dilated small and large bowel loops, compatible with
ileus. No
definite evidence of gastric outlet obstruction.
Brief Hospital Course:
An 88 yoM with PMH CABG, CHF LVEF 25-30%, metastatic colon
cancer readmitted with worsening diarrhea.
.
# Hypotension: On arrival to the ED, patient was hypotensive to
76/45, he was mentating well, but was noted to be in acute renal
failure. He was admitted to the ICU where he was resuscitated
with 7L IVNS with stabilization of pressures and good urine
output. Vasoactive medications were not necessary. He was then
called out to the Oncology service for further care.
.
# Diarrhea: Previously attributed to chemotherapy, diarrhea had
been improving until 3 days prior to admission. On admission, he
was afebrile with epigastric tenderness, labs were remarkable
for WBC 3.4 and 20% bands. He was treated with PO Vanco and
metronidazole IV for presumed C. Diff. Stool was negative for
C.diff x 2, so Flagyl and vancomycin were dicontinued. C diff
PCR was negative. WBC count normalized and the patient was
afebrile. Diarrhea was ultimately felt to be [**12-20**] chemotherapy as
all infectious stool studies were negative.
.
# Acute on chronic kidney injury: Creatinine 3.6 on admission up
from baseline of 1.5-1.7. With crystalloid resuscitation,
creatinine trended down to baseline. Acute injury is attributed
to low right sided filling pressures in the setting of poor po
intake and diarrhea.Cr was stable throughout the rest of his
admission.
.
# Ileus: on admission, CT abdomen showed no passage of contrast
beyond pylorus concerning for gastric outlet obstruction. He
reported vomiting x 2days shortly after meals. Repeat abdominal
plain film showed passage of contrast and gas into the large and
small bowel and dialated loops of large and small bowel
consistent with ileus. An NG tube was placed to decompress the
intestine. NGT was removed prior to transfer to the Oncology
floor. His diet was advanced,a dn her was tolerating a regular
diet for several days prior to discharge.
.
# Chronic congestive heart failure with systolic dysfunction:
LVEF 30% to 35% Chest xray from admission shows small pleural
effusions. He had trace peripheral edema but did not appear to
be in acute CHF exacerbation. After aggressive volume
resuscitation, he appeared euvolemic and did not develop acute
CHF. Furosemide had been held in prior admission. The patient
had one episode of SOB on the floor that resolved with IV Lasix.
Otherwise, diuresis was held. In fact, he required a few boluses
of D5W for hypernatremia [**12-20**] intravascular dryness. Pt was
taking good po, and Na was stable for 48 hours prior to
discharge.
.
# Coronary artery disease: Patient with PMH of CABG. Complained
of chest pressure on admission, EKG was unchanged, Trops
negative x 3. Ruled out for myocardial infarction.
.
# A fib: Pt has a history of pAF for which he was previously on
Coumadin. His metoprolol had been stopped on admission. Coumadin
had been stopped [**12-20**] hematemesis. Pt had an episode of AF with
RVR. His rate slowed down with metoprolol, which was titrated to
25mg [**Hospital1 **]; he will be discharged on 50mg metoprolol succinate
qdaily. CHADS2 score 3, so from this standpoint pt should be on
anticoagulation. However, pt has likely months to live from the
standpoint of his malignancy. Discussed risk of stroke vs
benefits of anticoagulation with the patient. He has decided
against Coumadin or Lovenox.
.
# Hypothyroidism: Continued home regimen
.
Pt was full code this admission. Hospice services were brought
up, but the patient was not interested.
Medications on Admission:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
3. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-19**]
Puffs Inhalation Q4H (every 4 hours) as needed for shortness of
breath or wheezing.
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lovastatin 10 mg Tablet Sig: 0.5 Tablet PO once a day.
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
7. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed for nausea.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
13. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
14. triamcinolone acetonide 0.1 % Ointment Sig: One (1)
application Topical twice a day as needed for itching.
15. valsartan 80 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. ergocalciferol (vitamin D2) 400 unit Tablet Oral
18. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
19. Guaifenesin NR 100 mg/5 mL Liquid Sig: Ten (10) mL PO every
four (4) hours as needed for cough.
Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-19**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
3. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. lovastatin 10 mg Tablet Sig: 0.5 Tablet PO once a day.
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day: hold for HR
< 60, SBP < 100.
6. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO twice a day as needed for nausea.
8. ranitidine HCl 150 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 once a day.
10. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
13. triamcinolone acetonide 0.1 % Cream Sig: One (1) application
Topical twice a day as needed for itching.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
15. ergocalciferol (vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
16. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2)
Tablet PO every six (6) hours as needed for pain.
17. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
18. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, flush with 10 mL Normal Saline followed by
Heparin as above per lumen.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Primary: diarrhea
dheydration
paroxysmal atrial filbrilation
.
Secondary: metastatic colon cancer
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:
Mr. [**Known lastname 10239**],
Thank you for coming to [**Hospital1 69**] for
you care. You were admitted because of dehydration, likely due
to a combination of diarrhea and not eating much. You did not
have an infection causing your diarrhea. We rehydrated you with
IV fluids. You went into an abnormal heart rhythm while you were
here, called atrial fibrilation. We increased your metoprolol to
help slow your heart down. You have had this in the past and
used to be on a medicine called Coumadin to decrease your risk
of stroke. You decided that you did not want to take Coumadin
again.
.
We made the following changes to your medications:
- Please INCREASE metoprolol to 50mg daily
- Please STOP taking valsartan for now. Your doctor may re-start
this medicine if your blood pressure becomes high.
- Please continue to NOT take Lasix.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2142-2-26**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10280**], PA [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2142-2-26**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"786.59",
"V10.05",
"787.91",
"584.9",
"E933.1",
"276.8",
"428.0",
"458.9",
"428.23",
"285.9",
"272.4",
"V45.81",
"276.0",
"197.7",
"414.00",
"412",
"197.0",
"244.9",
"560.1",
"401.9",
"E849.0",
"427.31",
"787.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
12582, 12704
|
5162, 8623
|
235, 241
|
12846, 12846
|
3940, 5139
|
13893, 14562
|
3316, 3365
|
10563, 12559
|
12725, 12825
|
8649, 10540
|
13029, 13644
|
3380, 3921
|
13673, 13870
|
187, 197
|
269, 2180
|
12861, 13005
|
2202, 3059
|
3075, 3300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,297
| 139,427
|
42159
|
Discharge summary
|
report
|
Admission Date: [**2130-8-20**] Discharge Date: [**2130-9-20**]
Date of Birth: [**2095-7-23**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
dyspnea
transfer from OSH for hypoxic respiratory failure
Major Surgical or Invasive Procedure:
arterial line
chest tube placement
debridement of left lower leg
bronchoscopy x2
esophagogastroduodenoscopy
History of Present Illness:
35 F yo with history of narcotic use, transfered from [**Hospital 91429**]
hospital for respiratory failure and hypotension.
.
She initially presented there on [**8-15**] with 1 week of dyspnea,
new somnolence and a reported 35-60 lb weight loss over 6 month.
Found to have spontaneous ride sided tension pneumothorax at
admission. Had R anterior and posterior chest tubes inserted on
[**8-15**]. At admission also stated to have severe metabolic
acidosis with multiple electrolyte abnormalities and was
severely malnourished.
.
At admsision, she was noted to have a Hct of 22 and was
transfused 5 Units to 31 today. She was transfused 3 units on
[**8-15**] and 2 units [**8-18**].
.
Also at admittion noted to have chronic ulcer of left lower leg
calf (family states sleeps in chair and has been present for a
year). On [**8-17**] anterior chest tube removed and on [**8-18**]
posterior chest tube out and RIJ inserted after she began to
vomit. CT scan at that time showed large b/l pulmonary emboli
and hepatosplenomegally. [**8-19**] notes to have right posterior
draining brown foul smelling fluid.
.
Overnight prior to [**8-20**] she devloped worsening respiratory
status with ABG 7.16. She had a TTE on [**8-18**] which showed normal
EF with moderate mitral regurgitation and mild tricuspid
regurgitation.
.
Over the 24 hours prior to transfer she became increasingly
hypoxic,unresponsive, requiring intubation on [**8-20**]. New left
consolidation at that time noted on CXR. Became unresponsive
prior to intubation. At time of transfer she was on AC
450/28/100%/5. Thought to have ARDS. OG tube placed and drained
900 cc (had previously been on TPN). Was guiaic positive. At
time of transfer, was becoming hypotensive to SBPs in 80s and
was bolused 2L IVF. Started on levophed prior to transfer. Vanc
and Zosyn given prior to transfer.
.
On the floor, she arrived intubated and sedated after receiving
rocuronium in [**Location (un) **]. She arrived on levophed.
Past Medical History:
familial lymphedema
chronic anemia, baseline Hct in 20s [**First Name8 (NamePattern2) **] [**Last Name (un) 4199**]
chronic left leg wound X 1 year.
Social History:
Family states she is homebound except for going to her methadone
clinic.
- Tobacco: [**12-4**] PPD from 1 PPD
- Alcohol: denied at OSH
- Illicits: history of percocet use/opiate addiction.,
methadone 130mg (changed to 50mg at OSH, last received [**8-20**])
Family History:
familial lymphedema, paternal GF with esophageal ca, maternal
GF with bladder ca
Physical Exam:
ADMISSION LABS:
Vitals: 95.2, 100, 108/65, 18, 75%
General: Intubated and sedated pale.
HEENT: MMM, oropharynx clear
Neck: JVP not elevated
Lungs: Decreased BS left side, rhonchorus on right. Airleak from
opening in right chest wall.
CV: tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, poor hygiene. Large ulcer
over left shin/ankle, hand-size
.
DISCHARGE EXAM:
Vitals: 97.5, 71-93, 104-110/60-72, 18, 99% RA 2670/2050+1BM
600/850
General: cachetic woman in NAD. anxious. Communicative.
HEENT: MMM, oropharynx clear without lesions. Edentulous with
gum necrosis noted. Hair is thin and seborrhea noted diffusely.
Ulcerative lesion on posterior aspect of head.
Neck: JVP not elevated
Lungs: CTAB good air movement bilaterally.
CV: tachycardia, RR, normal S1 + S2, no murmurs, rubs, gallops
Chest: R chest with hemorrhagic lesion on R chest in
mid-axillary line. No air movement appreciated through the
lesion.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, [**12-4**]+ edema bilaterally. L
LE with bandage in place, tender to palpation. Removal of
bandage deferred.
Pertinent Results:
At admission:
[**2130-8-20**] 07:19PM BLOOD WBC-23.5* RBC-4.25 Hgb-11.1* Hct-36.3
MCV-85.6 MCH-26.2* MCHC-30.6* RDW-17.7* Plt Ct-447*
[**2130-8-20**] 07:19PM BLOOD Neuts-19* Bands-57* Lymphs-10* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-7* Myelos-6*
[**2130-8-20**] 07:19PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-2+ Polychr-1+ Ovalocy-1+ Burr-2+ Tear Dr[**Last Name (STitle) **]1+
Acantho-2+
[**2130-8-20**] 07:19PM BLOOD PT-14.8* PTT-57.7* INR(PT)-1.3*
[**2130-8-20**] 07:19PM BLOOD Glucose-118* UreaN-26* Creat-1.1 Na-135
K-3.6 Cl-110* HCO3-17* AnGap-12
[**2130-8-20**] 07:19PM BLOOD Calcium-8.3* Phos-4.9* Mg-2.1
[**2130-8-20**] 07:33PM BLOOD Type-ART Temp-35.0 Rates-22/8 Tidal V-450
PEEP-5 FiO2-100 pO2-41* pCO2-75* pH-7.03* calTCO2-21 Base XS--13
AADO2-612 REQ O2-98 -ASSIST/CON Intubat-INTUBATED
[**2130-8-20**] 09:31PM BLOOD freeCa-1.27
[**2130-8-20**] 09:31PM BLOOD Lactate-1.1
[**2130-8-20**] 07:32PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2130-8-20**] 07:32PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2130-8-20**] 07:32PM URINE RBC-27* WBC-8* Bacteri-FEW Yeast-NONE
Epi-0
[**2130-8-20**] 07:32PM URINE CastGr-2* CastHy-3*
[**2130-9-7**] 11:58PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2130-8-26**] 10:44PM URINE RBC->50 WBC-[**5-12**]* Bacteri-OCC Yeast-NONE
Epi-<1
[**2130-8-24**] 12:52AM URINE Eos-NEGATIVE
[**2130-8-24**] 12:52AM URINE Hours-RANDOM UreaN-439 Creat-34 Na-<10
K-28 Cl-16
[**2130-8-29**] 08:21PM PLEURAL WBC-3413* RBC-4700* Polys-47*
Lymphs-10* Monos-3* Eos-1* Meso-20* Macro-19*
[**2130-8-29**] 08:21PM PLEURAL TotProt-1.9 Glucose-92 LD(LDH)-563
Cholest-17
.
H. Pylori [**2130-9-19**]: positive
Bronchial washings [**2130-9-8**]: yeast (acid fast pending)
Blood cultures [**Date range (1) 91430**] NEGATIVE except blood culture from
[**8-26**]: ENTEROCOCCUS FAECIUM
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Bronchalveolar lavage [**8-24**]: negative
catheter tip [**2130-8-23**]: negative
pleural fluid [**2130-8-29**]: PMNs seen (acid fast pending)
c.diff toxin A and B negative x2 ([**9-9**], [**9-4**], [**9-1**] and [**8-24**])
wound culture [**8-26**] negative
tissue [**8-29**] negative
urine culture x4 negative
Sputum culture [**2130-8-27**]: ALCALIGENES FAECALIS
AMIKACIN-------------- 8 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 2 S
CEFTRIAXONE----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 2 S
MEROPENEM------------- S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- R
.
CXR [**2130-8-20**]:
The ET tube tip is 4 cm above the carina. The right internal
jugular line tip is at the level of mid SVC. The NG tube tip is
in the stomach. Right apical pneumothorax is small. There are
widespread consolidations seen. The left lung is almost entirely
obscured by consolidation with air bronchogram, most likely
consistent with large infectious process. On the right, there
are focal consolidations with some lucencies that might
represent cavitary lesions and should be correlated with
cross-sectional imaging. Bilateral pleural effusions are most
likely present.
TTE [**2130-8-21**]:
The left atrium and right atrium are normal in cavity size. A
patent foramen ovale is present. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is moderately dilated with mild global free
wall hypokinesis. Apical function is preserved ([**Last Name (un) 13367**]
sign). 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.There is mild pulmonary artery hypertension. There is
no pericardial effusion. IMPRESSION: Right ventricular cavity
enlargement with free wall hypokinesis. Pulmonary artery
hypertension.
LOWER EXTREMITY U/S [**2130-8-21**]:
1. DVT of the left femoral vein in its mid and distal part and
of the left
popliteal vein.
2. DVT in the right posterior tibial vein and peroneal vein.
CT CHEST [**2130-8-22**]:
Marked pulmonary parenchymal damage with multifocal cavitary
consolidations, ground-glass opacity and nodular opacities, all
compatible
with advanced infectious process. Frank disruption of the chest
wall between the right fifth and sixth lateral ribs
communicating with the largest cavity in the right middle lobe.
A bronchus supplying the lateral segment of the right middle
lobe suggests bronchopulmonary fistulization.
CT TORSO [**2130-8-27**]:
1. Interval progression in lung consolidation, particularly in
the right
lower lobe and left upper lobe.
2. Interval decrease in size in the largest of the lung cavities
on the right with a larger air-fluid level. Although there is
now some soft tissue at the base of the subcutaneous defect,
this cavity may communicate with the skin defect, and may
explain the presence of brown discharge from the wound.
3. Probable bronchopleural fistula of a right upper lobe branch
which extends into the main right-sided lung cavity.
4. Increasing pleural effusions and bibasilar atelectasis.
5. Near complete resolution of the subcutaneous emphysema within
the chest
but persistent subcutaneous emphysema in the abdomen.
6. Ascites.
CT HEAD [**2130-8-27**]:
Extremely limited study. Within this limitation, no acute
intracranial
abnormality is seen. NOTE ADDED AT ATTENDING REVIEW: There is a
possible right frontal subarachnoid hemorrhage (series 2a,
images 19 and 20). This may be an artifact due to extensive
motion. If this is a clinical concern, then a repeat head CT may
be helpful.
CT LOWER EXTREMITY [**2130-8-27**]:
1. Two foci centered in the skin compatible with, but not
specific for,
hemorrhagic bullae. ? areas of skin ulceration, best assessed on
physical
exam.
2. No disproportionate fluid collection along the fascia to
suggest
fasciitis. No subcutaneous emphysema.
3. Findings compatible with cellulitis.
4. Patchy enhancement in the musculature could reflect myositis,
areas of
ischemic change, or altered hemodynamics.
5. Findings compatible with provided history of DVT. Please see
comment.
6. No evidence of osteomyelitis. No evidence of intramuscular
abscess on
this exam.
TTE [**2130-8-31**]:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). There is a mild resting left
ventricular outflow tract obstruction. The right ventricular
cavity is mildly dilated with borderline normal free wall
function. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are mildly thickened. No
mass or vegetation is seen on the mitral valve. An eccentric,
posteriorly directed jet of trivial to mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Biatrial enlargement. Normal left ventricular cavity
size and wall thickness with preserved global and regional left
ventricular systolic function. Mild resting LVOT obstruction.
Mildly dilated right ventricle with borderline preserved global
systolic function. No valvular vegetations or abscesses
appreciated. At least moderate pulmonary artery systolic
pressure (patient intubated, cannot assess estimate of RA
pressure from IVC).
CT Chest [**9-4**]
1. Since [**2130-8-27**], bilateral cavitary consolidations
with right
bronchopleural fistula are unchanged whereas non-cavitary
multifocal
consolidations have improved.
2. Moderate left pleural effusion has developed several small
loculated
components whereas right loculated collection near the lung base
has
decreased in size.
3. Within the limitations of the CT technique, the pulmonary
emboli in the
left interlobar branches appear unchanged whereas the bilateral
lower lobe
segmental artery emboli have minimally resolved.
4. Minimal decrease in the size of mediastinal lymphadenopathy
CXR [**2130-9-11**] In comparison with the study of [**9-9**], there are
slightly lower lung volumes but little overall change in the
bilateral lung abscesses. Air-fluid level is suggested in the
left upper zone. Continued bilateral pleural effusions and
elevation of pulmonary venous pressure. Central catheter remains
in place.
EGD [**2130-9-19**] Esophagus:
Mucosa: Grade [**1-5**] esophagitis was seen in the distal esophagus,
compatible with esophagitis.
Stomach: Contents: A large amount of bilious fluid with mx
pills was seen in the body of stomach. Excavated Lesions A
single chronic cratered non-bleeding 2-3 cm ulcer was found in
the pylorus and antrum. Greater than 6 cold forceps biopsies
were performed for histology at the end and base of stomach
antrum ulcer.
Duodenum: Not examined.
Impression: Grade [**1-5**] esophagitis in the distal esophagus
compatible with esophagitis
Ulcer in the pylorus and antrum (biopsy)
Retained fluids in stomach
Recommendations: follow-up biopsy results
Further recommendations per the GI consult team
.
DISCHARGE LABS:
[**2130-9-19**] 05:32AM BLOOD WBC-7.9 RBC-2.71* Hgb-8.3* Hct-25.1*
MCV-93 MCH-30.5 MCHC-32.9 RDW-16.7* Plt Ct-372
[**2130-8-28**] 04:55AM BLOOD Neuts-78* Bands-1 Lymphs-8* Monos-5
Eos-5* Baso-0 Atyps-0 Metas-3* Myelos-0
[**2130-9-19**] 05:32AM BLOOD Glucose-107* UreaN-11 Creat-0.4 Na-135
K-3.7 Cl-105 HCO3-21* AnGap-13
[**2130-9-19**] 05:32AM BLOOD Albumin-2.9* Calcium-8.5 Phos-2.7 Mg-2.1
[**2130-9-13**] 05:35AM BLOOD TSH-6.7*
[**2130-8-24**] 05:52PM BLOOD Triglyc-163*
[**2130-8-22**] 05:15PM BLOOD calTIBC-72* Hapto-261* Ferritn-520*
TRF-55*
[**2130-9-13**] 05:35AM BLOOD T4-6.8
[**2130-9-19**] 05:32AM BLOOD IgA-326
Brief Hospital Course:
35 yo F with history of narcotic use on chronic methadone
presents as outside hospital transfer with hypoxic respiratory
failure related to a right pulmonary abcess with bronchopleural
fistula, tension pneumothorax, left-sided diffuse pneumonia, and
bilateral pulmonary emboli.
ACTIVE ISSUES:
1. BRONCHOPLEURAL FISTULA/TENSION PNEUMOTHORAX: She was
admitted to OSH with a spontaneous right apical and posterior
tension pneumothorax related to a large pulmonary abscess. Two
chest tubes placed on [**8-15**] and removed on [**8-18**] prior to transfer
for hypoxic respiratory failure. On admission, two ventilators
were used to independently vent her lungs so as to protect her
right lung from excessive pressures, though some PEEP was
necessary for adequate oxygenation. She was chemically paralyzed
to improve vent synchrony. She was placed on a single
ventilator within two days, and then underwent bronchoscopy on
[**8-24**] by IP, revealing air leakage of most major segmental
bronchi which essentially precluded an endoscopic plugging of
the BPF. Fibrin glue was deployed but failed to stop the leak.
Thoracic surgery followed throughout the hospitalization, and
intermittently applied pressure dressings to prevent air efflux.
She was ventilated with a low tidal volume, low PEEP, and high
rate system to prevent excess pressure on the fistula site. She
was weaned from the vent and extubated on [**8-30**]. The patient was
subsequently followed on the floor. IP performed bronchoscopy on
the patient in order to place a valve in the fistula, but found
that the fistula was closed from the cutaneous aspect. She will
need re-evaluation with CT and follow up appointment with IP to
discuss long-term management of the bronchopleural fistula 2
weeks after discharge. She did require oxygen during her
hospitalization, but it seems likely that there is a component
of anxiety as she was satting 100% on 2L but would not allow
weaning initially. Prior to discharge, she was weaned and was
satting 100% on RA. She was using ipratropium nebs
intermittently during her course but was no longer using them at
time of discharge.
2. HYPOXIC RESPIRATORY FAILURE: She presented in respiratory
failure from an OSH, intubated, due to a multifactorial
combination of right sided pulmonary abscess and bronchopleural
fistula, left sided diffuse consolidation, right tension
pneumothorax, and bilateral pulmonary emboli. Please see
individual problems for treatment details.
3. RIGHT PULMONARY ABSCESS/LEFT PNEUMONIA: She received
vanco/zosyn at the OSH, and continued to receive
vanco/zosyn/tobramycin for enhanced gram negative coverage.
Sputum culture from [**8-22**] showed pan sensitive MSSA and sparse
GNR. Bronchoalveolar lavage on [**8-24**] showed no organisms,
including PCP/acid fast/fungi. Sputum culture from [**8-25**] showed
a pair of non-fermenting GNR sensitive to zosyn/tobra. ID was
consulted for antibiotic guidance. CT scan of chest on [**8-22**]
showed marked pulmonary parenchymal damage with multifocal
cavitary consolidations, ground-glass opacity and nodular
opacities, all compatible with advanced infectious process.
Despite broad antibiotic coverage, she remained intermittently
febrile to 102 during her ICU stay. CT torso on [**2130-8-27**]
revealed improvment of his RML/RUL cavitating lesion with a new
fluid level within the cavity and a more dense consolidation
RLL. Abdomen and pelvis revealed no strikinga abnormalities.
Antibiotics were later changed to linezolid/zosyn/ tobramycin on
[**8-29**] when blood cultures grew VRE from a suspected infected
femoral CVL, subsequently, zosyn/tobramycin was discontinued per
ID recs and meropenem was started. As mentioned, she was
initially ventilated on two machines, and was eventually fully
extubated on [**2130-8-30**]. A left chest tube was placed on [**8-29**] with
drainage of about 1L of fluid. Clinical and radiographic
improvement noted thereafter, with removal of the drain on
[**2130-9-2**]. Her sputum culture from [**8-27**] revealed ALCALIGENES
FAECALIS, which was treated with meropenem from [**Date range (1) 91431**].
Linezolid course for VRE in the blood was discontinued on
[**2130-9-12**].
4. PULMONARY EMBOLUS, BILATERAL: She underwent CTA prior to
transfer that demonstrated bilateral pulmonary emboli. She had
bilateral lower extremity DVT on ultrasound following transfer
as well. She arrived and was maintained on a heparin gtt
thoughout her stay, before changing to subq lovenox prior to
floor transfer. The source of her clots were unclear, but she
was apparently extremely sedentary for several months prior to
admission. Consideration for bridging to coumadin in the future
is indicated, after the patient has met with surgery and
interventional pulmonary regarding her care and they have
determined her need for intervention.
5. SEPTIC SHOCK: She initially presented hypotensive with
systolic BP in the 80s around the time of her intubation. She
arrived on levophed, which was continued throughout her first
few hospital days. With leukocytosis to 23 with heavy bandemia,
fevers, and multifocal pneumonia, a septic source was likely.
Levophed was discontinued [**2130-8-27**]. He was broadly covered with
vanco/tobra/zosyn initially as above with resolution of the
leukocytosis and improvement her hemodynamics. TTE failed to
reveal evidence of cardiogenic shock.
6. LOWER EXTREMITY ULCERATION: She carries a diagnosis of
hereditary lymphedema. OSH records note a chronic left lower leg
ulcer prior to transfer. A gradually enlarging bullous,
hemorrhagic lesion was noted on her left calf. Vascular surgery
consulted, and unroofed and evacuated the lesion on [**8-29**],
clearing abundant clots. She underwent several debridements.
General surgery was consulted for management, and they
recommended wound care with collagenase ointment on the necrotic
areas. The wound was improving with decreasing areas of
necrosis. The patient will follow up with surgery to discuss
management of her legs in about 2 weeks. She requires morphine
with dressing changes, we were using IV morphine because of the
patient's nausea and vomiting, but recommend transition to PO
and eventual discontinuation, especially given her hx of opioid
abuse.
7. VRE BACTEREMIA: Blood culture from [**2130-8-26**] grew out
vancomycin resistant enterococcus, likely from a femoral line
that subsequently became contaminated. she began linezolid on
[**2130-8-27**] to complete a 2 week course on [**2130-9-12**].
8. NUTRITION/WEIGHT LOSS: A 30 pound weight loss was noted
prior to admission. Anorexia was suspected. TPN was continued
during her acute illness, with her GI tract slow to regain
motility. She was likewise slow to resume PO intake following
extubation and experienced significant anxiety and nausea
related to eating and pre-treatment with lorazepam and zofran
did not improve her appetite. She was engaging in behaviors,
such as breaking her food into small pieces but not eating
anything, which are classic for anorexia but she denied body
image issues. Dobhoff was placed for tube feeds with
discontinuation of TPN, however, the patient twice vomited up
the Dobhoff and was unable to tolerate this. The goal is for the
patient to avoid PEG placement as she will likely regain her
ability to eat orally again and should not undergo a surgery
when there are alternatives. Tubefeeds were not tolerated due to
vomiting as above. At time of discharge, her oral intake had
finally started to increase. She was able to eat about a third
of each meal with 2 Ensures per day. Psychiatry and social work
were consulted to help advise regarding her food aversion, and
they thought that her medical problems (ie gastric ulcer) might
be contributing and it is difficult to assess her underlying
disorder while these are ongoing. It would be helfpul to have
continued social work and nutrition input during her [**Hospital1 1501**] stay.
9. ANEMIA: Patient had persistent anemia to the low 20s during
her hospitalization. She was transfused 8 units prior to
transfer, with guaiac +NGT aspirate noted. She required 7 units
of PRBC during her MICU stay. Source of bleeding unclear, with
iron studies reflecting some degree of chronic inflammation. A
low retic count of 1 likely reflected a sluggish marrow in the
context of systemic illness. The patient had a low iron, of 6,
which was improved with administration of IV iron. She did not
require further transfusions after she was discharged from the
MICU and maintained a hematocrit of 22-24. No further UGIB was
seen although she was diagnosed with an ulcer on EGD.
10. OPIATE DEPENDENCE: She was on methadone 137mg daily at
home, and had large sedation/narcotic requirement while
intubated. She was continued on Methadone 20mg QID while in
house. She did experience some diarrhea, which may have been
withdrawal (c.diff x3 and stool cultures were negative), and the
diarrhea resolved prior to discharge. We recommend that you
continue to taper her methadone in the rehab setting.
11. SUBCLINICAL HYPOTHYROIDISM: the patient has a TSH of 6.7 and
T4 6.8. This should be re-checked in about 6 months to see if
the patient's hypothyroidism is related to her acute illness.
12. GASTRIC ULCER: the patient was diagnosed with gastric ulcer
by EGD. As mentioned above, a small amount of blood had been
seen at OSH with NGT placement and the patient had been c/o
ongoing nausea and vomiting. Biopsies were taken. Malignancy is
certainly in the differential although so is stress ulcer. H.
Pylori is positive, found after the patient left, called rehab
to initiate treatment and spoke to the physician caring for the
patient. She will follow up with GI and repeat EGD in [**5-10**] weeks;
the biopsies results will be discussed at that time. No bleeding
was seen on the EGD and so recommendation for continuation of
Lovenox (for bilateral PEs).
ISSUES OF TRANSITIONS IN CARE:
# Communication: Mother [**Name (NI) **] [**Telephone/Fax (1) 91432**], sister [**Name (NI) **] [**Telephone/Fax (1) 91433**], [**Telephone/Fax (1) 91434**] share HCP
# Code: Full (discussed with mother and confirmed with patient)
# PENDING STUDIES AT TIME OF DISCHARGE:
- [**2130-8-29**] pleural fluid acid fast preliminary
- [**2130-9-8**] bronchial washings acid fast preliminary
# ISSUES TO FOLLOW UP ON:
- the patient had subclinical hypothyroidism. This may have been
related to her acute illness so the TSH and T4 should be
rechecked in about 6 months or so.
- the patient can be bridged to Coumadin after she has met with
interventional pulmonary and surgery regarding procedures in 2
weeks.
- the patient will need to follow up with surgery in about 2
weeks to discuss management of the areas of debridement in her
LLE.
- the patient will require management per interventional
pulmonary/ thoracic surgery of her fistula.
- the patient will require management of her methadone use
- the patient will require psychiatric care to manage her
methadone use, anxiety, depression, anorexia
- encourage PO intake
- taper methadone dose
- follow up repeat EGD and biopsy results from gastric biopsy
with GI
Medications on Admission:
on transfer
TPN (stopped once deemed septic), not tolerating OG feeds
Ativan 2mg Q2H prn sedation
Methadone 50mg daily
Reglan 10mg QID
Nicotine 14mg patch
Protonix 40mg [**Hospital1 **]
Zosyn 3.375mg Q6H [**7-20**] 12:41, started [**8-19**]
Vancomycin 750mg Q12H 8:30, started [**8-19**]
Heparin gtt 21ml /hr
propofol 1.8-18mL/hr
.
Home medications
Ibuprofen
Methadone 137 mg daily (confirmed by OSH with methadone clinic)
for 11 years
Discharge Medications:
1. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous Q12H (every 12 hours).
2. methadone 10 mg Tablet Sig: Two (2) Tablet PO four times a
day.
3. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO twice a day.
4. collagenase clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical [**Hospital1 **] (2 times a day): Apply to black areas of
wound then cover with adaptic and wrap with kerlex. Then wrap
with ACE.
5. morphine 5 mg/mL Solution Sig: Two (2) mg Injection Q12H
(every 12 hours) as needed for dressing changes: use for
dressing changes.
6. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital [**Hospital1 8**]
Discharge Diagnosis:
primary diagnoses: lung abscesses
gastric ulcer
bacteremia
bullous edema
bronchopleural fistula
malnutrition
deconditioning
methadone addiction
pulmonary embolism
anemia of iron deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 4587**],
You were admitted to the hospital because you had shortness of
breath. You were found to have a collapsed lung and you had
tubes placed to repair the lung. After the tubes were removed,
you had a hole which was leading from inside your lung outside
to your skin. This hole has now healed from the outside but you
do still have a hole there on the inside. You were also found to
have an infection in your lung and so you were treated with
antibiotics. You were also found to have bacteria in your blood,
so another antibiotic was used. Another thing, your leg
developed a blister from your swelling, and you had the skin
removed from this large area of blistering. This will still need
to be cared for. As you know, you had difficulty with eating
and you became malnourished. Also, you had clots in your lungs
on both sides. You were found to have an ulcer in your stomach
and you will need another scope in [**5-10**] weeks to assess this as
well as follow up with GI to follow up biopsy results.
Please note the following changes to your medications:
- START Lovenox
- START Pantoprazole
- START Collagenase ointment for your leg
- START morphine for your dressing changes on your leg
- START Reglan
- START Zofran
- AVOID NSAIDS, which are medications such as ibuprofen,
naproxyn, etc.
Please be sure to keep all of your follow up appointments,
including re-imaging of your lungs in about 2 weeks. You will
also need to see your PCP when you get out of rehabilitation.
Also, please discuss transition from Lovenox to Coumadin with
your physicians.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: FRIDAY [**2130-9-29**] at 3:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please call our Thoracic Surgery department to book a follow up
appointment within 2 weeks of your hospital discharge. The
office number is [**Telephone/Fax (1) 3020**].
We are working on a follow up appointment in Gastroenterology
within 2 weeks. The office will contact you at home with an
appointment. If you have not heard within 2 business days or
have any questions or concerns please call the office at
[**Telephone/Fax (1) 463**].
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46,411
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40233
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Discharge summary
|
report
|
Admission Date: [**2156-11-18**] Discharge Date: [**2156-12-13**]
Date of Birth: [**2108-3-22**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
trauma
Major Surgical or Invasive Procedure:
[**2156-11-18**]
S/P ex lap with splenectomy, washout
[**2156-11-19**]
Bolt placed
[**2156-11-20**]
Bolt removed
[**2156-11-23**]
1. Open reduction internal fixation right bimalleolar ankle
fracture.
2. Debridement open fracture to bone right ankle.
3. Examination under anesthesia right elbow.
[**2156-11-24**]
1. Percutaneous tracheostomy.
2. Bronchoscopy.
[**2156-11-24**]
Percutaneous G tube placement
[**2156-11-26**]
1. Open reduction internal fixation with plate and screw
fixation right thumb.
2. Application short-arm thumb spica splint right hand.
3. Closed reduction and application of external fixation
apparatus left hand at the fifth ray.
4. Closed reduction PIP dislocation left fifth finger.
5. Application short-arm splint left hand and forearm.
[**2156-12-1**]
Open reduction internal fixation of left zygomaticomaxillary
complex fracture via multiple
surgical approaches.
[**2156-12-6**]
Right basilic DL PICC
[**2156-12-7**]
Inferior vena cava filter.
History of Present Illness:
Per ED note:
48 M yo S/P FALL,[**2149**]0 feet
from a roof. Patient with visible head trauma. Very minimal
movement noted in field- but purposeful with right arm.
Bruising, large amount of blood on face and scalp, pupils
nonreactive. Blood in airway per EMS, LMA placed- able to
ventilate and maintain saturations. No hypotension in the
field. Deformity to right clavicle, right lower tib /fib,
and left wrist, and large laceration to left fifth digit.
Cervical collar in place.
Past Medical History:
PMH: HCV
PSH: none known
Social History:
Divorced, has children
+ tobacco, + IVD, + ETOH
Family History:
NC
Physical Exam:
Per ED note:
Temp 96 HR 60 BP 100/60 RR 12 intubated. O(2)Sat:96%
Constitutional: LMA in place
HEENT: large amount of swelling forehead and upper face,
blood matted in hair, unclear source, pupils 4mm fixed
LMA in place, Cervical Collar
Chest: Course Breath Sounds
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
Extr/Back: extremity Pulses palpable, warm well perfused.
Deformity right ankle, Left wrist, open laceration -right
fifth digit
Neuro: GCS=5 Some movement of the right arm, breathing,
biting down
Pertinent Results:
MICRO:
[**11-18**] MRSA screen: negative
[**11-19**] MRSA screen: negative
[**11-21**] BCx: NGTD
[**11-21**] UCx: NGTD
[**11-21**] sputum: GS- >25 PMNs, no orgs; Cx- YEAST
[**11-23**] BCx: NG
[**11-23**] UCx: NGTD
[**11-23**] sputum: pan-sensitive SERRATIA MARCESCENS, YEAST,
commensal resp flora
[**11-26**] mini-BAL: GS- 1+GPC in pairs,1+GNR; pan-sensitive SERRATIA
MARCESCENS
[**11-26**] BCx: GPRs in [**1-3**] bottles, CORYNEBACTERIUM in 1 bottle only
[**11-26**] UCx: NGTD
[**12-2**]: BCx: P
[**12-2**]: UCx: No Growth
[**12-4**]: UCx: P
[**12-4**]: BCx x 2: P
[**12-4**]: Sputum Cx: 3+ GNR (mod growth). Serratia - pan sensitive
[**12-6**]: Urine Cx: P
[**12-6**]: Sputum Cx: contaminated
[**12-6**]: Blood Cx: P
[**12-6**]: Catheter Tip Cx: P
IMAGING:
[**11-18**] CXR: 1. Multiple bilateral rib fractures with subcutaneous
emphysema. There is likely a small right pneumothorax. 2. Right
proximal clavicular displaced fracture.
[**11-18**] CT Torso: Fracture of right clavicle, multiple ribs
bilaterally.
small to moderate right Pneumothorax with pulmonary
hemorrhage/contusion and lacerations. Tiny left pneumothorax.
Right renal laceration without collecting system injury. Splenic
laceration with active extravasation.
[**11-18**] CT Head: Multiple intraparenchymal hemorrhages at
grey-white junction and in midbrain c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
[**11-18**]: CT C-Spine: no acute fracture of cervical spine.
[**11-18**]: CT Facial: Fracture of left frontal bone extending to
postero superior medial wall of orbit. fracture of lateral wall
of left orbit. Communited fracture of floor of left orbit
without muscle entrapment, but fragment impinging on inferior
rectus with adjacent stranding and blood. Communited fracture of
left zygomatic arch. antero, posterolateral and medial wall
fracture of left maxillary sinus with some fragments in sinus
itself. Inferior to right orbit is a small locule of gas, which
raises suspicion for fracture although no definite fracture
seen. Fracture of bony nasal septum. Comminuted fracture of
right condylar process without dislocation. Fracture of
left mandibular ramus. Left orbital proptosis with globe intact.
[**11-18**] XR L FOREARM/ELBOW/WRIST: 1. No evidence of fracture,
dislocation about the elbow. 2. External devices limit
evaluation of the region of the wrist. Within this limitation,
irregular linear lucencies in the distal radius may represent
non-displaced radial fractures. Recommend repeat radiographs.
[**11-18**] XR R TIB/FIB: 1. Minimally displaced fractures of the
medial malleolus and distal fibula. 2. Focal sclerosis within
the proximal tibial shaft may represent an enchondroma versus
infarct.
[**11-19**] XR B/L HAND: 1. Right hand acute thumb metacarpal
fracture.
2. Right hand old scaphoid fracture with SNAC wrist. 3. Probable
non-displaced right radial styloid fracture. 4. Acute left small
finger proximal phalanx intra-articular comminuted fracture. 5.
Probable non-displaced left ring finger proximal phalanx
fracture. 6. Possible left distal radius fracture.
[**11-19**] XR L KNEE/TIB/FIB: no fx
[**11-19**] CT HEAD: 1. Interval evolution of multiple
intraparenchymal contusions. 2. Interval extension into the
ventricle with blood layering in the posterior [**Doctor Last Name 534**] of the
lateral ventricles. 3. No hydrocephalus. No subfalcine or uncal
herniation. 4. Multiple facial fractures
[**11-19**] CXR: No evidence of pneumothorax after bronch with stable
appearance of the bilateral pulmonary opacifications and two
right-sided chest tubes.
[**11-20**]:Orogastric tube ends in the upper stomach but should be
advanced 5 cm to move all the side ports beyond the GE junction.
ET tube is in standard placement. Left lower lobe consolidation
has not changed since earlier in the day, but has developed over
the past 24 hours. Two right apical pleural tubes are still in
place, and there is no appreciable pneumothorax or right pleural
effusion. Remainder of the lungs are clear. Upper mediastinum
normal. ET tube is in standard placement. Left subclavian line
ends at the junction of
brachiocephalic veins.
[**11-21**]: Nasogastric tube ends in the stomach. ET tube in standard
placement. Right apical pleural drain still in place. Left
subclavian line ends at the junction of brachiocephalic veins.
Left lower lobe remains collapsed although lung volumes have
improved and vascular congestion has decreased. Small left
pleural effusion is stable.
[**11-22**] CXR: worsening pulmonary edema, worsening L pleural
effusion and RLL ground glass opacity, unchanged [**Name (NI) 14245**] PTX
[**11-24**] CXR: left costophrenic angle not included in field. right
pleural effusion improved since prior. small retrocardiac
opacificaiton may represent technique/pt positioning, however
atelectasis vs infection can't be excluded in correct clinical
setting.
[**11-26**] CXR:1. Possible tiny right apical pneumothorax with right
chest tube in place. 2. Small bilateral pleural effusions with
associated atelectasis, greatest in the left lower lobe.
[**11-27**] CXR: The right chest tube is in unchanged position with
its tip terminating at the right apex. There is no change in the
left subclavian line tip, which is in the superior SVC.
Cardiomediastinal silhouette is unchanged, left retrocardiac
consolidation is unchanged and the right basal opacity, the last
two most likely representing atelectasis, although infection
cannot be excluded. No appreciable pneumothorax is seen.
[**11-29**]: CXR: Right jugular line passes to the mid SVC. The
pneumothorax demonstrated by a torso CT scan performed earlier
today is not visible, no appreciable right pleural effusion.
[**11-29**]: CT sinus: Persistent pan-sinus opacification with new
hyperdense material, likely representing a combination of
post-traumatic hemorrhage and retained fluid secondary to supine
positioning and intubation. Extensive facial
fractures.Improvement in left orbital proptosis with persistent
left periorbital edema. Evolving extensive left frontal lobe
hemorrhagic contusion.
[**11-29**] CT torso: Moderate left pleural effusion. Increased
bilateral lung opacities.Decrease in small-to-moderate right
pneumothorax with resolution of left pneumothorax. Evolving
right renal laceration. Post-splenectomy changes.Multiple rib
fractures bilaterally with fracture of the right clavicle.
[**11-30**]: CXR(post CT insertion):left pleural effusion has
resolved and there is no pneumothorax.Lung volumes are generally
improved, but there is greater consolidation at the right lung
base either atelectasis or new pneumonia. The left basal
atelectasis has decreased. Mild-to-moderate cardiomegaly is
unchanged.
[**12-1**]: CT Chest: PRELIM: Small left pleural effusion is improved,
increased bilateral lung opacities. While on the right it may
represent contusion, laceration and hemorrhage, underlying
infectious process cannot be excluded. Left opacity more
prominent at the base, likely represent atelectasis, but
underlying infectious process cannot be excluded.
[**12-1**]: Head CT: PRELIM: Expected interval change since prior
bleed, no evidence of stroke
[**12-2**]: CXR s/p L CT to water seal: P
[**12-4**]: CXR:Mild atelectatic changes are seen in the retrocardiac
region. Bilateral chest tubes are in place. No definite
pneumothorax is appreciated.
[**12-4**]: CTHead: Continued interval evolution of left frontal,
bilateral temporal and parietal contusions with beginning
encephalomalacia in the left frontal lobe. Decreased but
persistent small intraventricular hemorrhage without evidence of
hydrocephalus.
[**12-4**]: EEG: P
[**12-6**]: CXR (s/p removal b/l CT): ?slow reaccumulation L effusion
[**2156-12-8**] Three views of the right ankle are compared to the prior
study from [**2156-11-19**]. These demonstrate fixation hardware at
the lateral aspect. These demonstrate lateral fixation plate and
screws as well as medial fixation plate and screws transfixing
lateral malleolar fracture and distal tibial fracture brought
into near anatomic alignment without evidence of hardware
complication at this time. There is a small fracture fragment
arising at the lateral aspect of the distal tibia. The mortise
appears intact. Talar dome is intact. There is medial soft
tissue swelling. Small joint effusion. Mild talonavicular
osteoarthritis. Small plantar calcaneal enthesiophyte.
Brief Hospital Course:
Trauma eval in [**Name (NI) **], pt admitted to trauma ICU and taken to OR for
emergent ex lap/splenectomy on [**11-18**]
ICU Course: per Dr. [**Last Name (STitle) **]
EVENTS:
[**11-18**]: Admitted to the TSICU with multiple injuries, splenic
lac, remained hypotensive and on Neo. A L subclavian line was
placed. A second chest tube was placed on the right for a
complete white out on xray. This was followed by a bronch which
showed the right lung filled with blood which was suction with
good effect. He was then taken to the OR for a stat ex-lap,
splenectomy. While in the OR, plastics repaired his facial
lacerations, but left the L lateral eye lac open due to the fact
that suturing it increased the proptosis. Ortho repaired the
hand lacs and splinted him. He returned to the TSICU from ther
OR after midnight.
[**11-19**]: neurosurgery placed bolt, ICP initially 29 but dropped to
mid-teens after HOB elevated. hcts stable so q4 hct checks
d/c'd. vaccinations ordered. ophtho performed dialted exam after
bolt placed, noted normal IOP.
[**11-20**]:bolt dc'ed by neurosurgery, eye lac repaired by plastics,
cosopt dc'ed per ophto
[**11-21**]: Pt. did well throughpout the day, but spiked temp. He was
pan cultured, no antibiotics were started. Discussion today with
multiple teams and plan to go to OR with ortho today and likely
trach/PEG. OMFS signed off on mandible fracture and plastics as
well as hand will likely address fractures at the end of the
week.
[**11-22**]: vent weaned to PSV 5/5. plastics expressed preference for
trach for post-op pt safety. trach and PEG deferred by ACS team.
[**11-23**]: to OR for ORIF right ankle, open trach by ACS
[**11-24**]: Went for IR placed PEG tube
[**11-25**]: TFs resumed. Tolerated trach collar trials for ~6hrs but
tired out and had to be put back on the vent. Started on PO pain
meds and clonidine. Became agitated later in the evening and
given zyprexa.
[**11-26**]:s/p OR (left 5th digit ex fix and skin graft, right 1st
digit orif), pancultured for elev.WBC and fever, new left eye
ulcer-eye gtt switched per ophto recs
[**11-27**]: staples d/c'd by ACS. got fleets enema and
methylnaltrexone ordered for constipation but pt had BM on his
own prior to getting it.
[**11-28**]: vanc trough 7.0, dose increased to 1250 Q12, tolerating
trach mask trials. S&S eval ordered for PMV fitting.
[**11-29**]: changed eye treatment per ophtalmology recs. agitation.
CT w/ pulmonary infiltrates, L pleural effusion.
[**11-30**]: left CT iserted; drained 550cc; post insertion CXR showed
significant improvement in lung vol, right IJ inserted.
[**12-1**]: CT of chest showed increased opacity in the right lung. He
had no change in his respiratory status. He was taken to the OR
by plastics. He was noted to have L>R pupil size and as a result
a stat head CT was done, neurosurgery aware and CT showed new
hypodensity in L frontal area which is most likely c/w interval
change from his contusion.
[**12-2**]: Left CT to water seal. LTAC placement being set up -
likely in next 1-2days.
[**12-4**]: Pt continued to be somnolent and as a result he was sent
for a repeat head CT. CT put to clamp, but had increased leakage
around the site. Spiked temp to 101 and was cultured. EEG done
and pending results. Became agitated and awoke early evening,
responded well to zyprexa and haldol.
[**12-5**]: Pulled Left then Right CTs - CXR with ?L reaccumulation
effusion.
[**12-7**]: IVC Filter placed, started on standing zyprexa and given
haldol x 2 for agitation with good effect.
On [**2156-12-9**] after a long ICU stay he was transferred out to the
Trauma floor. Systems review done by M. [**Doctor Last Name 3647**] PA-C.
Neurologically he is arousable to voice and stimulation by
opening his eyes and can localize the voice. He does not always
follow commands but sometimes smiles and nods. He also however
has periods of agitation which is treated with Haldol prn and
standing Zyprexa and Clonidine. He moves all 4 extremities with
equal strength despite his limitations with braces and splints.
A recent EEG was obrtained on [**2156-12-4**] and was consistent with
severe encephalopathy. There was no evidence of seizure
activity but he will remain on Keppra per Neurology. He will
need to follow up with the Neurosurgery service in 4 weeks.
From a pulmonary standpoint he is maintaining adequate
oxygenation on a 35% trach collar and coughs up most of his
secretions. he requires deep suctioning 3-4 times a day. He
also uses a PMV valve during the day which helps with some
communication. His last sputum culture from [**2156-12-6**] was no
growth after being treated for Serratia marcens pneumonia.
He tolerates his tube feedings of Isosource at 50ml/hr. without
any difficulty
and his last bowel movement was today. His hematocrit has been
in [**Last Name (un) **] 33 range over the last 4 days. His PEG site is clean
and his abdominal wound is well healled.
From a GU standpoint his urine output is quantity sufficient and
his last urine culture is negative from [**2156-12-6**]. His renal
function is normal and has been so from admission.
ID : He received all of his vaccinations post splenectomy and
his most recent WBC is 17K which has been his range over the
last 4-5 days. He has had no fevers and his last Blood culture
from [**2156-12-6**] was no growth. He is off of antibiotics.
The opthomology service followed him closely for left traumatic
optic neuropathy and he remains on Emycin ointment. They do not
expect much visual return in the future. His left eye is
impoved but still has alot of redness and edema. He also has a
healing corneal ulcer in the left eye.
MSK; His multiple facial fractures and extremity fractures have
been either surgically repaired or splinted. Right lower
extremity is TDWB in an air cast boot, left upper extremity non
weight bearing and his right upper extremity is in a hinged
elbow brace for an unstable elbow ( no fracture ).
After a very unfortunate accident and a long hospital course he
is being transferred to an acute rehab facility for aggressive
OT/PT with the hopes of improving his mental and physical
abilities over time.
Medications on Admission:
celexa
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane QID (4 times a day).
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day).
11. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) ml PO
Q6H (every 6 hours) as needed for fever, pain.
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) ribbon
Ophthalmic QID (4 times a day): both eyes.
14. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. olanzapine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
17. clonidine 0.1 mg Tablet Sig: 0.1 mg PO TID (3 times a day).
18. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
19. Haloperidol 2.5 mg IV Q6H:PRN agitation
20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
S/P [**2156**]0 feet
1. Right bimalleolar ankle fracture.
2. Right elbow instability.
3. Acute respiroatory failure
4. Multiple small IPH/[**Doctor First Name **]
5. Splenic laceration
6. Liver laceration
7. Rib fractures B/l
8. Right clavicle fracture
9. Comminuted fracture metacarpal right thumb.
10.Comminuted fracture proximal phalanx left fifth finger.
11.Complete dislocation proximal interphalangeal joint left
fifth finger.
12.Comminuted left zygomaticomaxillary complex fracture.
13.Left frontal orbit bone fracture
14. Traumatic optic neuropathy left eye
15. Hemoperitoneum
16. Hemorrhagic shock
17. Acute blood loss anemia
18. Bilateral pleural effusions
19. Pneumonia
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert, not oriented, sometimes agitated.
Discharge Instructions:
* You were admitted to the hospital with multiple injuries after
falling 30 ft. off a roof.
* You have had multiple operative procedures to repair many
broken bones and they are healing.
* Unfortunately you also have a traumatic head injury which will
make your recovery more difficult.
* The injury to your left eye has decreased your vision
dramatically and it may not return. This will need to be
followed by your own eye doctor or someone at rehab.
* You are being transferred to an acute rehab facility so that
you will get the best opportunity to improve both physically and
mentally.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 4 weeks.
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment in 4 weeks.
Call the Plastic Surgery Clinic at [**Telephone/Fax (1) 5343**] for a follow up
appointment in 4 weeks.
Call the [**Hospital 4695**] Clinic at [**Telephone/Fax (1) 88320**] for a follow up
appointment in 4 weeks with a repeat Head CT
Evaluation by an opthomologist in [**2-4**] weeks.
Call the Hand Clinic at [**Telephone/Fax (1) 5343**] for a follow up appointment
in 4 weeks.
Completed by:[**2156-12-13**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.7",
"96.72",
"33.23",
"79.33",
"78.14",
"01.10",
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icd9pcs
|
[
[
[]
]
] |
18833, 18930
|
10944, 17100
|
312, 1307
|
19659, 19659
|
2530, 3771
|
20468, 21085
|
1946, 1950
|
17158, 18810
|
18951, 19638
|
17126, 17135
|
19852, 20445
|
1965, 2511
|
266, 274
|
1335, 1816
|
5668, 9595
|
9604, 10921
|
19674, 19828
|
1838, 1865
|
1881, 1930
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,847
| 194,980
|
16317
|
Discharge summary
|
report
|
Admission Date: [**2143-2-13**] Discharge Date: [**2143-2-18**]
Date of Birth: [**2092-4-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
anemia, fever, dyspnea
Major Surgical or Invasive Procedure:
arterial line
History of Present Illness:
50 year old male with CAD s/p CABG (and LVEF=15-20%), DMII,
pulmonary mucor and ESRD s/p LRRT [**5-25**] (from son), who presented
on [**2-13**] with 24 hrs of fevers, body aches and cough. Seen in
nephrology/transplant clinic on [**2-12**] and noted to have hct 18
(recently 18-22 but baseline Hct 26-30) and Cr of 3.6 (recent
baseline [**2-19**]). Given his new anemia, EBV & Parvo B19 were sent
and remain pending from [**2-12**]. In the ER he was tachycardic and
SBP dropped to 78/30. He received NS 2 L, HR 110s and his temp
spiked at 103. He then became SOB, with IVF, but sats remained
stable. EKG was without ischemic changes. He was admitted to the
MICU for further w/u & management.
Past Medical History:
* ESRD [**1-19**] DM2/HTN/post-CABG ATN s/p LRRT [**5-/2142**] from son
* Mucormycosis pulmonary infection [**7-/2142**] when neutropenic from
high-dose immunosuppression for LRRT
* CAD s/p acute anterior MI, 4v CABG at [**Hospital1 2177**] in [**2134**]
* ischemic cardiomyopathy with [**5-/2142**] TTE showing EF 15-20% with
severe global hypokinesis, 2+ MR, 1+ TR
* HTN
* DMII, last HbA1c 6.8 [**10/2141**]
* anemia
* thrombocytopenia
* sinusitis
* right inguinal hernia repair post-transplant
Social History:
Indian man from [**Location (un) 4708**], emigrated 11years ago. Studied
Electrical Engineering at [**University/College 5130**] [**Location (un) **], currently on
leave from work. He has 5 healthy children, the oldest son is
24years old and donated his kidney.
former tobacco use, quit [**2129**]. Runs two restaurants. Has 5
children. social etoh twice a month
Family History:
Father died at age 64 from colon cancer. Mother is alive, has
had diabetes x30 years. Sister and children are healthy.
Otherwise no family history.
His mother has diabetes. His father died of
stomach cancer. maternal GF died at age 48 of likely MI
Physical Exam:
Vitals
General Appearance
HEENT
COR
LUNG
ABD
EXT
Neuro
Pertinent Results:
[**2143-2-13**] 08:36PM LACTATE-1.9
[**2143-2-13**] 08:30PM GLUCOSE-213* UREA N-48* CREAT-3.6* SODIUM-136
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-15* ANION GAP-18
[**2143-2-13**] 08:30PM LIPASE-19
[**2143-2-13**] 08:30PM CK-MB-2 cTropnT-0.04*
[**2143-2-13**] 08:30PM WBC-6.0# RBC-2.03* HGB-6.1* HCT-18.3* MCV-90#
MCH-30.0 MCHC-33.3 RDW-18.1*
[**2143-2-13**] 08:30PM NEUTS-96.6* BANDS-0 LYMPHS-2.4* MONOS-0.7*
EOS-0.2 BASOS-0.1
[**2143-2-13**] 08:30PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-3+
MACROCYT-2+ MICROCYT-2+ POLYCHROM-1+ OVALOCYT-3+
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
[**2143-2-13**] 08:30PM PLT SMR-LOW PLT COUNT-113*
[**2143-2-12**] 09:50AM GLUCOSE-188*
[**2143-2-12**] 09:50AM UREA N-40* CREAT-3.0* SODIUM-140
POTASSIUM-6.0* CHLORIDE-110* TOTAL CO2-18* ANION GAP-18
[**2143-2-12**] 09:50AM ALT(SGPT)-15 AST(SGOT)-14 TOT BILI-0.4
[**2143-2-12**] 09:50AM ALBUMIN-4.4 CALCIUM-9.3 PHOSPHATE-3.4
[**2143-2-12**] 09:50AM FK506-5.5
[**2143-2-12**] 09:50AM URINE HOURS-RANDOM CREAT-120 TOT PROT-28
PROT/CREA-0.2
[**2143-2-12**] 09:50AM WBC-3.0*# RBC-2.00* HGB-6.3* HCT-19.5* MCV-98
MCH-31.7 MCHC-32.5 RDW-22.4*
[**2143-2-12**] 09:50AM PLT COUNT-137*
[**2143-2-12**] 09:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2143-2-12**] 09:50AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
Brief Hospital Course:
He received 3 units of PRBCs, had an a-line was placed. His
Prograf was continued, but given his anemia his MMF was
initially held. His MMF was restarted yesterday, and his
Hydrocort was discontinued.. He was given 30mL of Kayexylate
today for a K of 5.4; repeat K currently pending. ID was
consulted who agreed with above recommendations; they are
concerned for a possible Klebsiella PNA. He is being called out
to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service for continued management.
.
Mr. [**Known lastname 46505**] is a 50 year old male with CAD s/p CABG, ESRD
s/p living donor transplant in [**5-25**] with post op course
complicated by mucor pulmonary infection and acute rejection in
[**11-24**] admitted with pneumonia, bacteremia & anemia.
1)Pneumonia/E.coli Bacteremia - On chest xray he has RML/RLL
infiltrate with E.coli bacteremia. He was initially admitted to
the MICU given fever and hypotension. He was also treated with
Hydrocort 100 IV q8 given his relative hypotension on admission,
although his blood pressure did respond to IVF. He was
improving on IV antibiotics, initially treated with cefepime,
azithromycin, and Vancomycin. Once blood cultures returned his
vancomycin and azithromycin were discontinued and he was
transferred to the floor on ceftriaxone. He also has known
mucor pulmonary infection but this appears stable on
posiconazole. DFA & Legionella were negative. He was discharged
with PICC and VNA to continue ceftriaxone for one more week
(last dose 3/9) then start ciprofloxacin for one week to
complete 3 week course of antibiotics. He will f/u with Dr.
[**Last Name (STitle) 724**] as an outpatient.
2)Anemia: likely [**1-19**] ESRD. Guaiac negative in the ED. Hemolysis
labs negative. He has been transfused 4u pRBC over the course of
his admission with good response in hct. Parvo and EBV were
negative. His MMF was initially held on admission due to his
anemia, however was restarted prior to transfer to the floor.
His severe anemia likely due to chronic kidney disease. He was
continued on Procrit 10K MWF.
3) Pulmonary Mucormycosis - medication compliance has been an
issue in the past, no active issues on this admission. He was
continued on QID dosing of posaconazole.
4) ESRD s/p transplantation with rejection since [**11-24**]:
Rejection thought [**1-19**] patient stopping posiconazole and
subsequent decrease in immunosupression levels. Creatinine
currently stable at current baseline ~3. His FK 506 levels,
were followed daily with goal of [**3-25**]. He was continued on MMF,
bactrim ss and valgancyclovir.
5) Type I DM:He was continued on his home dose of glargine 10
units qhs, hiss.
6) CAD s/p CABG: no acute issues, He was continued on
atorvastatin, ASA, and carvedilol.
7)Chronic systolic heart failure: Echo from [**2143-2-14**] showed EF of
25%, slightly improved c/w [**12-24**].
8) Hyperlipidemia: -cont Lipitor
9) HTN: stable, continue carvedilol
10)Code Status: Full
Medications on Admission:
Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY
Pantoprazole 40 mg Tablet One Tablet PO Q24H
Atorvastatin 40 mg One Tablet PO DAILY
Mycophenolate Mofetil 500 mg One Tablet PO BID
Folic Acid 1 mg Tablet PO DAILY
Valganciclovir 450 mg PO 2X/WEEK ([**Doctor First Name **],WE)
Carvedilol 12.5 mg PO BID
Posaconazole 200 mg PO QID WITH MEALS
Tacrolimus 0.5 mg PO Q12H
ASA daily
Procrit 20K (recently increased from 10K) weekly
Florinef 0.1 mg PO daily
calcium/vitamin D
Discharge Medications:
1. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 6 days.
Disp:*7 gram* Refills:*0*
2. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ml Intravenous once a day for 6 days: 10 ml NS followed by 2 mL
of 100 Units/mL heparin (200 units heparin) each lumen Daily.
Disp:*QS QS* Refills:*0*
3. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection DAILY (Daily) as needed for 6 days: 10 ml NS followed
by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen
Daily .
Disp:*QS ML(s)* Refills:*0*
4. Midline care per protocol
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: Do not start this medication until
Monday [**2143-2-25**], once you finish the IV antibiotics.
Disp:*7 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
12. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Os-Cal 500 + D 500 (1,250)-400 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
14. Posaconazole 200 mg/5 mL Suspension Sig: Two Hundred (200)
mg PO QID (4 times a day).
Disp:*[**Numeric Identifier 17514**] mg* Refills:*2*
15. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
16. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
19. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
20. Epoetin Alfa Injection
21. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary diagnoses:
1. Pneumonia
2. Bacteremia
3. Anemia
Secondary
- End-stage renal disease due to diabetes/hypertension/post-CABG
acute tubular necrosis status post renal transplant [**5-/2142**] from
son complicated by chronic rejection
- Mucormycosis pulmonary infection [**7-/2142**] when neutropenic from
high-dose immunosuppression for renal transplant
- Coronary artery disease status post acute anterior myocardial
infarction, CABG [**2134**]
- Congestive heart failure with EF 25%
- Hypertension
- Type 2 diabetes
- Thrombocytopenia
- Sinusitis
- Right inguinal hernia repair post-transplant
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were admitted to the hospital because you were having fever
and cough. You were found to have a pneumonia in your right
lung. You also had bacteria in your blood which likely came
from the pneumonia. You were treated with intravenous
antibiotics and your symptoms improved. You will continue
intravenous ceftriaxone for six days and then take ciprofloxacin
orally to complete a 21-day course.
In addition you had a low red blood cell count on admission.
You were transfused 4 units of blood total during your
admission. Your blood count has remained stable.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, increased cough, or any other
concerning symptoms.
Please take your medications as prescribed.
- You should take ceftriaxone 1 gram intravenously once daily
for six days.
- You should then take ciprofloxacin orally to complete a total
21-day course of antibiotics. The first dose of ciprofloxacin
will be [**2143-2-25**].
- You should continue posaconazole indefinitely.
- You were started on sodium bicarbonate because of low levels
in your blood.
- Your epoeitin dose was increased as an outpatient and you
should continue as per previous.
For you heart failure:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
No fluid restriction.
Followup Instructions:
You had the following appointments scheduled:
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-2-25**] 3:00
Please keep your already scheduled appointments:
1. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-4-23**] 9:30
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-4-9**] 9:00
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
|
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"250.40",
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"428.0",
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"V45.81",
"790.7",
"401.9",
"583.81",
"428.32",
"585.6",
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icd9cm
|
[
[
[]
]
] |
[
"38.91",
"99.04"
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icd9pcs
|
[
[
[]
]
] |
9497, 9549
|
3712, 6693
|
338, 353
|
10195, 10227
|
2333, 3689
|
11629, 12306
|
1993, 2243
|
7211, 9474
|
9570, 10174
|
6719, 7188
|
10251, 11606
|
2258, 2314
|
276, 300
|
381, 1075
|
1097, 1596
|
1612, 1977
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,641
| 111,640
|
42177
|
Discharge summary
|
report
|
Admission Date: [**2104-11-8**] Discharge Date: [**2104-11-12**]
Date of Birth: [**2053-10-2**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Tracheal foreign body
Major Surgical or Invasive Procedure:
Bronchoscopic removal of airway foreign body, removal of trach
tube: Dr. [**Last Name (STitle) 3373**] [**2104-11-8**]
History of Present Illness:
51F transfer from outside hospital hospital, was cleaning her
trach with a metal rod in brush when it broke off and is lodged
into her trachea. Outside hospital bronchoscopy was performed
showing piece of the metal with a brush attached in her left
mainstem bronchus. Patient doesn't have any shortness of breath
but does have some discomfort when she coughs patient was
transferred to b.i.d. for interventional pulmonology.
In the ED, initial VS were: 98.2 100 104/70 16 100% 6L. IP saw
the patient and rec'd admission. On arrival to the MICU, she is
stable and in NAD.
Past Medical History:
Throat cancer in [**2102**] S/p Tracheostomy
Social History:
- Tobacco: Occasional cigarettes
- Alcohol: None
- Illicits: None
Family History:
NC
Physical Exam:
Physical Exam on Admission:
Vitals: T98.2 HR100 BP104/70 RR16 O2Sat100% 6L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, Tracheostomy is CDI without edema or induration
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally diminished breathsounds
bilaterally
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Grossly intact
Physical Exam on Discharge:
Neck: tracheostomy tube is now removed
Lungs: slight diminished breath sounds in the left lower lung
field, otherwise good air movement bilaterally
Exam otherwise unchanged from admission
Pertinent Results:
Admission Labs:
[**2104-11-8**] 12:00AM WBC-7.1 RBC-3.99* HGB-12.6 HCT-38.0 MCV-95
MCH-31.7 MCHC-33.3 RDW-12.8
[**2104-11-8**] 12:00AM PLT COUNT-245
[**2104-11-8**] 12:00AM GLUCOSE-89 UREA N-7 CREAT-0.6 SODIUM-137
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16
[**2104-11-8**] 12:00AM PT-13.0 PTT-25.5 INR(PT)-1.1
IMAGING:
CT CHEST W/O CONTRAST [**2104-11-7**]
INDICATION: 51-year-old female with foreign body in trachea.
TECHNIQUE: Multidetector helical CT scan targeted to the region
of interest in the trachea was obtained without the
administration of contrast. Coronal and sagittal reformations
were prepared.
COMPARISON: None available.
FINDINGS: There is a linear dense foreign body measuring up to
6.6 cm in
length beginning in the mid trachea and extending inferiorly to
the left
mainstem bronchus. The proximal portion of the foreign body
abuts the right tracheal wall and appears lodged by
approximately 3 mm. Beginning at the left main bronchus, there
is fluid/mucoid material seen with several distended impacted
bronchi throughout the left lower lobe. Additionally, there are
ground-glass opacities of the lung parenchyma which are
nonspecific. A ground-glass opacity of the medial basal segment
of the right lower lobe is also nonspecific. There is a
tracheostomy.
The visualized portions of the heart and great vessels are
unremarkable. No concerning osseous lesion is seen. No
lymphadenopathy identified in the
visualized portions of the mediastinum and axilla. Incidental
note is made of scattered blebs.
IMPRESSION:
6.6-cm linear foreign body from the mid trachea and extending to
the left
mainstem bronchus. The left mainstem bronchus and distal bronchi
appear
distended with fluid/mucoid impaction. Distal ground-glass
opacities within the lung are nonspecific and consistent with
inflammation or possible infection likely postobstructive in
nature.
POST-PROCEDURE CXR [**2104-11-9**]:
The previously seen left-sided radiopaque foreign body is no
longer
visualized. There is volume loss with shift of the mediastinum
to the left
and elevation of the left hemidiaphragm. There is opacification
of the lower lung with obscuration of the cardiac borders,
slightly worse than on [**2104-11-8**]. There is some patchy opacity in
the remaining aerated left upper lung, which is also slightly
worse. The right diaphragm is slightly hyperinflated, with
findings raising question of background COPD, but no acute
right-sided pulmonary process is identified and there is no
right-sided effusion.
IMPRESSION: Interval removal of radio-opaque foreign bodies.
Volume loss on the left, with increased opacity in the left lung
and with slight increase in opacity of the left lung compared
with [**2104-11-8**] at 4:43 a.m. No pneumothorax is detected.
[**11-10**] CXR:FINDINGS: In comparison with the study of [**11-9**], there
is a slight increasein opacification in the left hemithorax,
consistent with increasing effusion.Shift of the mediastinum to
the left is consistent with substantial volume loss in the lower
lobe and lingula. Right lung remains clear.
[**11-11**] CXR: MPRESSION: Improved aeration of left lung with
continued significant volume loss of left lower lobe.
[**11-12**] CXR: IMPRESSION: Worsening left upper lobe opacity
concerning for pneumonia. Left lower lobe collapse and
atelectasis appears stable.
Lab Results on Discharge:
[**2104-11-12**] 06:00AM BLOOD WBC-5.5 RBC-3.45* Hgb-10.6* Hct-31.7*
MCV-92 MCH-30.7 MCHC-33.4 RDW-12.6 Plt Ct-301
Brief Hospital Course:
Primary Reason for Hospitalization:
51 [**Last Name (un) 9232**] with tracheostomy [**2-20**] throat cancer who presented to
[**Hospital1 18**] for removal of part
of a brush that broke off during cleaning of her tracheostomy
tube. The foreign body was removed, and the collapsed lung
beyond the lodged object re-expanded.
Acute Care:
1. Tracheal Foreign body: Patient was evaluated by
interventional pulmonology service, and bronchoscopy was
performed on [**2104-11-8**] to remove the foreign body. She tolerated
the procedure well without complications. During bronchoscopy
the tracheostomy site appeared narrowed indicating good upper
airway ventilation, and when the tube was covered she maintained
O2 saturation. Since she did not appear to require the trach
tube to maintain adequate ventilation, the tube was removed.
Following the procedure she was maintained on oxygen via nasal
canula which was slowly weaned as the lung distal to the site of
the foreign body impaction re-expanded. She had no fever and no
leukocytosis and showed no sign of post-obstructive pneumonia,
and was discharged home to f/u with PCP. [**Name10 (NameIs) 3754**] was an area of
haziness on CXR on final day of hospitalization but patient
showed no leukocytosis or fever, so she was left to follow-up
with PCP.
Chronic Care:
1. S/p chemo/radiation for tongue/laryngeal cancer: Speech and
swallow evaluated patient and found no swallowing deficits. She
was maintained on a puree diet per her request for comfort given
that she is edentulous and does not chew food. PT deemed her
appropriate for home discharge.
Transitions in Care:
Patient was scheduled for a follow-up appointment with her PCP,
[**Name10 (NameIs) **] with her outpatient radiation oncologist.
Medications on Admission:
Multivitamin
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
Primary: foreign body in airway
.
Secondary: History of laryngeal cancer with tracheostomy tube
placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 71673**],
.
It was a pleasure taking part in your care. You were admitted to
the hospital because part of the brush you were using to clean
your tracheostomy tube broke off and became lodged in your
airway. In the hospital we removed the brush and saw
inflammation and that your lung had collapsed beyond where the
brush was lodged. Once the brush was removed your lung opened up
again and you no longer needed oxygen. We discharged you home
with no tracheostomy tube and plans to allow the stoma to heal.
.
Please do not make any changes to your medications and please
keep your follow-up appointment with your primary care
physician.
Followup Instructions:
Name: [**Last Name (LF) **],[**Name6 (MD) 3049**] CHALICE MD
Location: DEPT OF RADIATION ONCOLOGY
Address: [**Hospital3 **], [**Hospital1 **],[**Numeric Identifier 53049**]
Phone: [**Telephone/Fax (1) 87329**]
Appointment: Wednesday [**2104-11-19**] 1:00pm
*Appointment is downstairs.
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: FAMILY MEDICAL ASSOC
Address: [**Location (un) 24577**] [**Apartment Address(1) 91469**], [**Location (un) **],[**Numeric Identifier 6086**]
Phone: [**Telephone/Fax (1) 40489**]
**We were unable to schedule your follow up appointment with
your PCP. [**Name10 (NameIs) 357**] contact the office at the number above to
schedule and appointment. It is recommended you see your PCP
[**Name Initial (PRE) 176**] 1 week from your discharge**
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"97.37",
"98.15"
] |
icd9pcs
|
[
[
[]
]
] |
7394, 7453
|
5488, 7240
|
326, 446
|
7603, 7603
|
1963, 1963
|
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|
1215, 1219
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1234, 1248
|
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5349, 5465
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265, 288
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474, 1047
|
1980, 5334
|
1262, 1727
|
7618, 7730
|
1069, 1115
|
1131, 1199
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,072
| 129,063
|
37268
|
Discharge summary
|
report
|
Admission Date: [**2177-12-26**] Discharge Date: [**2177-12-31**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Subdural Hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a [**Age over 90 **] y/o female, [**Hospital3 **] resident with normal
ADLs, on ASA and Plavix, who fell backwards from a standing
position, possibly a syncopal episode. The patient was alert and
oriented and was seen at an OSH. At the OSH, the patient's
neurological status deteriorated and she was intubated
and transferred to [**Hospital1 18**] with a L. SDH. The patient received
Dilantin and mannitol en route to [**Hospital1 18**].
Past Medical History:
CAD (s/p stent placement 5 yrs ago), R. aneursym clipping
([**10-23**] yrs ago), breast cancer (s/p mastectomy with implant).
Social History:
Lives in [**Hospital3 **] facility
Family History:
No hx of aneursyms
Physical Exam:
O: BP: 180/79 HR: 74 R 12 O2Sats 100%
Gen: intubated, sedated
HEENT: Pupils: L 4-3mm sluggish, R surgical pupil
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated/sedated.
Orientation: intubated/sedated.
Cranial Nerves:
I: Not tested
II: Left pupil 4-3 mm sluggish, R surgical pupil.
III-[**Doctor First Name 81**]: unable to determine
Motor: twitching upper and lower extremities, does not follow
commands.
Rest of exam limited by sedation.
Pertinent Results:
[**2177-12-29**] 05:55AM BLOOD WBC-12.2* RBC-3.62* Hgb-11.2* Hct-32.4*
MCV-90 MCH-31.0 MCHC-34.5 RDW-13.1 Plt Ct-232
[**2177-12-29**] 05:55AM BLOOD Plt Ct-232
[**2177-12-29**] 05:55AM BLOOD Glucose-147* UreaN-17 Creat-0.7 Na-138
K-3.7 Cl-109* HCO3-22 AnGap-11
[**2177-12-29**] 05:55AM BLOOD Albumin-3.4 Calcium-7.9* Phos-1.6* Mg-2.0
[**2177-12-29**] 05:55AM BLOOD Phenyto-16.5
[**2177-12-27**] 10:49AM BLOOD Type-ART pO2-167* pCO2-38 pH-7.44
calTCO2-27 Base XS-2
Brief Hospital Course:
Ms [**Known lastname **] was admitted to the SICU for close observation and
monitoring. Her follow up CT on admission showed interval
increase in both SDH and SAH blood. A CTA was done due to the
patients history of aneursyms which was negative and showed good
clip positioning of previously clipped aneurysm and no new
aneursyms. A CT of the neck showed no fracture. The patient
required a Nicardipine drip due to hypertension. Serial CT's
showed interval stable blood but slightly increased right to
left shift. The patients exam at best was slight eye opening,
minimal to no movement of right upper extremity. The family had
made the patient DNR/DNI intially however with her poor exam and
no improvement of her exam over her hospital course they decided
to make the patient CMO. A pallative care consult was obtained
and assisted our management of her care. The patient was
discharged to hospice on [**12-31**] she had minimal eye opening and
appeared comfortable with respirations in the low teens prior to
discharge.
Medications on Admission:
Lipitor, Plavix, Buproprion,
Atenolol, Vit D, B, Asprin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q2H
(every 2 hours) as needed for Comfort.
Disp:*60 mg* Refills:*0*
3. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours as needed for oral secretions.
Disp:*5 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
Subdural Hematoma and SAH
Discharge Condition:
Activity Status:Bedbound
Level of Consciousness:Lethargic and not arousable
Discharge Instructions:
Patient is being transferred to hospice enviornment
Comfort care measures only
Followup Instructions:
None
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2178-1-10**]
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
]
] |
3586, 3644
|
2065, 3089
|
286, 293
|
3714, 3792
|
1578, 2042
|
3919, 4050
|
987, 1007
|
3196, 3563
|
3665, 3693
|
3115, 3173
|
3816, 3896
|
1022, 1251
|
229, 248
|
321, 769
|
1334, 1559
|
1266, 1318
|
791, 919
|
935, 971
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,617
| 120,423
|
46577
|
Discharge summary
|
report
|
Admission Date: [**2119-1-18**] Discharge Date: [**2119-1-27**]
Date of Birth: [**2038-3-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Closed reduction of left talus fracture
History of Present Illness:
80F presenting with history of breast CA, Diabetes,
hyperlipidemia, obesity, laryngeal SCC s/p surgery & XRT p/w leg
pain after a fall at home.
.
Patient was getting into a car, lifting right leg to get into
driver's seat (!), with all weight on left leg, he leg 'buckled'
and she fell straight down onto her behind. No Dizziness,
lightheadedness, LOC. No head injury. No pain at the time of the
fall. Later that evening she awoke with severe left ankle pain.
.
Of note she also is chronically short of breath . She does not
think this has gotten worse recently. No PND, orthopnea, no
chest pain, no diaphoresis. No fevers/chills. She also notes
slow speech, and a feeling like her tongue is big and it is
difficult to make words. This started several months ago.
.
ED VS: T 97.3, HR 60, BP 166/88, RR 18, 95%/RA Given IV morphine
for pain, 1L NS, ASA and tylenol. Foot plain films demonstrated
a talus fracture. Ortho saw her, did not recommend surgery, they
did reduce her fracture, and place her leg in a brace. Neurology
was consulted for her speech changes and their consult was
pending at the time of admission. She was admitted to medicine
for shortness of breath.
Past Medical History:
- h/o right breast cancer, s/p lumpectomy & XRT [**2107**]
- h/o laryngeal squamous cell ca, s/p surgery & XRT - 3 years
ago
- Hypertension
- Hypercholesterolemia
- Diabetes
- Obesity
- GERD
- Multinodular goiter
- s/p right knee replacement
- s/p TAH-BSO, w/ small piece of ovary left in
Social History:
Pt is married and lives with her husband. Graduated from college
and majored in economics but never worked outside the home.
Former smoker, 40-pack-year hx, quit [**2087**]. No known asbestos
exposure. Independent in ADLs including driving. HCP is husband,
[**Name (NI) **] [**Name (NI) 30944**] and code status is DNR/DNI.
Family History:
Father: lung cancer, laryngeal cancer.
Mother: hypertension, coronary artery disease s/p MI, stroke,
hypercholesterolemia.
Healthy children and grandchildren.
Physical Exam:
Vitals - T: 96.0 BP: 128/92 HR: 75 RR: 20 02 sat:88-89/ra, 91/2L
GENERAL: No acute distress
HEENT: Oropharynx clear
CARDIAC: RRR, no m/r/g
LUNG: CTAB, distant lung sounds
ABDOMEN: NT, ND, BS+
EXT: No edema, pulses 1+ RLE, LLE in brace
NEURO: AAO x 3, speech slow, good memory, registration,
calculation, strength 5/5 b/l, grossly normal sensation. face
symmetric
DERM: intact
Pertinent Results:
[**2119-1-18**] 10:40AM BLOOD WBC-11.7* RBC-5.93* Hgb-15.2 Hct-47.9
MCV-81* MCH-25.7* MCHC-31.8 RDW-14.9 Plt Ct-260
[**2119-1-19**] 05:20AM BLOOD WBC-13.3* RBC-5.98* Hgb-15.3 Hct-49.9*
MCV-83 MCH-25.6* MCHC-30.6* RDW-15.3 Plt Ct-262
[**2119-1-20**] 08:40AM BLOOD WBC-11.1* RBC-5.31 Hgb-13.7 Hct-43.7
MCV-82 MCH-25.8* MCHC-31.4 RDW-15.0 Plt Ct-207
[**2119-1-21**] 05:20AM BLOOD WBC-7.9 RBC-5.39 Hgb-13.8 Hct-45.7 MCV-85
MCH-25.5* MCHC-30.1* RDW-14.9 Plt Ct-220
[**2119-1-18**] 10:40AM BLOOD Neuts-86.2* Lymphs-8.1* Monos-5.1 Eos-0.3
Baso-0.2
[**2119-1-20**] 08:40AM BLOOD Neuts-88.7* Lymphs-5.7* Monos-5.2 Eos-0.2
Baso-0.1
[**2119-1-18**] 10:40AM BLOOD PT-11.1 PTT-23.8 INR(PT)-0.9
[**2119-1-18**] 10:40AM BLOOD Glucose-129* UreaN-29* Creat-1.3* Na-146*
K-3.8 Cl-103 HCO3-33* AnGap-14
[**2119-1-19**] 05:20AM BLOOD Glucose-122* UreaN-23* Creat-1.0 Na-145
K-4.0 Cl-105 HCO3-31 AnGap-13
[**2119-1-20**] 08:40AM BLOOD Glucose-108* UreaN-22* Creat-1.1 Na-146*
K-3.8 Cl-101 HCO3-38* AnGap-11
[**2119-1-21**] 05:20AM BLOOD Glucose-126* UreaN-20 Creat-1.2* Na-145
K-3.6 Cl-99 HCO3-40* AnGap-10
[**2119-1-18**] 10:40AM BLOOD cTropnT-0.02*
[**2119-1-19**] 02:30AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2119-1-18**] 10:40AM BLOOD CK(CPK)-76
[**2119-1-19**] 02:30AM BLOOD CK(CPK)-65
[**2119-1-19**] 05:20AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.8
[**2119-1-19**] 05:20AM BLOOD VitB12-854 Folate-9.6
[**2119-1-19**] 05:20AM BLOOD TSH-3.5
[**2119-1-18**] 06:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2119-1-18**] 06:25PM URINE Blood-NEG Nitrite-NEG Protein-150
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG
[**2119-1-18**] 06:25PM URINE RBC-0-2 WBC-[**2-24**] Bacteri-FEW Yeast-NONE
Epi-0-2
[**2119-1-18**] 06:25PM URINE CastHy-[**2-24**]*
ECG:
[**2119-1-18**]:
Sinus rhythm. Normal tracing. Compared to the previous tracing
non-diagnostic Q waves are recorded in lead aVF. Compared to the
previous tracing of [**2117-7-27**] no diagnostic interim change. The
rate has slowed.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 204 88 [**Telephone/Fax (2) 98887**] 70
CT Head [**2119-1-18**]:
FINDINGS:
No acute hemorrhage, midline shift, hydrocephalus, or acute
large infarct is present. The ventricles and sulci are mildly
prominent, consistent with
age-related involutional changes. The mastoid air cells and
paranasal sinuses are well aerated. No fractures are present.
IMPRESSION:
No acute intracranial abnormality.
Plain films, ankle
[**2119-1-18**]:
IMPRESSION:
1. Findings concerning for talus avulsion fracture. Superior
widening of the ankle mortise.
2. Suprapatellar joint effusion. Moderate knee osteoarthritic
changes,
possible chondrocalcinosis.
3. The left aspect of the pubic symphysis appears slightly
inferior in
relation to the right aspect of the pubic symphysis, of
indeterminate age.
Plain film, ankle post reduction:
[**2119-1-18**]:
LEFT ANKLE, THREE VIEWS: Cast material obscures fine bone
detail. Within
this limitation, alignment of the mortise is improved. The
possible talar
avulsion fracture is well seen due to overlying cast.
IMPRESSION: Improved alignment of the left ankle status-post
reduction.
CXR:
[**2119-1-18**]:
1. Mild bibasilar, right greater than left, atelectasis. No
focal
consolidation or pleural effusion.
2. Persistent prominence of the aortopulmonary window/main
pulmonary artery, which may be secondary to pulmonary arterial
hypertension versus pulmonary valvular stenosis.
CTA Chest
[**2119-1-20**]:
CT OF THE CHEST WITH IV CONTRAST:
The heart is mildly enlarged. There is no pericardial effusion.
Moderate
calcification of the aortic valve and coronary artery is
present. The
ascending aorta measures 3.7 mm in diameter. Mild calcification
is present
throughout the thoracic aorta. The main pulmonary artery is
enlarged,
measuring 41 mm in diameter. No pulmonary embolism is present to
the
subsegmental levels.
Multiple mediastinal lymph nodes are present, the largest
measuring 12 mm in the subcarinal region. Scattered axillary
lymph nodes do not meet CT criteria for lymphadenopathy.
Moderate centrilobular emphysema is present throughout the
lungs. There is a moderate degree of basilar, dependent
atelectasis bilaterally. Within the
left lower lobe, there is a 25 x 18 x 24 mm cavitary lesion,
which may
represent a focus of infection, neoplasm, vascular abnormality,
or septic
embolus. Given the patient's prior history of squamous cell
cancer, however, there is a high suspicion for neoplasm. There
is no pleural effusion.
Included views of the neck demonstrate multinodular goiter, with
hypodense
nodules, measuring up to 17 mm in the right lobe.
OSSEOUS STRUCTURES:
There is no acute fracture or dislocation. Within single right
mid thoracic
rib, there is a focal expansion up to 11 mm, with no evidence of
cortical
destruction or sclerosis. No sclerotic or lytic lesion is
detected.
IMPRESSION:
1. Left lower lobe cavitary lesion is highly suspicious for
neoplasm, given
the patient's prior history of squamous cell carcinoma.
2. A 12-mm subcarinal lymph node is concerning for malignancy
given the
patient's history. Reactive lymphadenopathy is also a
possibility.
3. Focal enlargement of the mid right thoracic rib is likely a
benign entity such as fibrous dysplasia or healed injury.
4. No pulmonary embolism is detected. However, the main
pulmonary artery is
enlarged, compatible with pulmonary hypertension.
5. Multinodular goiter, with hypodense lesions measuring up to
17 mm.
Continued ultrasound surveillance is recommended.
Brief Hospital Course:
ASSESSMENT & PLAN: 80F with h/o Breast CA, vocal cord CA s/p
surgery, p/w fall at home and increased SOB and increased BNP.
Found to have talar fracture, set in ED.
.
# Fall. It was thought that this fall was likely mechanical. She
has chronic knee pain that limits her activity. Lack of prior
symptoms makes arrhythmia, seizure, stroke less likely. She was
monitored on telemtery for 24 hours, and had no events.
Myocardial infarction was ruled out with electrocardiogram and
serial cardiac biomarkers.
.
#. Talar fracture. Orthopedic surgery was consulted in the
emergency department and performed a closed reduction and put
her leg in a cast. She will follow up with orthopedic surgery
in several weeks. Pain control was achieved with tylenol. She
was discharged to rehab with instructions to continue heparin
injections while immobile.
# Dyspnea/Hypercarbic respiratory failure- Though stable on
admission, the patient became progressively hypoxic and imaging
revealed a LLL cavitary lesion, thought to represent aspiration
pneumonia. She was covered broadly with vancomycin, zosyn and
levofloxacin. Her dyspnea was subsequently stable and she
remained afebrile, and her WBC decreased to the normal range.
Pulmonary was consulted and recommended 6 weeks of PO augmentin,
followed by repeat chest CT. Patient requested a sleep aide, and
was given trazodone 25mg PO once. On [**1-23**], patient was found to
be hypoventilating, somnolent and required intubation and a
brief period of mechanical ventilation. She has known
obstructive ventilatory disease likely from smoking history.
Given her body habitus she likely has undiagnosed component of
OSA. Patient was extubated the same day, alert and conversant.
She did develop dyspnea on [**1-24**] and was started on BiPAP with
significant improvement. Patient was also hypertensive to the
190s, requiring hydral X2 and eventually nitroglycerin drip.
Briefly, whenever her BiPap was removed, her blood pressures
with increase (SBP ~220). Eventually patient was restarted on
home amlodipine as well as atenolol and lisinopril, with good
effect. She was also intermittently diuresed with Lasix with a
goal of mildly negative. Patient was eventually weaned off BiPap
and underwent BiPap sleep study overnight to determine Bipap
settings patient can be discharged home/to rehab with. Patient's
blood sugars started running high on Solumedrol --> Prednisone
so she was briefly started on a low-dose insulin sliding scale.
She was not discharged on any diuretics but this can be
revisited depending on her volume status at her rehab facility.
Her steroids will also need to be tapered while at rehab.
.
#. Confusion/speech difficulty. On exam, patient did have slow
speech, but per patient this has been a chronic problem with no
recent change. Neurologic exam was non focal. Neurology was
consulted, and felt that her slow speech was likely mechanical
from her multiple laryngeal surgeries and XRT. No additional
imaging was performed.
.
#. Hypertension: As above, temoporarily required nitroglycerin
gtt for adequate BP control. As her hypoxia was stabilized, her
BP was also more controllable. She was continued on amlodipine,
atenolol, lisinopril per above
.
#. Hyperlipidemia: Patient was continued on ASA, atorvastatin.
Medications on Admission:
Amlodipine 5mg PO daily
Atenolol 25mg PO bid (?)
Atorvastatin 80mg PO daily (?)
Lisinopril 20mg PO daily
Omeprazole 20mg PO daily
Trazodone 50mg PO qhs prn insomnia
ASA 81mg PO daily
Calcium-Vitamin D 600 mg (1,500 mg)-200 unit Tablet
Multivitamin
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhaler Inhalation Q6H (every 6 hours)
as needed for shortness of breath or wheezing.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
9. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 3 days: From [**Date range (1) 70212**].
10. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days: From [**Date range (1) 98888**].
11. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days: From [**Date range (1) 77547**].
12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: From [**Date range (1) 5553**].
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
16. Calcium 600 with Vitamin D3 600 mg(1,500mg) -200 unit Tablet
Sig: One (1) Tablet PO once a day.
17. Heparin (Porcine) 5,000 unit/mL Syringe Sig: One (1)
Injection/Syringe Injection three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Hypercarbic respiratory failure
Secondary: Hypertension
Diabetes
Hyperlipidemia
Left talar fracture
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:
Ms. [**Known lastname 30944**],
You were admitted to the hospital for shortness of breath that
was thought to be due to pneumonia. Your respiratory status
worsened and you were placed on a mechanical ventilator for a
brief period of time. Your breathing tube was removed but you
required intermittent supplemental oxygen through a face mask.
You were also treated with steroids, antibiotics, diuretics, and
inhaled nebulized medications.
You were found to have a fractured foot on imaging studies. You
will follow up with the orthopedic surgeons (see appointment
below).
You had some severely elevated blood pressures that were treated
with IV medications.
The following changes were made to your medications:
-Reduced ATENOLOL to 25 mg by mouth, ONCE DAILY, to control your
heart rate and blood pressure. You should discuss this with your
cardiologist at your next visit
-Increased your LISINOPRIL dose to 30 mg by mouth, ONCE DAILY
-Added ALBUTEROL Nebulizers 0.083% Inhaled solution every six
hours as needed for shortness of breath or wheeze
-Added IPRATROPIUM Nebulizer 0.02% Inhaled solution every six
hours as needed for shortness of breath or wheeze
-Added COLACE (a stool softener) and SENNA (a laxative) to be
used 1-2 times/day AS NEEDED for constipation.
-Added PREDNISONE, an oral steroid, to reduce inflammation in
your airway. The doses of this medication will be tapered down
over the next several weeks as follows:
40 mg daily from [**Date range (1) 70212**]
30 mg daily from [**Date range (1) 98888**]
20 mg daily from 2/11/2/13
10 mg daily from [**Date range (1) 5553**]. After [**2-7**], your steroid course will
be complete.
-We also started treating you with an INSULIN sliding scale,
since the steroids you have been taking are expected to increase
your blood glucose levels. Please see the attached chart for
dosing.
-Finally, we started giving you HEPARIN subcutaneous injections
THREE TIMES DAILY, to prevent blood clots, given your immobility
since your fracture
Please take all of your medications and keep all of your
appointments (below), as directed
Followup Instructions:
Provider: [**Name10 (NameIs) **], orthopedic, [**Hospital Ward Name 23**] [**Location (un) **], appointment
for xray at 9AM, doctor appointment at 9:20, [**2119-9-16**]
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2119-2-2**] 9:10
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2119-2-2**] 9:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2119-2-2**] 9:30
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
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"518.81",
"293.0",
"507.0",
"272.4",
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
"79.07",
"96.04",
"93.90",
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icd9pcs
|
[
[
[]
]
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13603, 13669
|
8363, 11638
|
326, 368
|
13823, 13823
|
2811, 8340
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282, 288
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396, 1569
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1591, 1881
|
1897, 2222
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,272
| 134,151
|
54975
|
Discharge summary
|
report
|
Admission Date: [**2176-6-28**] Discharge Date: [**2176-7-5**]
Date of Birth: [**2102-3-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2176-6-28**] Coronary artery bypass graft x 4 with left internal
mammary artery graft to left anterior descending, reverse
saphenous vein graft to diagonal branch, marginal branch, and
posterior descending artery.
History of Present Illness:
74 year old gentleman with complex coronary artery disease not
amenable to percutaneous intervention. In [**2176-3-19**], he was
admitted to [**Hospital3 **] Hospital for symptomatic bradycardia and a
dual chamber pacemaker was placed. An elective cardiac
catheterization this past Spring was performed when patient
complained of chest pain, which revealed severe three vessel
disease not amenable to percutaneous intervention. Currently he
is symptomatic with some dyspnea on exertion. Given the severity
of his disease, he has been referred for surgical evaluation.
Past Medical History:
Coronary artery disease
Sick sinus syndrome s/p PPM
Hypertension
Prostate cancer with brachytherapy
Ileorectal abscess [**2174**]
Peripheral vascular disease
Acute renal failure
Hyperlipidemia
Right renal artery stenosis - 70% stenosis
Abdominal aortic aneurysm 3.5cm
Appendectomy
Hernia Repair
Prostate Seed implant
Surgery for ischiorectal abscess
Social History:
Race: Caucasian
Last Dental Exam: N/A
Lives alone
Occupation: Works in real estate
Cigarettes: Smoked no [] yes [X] last cigarette [**10/2175**] Hx:
<1ppd
x 60 yrs
ETOH: < 1 drink/week [] [**12-26**] drinks/week [] >8 drinks/week [X]
Fifth of gin daily
Illicit drug use: Denies
Family History:
Father died of MI in his 70's, Sister died of MI in her 60's,
Brother died of MI in his 40's.
Physical Exam:
Pulse: 64 Resp: 16 O2 sat: 99%
B/P Right: 128/68 Left: 127/69
Height: 5'8" Weight: 178 lbs
General: Well-developed male in no acute distress
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT[X] 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/Varicosities:
None
[X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: Right: - Left: -
Pertinent Results:
[**2176-7-3**] TTE
Overall left ventricular systolic function is mildly depressed
(LVEF= 40-45%) secondary to dyskinesis of the basal-mid
infero-lateral wall and akinesis of the basal-mid inferior wall.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The mitral valve leaflets are
mildly thickened. ? Trivial mitral regurgitation is seen.The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: poor technical quality due to patient's body
habitus. Mild regional and global left ventricular systolic
dysfunction c/w CAD. The right ventricle is not well seen. No
pathologic valvular abnormality seen. Pulmonary artery systolic
pressure could not be determined.
[**2176-7-5**] 06:40AM BLOOD WBC-9.7 RBC-4.33* Hgb-13.8* Hct-40.8
MCV-94 MCH-31.8 MCHC-33.8 RDW-14.1 Plt Ct-327
[**2176-7-4**] 03:43AM BLOOD WBC-9.9 RBC-3.79* Hgb-12.3* Hct-35.6*
MCV-94 MCH-32.5* MCHC-34.6 RDW-14.5 Plt Ct-281
[**2176-7-3**] 02:14AM BLOOD WBC-9.6 RBC-3.86* Hgb-12.6* Hct-35.7*
MCV-93 MCH-32.5* MCHC-35.1* RDW-14.4 Plt Ct-272
[**2176-7-5**] 08:30AM BLOOD PT-13.0* INR(PT)-1.2*
[**2176-7-4**] 03:43AM BLOOD PT-17.6* PTT-29.3 INR(PT)-1.7*
[**2176-7-3**] 03:53PM BLOOD PT-41.6* PTT-35.9 INR(PT)-4.1*
[**2176-7-3**] 09:25AM BLOOD PT-62.1* PTT-36.3 INR(PT)-6.2*
[**2176-7-3**] 07:39AM BLOOD PT-60.0* PTT-34.5 INR(PT)-6.0*
[**2176-7-2**] 03:03AM BLOOD PT-18.8* PTT-29.9 INR(PT)-1.8*
[**2176-6-28**] 03:15PM BLOOD PT-13.0* PTT-28.7 INR(PT)-1.2*
[**2176-7-5**] 06:40AM BLOOD Glucose-137* UreaN-36* Creat-1.4* Na-136
K-4.1 Cl-94* HCO3-31 AnGap-15
[**2176-7-4**] 03:43AM BLOOD Glucose-154* UreaN-39* Creat-1.3* Na-137
K-3.5 Cl-96 HCO3-28 AnGap-17
[**2176-7-3**] 03:53PM BLOOD UreaN-40* Creat-1.3* Na-136 K-3.4 Cl-95*
[**2176-7-3**] 02:14AM BLOOD Glucose-110* UreaN-42* Creat-1.5* Na-138
K-3.7 Cl-96 HCO3-30 AnGap-16
[**2176-7-2**] 02:08PM BLOOD Na-135 K-2.9* Cl-94*
[**2176-7-2**] 03:03AM BLOOD Glucose-97 UreaN-48* Creat-1.8* Na-136
K-3.2* Cl-95* HCO3-29 AnGap-15
[**2176-7-1**] 09:04PM BLOOD Na-135 K-3.5 Cl-95*
[**2176-7-1**] 02:40AM BLOOD Glucose-100 UreaN-44* Creat-2.1* Na-137
K-3.5 Cl-98 HCO3-25 AnGap-18
Brief Hospital Course:
Mr. [**Known lastname 112268**] was a same day admit and on [**6-28**] he was brought to
the operating room where he underwent a coronary artery bypass
graft x 4. Please see operative note for surgical details. He
arrived from unit intubated on Levophed. He weaned and extubated
without difficulty. Pressor was weaned off, he started on low
dose Lopressor and Lasix. Permanent pacemaker reprogrammed. On
POD#2 he became SOB/wheezy with low sats, thick secretions that
were difficult to raise. His ABG revealed p02 of 49. He received
aggressive pulmonary toileting,mucinex and required high flow
fio2. CXR appeared wet and he was started on a Lasix gtt and was
aggressively diuresed. He responded well to treatment and over
the course of the next 24-48hrs his Fio2 was weaned down. His
Creatinine peaked to 2.1 with diuresis but has since been
trending down. It was 1.4 at the time of discharge. On POD#2 he
went into rate controlled afib and was started on amiodarone.
His PPM was noted to be inappropriately sensing and pacing and
it was evaluated by the EP department. His atrial lead was not
sensing/pacing properly which was felt to be related to post-op
edema. He was diuresed and PPM was reinterrogated on [**7-4**] by EP
service and felt to be pacing appropriately. This is to be
reinterrogated at follow up appointment with cardiologist in 3
weeks. His epicardial wires were eventually removed without
difficulty. His amiodarone was discontinued 2nd to sinus
Bradycardia. He was started on Coumadin for post-op a-fib. He
became supratherapuetic on [**7-3**] with a peak INR of 6.5 and was
given Vitamin K and Coumadin was held. INR was 1.2 at the time
of discharge and the patient was instructed to take 1 mg
Coumadin on [**7-5**]. Coumadin dosing will be followed by Dr
[**First Name (STitle) **] and the nurse in the [**Hospital 197**] clinic at Dr[**Name (NI) 11574**]
office was contact[**Name (NI) **] and faxed with recent INR/ Coumadin doses.
Chest tubes were removed without difficulty. On POD 6 he
transferred to the floor. Once on the floor, he continued to
progress well. He was weaned off oxygen, tolerating a full oral
diet and ambulating in the halls without difficulty. On POD 7,
he was cleared by physical therapy for home. All follow up
appointments were made. Of note, he needs follow up for LLL
calcified node in 6 months.
Medications on Admission:
**Plavix 75mg daily
Isosorbide 30mg daily
Norvasc 15mg daily
Aspirin 325mg daily
Zocor 40mg daily
Bystolic 5mg daily
Hydrochlorothiazide 25mg daily
Ambien 5mg QHS
Ativan 1mg daily as needed
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Lorazepam 0.5 mg PO Q8H:PRN anxiety
3. Metoprolol Tartrate 25 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
4. Ranitidine 150 mg PO DAILY
RX *Acid Reducer (ranitidine) 150 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *Ultram 50 mg 1 tablet(s) by mouth Q 6 hrs Disp #*30 Tablet
Refills:*0
6. Simvastatin 40 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
RX *Flovent HFA 220 mcg 1 puff twice a day Disp #*1 Inhaler
Refills:*0
8. Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
RX *potassium chloride 20 mEq 1 tablet by mouth once a day Disp
#*5 Tablet Refills:*0
9. Warfarin MD to order daily dose PO DAILY16
Take as directed for INR goal 2.0-2.5 for atrial fibrillation
RX *Coumadin 1 mg [**11-20**] tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
10. Amlodipine 5 mg PO DAILY
11. Albuterol-Ipratropium [**11-20**] PUFF IH Q6H:PRN dyspnea
RX *Combivent 18 mcg-103 mcg (90 mcg)/actuation 1-2 puffs four
times a day Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
Sick sinus syndrome s/p PPM
Hypertension
Prostate cancer with brachytherapy
Ileorectal abscess [**2174**]
Peripheral vascular disease
Acute renal failure
Hyperlipidemia
Right renal artery stenosis - 70% stenosis
Abdominal aortic aneurysm 3.5cm
Appendectomy
Hernia Repair
Prostate Seed implant
Surgery for ischiorectal abscess
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**2176-8-7**] at 1:00p [**Hospital Unit Name **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) **] [**2176-7-23**] at 9:30am
Needs PPM reinterrogated at follow up appointment
Wound Check [**2176-7-11**] at 10:30a [**Hospital Unit Name **] [**Hospital Unit Name **]
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) 1399**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 112269**] in [**2-22**] weeks
***Needs follow up for Left lower lobe calcified nodule
(unchanged since [**2176-6-25**], measuring 11 mm)***
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2-2.5
First draw day after discharge then every M-W-F
Results to phone: [**Telephone/Fax (1) 33732**] or fax [**Telephone/Fax (1) 112270**]
**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:[**2176-7-5**]
|
[
"443.9",
"441.4",
"272.4",
"V45.01",
"427.31",
"V10.46",
"996.72",
"E879.8",
"414.01",
"401.9",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.45",
"36.13",
"36.15",
"39.61",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8806, 8865
|
4974, 7330
|
328, 546
|
9317, 9541
|
2652, 4951
|
10343, 11464
|
1827, 1922
|
7570, 8783
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8886, 8947
|
7356, 7547
|
9565, 10320
|
1937, 2633
|
269, 290
|
574, 1143
|
8969, 9296
|
1532, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,615
| 112,432
|
11580
|
Discharge summary
|
report
|
Admission Date: [**2145-2-14**] Discharge Date: [**2145-3-4**]
Date of Birth: [**2080-7-21**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64M with a hx of ETOH abuse, depression, multiple falls who
called 911 this morning with vague complaints. Patient initially
gave 911 the incorrect address (he gave his childhood address).
When EMS arrived to patient's home, he was
ambulatory,intoxicated. Per report the patient was combative at
the outside hospital and was sedated and intubated in order to
obtain a Head CT for a suspected head bleed.
Past Medical History:
Depression
Diverticular bleed in [**2135-10-1**]
Social History:
Unemployed. Lives alone. Daughter lives nearby. Per daughter,
patient has been struggling with depression and ETOH abuse since
being unemployed. He was in detox/rehab about a year ago. He has
the hx of mixing his antidepressants w/ETOH and hx of falls.
Family History:
NC
Physical Exam:
Gen: L eye ecchymosis, facial scratches, intubated, sedated
Initial Neuro Exam:
No EO, no commands. PERRL 3-2mm, R corneal. BUE attempts to
localize, BLE triple flexion.
Repeat Neuro Exam off sedation:
EO to loud voice, MAE- LUE purposeful, squeezes hands
bilaterally, BLE withdraws.
Exam at time of Discharge:
Nonfocal, neurologically intact.
Alert and Oriented to person, place and date.
Following commands, Fluent speech.
Full strength in all 4 extremities.
Upon discharge:
alert, oriented x 3,understands reason for hopsital stay, motor
full, ambulating in halls
Pertinent Results:
CT HEAD W/O CONTRAST [**2145-2-14**]
Stable right temporal intraparenchymal hemorrhage and subdural
hematoma. Slight increase in intraventricular hemorrhage. No
significant
midline shift. No fracture identified.
CT HEAD W/O CONTRAST [**2145-2-15**]
Stable appearance of right temporal intraparenchymal hemorrhage
as well as
intraventricular hemorrhage. Interval decrease in prominence of
right
cerebellar tentorium density.
Brief Hospital Course:
64 y/o M +ETOH and question of fall was taken to OSH where he
was combative and aggressive. Patient was intubated and sedated
to obtain head CT. Head CT revealed R temporal IPH and patient
was transferred to [**Hospital1 18**] for further neurosurgical intervention.
On examination without sedation, patient EO to voice, PERRL, BUE
purposeful, and w/d BLE. He was admitted to the ICU for
monitoring. He was extubated and exam remained stable. On [**2-15**],
repeat head CT was stable and cipro was started for a UTI. In
afternoon, patient became aggitated and pulled out his foley. He
was given ativan and on CIWA scale for possible DTs. Dilantin
level corrected was 6, he was given a 500mg bolus of dilantin.
His level the following morning improved to 13.7 and he remained
on 100mg TID for 10days and then discontinued. He was
transferred from the ICU to the stepdown unit and he continued
to require ativan per the CIWA scale for his DT's. His
neurological exam at this time was eyes open, following commands
intermittently, agitated and trying to get OOB. For patient
safety, he remained in restraints. On [**2-19**] he was more alert- he
was oriented to hospital, city and month but not the year. His
hand and wrist restraints were DC'd but he did require a posey
as he was continually getting OOB without the help of nursing
and was increased fall risk. He was started on PO seroquel on
[**2-19**] and this was titrated to 50mg twice daily. His mental
status continued to improve and on [**2-22**] he was more awake and
oriented to self and year but not to place. Despite up
titration of Seroquel, he continued to require restraints for
agitated behavior and so Geriatric medicine consult was called
for recommendations on [**2-25**]. They recommended to wean the ativan
to off over 3 days as well as wean seroquel to off over 2 days.
A full lab workup was obtained including B12, TSH, LFTs and
these values were all within normal limits. A U/A was consistent
with infection and he was started on a 10 day course of
ciprofloxacin to finish [**2145-3-6**].
Patient's mental status continued to clear and by [**3-1**] the
restraints were no longer needed to maintain patient safety. He
was seen in consultation by psychiatry who were very helpful
with medication adjustment. He was started on celexa 20 qd
(usual dose 60mg qd) but as he was without it for extended
period of time this was introdeced at lower dose. Per his
daughter he had also been on neurontin 600 [**Hospital1 **], doxepin 100 at
bedtime and ativan 0.5mg [**Hospital1 **] - these have not yet been resumed.
Multiple attempts were made to contact his psychiatrist but
calls have not been returned. (Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 36815**])
Patient was oriented and expressing desire for to focus on
addiction issues. Psychiatry recommended psychiatric consult at
rehab.
PT and OT evaluated the patient and found him appropriate for
rehab for cognitive needs. He had follow up head CT on [**2145-3-4**]
prior to discharge that showed resolution of all hemorrhage.
Medications on Admission:
Celexa60 qd, Ativan 0.5mg [**Hospital1 **], neurontin 600 [**Hospital1 **], doxepin 100
hs
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve 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. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours): last dose [**2145-3-6**].
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Right Intraparenchymal Hemorrhage
Delerium Tremens
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
.Take medicine as prescribed.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 2726**] Dr. [**Last Name (STitle) 548**] office as needed for any
questions but no formal follow up or CTs are needed.
Completed by:[**2145-3-4**]
|
[
"562.10",
"V13.01",
"E939.4",
"296.50",
"292.81",
"853.01",
"291.1",
"V15.88",
"E885.9",
"852.01",
"V49.87",
"303.90",
"291.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5961, 6033
|
2190, 5250
|
329, 336
|
6127, 6127
|
1740, 2167
|
6331, 6556
|
1130, 1134
|
5392, 5938
|
6054, 6106
|
5277, 5369
|
6277, 6308
|
1149, 1614
|
268, 291
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1630, 1721
|
364, 770
|
6142, 6253
|
792, 843
|
859, 1114
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,125
| 128,929
|
4499+55583
|
Discharge summary
|
report+addendum
|
Admission Date: [**2103-1-5**] Discharge Date: [**2103-1-16**]
Service:
CHIEF COMPLAINT:
Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is an 88-year-old female
with severe chronic obstructive pulmonary disease with an
FEV1 measured at 0.6 liters, on home oxygen, who was admitted
to the hospital for chronic obstructive pulmonary disease
flare. The patient has had recent multiple admissions over
the past nine months for similar symptoms, requiring
Intensive Care Unit stays. The patient now presents
following several days of lethargy and upper respiratory
infection symptoms accompanied by increasing shortness of
breath and declining mental status to the point of somnolence
with respiratory rate of 40. She was intubated in the field
and brought to the Emergency Department where initial
presenting gases were 7.24/119/161 with unknown ventilator
parameters.
She initially had a blood pressure of 99/48 with a pulse of
93 and then was noted to be hypotensive with pressure of
57/33 and a pulse of 63 and was given two liters of normal
saline, one amp of Narcan, 125 mg of Solu-Medrol, 1 gram of
ceftriaxone and started on a Dopamine 10 mcg/kg/minute drip
with an increase in her blood pressure to 78/43 and a pulse
of 83.
While in the Emergency Department, a left subclavian triple
lumen was placed, and a right radial arterial line. When the
arterial line was placed, the blood pressure was noticed to
be 120/64 with a pulse of 88, and the dopamine was weaned off
in the next ten minutes. A transthoracic echocardiogram at
the bedside showed normal left ventricular systolic function
and no effusion. Chest x-ray showed emphysema and no
infiltrate.
PAST MEDICAL HISTORY: Her past medical history is
significant for chronic obstructive pulmonary disease with
FEV1 of 0.66 and FVC of 1.36, ratio measured 78 percent of
predicted. She is on three liters of oxygen at home via
nasal cannula. She has a history of colon cancer, Duke stage
A, status post low anterior resection in [**4-/2098**], status post
seizure in [**2097**] from hyponatremia, syndrome of inappropriate
diuretic hormone, osteoarthritis, lower back pain,
osteoporosis, old lacunar infarct in the right corona
radiata. Transthoracic echocardiogram in [**9-/2102**] showed
ejection fraction of 60 percent with normal valves.
ALLERGIES: The patient is allergic to doxycycline.
MEDICATIONS: Her medications on admission were Serevent two
puffs b.i.d., Atrovent two puffs q.6 hours p.r.n., albuterol
two puffs p.r.n., regular insulin sliding scale, Tums t.i.d.,
Protonix 40 mg p.o. q.day, Klonopin 0.25 mg b.i.d.
SOCIAL HISTORY: The patient lives with her children. She
has a history of smoking one pack per day for 20 years. She
stopped 30 years ago. She has no occupational exposures.
She is followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**]. Her pulmonologist is
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 217**].
FAMILY HISTORY: Family history is positive for tuberculosis
and lung cancer.
PHYSICAL EXAMINATION: On admission, her vitals were
temperature 98.4, heart rate 104, blood pressure 100/68,
respiratory rate 18, saturating at 100 percent on ventilator
settings (unknown). The patient was intubated and sedated
but arousible and moving all arms and legs on repositioning.
There was no evidence of jaundice. Pupils were equal, round
approximately 2-3 mm and reactive to light but sluggish.
There was no nasal discharge. Her heart had a regular rate
and rhythm. Her lungs had wheezing in the left upper lobe
and scattered crackles in the bases bilaterally.
Her abdomen was nondistended. Normoactive bowel sounds were
present. There was a question of fullness in the abdomen.
Extremities were cool to touch. There was no cyanosis,
clubbing. There was 1+ pitting edema to the mid ankles.
Dorsalis pedis and posterior tibials were not appreciated.
LABORATORY DATA: White blood cell count 8.8, hematocrit
39.4, platelets 247. Sodium 132, potassium 5.2, chloride 87,
bicarbonate 39, BUN 15, creatinine 0.6, glucose 127.
Coagulations: PT 11.2, PTT 27.6, INR 0.8. Her repeat gas on
assist-control of 18 times 550 with 40 percent FiO2 was
7.46/55/150/40. Ventilator settings were subsequently
changed to 16 times 500.
CK was 40. Chest x-ray showed emphysematous changes in upper
lobes bilaterally, engorgement of pulmonary veins, arteries
at bases, question of pruning, flattened hemidiaphragms, left
subclavian in good position, endotracheal tube 5 cm from
carina. Electrocardiogram was normal sinus rhythm at 71
beats per minute, normal axis, PR, QRS, QT intervals,
elevation of ST segment of 1 mm in leads II, III, F, and
V3-V4, not seen in previous tracing on [**2102-12-15**], peaked Ts
in leads [**5-13**], T wave inversion in aVL, notched P waves, poor
R wave progression in V1-V3.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit with chronic obstructive pulmonary disease
exacerbation, hypercarbic respiratory failure, hypotension.
Shortly after the patient arrived to the floor, she was very
agitated, moving all extremities, following commands
intermittently, then noted to have a grand mal seizure with
coarse bucking body tremors, desaturation into the 60s, eyes
rolling back into the head. Following this, the patient had
supraventricular tachycardia in the 190s which converted
without intervention during seizure activity. The patient
was given 2 mg of Ativan, and the seizure then resolved.
Noncontrast head CT was completed which showed no extra-axial
collection, no mass effect, no shift, no acute hemorrhage,
old right caudate lacunar lesion, slightly more prominent
cerebral white matter with patchy hypodensity probably
relating to microvascular ischemic gliosis and infarction.
MRI of the head showed moderate changes of small vessel
disease, brain atrophy, no evidence of hydrocephalus or mass
effect, no evidence of abnormal enhancement, no evidence of
acute infarct. Electroencephalogram showed mildly slow
background with burst of generalized data and delta slowing
with sharp features. There were times of focal slowing in
the left hemisphere and left temporal lobe.
Neurology was consulted, and the patient was loaded with
Dilantin. It was thought that the seizure was precipitated
by a rapid correction in her bicarbonate. No further seizure
activity was noted during her hospital course.
The patient was started on empiric antibiotics of Levaquin
and ceftriaxone. She was started on steroids with a rapid
taper. She was extubated on [**2103-1-6**] with her gas after
extubation on three liters nasal cannula with an oxygen
saturation of 92 of 7.44/58/85. The patient had recurrent
episode of hypotension with systolic low as the 80s and MAPs
in the 50s and was restarted on low-dose dopamine which was
then discontinued.
The patient was transferred to the floor on [**2103-1-8**]. She
continued to have a rapid respiratory rate as high as the 40s
but denied any complaints of shortness of breath. Her oxygen
saturation was maintained between 88 and 92 percent, and her
oxygen requirement was weaned from three liters down to one
liter. Pulmonary was consulted given the patient's repeated
intubations this year. The recommendation was made for
follow-up pulmonary function test which revealed poor effort
but FEV1 of 0.65 which is 52 percent of predicted, and FVC of
0.74 which is 33 percent. Arterial blood gases were
7.39/65/57. Follow-up CT showed extensive emphysema with
bullae. No infiltrate. Mucous in the trachea. Left pleural
effusion, small. Marked hyperexpansion. There was a
question of possible thrombus in the pulmonary vasculature.
The patient was started empirically on heparin infusion while
CTA was obtained which was negative for pulmonary embolus.
The patient's CT was concerning for numerous pulmonary
nodules which were coarsely calcified and consistent with
granulomatous infection. She had two irregular nodular
densities in the right upper lobe which lacked calcification
and were associated with right hilar adenopathy.
A Speech and Swallow evaluation showed that the patient has
silent aspiration of liquids via straw. She is able to
tolerate regular liquids via cup. Cough reflex is quite
poor. Follow-up echocardiogram showed ejection fraction of
greater than 75 percent, no mitral regurgitation or aortic
regurgitation, hyperdynamic heart. It was recommended that
the patient try bi-PAP at night in order to rest her
respiratory muscles and hopefully improve oxygenation over
night. The patient was not able to tolerate the bi-PAP mask.
She was transitioned to metered dose inhalers, but there was
a question of whether the patient was able to use them
appropriately. She was then returned to nebulizers. She was
started on Flovent as well.
She had continued low sodium, predominantly in the 130s which
is at her baseline. The patient was fluid restricted for
likely syndrome of inappropriate diuretic hormone given her
uric acid was 1.0. Despite this, her sodium did not
increase. At one point, her sodium decreased to 126. The
patient was given one liter of normal saline as a trial for
possible dehydration which improved her sodium to 128. It
was felt like this was her baseline, and the patient should
continue with a fluid restriction. Repeat urine electrolytes
were pending at the time of this dictation. It was felt that
given her chronic lung disease as well as the pulmonary
nodules, the patient has syndrome of inappropriate diuretic
hormone; however, the patient is asymptomatic with sodium at
this level.
It was the opinion of the pulmonary and primary medical team
that given the patient's advanced chronic obstructive
pulmonary disease and accelerating clinical course, that no
further workup is recommended for the pulmonary nodules at
this time. Repeat chest CT in three to six months is
recommended. The rationale is that the patient's mortality
for chronic obstructive pulmonary disease with an FEV1 less
than 30 percent predicted is likely to be higher than that
from a pulmonary nodule which is not radiographically seen.
Also, the patient is a poor candidate for intervention
whether by bronchoscopy, biopsy, radiation, or chemotherapy.
The possibility of mini tracheotomy for more frequent
suctioning and pulmonary toilet is a possibility to be
discussed with the family in the future in order to possible
prophylaxis further intubation and decrease the number of
chronic obstructive pulmonary disease exacerbations.
However, this would be aggressive management, and at the time
of this dictation, a lengthy family discussion regarding Mrs.
[**Known lastname 19219**] had not taken place yet.
Physical therapy evaluated the patient and felt that she
would benefit from acute level rehabilitation.
CONDITION AT DISCHARGE: The patient's condition upon
discharge is fair.
DISCHARGE DIAGNOSIS:
Chronic obstructive pulmonary disease exacerbation, status
post seizure, hyponatremia.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcutaneously b.i.d.
2. Prednisone taper, currently at 30 mg p.o. q.day, started
on [**2103-1-15**] with decrease to 20 mg on [**2103-1-17**], with
decrease to 10 mg on [**2103-1-21**] for four additional doses
and then discontinue.
3. Atrovent nebulizers one nebulizer q.6 hours.
4. Albuterol nebulizers one nebulizer q.6 hours.
5. Fluticasone propionate 110 mcg two puffs b.i.d. with
spacer.
6. Aggrenox one capsule p.o. b.i.d.
7. Metoprolol 40 mg p.o. q.day.
8. Colace 100 mg p.o. b.i.d.
9. .................... sodium 5 mg p.o. q.day.
10. Vitamin D 400 units p.o. q.day.
11. Calcium carbonate 500 mg p.o. t.i.d.
12. Levofloxacin 500 mg p.o. q.day for a total of a two-week
course, to discontinue on [**2103-1-19**].
13. Dilantin 100 mg p.o. t.i.d.
The patient is to be on aspiration precautions, not to drink
any liquids via straw. She is to be on a strict fluid
restriction of one liter in. Crush medications that can be
crushed with food. Maintain nasal cannula for oxygen
saturation approximately of 90 percent with range between 88
and 92 percent.
FOLLOW-UP: She as a follow-up appointment already scheduled
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10029**] of Neurology on [**2102-3-1**]. She is to
have an outpatient electroencephalogram prior to this visit.
She should have a Dilantin level checked two weeks after
discharge from the hospital. She should also follow-up with
Dr. [**Last Name (STitle) 217**] of Pulmonary two weeks after discharge from
rehabilitation.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern1) 4988**]
MEDQUIST36
D: [**2103-1-15**] 15:18
T: [**2103-1-15**] 18:56
JOB#: [**Job Number 19220**]
Name: [**Known lastname 3133**], [**Known firstname 634**] Unit No: [**Numeric Identifier 3134**]
Admission Date: [**2103-1-5**] Discharge Date: [**2103-1-18**]
Date of Birth: [**2014-4-1**] Sex: F
Service:
HOSPITAL COURSE: (Addendum) Please note that the patient
had decreasing sodium despite her fluid restriction to a
sodium from 130 to 126. At that point, it was felt that the
patient might be dehydrated, and a trial of one liter normal
saline was given. Sodium decreased even further to 123. At
that point, a 3 percent hypertonic saline solution was
administered slowly at 30 cc/minute. The sodium gradually
rose from 123 to 126 and eventually to 130 after 750 cc of
this infusion. The patient was continued for 250 cc more of
this hypertonic saline.
The additions to her medications since the discharge summary
are sodium chloride tablets 1 gram p.o. t.i.d. with meals.
The patient is still on a one liter free water fluid
restriction but may have in addition to that one Boost
supplement q.day. It is recommended that her sodium levels
be checked more regularly with goal sodium in the 130s which
appears to be the patient reset baseline and which she does
not have any symptoms.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 166**]
Dictated By:[**Last Name (NamePattern1) 3135**]
MEDQUIST36
D: [**2103-1-18**] 10:49
T: [**2103-1-18**] 10:58
JOB#: [**Job Number 3136**]
|
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74,185
| 101,011
|
17198
|
Discharge summary
|
report
|
Admission Date: [**2162-5-16**] Discharge Date: [**2162-6-3**]
Date of Birth: [**2094-7-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Respiratory distress
Pulmonary emboli
Major Surgical or Invasive Procedure:
Endotrachial intubation and mechanical ventilation
Central venous line placement
Arterial line placement
IVC filter placement
PICC line placement
History of Present Illness:
This is a 67 year old man with hx Non-Small Cell Lung CA, DVT,
recent GIB who is transfered from [**Hospital1 **] [**Location (un) 620**] with dx of PE. [**First Name8 (NamePattern2) **]
[**Location (un) 620**] notes, he was found to be hypoxic with SaO2 50%. CTA
showed multifocal PE's with RV strain on CT. Heparin gtt
started. Bp 96/73 and HR 135. Given recent GIB, decided not to
TPA but transfer to [**Hospital1 18**].
In the ED: The patient arrived tachpnic, "dusky", BP 118/80. ABG
showed alkalosis and hypoxia: 7.56/28/56. The patient was
intubated and required high amounts of versed for sedation.
Cardiothoracic surgery saw the patient and did not think
embolectomy would be indicated. An echo was performed by
cardiology, with RV strain and dilation but no collapse or HD
compromise.
Vitals on arrival: 96.1 133 118/80 34 abg 87 nrb
Vitals at transfer: Hr 106 BP 90/60 (87/67 - since sedation)
Past Medical History:
1. Non-small cell Lung CA s/p resection in [**2157**]
2. History GIB in [**2162-4-17**]
3. DVT [**2152**], on coumadin for years, dc'ed one month ago
4. Hypertension
5. Low back pain
6. Alcohol abuse
7. History of alcoholic hepatitis
Social History:
He worked as a painting contractor. He is married, with two
grown children. His wife works part-time at the [**Name (NI) 4068**]. He
smoked at least a pack per day for about 45 years but was able
to stop smoking albeit with some difficulty and help of a patch
since his diagnosis. He drinks two to three alcoholic drinks
per night.
Family History:
His father also heavy smoker died at age 53 of lung or head/neck
ca. His mother had a stroke. His one-half sibling died of a
ruptured aneurysm, one died of motor vehicle accident. He thinks
his grandmother may have had ovarian cancer.
Physical Exam:
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy.
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
-DTRs: 2+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was flexor
bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2162-5-16**] 06:22PM WBC-4.4 RBC-2.95* HGB-10.0* HCT-31.2*
MCV-106* MCH-34.0* MCHC-32.2 RDW-13.7
[**2162-5-16**] 06:22PM PLT COUNT-147*
[**2162-5-16**] 06:22PM PT-14.3* INR(PT)-1.2*
[**2162-5-16**] 06:22PM GLUCOSE-87 UREA N-12 CREAT-1.0 SODIUM-145
POTASSIUM-3.2* CHLORIDE-117* TOTAL CO2-20* ANION GAP-11
DISCHARGE LABS:
White Blood Cells 8.5
Red Blood Cells 2.29
Hemoglobin 7.3
Hematocrit 23.8
MCV 104
MCH 32.1
MCHC 30.9
RDW 14.3
Platelet Count 838
ANEMIA LABS:
Iron: 19
TIBC: 166
Ferritin: 232
Reticulocyte count: 3.0
Haptoglobin: 253
LDH: 236
Tbili: 0.4
Folate: 14.7
Vitamin B12: 534
ECHO ([**2162-5-16**]):
The left ventricular cavity is unusually small. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is markedly
dilated with severe global free wall hypokinesis. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
ECHO ([**2162-5-18**]):
The left ventricular cavity is small. Left ventricular systolic
function is hyperdynamic (EF>75%). The right ventricular cavity
is dilated with depressed free wall contractility. The
interatrial septum is markedly thickened around the fossa ovale
secondary to lipomatous hypertrophy. Compared with the findings
of the prior study (images reviewed) of [**2162-5-17**], the
interatrial septum and right atrium are better visualized, and
the mass in the right atrium is now seen clearly to be secondary
to lipomatous hypertrophy of the interatrial septum.
LENI ([**2162-5-16**]):
1. Right popliteal DVT extending to the calf veins.
2. Partially occlusive DVT in the left popliteal [**Last Name (LF) 5703**], [**First Name3 (LF) **] be
subacute, with extension to the calf veins.
CT HEAD WITHOUT CONTRAST ([**2162-5-22**]):
No evidence for acute hemorrhage or acute transcortical
infarction.
ABDOMINAL ULTRASOUND ([**2162-5-27**]):
1. Diffusely fatty liver markedly limits evaluation for focal
liver lesion although no large liver lesion is identified.
2. Mild splenomegaly to 12.3 cm. No evidence of ascites.
LOWER EXTREMITY ULTRASOUND ([**2162-5-31**]):
Partially occlusive DVT in the left popliteal [**Month/Day/Year 5703**], which has
not significantly changed from [**2162-5-16**].
PLAIN FILMS LEFT HIP AND FEMUR ([**2162-6-1**]):
There is severe degenerative change of the lower lumbar spine.
There are mild degenerative changes of the hip joints. No
fracture is identified.
Incidental note is made of a sclerotic lesion in the distal
femur of unclear etiology. Does the patient have a history of
primary malignancy or metastatic disease?
MRI LEFT LEG ([**2162-6-2**]): (wet read):
Preliminary Report !! WET READ !! 18.7 cm hematoma in left
vastus lateralis muscle. While this may reflect trauma and
anticoagulation, an underlying neoplasm cannot be excluded and
follow-up upon resolution (ie 4 months) is recommended.
Bilateral femoral head avascular necrosis. Sclerotic femur
diaphysis lesion atypical for metastasis though should be
followed radiographically.
MICRO DATA:
-respiratory culture ([**2162-5-27**]):
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
-respiratory culture from ET tube ([**2162-5-19**]):
SENSITIVITIES: MIC expressed in MCG/ML
CITROBACTER FREUNDII COMPLEX
| AEROMONAS HYDROPHILA
| |
AMPICILLIN/SULBACTAM-- <=8 S
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S <=2 S
CEFTRIAXONE----------- <=1 S <=4 S
CEFUROXIME------------ S
CIPROFLOXACIN---------<=0.25 S <=0.5 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- S
MEROPENEM-------------<=0.25 S S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=2 S
-fecal culture ([**2162-5-18**]):
FECAL CULTURE (Final [**2162-5-21**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2162-5-20**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2162-5-19**]): NO OVA AND PARASITES SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2162-5-18**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 48228**] AT 13:15PM ON [**2162-5-18**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
-Blood and urine cultures: NEGATIVE on [**4-13**], [**5-21**], [**5-22**], [**5-25**],
[**5-28**]
Brief Hospital Course:
A 67 yo man with history of NSCLC s/p resection, EtOH, h/o DVTs
on coumadin until one month PTA, recent GIB, now transferred
from OSH with respiratory distress and multiple bilateral
pulmonary emboli.
# Bilateral pulmonary emboli: He presented having a prior
history of DVT, having previously been on coumadin. At the time
of admission, he was in respiratory distress with evidence of
right-heart strain on echo. Given lower extremity clot burden,
IVC filter was placed. On [**5-17**], TPA was administered for
suspected right atrial clot (later found to be lipomatous
hypertrophy of interatrial septum). He was started on LMWH,
awaiting EGD/colonoscopy before initiation of coumadin. He will
continue on anticoagulation (now on heparin) until his
colonoscopy/EGD. As long as there is no active bleeding, he can
be switched to coumadin for long-term anticoagulation.
# Alcohol withdrawal: He has a significant alcohol history. He
was intubated during much of the period of anticipated
withdrawal. After extubation, he was transferred to the floors
(hospital day 10). Although he was tachycardic, he was not
diaphoretic or agitated and his tachycardia was felt to be due
to PE as above, rather than alcohol withdrawal. He did not
require benzodiazepines or CIWA scale monitoring.
# Ventilator associated pneumonia: He began spiking fevers on
[**5-19**] with sputum growing GNR and staph (found to be pansensitive
Citrobacter freundii, sparse Aeromonas and sparse coag+ staph).
The ventilator associated pneumonia was treated with vancomycin
and Zosyn for eight days; course was completed on [**5-28**].
# Clostridium dificile colitis: This was found on stool studies
from [**5-18**]. He was treated with oral vancomycin during the VAP
antibiotic course, and he should continue oral vancomycin to
finish on [**6-7**].
# Recent GIB: Anticoagulation had been stopped one month PTA for
GIB. Per patient his INR was supratherapeutic at that time. He
was restarted on anticoagulation during this admission for DVT
and PE. Plan is to continue heparin for three weeks to allow
time for his pulmonary emboli to dissolve and his clinical
status to stabilize, at which time EGD and colonoscopy can be
done. Of note, he was found to be guiaic positive during this
admission, with brown stools (non-melanotic, non-bloody). His
hematocrit stablized in the mid to high 20s. Also, of note, he
underwent abdominal ultrasound to evaluate extent of liver
disease, also to evaluate for portal hypertension and assess
risk for varices. The ultrasound showed no ascites, a diffusely
fatter liver, and mild splenomegaly.
# Anemia: This is a macrocytic anemia with stabilization of
hematocrit in the mid to high 20s. Hemolytic work-up was
negative. Reticulocyte count was 3.0. Iron was 19 with a TIBC of
166 and ferritin of 232, indicative of deficiency. Folate and
vitamin B-12 were normal. As above, he was guiaic positive. His
anemia is likely a combination of marrow suppression from acute
illness and iron deficiency from recent GIB and poor nutrition.
We have recommended for outpatient colonoscopy and EGD for
further work-up. This is scheduled at [**Hospital1 18**]. He received one
unit of PRBCs on [**6-3**].
# Nose bleed: This occurred in the setting of anticoagulation
with Lovenox. Bleeding resolved after treatment with Afrin
(several squirts) and holding pressure for 20 minutes. Due to
persistent oozing from the left nostril, ENT was consulted. They
recommended for preventative management with aggressive blood
pressure control, saline nasal spray, bactroban vaseline
ointment, and humidified air. If bleeding recurs, several sprays
of Afrin can be delivered to the bleeding nostril, with pressure
held for at least 15 minutes and patient leaning forward.
# Hypoalbuminemia: Albumin was 1.9 on [**5-18**], down from 2.2 at
admission; repeat albumin on [**6-2**] was 2.7. Tbili was 0.4 with
PTT 27.1 and INR 1.0. As above, abdominal ultrasound did not
show signs of cirrhosis; the liver was diffusely fatty. We added
ensure supplement to his diet. Albumin can be followed up as
outpatient.
# Thrombocystosis: His platelet count was trending up to low
800s at time of discharge. We felt that this was likely
secondary to infection and acute inflammatory response. Platelet
levels can be followed up as outpatient after his infection has
been treated.
# Left leg pain and hematoma: He worked with physical therapy
and complained of leg pain over the lateral aspect of his left
thigh. On exam there was tenderness over the left lateral
quadriceps muscle, with small amount of swelling/induration on
left compared to right; there was no clear hematoma or skin
discoloration. There was concern of extension of DVT versus
fracture, given that he said he had fallen on his left leg prior
to admission. Lower extremity doppler ultrasound showed stable
DVT in left popliteal [**Month/Year (2) 5703**]. Plain films of the left hip and
femur showed sclerotic lesion in the distal femur so MRI was
done for further evaluation. This showed an 18 cm hematoma in
the left lateralis muscle. The femoral sclerotic lesion was felt
to be atypical for metastases, but radiology has recommended
follow-up imaging in four months. In addition, vascular was
curbsided and felt that the hematoma could be followed
clinically. We have switched anticoagulation to heparin drip to
allow for ease of stopping anticoagulation if the hematoma grows
in size. Meanwhile, we have outlined the area of induration with
marker (measuring 22cm in length and 8cm in width on our exam)
and recommended that patient have follow-up imaging with
ultrasound in 2 to 3 days to assess for interval change. Daily
CBC monitoring as well will be important to assess for
progression.
# FEN: He was progressed to normal diet, with ground solids and
nectar prethickend liquids.
# Prophylaxis: Anticoagulated as above.
# Code status: Full code.
# Disposition: To rehabilitation facility.
Medications on Admission:
-Oxycodone-Acetaminophen [**1-15**] TAB PO Q6H:PRN pain
-Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever
-Piperacillin-Tazobactam Na 4.5 g IV Q8H
-Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
-Enoxaparin Sodium 90 mg SC Q12H
-Senna *NF* 8.8 mg/5 mL Oral [**Hospital1 **] PRN constipation
-Fludrocortisone Acetate 0.1 mg PO DAILY
-FoLIC Acid 1 mg PO/NG DAILY
-Thiamine 100 mg PO/NG DAILY
-Insulin SC (per Insulin Flowsheet)
-Vancomycin 1000 mg IV Q 12H
-Ipratropium Bromide Neb 1 NEB IH Q6H
-Vancomycin Oral Liquid 125 mg PO Q6H
-Lansoprazole Oral Disintegrating Tab 30 mg PO BID
-Xopenex *NF* 0.63 mg/3 mL Inhalation q 4hrs prn sob/ wheeze
-Miconazole Powder 2% 1 Appl TP QID:PRN rash
-traZODONE 25 mg PO ONCE MR1
-Multiple Vitamins Liq. 5 ml NG DAILY
Discharge Medications:
1. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. 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. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath/wheezing.
7. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q 4hrs prn () as needed for sob/ wheeze.
8. Senna 8.8 mg/5 mL Syrup Sig: 8.8 MLs PO BID PRN () as needed
for constipation.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
11. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): Please continue through [**6-7**].
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
13. Mupirocin Calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **]
(2 times a day) for 5 days.
14. Sodium Chloride 0.65 % Aerosol, Spray Sig: Three (3) Spray
Nasal TID (3 times a day).
15. Oxymetazoline 0.05 % Aerosol, Spray Sig: Three (3) Spray
Nasal [**Hospital1 **] (2 times a day) as needed for nose bleed for 1 days.
16. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: ASDIR units Intravenous continuous: Heparin IV per
Weight-Based Dosing Guidelines
Start New Infusion Now.
Diagnosis: Pulmonary Embolism
Patient Weight: 90.2 kg
No Initial Bolus
Initial Infusion Rate: 1600 units/hr
Target PTT: 60 - 100 seconds
PTT <40: 3600 units Bolus then Increase infusion rate by 350
units/hr
PTT 40 - 59: 1800 units Bolus then Increase infusion rate by 200
units/hr
PTT 60 - 100*:
PTT 101 - 120: Reduce infusion rate by 200 units/hr
PTT >120: Hold 60 mins then Reduce infusion rate by 350
units/hr.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
PRIMARY DIAGNOSES
Extensive bilateral pulmonary emboli
Bilateral deep venous thrombi
Ventilator-associated pneumonia
Clostridium dificile colitis
Left lateralis muscle hematoma
SECONDAY DIAGNOSES
History of non-small cell lung cancer s/p resection in [**2157**]
History of gastrointestinal bleed in setting of supratherapeutic
INR
Deep venous thrombosis in [**2152**], on coumadin until one month PTA
Hypertension
History of heavy alcohol use
History of alcohol-related hepatitis
Discharge Condition:
Vital signs stable. Afebrile. Satting well on room air.
Discharge Instructions:
You were admitted to the hospital for low oxygenation in the
blood and respiratory distress. You were found to have extensive
blood clots in the arteries in the lungs on both sides. You were
intubated and treated with medicines to thin the blood and
prevent new blood clots from forming. Furthermore, a filter was
placed in a [**Year (4 digits) 5703**] in the abdomen to prevent more clots from
traveling from the legs to the lungs. With the above treatments,
your respiratory status improved.
The hospital course was complicated by development of pneumonia
(treated with antibiotics) and bacterial infection in the gut
(also treated with antibiotics). Please complete a course of
oral vancomycin to end on [**6-7**].
Please take all of your medicines as prescribed:
-we added oral vancomycin, to finish on [**6-7**]
-we added heparin, to be taken by continuous infusion
-we added medicines to help prevent nose bleeds
-we did not make any other changes to the medicines
Please note your follow-up appointments below.
Please call your doctor or return to the emergency room if you
develop chest pain, shortness of breath, abdominal pain or
distention, or any other new concerning symptoms.
Followup Instructions:
APPOINTMENTS OUTSIDE OF [**Hospital1 18**]
-please schedule an appointment with your primary physician,
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in the next 1-2 weeks, [**Telephone/Fax (1) 17753**].
APPOINTMENTS SCHEDULED AT [**Hospital1 18**]
-follow-up for colonoscopy and upper endoscopy
PAT RM 1 PAT-Date/Time:[**2162-7-5**] 11:30
[**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2162-7-12**]
2:00
GI [**Apartment Address(1) 3921**] (ST-3) GI ROOMS Date/Time:[**2162-7-12**] 2:00
-follow-up for nose-bleeds in [**Hospital **] clinic: Call [**Telephone/Fax (1) 2349**] to
schedule a follow up appointment with General ENT in [**3-17**] weeks.
Completed by:[**2162-6-4**]
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] |
17198, 17281
|
8322, 14261
|
350, 498
|
17806, 17864
|
3258, 3258
|
19106, 19890
|
2059, 2295
|
15066, 17175
|
17302, 17785
|
14287, 15043
|
17888, 19083
|
3606, 8299
|
2909, 3239
|
2310, 2892
|
273, 312
|
526, 1433
|
3274, 3590
|
1455, 1690
|
1706, 2043
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,225
| 108,356
|
4297
|
Discharge summary
|
report
|
Admission Date: [**2174-5-3**] Discharge Date: [**2174-5-6**]
Date of Birth: [**2147-8-13**] Sex: F
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 26 year old
female with a past medical history significant for systemic
lupus erythematosus, end stage renal disease on hemodialysis,
idiopathic thrombocytopenic purpura, hypertension who
presented to the primary care physician on the day of
admission with a one month history of shortness of breath,
patient reports shortness of breath after walking one flight
of stairs. She also reports paroxysmal nocturnal dyspnea and
orthopnea. She denies any chest pain or palpitations. No
bright red blood per rectum, melena, or rashes. She was sent
to the Emergency Department, also for further evaluation.
The patient was also noted to have cervical lymphadenopathy
and hepatomegaly in the primary care physician's office as
well. In the Emergency Department, she was found to have a
blood pressure of 210/180. She was placed on a Labetalol
drip and her blood pressure decreased to 180/140. However,
when the Labetalol drip was discontinued, her blood pressure
went back up to 200/160. The patient does report having
headaches, in the last couple of weeks. She, however, denies
any visual changes or any focal neurological complaints. She
is not complaining of any abdominal pain either, in the
setting of this new hepatomegaly. She denies any
appreciation of scleral icterus, no fevers at home. The
patient had hemodialysis on [**5-2**] without complaint. The
patient also reports being compliant with all her
medications.
PAST MEDICAL HISTORY: Systemic lupus erythematosus.
End stage renal disease on hemodialysis.
Methicillin-sensitive Staphylococcus aureus endocarditis in
[**2173-5-9**]. She has 3+ mitral regurgitation.
Hypertension. Medication adjustment recently with
discontinuation of Minoxidil three weeks prior to admission.
History of osteoporosis secondary to steroids.
Ventricular septal defect repair at the age of 13.
Pulmonary hypertension.
History of methicillin-resistant Staphylococcus aureus
urinary tract infection.
Gastroesophageal reflux disease.
Sickle trait.
Idiopathic thrombocytopenic purpura with baseline platelets
between 50 and 100,000.
History of restrictive lung disease.
MEDICATIONS ON ADMISSION:
1. Labetalol 1000 mg p.o. b.i.d.
2. Prednisone 5 mg p.o. q. day.
3. Nephrocaps.
4. Procardia XL 90 mg p.o. q. day.
5. Protonix 40 mg p.o. q. day.
6. Moexipril 15 mg p.o. b.i.d.
7. Clonidine 0.6 mg p.o. b.i.d.
ALLERGIES: The patient has an allergy to Demerol which
causes anaphylaxis. She also has a questionable history to
cephalosporins which cause a rash and a history of allergy to
Unasyn which causes a rash.
SOCIAL HISTORY: No tobacco, no alcohol and no intravenous
drug use. She lives with her mother. She is a Jamaican
immigrant who came to this country in [**2163**].
PHYSICAL EXAMINATION: On physical examination she was
afebrile, 96.8, blood pressure was initially 211/179 which
responded to intravenous Labetalol drip, to 188/148, pulse
69, respiratory rate 99 percent on room air. Head, eyes,
ears, nose and throat, the fundi are normal bilaterally. Her
extraocular movements are intact. She has bilateral
preauricular and anterior, submandibular and axillary
lymphadenopathy. Chest is clear bilaterally. Cardiac
examination is regular, no murmurs. Abdomen, she had good
bowel sounds. She has a liver edge 4 fingerbreadths below
the costal margin. She has mild tenderness in the right
upper quadrant. The extremities showed no edema and no
rashes.
LABORATORY DATA: For laboratory data she had a white count
of 8.3, hematocrit of 37, she had platelets of 56. She had a
chem-7 notable for a creatinine of 7.1. She had normal
coags. She had normal liver function tests and an ALT of 34
and AST of 27, amylase of 68, and alkaline phosphatase of
118, total bilirubin was 0.7. Chest x-ray showed stable
cardiomegaly, interstitial and alveolar edema and a small
left pleural effusion. Electrocardiogram showed a normal
sinus rhythm at 65. She has positive LDH. She has no
significant ischemic changes compared to an old
electrocardiogram.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for further management of her
hypertensive urgency. The patient was continued on a
Labetalol drip in the Intensive Care Unit, however, this was
discontinued on [**2174-5-4**], and she was started on her home
medications which include her Moexipril 15 b.i.d., her
Labetalol 1000 b.i.d., her Clonidine 0.6 b.i.d. The patient
was also started on her Nifedipine initially at 90 mg q. day
which was her home dose. This was increased to 120 q. day.
The patient had adequate control of her blood pressure on
this home regimen and was transferred out of the Intensive
Care Unit. The patient also did initially receive some
Hydralazine in the Intensive Care Unit for prn control of
blood pressure. This was run by the Rheumatology Consultants
and was deemed okay in light of her history. The patient was
transferred out to the floor. Once her blood pressure was
stabilized, she was continued on her home regimen with the
noted increase in her calcium channel blocker from 90 to 120
q. day. She did not need any Hydralazine over night. She
went to hemodialysis on the day of discharge where her blood
pressures were adequately maintained in the 120s to 130s.
Over night, on the night prior to discharge, her blood
pressures remained adequately controlled with systolic blood
pressures in the 130s to 150s. The patient did not have any
further symptoms of headache or shortness of breath on the
floor. She was continued on her 5 mg of Prednisone for her
history of lupus. The patient also received a right upper
quadrant ultrasound on the day of discharge for further
evaluation of her hepatomegaly in the setting of normal liver
function tests. The result of this right upper quadrant
ultrasound is still pending. The patient did receive
hemodialysis on the day of discharge. Her platelets remained
stable during the course of her hospital stay. She does have
a history of idiopathic thrombocytopenic purpura. The
patient was consented for a human immunodeficiency virus
test, the result of this is still pending. The patient will
be discharged on the following blood pressure regimen,
Labetalol 1000 mg p.o. b.i.d., Moexipril 50 mg p.o. b.i.d.,
Clonidine 0.6 mg p.o. b.i.d. and Nifedipine sustained release
120 mg p.o. q. day. The patient has been scheduled for an
appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at the [**Hospital 191**] Clinic on [**2174-5-10**] for follow up of her blood pressure. At that time if
her blood pressure remains elevated, increasing her Labetalol
should be considered.
CONDITION ON DISCHARGE: Fair.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Hypertensive urgency.
Lupus.
Congestive heart failure.
Hepatomegaly of unclear etiology.
Lymphadenopathy of unclear etiology.
MEDICATIONS ON DISCHARGE:
1. Prednisone 5 mg p.o. q. day.
2. Vitamin B complex.
3. Vitamin C
4. Folate capsule, one tablet p.o. q. day.
5. Protonix 40 mg p.o. q. day.
6. Clonidine 0.6 mg p.o. b.i.d.
7. Moexipril 15 mg p.o. b.i.d.
8. Sevelamer 800 mg p.o. q.i.d.
9. Labetalol 1000 mg p.o. b.i.d.
10. Nifedipine sustained release 120 mg p.o. q. day.
FOLLOW UP: The patient, again, will follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2174-5-10**] for a blood pressure check. The
patient also has a follow up appointment with Dr. [**First Name (STitle) **]
[**MD Number(4) 9138**] on [**2174-5-24**]. At that time the results of her
right upper quadrant ultrasound and her human
immunodeficiency virus test should be discussed with the
patient.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 18612**]
Dictated By:[**Last Name (NamePattern1) 18613**]
MEDQUIST36
D: [**2174-5-6**] 15:33:19
T: [**2174-5-6**] 17:10:24
Job#: [**Job Number 18614**]
|
[
"428.0",
"585",
"V45.1",
"E932.0",
"424.0",
"287.3",
"401.9",
"710.0",
"733.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6923, 7054
|
7080, 7409
|
2336, 2754
|
4227, 6840
|
7421, 8117
|
2944, 4209
|
163, 1612
|
1635, 2310
|
2771, 2921
|
6865, 6901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,814
| 188,722
|
6144
|
Discharge summary
|
report
|
Admission Date: [**2145-10-17**] Discharge Date: [**2145-11-1**]
Date of Birth: [**2071-1-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
admitted to MICU with urosepsis
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
74 yo female with h/o CAD s/p CABG in [**2137**], CHF (ECHO [**12-20**]: EF
30%), DM, a fib (on coumadin), CRI (baseline Cr 1.5-1.8) s/p
NSTEMI in [**8-/2145**] who presented [**10-17**] with symptoms of DOE,
confusion and abdominal bloating x 2 days.
On admission to the ED the patient decompensated with drop in
blood pressures from 170/130 to 88/60, Temp to 100.6 and
increasing shortness of breath and abdominal pain. Hypotension
was unresponsive to 6Liters NS IVF. She subsequently became
hypoxemic w/ hypercarbic respiratory failure. She was initiated
on sepsis protocol, intubated and admitted to the ICU. She was
started on 3 pressor support given tenuous SBP's in the 40's.
Past Medical History:
1. CAD s/p CABG '[**37**]
2. CHF (this admission EF 20%)
3. PAF, SSS s/p pacer
4. hypercholesterolemia
5. HTN
6. DM (Hgb A1C 8.9 in [**2145-3-18**])
7. PVD s/p rt and lt toe amputations
8. PA systolic HTN
9. CRI (bl Cr 1.5-1.8)
10. NSTEMI - admitted in [**8-/2145**]
Social History:
Lives with husband, non-[**Name2 (NI) 1818**], occassional alcohol, Home health
care
Family History:
non-contributory
Physical Exam:
96.9 110/54 75 22 100% 4L --> 99% on 2L
General: obese female lying in bed in NAD, alert, oriented to
self, place, year, answers questions appropriately, agitated
HEENT: NC in place, NC, AT, OP clear
Neck: R IJ triple lumen w/o signs of infection, JVD difficult to
assess due to body habitus
CV: irregularly irregular, no m/g/r
Pulm: bilateral crackles
Abd: + BS, soft, protuberant, NT
Extr: no c/c, trace edema, pneumoboots in place
Pertinent Results:
[**2145-10-21**] 04:04AM BLOOD WBC-12.5* RBC-3.14* Hgb-8.1* Hct-26.3*
MCV-84 MCH-25.9* MCHC-30.9* RDW-15.0 Plt Ct-433
[**2145-10-21**] 04:04AM BLOOD Plt Ct-433
[**2145-10-19**] 03:25AM BLOOD FDP-10-40
[**2145-10-19**] 03:25AM BLOOD Fibrino-285 D-Dimer-3771*
[**2145-10-20**] 04:40PM BLOOD ESR-10
[**2145-10-21**] 04:04AM BLOOD Glucose-130* UreaN-73* Creat-4.5* Na-138
K-5.1 Cl-105 HCO3-20* AnGap-18
[**2145-10-20**] 08:58PM BLOOD CK(CPK)-145*
[**2145-10-17**] 09:50AM BLOOD ALT-18 AST-40 CK(CPK)-219* AlkPhos-92
Amylase-77 TotBili-0.6
[**2145-10-21**] 04:04AM BLOOD Calcium-8.4 Phos-6.9* Mg-2.3
[**2145-10-20**] 04:40PM BLOOD CRP-1.96*
[**2145-10-20**] 12:18PM BLOOD Vanco-18.3*
[**2145-10-20**] 12:18PM BLOOD Digoxin-0.3*
[**2145-10-19**] 03:57PM BLOOD Type-ART pO2-132* pCO2-34* pH-7.38
calHCO3-21 Base XS--3
[**2145-10-19**] 03:57PM BLOOD Lactate-1.2
ECHO [**10-18**]: EF <20%. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated. LV mildly dilated. Severe
global
LV hypokinesis. No masses or thrombi are seen in the left
ventricle. There is [**Last Name (Prefixes) 1192**] global RV free wall hypokinesis. 2+
MR. [**First Name8 (NamePattern2) 1192**] [**Last Name (Titles) 6879**]. no pericardial effusion.
Imaging:
** [**10-20**] Head CT - no hemorrhage, no infarct
** [**10-20**] CXR - persistent mild CHF, unchanged bilateral pleural
effusion, persistent LLL consolidation or atelectasis
** [**10-17**] abd X-ray - non-specific bowel/gas pattern, probable
ascites
** [**10-17**] CXR - cardiomegaly with interstitial edema, no
infiltrate
** [**10-17**] CT abd/pelvis - large ascitis, bilateral pleural
effusions, no dissection\
culture data:
Blood [**10-20**]- negative
[**10-17**]- negative
[**10-17**]- coag neg Staph
[**10-17**] - negative
[**10-18**] - negative
[**10-18**] - negative
[**10-20**] negative
Urine [**10-20**]- negative
[**10-17**] - enterococcus (amp, levo and vanc sensitive)
[**10-17**] - enterococcus
[**10-20**] - negative
Sputum [**10-17**] - OP flora (<10 epi cells)
Brief Hospital Course:
This is a 74 y/o female with h/o CAD, s/p CABG, CHF (EF<20%),
who presented with abdominal bloating, dyspnea on exertion and
confusion. On admission, the patient was found to be febrile,
with leukocytosis (WBC 20.5 and 90% neutrophils, no bands). She
developed hypotension with BP 172/131 down to SBP in 80's then
became bradycardic with SBP to 40's. She was intubated, admitted
to ICU and started on Levo/Flagyl/Vanco and pressors (Levophed,
dobutamine, vasopressin). Urine culture grew enterococcus x 2
(sensitive to levo/amp/vanc). The patient was successfully
weaned off pressors and extubated on [**2145-10-19**]. Paracentesis
was performed and was negative for SBP. Hospital ICU course was
complicated by: 1) A fib with RVR with enzyme leak (trop 0.52
and CK 219, MB 16) 2) bilateral vision loss secondary to post
ischemic optic neuropathy from hypotension - failed treatment
with high dose steroids 3) oliguric ARF likely from ATN 4) wide
complex tachycardia - unclear if SVT with aberrancy or [**Name (NI) 6059**].
The patient was transferred to the general medicine service on
[**10-21**] for continued medical managment. A brief [**Hospital 11822**]
hospital course is outlined below.
1. Enterococcus UTI: Urine culture grew out Enterococcus for
which she was initally started on levofloxacin ([**2145-10-17**]).
However, given 2 positive blood cultures for coagulase negative
staph aureus, she was switched to IV Vancomycin to cover both
organisms. She was started on Vanco on [**2145-10-23**], dosed by levels
(to maintain >15) given her renal insufficiency. She has been
afebrile since that time. In addition, her blood cultures and
urine cultures have both cleared on antibiotics. She recieved
her last dose of vancomycin 1g IV on [**2145-11-1**]. She has recieved
a two week total course of antibiotics.
2. CAD: She had NSTEMI in setting of sepsis. Trop 3.84; CK 657
peaked on [**10-20**] and trended down prior to discharge. EKGs
remained unchanged and she remained chest pain free. We
continued her on B-Blocker (titrated metoprolol up to 50mg [**Hospital1 **]),
ASA, Statin. Off of plavix w/ no h/o stents.
3. Wide Complex Tachycardia: EP interrogated pacer and changed
to VVI on [**10-24**]. She has not had any episodes of wide-complex
tachycardia since that time, and she remains asymptomatic and
hemodynamically stable. EP did not feel she was a candidate for
[**Hospital1 **]-V pacer/ICD in future given her co-morbidities.
4. Atrial Fibrillation: The patient has a h/o paroxysmal afib
and was found to be in afib on admission. She was continued on
B-Blocker for rate control and anti-coagulation with Coumadin
for goal INR of [**1-19**]. In addition, she was started on Amiodarone
load [**10-21**] at 400mg PO BID for attempted medical conversion. She
has remained in persistent afib throughout her course and did
not convert following 10g Amiodorone. She was discharged on
200mg Qday amiodorone. She will f/u as outpatient w/ Dr.
[**Last Name (STitle) 73**] on [**11-10**] for potential electric cardioversion and w/
Dr. [**Last Name (STitle) **] on [**11-18**].
5. Oliguric ARF - Her acute renal failure was secondary to ATN
due to septic shock/poor cardiac output. She had no evidence of
hydronephrosis by abdominal CT. Urine was positive for
eosinophils on admission ([**10-21**]), which is now resolved. HD
commenced on [**10-22**] after temporary line was placed on RIJ for
volume removal. She recieved two treatments of hemodialysis with
ultrafiltration, removing 2kg and 3kg of fluid respectively. She
subsequently had improving urine production, so we held on HD to
challenge her kidneys. She was able to maintain good urine
output 1 to 1.5 liters/day. In addition, she was able to
self-diurese approximately 1 liter off each day. Concurrently,
her Cr continued trending down, now at 2.4 on discharge. The
renal team was following throughout and agreed with
discontinuing hemodialysis since her renal function has been
reversing well. The RIJ line was discontinued on [**11-1**].
7. CHF: EF<20% with severe global left ventricular hypokinesis.
She continues to have evidence of mild volume overload
(particularly in LE's), but her respiratory status has been
clinically stable. She has no SOB at rest or PND. It is unclear
what her exercise tolerance is since she has had minimal
exertional effort. However she is able to get up out of bed to
chair without complaint. She will need further physical therapy
for gait training and motor strengthening to assist with
ambulation. In addition she has had good self-diuresis off of
lasix. Lasix/Ace-I may be restarted once renal function
completely reverses back to baseline. Continued on B-Blocker.
8. DM - NPH 20 units qam and 12 units qpm + sliding scale
insulin. She has had good glycemic control off of steroids.
8. Anemia - HCT stable at 29-30. Low hct likely secondary to
impaired renal function. Received EPO w/HD. No evidence of
bleed. Hct has been stable over the last week of her hospital
stay.
9. Ischemic optic neuropathy: Pt with new onset biocular
blindness noted [**10-20**]. Pt had head CT stat [**10-21**] with no evidence
acute bleed or stroke. Blindness likely secondary to severe
hypotensive episode. ESR 10 + no evidence of temporal arteritis.
Ophtho consulted and attempted heroic measure of high dose IV
steroids x 3 days which did not have any visual response. Per
ophtho, visual acuity not expected to change at this piont. Will
f/u w/ ophtho as an outpatient for continued care.
10. Altered mental status: Resolving concurrently w/ resolution
of sepsis, uremia. Still has agitation at night, likely
component of sundowning/residual ICU psychosis. Good family
support, reassurance and re-orientation have all helped improve
her status. She remains oriented and appropriate through the day
and has fair understanding of her situation, although she does
have episodes of agitation. She has responded well to
olanzapine or IV haldol at night. She has not required
medication during the day.
Medications on Admission:
Digoxin
Pravastatin
Losartan
Atenolol
ASA
MVI
Iron
Coumadin 2.5 mg po qd
Lasix 40 mg po qd
NPH 22 qhs and 50 qam
regular insulin
Plavix
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
1. UTI w/ Enterococcus
2. Bacteremia w/ Coagulase negative staph (2 sets)
3. Acute renal insufficiency/ATN, secondary to hypoperfusion
4. Diabetes Mellitus II
5. Ischemic Optic Neuropathy, secondary to hypoperfusion,
leading to bilateral blindness
6. Delirium
7. CHF- EF 20-25%
8. Atrial fibrillation
Discharge Condition:
good. hemodynamically stable, afebrile. improving renal
function. no return of visual acuity.
Discharge Instructions:
Please report fever, chills, chest pain, shortness of breath to
your PCP.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: restrict fluid intake to 1.5 liters/day
Followup Instructions:
1. Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2145-11-10**] 11:30
2. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2145-11-25**] 2:15
|
[
"038.19",
"584.6",
"427.31",
"518.81",
"276.2",
"377.41",
"292.81",
"276.5",
"250.00",
"428.0",
"369.00",
"789.5",
"V45.01",
"599.0",
"401.9",
"V45.81",
"427.1",
"041.4",
"263.9",
"995.92",
"272.0",
"276.7",
"285.9",
"780.09",
"440.20",
"E932.0",
"458.9",
"785.52",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"96.6",
"96.71",
"54.91",
"89.48",
"38.93",
"38.95",
"00.14",
"96.04",
"38.91",
"39.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10290, 10337
|
4097, 9606
|
347, 361
|
10682, 10777
|
1986, 4074
|
11059, 11454
|
1493, 1511
|
10358, 10661
|
10130, 10267
|
10801, 11036
|
1526, 1967
|
276, 309
|
389, 1075
|
9621, 10104
|
1097, 1375
|
1391, 1477
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,582
| 139,436
|
42168
|
Discharge summary
|
report
|
Admission Date: [**2192-10-17**] Discharge Date: [**2192-10-22**]
Date of Birth: [**2138-3-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
[**2192-10-17**]
1. Right thoracotomy.
2. Mediastinal lymphadenectomy.
3. Sleeve lobectomy of right upper lobe.
4. End-to-end anastomosis of bronchus intermedius to right
main stem bronchus.
5. Wrapping of bronchial anastomosis with intercostal
muscle.
History of Present Illness:
54-year-old male former smoker (quit smoking about two and
half years ago) w/ squamous cell lung carcinoma and R
mainstem/[**Hospital1 **]
endobronchial tumor is s/p EBUS w/ negative TBNA of station 7 LN
[**2192-9-26**] now returns for further eval and management. On
[**2192-10-2**],
he had MR head w/o metastatic disease but CT chest demonstrated
increased number of mediastinal LNs, and the tumor has direct
contact w/ posterior aspects of vena cava, R main bronchus and
posterior aspects of R PA and subsequent complete RUL
atelectasis. He c/o several episodes of hemoptysis 2 days after
his bronch on [**9-26**] but has since subsided. He has intermittent
coughing productive of old clots. But his respiratory function
is grossly unchanged since his prior visit. He denies any other
new symptoms.
Past Medical History:
COPD, HTN, ADD, depression
Social History:
Lives with wife, active cyclist
Occupation: works in marketing, prior construction worker
Smoking history: 1-2ppd x 35 years, quit [**2189**]
Alcohol: occasional
Family History:
mother and father alive and healthy
Physical Exam:
BP: 136/113. Heart Rate: 80. Weight: 170.6. Height: 68. BMI:
25.9. Temperature: 97.5. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 99.
General Appearance: NAD, resting comfortably
HEENT: MMM, O/P clear, sclera anicteric
Neck: trachea midline, no stridor, supple
Lymphatics: no cervical or supraclavicular lymphadenopathy, no
thyromegaly
Chest: CTA Bilaterally, no wheezes or rales
Cardiovascular: reg rate, nl S1/S2, no MRG
Abdomen: soft, NT/ND, NABS, no HSM
Extremities: no CCE
Neurological: A&O x3, gait WNL
Psychiatric: normal mood, no depression/anxiety
Skin: No rash, skin eruptions, or erythema
Pertinent Results:
[**2192-10-17**] 05:07PM GLUCOSE-116* LACTATE-1.6 NA+-140 K+-4.2
CL--104
[**2192-10-17**] 05:07PM HGB-13.8* calcHCT-41
[**2192-10-17**] 11:23PM PLT COUNT-278
[**2192-10-17**] 11:23PM WBC-17.0* RBC-3.80* HGB-11.8* HCT-34.1*
MCV-90 MCH-31.1 MCHC-34.7 RDW-12.5
[**2192-10-17**] 11:23PM GLUCOSE-224* UREA N-12 CREAT-1.1 SODIUM-140
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16
Labs [**2192-10-21**] :
White Blood Cells 10.4 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.29* 4.6 - 6.2 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 10.2* 14.0 - 18.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 29.7* 40 - 52 %
PERFORMED AT WEST STAT LAB
MCV 90 82 - 98 fL
PERFORMED AT WEST STAT LAB
MCH 31.0 27 - 32 pg
PERFORMED AT WEST STAT LAB
MCHC 34.3 31 - 35 %
PERFORMED AT WEST STAT LAB
RDW 13.1 10.5 - 15.5 %
PERFORMED AT WEST STAT LAB
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count [**Telephone/Fax (3) 91460**] K/uL
PERFORMED AT WEST STAT LAB
Brief Hospital Course:
Mr. [**Known lastname 1968**] was admitted to the hospital and taken to the
Operating Room on [**2192-10-17**] where he underwent a right
thoracotomy and right upper lobe sleeve lobectomy. He tolerated
the procedure well and returned to the SICU in stable condition.
He maintained stable hemodynamics and his pain was controlled
with an epidural catheter. He underwent vigorous pulmonary
toilet including bronchodilator nebulizers and was gradually
able to wean off oxygen. His chest tubes had an intermittent
leak early on which resolved and there was minimal drainage.
His hematocrit was stable.
Following transfer to the Surgical floor he continued to make
good progress. His epidural catheter was removed on [**2192-10-19**]
and he had adequate pain relief with Oxycodone and scheduled
Tylenol. He was able to use his incentive spirometer
effectively and was ambulating independently after his chest
tubes were removed. His xray showed a small apical space post
chest tube removal but he remained asymptomatic. His incision
was dry and healing well and after an uneventful recovery he was
discharged to home on [**2192-10-22**] and will follow up in the Clinic
in 2 weeks.
Medications on Admission:
aspirin 81 mg dqaily
Pro Air 2 puffs q6hrs prn
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Nonsmall cell lung cancer from the right upper lobe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours. If it
starts to drain, cover it with a clean dry dressing and change
it as needed to keep site clean and dry.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2192-11-6**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report to the Radiology Department on the [**Location (un) **] of
the [**Hospital Ward Name 23**] Building 30 minutes before your appointment with Dr.
[**First Name (STitle) **] for a chest Xray.
Completed by:[**2192-10-22**]
|
[
"314.00",
"401.9",
"162.3",
"311",
"458.29",
"496",
"512.89",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"33.48",
"40.29",
"32.1"
] |
icd9pcs
|
[
[
[]
]
] |
5250, 5256
|
3348, 4533
|
317, 580
|
5352, 5352
|
2341, 3325
|
6963, 7509
|
1664, 1702
|
4630, 5227
|
5277, 5331
|
4559, 4607
|
5503, 6940
|
1717, 2322
|
272, 279
|
608, 1417
|
5367, 5479
|
1439, 1468
|
1484, 1648
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,827
| 188,192
|
12227+56344
|
Discharge summary
|
report+addendum
|
Admission Date: [**2136-6-18**] Discharge Date: [**2136-6-27**]
Date of Birth: [**2078-11-24**] Sex: M
Service: [**Doctor Last Name **]
HISTORY OF PRESENT ILLNESS: This is a 57 year-old male with a
history of Klatskin tumor status post cholecystectomy and
biliary drainage on continuous chemotherapy who presented to
an outside hospital with shortness of breath described as
being unable to get breath in. The patient denies that he had
chest pain but this was potentially reported at the outside
hospital. EKG at the outside hospital was read as having
acute changes. Troponin was 0.4 and a concern was raised for
acute coronary syndrome.
The patient was then transferred to the [**Hospital1 190**] for further evaluation.
PAST MEDICAL HISTORY:
1. Biliary duct adenocarcinoma with positive lymph nodes,
unresectable diagnosis [**2136-1-31**]. Status post exploratory
laparotomy and cholecystectomy in [**2136-3-2**] with biliary
drainage.
2. Diabetes mellitus.
3. Hypertension.
4. Multiple back surgeries for disc problems.
ALLERGIES: Zestril leads to unknown reaction. Versed leads to
seizure.
MEDICATIONS:
1. Protonix 40 mg po q day.
2. Oxycodone 5 mg po q day six hours prn.
3. OxyContin 40 mg po q eight hours.
4. NPH 12 units.
5. Chemotherapy of unknown [**Doctor Last Name 360**].
6. Augmentin one po bid.
PHYSICAL EXAMINATION: On presentation at [**Hospital1 346**] vital signs 98.0 F, blood pressure
124/69, heart rate 112, O2 saturation 96% on nonrebreather,
respiratory rate ranged from 27 to 36. General exam - alert
and oriented times 3, tachypneic. HEENT - pupils are equal,
round and reactive to light. Extraocular muscles are intact.
Oropharynx mucous membranes moist, neck is supple.
Cardiovascular - tachycardic with a grade II/VI slow murmur
at the right upper sternal base. Respiratory - crackles
bilaterally with an increase in right base to half way up.
Abdomen with biliary drains intact and soft though
protuberant with diffuse abdominal pain and no rebound.
Extremities - 3+ pitting edema to the knees. Neurologically -
cranial nerves II through XII are grossly intact. Strength is
[**6-3**].
ADMISSION LABORATORY DATA: White blood cell count 16.5,
hematocrit 27.4, platelet count 74, INR 1.7, sodium 133,
potassium 4.8, chloride 97, bicarb 23, BUN 25, creatinine
1.0, glucose 103, CK 32, Troponin 4.8.
EKG revealed normal sinus rhythm at a rate of 105 with a Q in
III and flipped T wave in lead III which was old. There was T
wave inversion in lead aVF and ST elevation in V1 and V2 with
T wave flattening in V3 and V6. T wave changes were new since
[**2136-4-30**].
ABG 7.47, Pco2 31, Po2 77 at 100% nonrebreather mask.
Echocardiogram revealed no focal wall motion abnormalities
with some right heart strain and a PA pressure of 58.
Head CT scan was negative for hemorrhage or mass affect or
masses.
ASSESSMENT: Given the EKG changes and echocardiographic
changes the patient was felt to have a pulmonary embolus.
A CT angiogram was performed which revealed thrombi in the
right tree and multiple bilateral thrombi, left basilar
atelectasis and a right effusion and ground glass appearance
in the upper lobes.
Chest x-ray revealed a moderate right pleural effusion but no
consolidation. Given the potential for hemodynamic
instability the patient was initially admitted to the
medical Intensive Care Unit for close observation. The
patient did well in the Medical Intensive Care Unit and was
called out to the floor the following day.
Upon presentation to the floor the patient denied chest pain,
headache, nausea, vomiting and decreasing shortness of
breath. He continued abdominal pain with no black or bloody
stools and no dysuria.
The patient was received on the following medications:
1. Heparin.
2. Morphine Sulfate.
3. Oxycodone.
4. OxyContin.
5. Augmentin.
6. Levaquin.
7. Flagyl.
Levaquin and Flagyl were added for a rising white count and
the presence of abdominal pain.
COURSE ON THE GENERAL MEDICAL SERVICE:
1. Pulmonary - For multiple bilateral pulmonary emboli the
patient was continued on Heparin and was started on Coumadin
therapy. His O2 saturation gradually improved over the course
of the hospitalization. He had no further complications of
his pulmonary emboli or its treatment.
2. Oncologic - The patient's oncologist was contact[**Name (NI) **] by the
Medical Intensive Care Unit team who reported that the
patient did not need further chemotherapy at this time. The
[**Doctor Last Name 360**] being used was unable to be determined. The oncologist
was contact[**Name (NI) **] but unsuccessfully by the floor team.
3. Infectious Disease - The patient was started on Levaquin
and Flagyl as described above for rising white count and
abdominal tenderness. The patient remained afebrile despite a
rising white blood cell count blood cultures were negative.
The patient was discontinued on Levaquin, Flagyl and
Augmentin by the floor team. He was followed clinically with
no further increase in temperature though white count
continued to rise. To evaluate for this the patient was
maintained on continuous biliary drainage and received a
cholangiogram at this hospital. The results of which are
pending at this time.
4. Ascites - The patient was felt to have tense ascites and
could benefit from a paracentesis for comfort reasons. This
was performed on [**2136-6-20**] with the removal of approximately
4.6 liters of fluid. Analysis of the fluid reveals white
blood cells [**Pager number **], red blood cells [**Pager number **], 54% polys, 1
lymphocytes, 36 monos and 9 macrophages, amylase 7, total
bilirubin 1.9, albumin 0.9. This was felt to be consistent
with a transient state and the patient was encouraged to
consume a low salt diet. He was started on Lasix and
Aldactone. Over the remaining course of the hospitalization
the fluid did slowly re-accumulate.
5. Cardiovascular - Though the Troponin was elevated, the
patient had no symptoms consistent with acute coronary
syndrome. He was watched closely and had no further chest
pain and no further work up of this problem ensued.
6. Diabetes mellitus - The patient was continued on regular
sliding scale insulin.
7. Prophylaxis - The patient was continued on Protonix and
was maintained on Heparin as described above.
DISPOSITION AND CODE STATUS: Extensive conversation took
place between the house officers and the palliative care
team, the patient and his family, the patient expressed in
his wishes that he not be placed on any machines and should
be DNR / DNI. He expressed concerned that DNR / DNI status
would prohibit further treatment which could be of benefit to
him. It was extensively explained to him that DNR / DNI
status does not preclude treatment of other medical problems
such as paracentesis or pulmonary emboli. The patient was
relieved to hear this and the family agreed that the patient
should be made DNR / DNI. The beginnings of Hospice care were
discussed as well and the patient elected to pursue further
management with Hospice at the time of his discharge.
At this point the patient is deemed prepared for transfer to
the [**Hospital 47**] [**Hospital 1281**] Hospital if a bed is available. At that
hospital upon his discharge he should be referred for hospice
care with the [**Hospital3 1280**] Hospice upon discharge from
[**Hospital 47**] [**Hospital 1281**] Hospital. The palliative care team at this
hospital spoke with [**First Name4 (NamePattern1) 3788**] [**Last Name (NamePattern1) **] from that hospice
institution.
ADDITIONAL RELEVANT LABORATORY TESTS: There was a culture
done on [**2136-6-21**] biliary fluid which is pending. Gram stain
of the [**2136-6-20**] peritoneal fluid was negative. [**2136-6-19**]
blood culture no growth to date at the time of this
dictation. The [**2136-6-19**] blood culture second bottle also
negative to date. There was a [**2136-6-19**] culture of biliary
fluid which grew enterococci species which were not treated.
Given the lack of symptoms suggesting a clinical infection.
The patient also had a hepatic ultrasound to evaluate for
Chiari syndrome and this was negative.
FINAL DIAGNOSIS:
1. Pulmonary embolus.
2. Klatskin tumor.
3. Ascites.
4. Diabetes mellitus.
5. Anemia.
DISCHARGE INSTRUCTIONS: The patient is deemed prepared for
transfer to the [**Location (un) 47**] [**Hospital3 1280**] Hospital for continued
management. He should follow up with his primary care
physician and his oncologist, Dr. [**Last Name (STitle) 38218**]. Dr.[**Name (NI) 38221**]
phone number is [**Telephone/Fax (1) 38222**].
DISCHARGE MEDICATIONS:
1. Lovenox.
2. Regular sliding scale insulin.
3. Oxycodone sustained released 100 mg po q eight hours.
4. Bisacodyl 10 mg po prn [**Hospital1 **].
5. Trazodone 50 mg po q HS prn.
6. Protonix 40 mg po q day.
7. Oxycodone 5 mg po four to six hours prn breakthrough
pain.
8. Coumadin 5 mg po q HS.
9. Lasix 40 mg po q day.
10. Spirolactone 100 mg po q day.
11. Ampicillin 1 gram IV q six hours times two doses status
post cholangiography.
12. Gentamycin 80 mg IV q eight hours times two doses status
post cholangiography.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAK
Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36
D: [**2136-6-22**] 10:58
T: [**2136-6-22**] 12:21
JOB#: [**Job Number 38223**]
Name: [**Known lastname 158**], [**Known firstname 3834**] Unit No: [**Numeric Identifier 6901**]
Admission Date: [**2136-6-18**] Discharge Date: [**2136-6-27**]
Date of Birth: [**2078-11-24**] Sex: M
DISCHARGE SUMMARY ADDENDUM: This addendum is to detail the
events from [**2136-6-22**] onward.
1. Pulmonary embolism - Upon returning from his
patient was noted to have a transient desaturation in his
oxygen level. He received an arterial blood gas, chest X-ray
and EKG all of which pointed to a repeat pulmonary embolus as
the cause. Over the remaining 24 hours his oxygen was weaned
down to 5 liters by nasal cannula where he had been after the
transfer from the Intensive Care Unit. He has since been
stable on 5 liters by nasal cannula.
On [**2136-6-26**] because of difficulties managing his Heparin
drip he was started on Lovenox. There were difficulties
managing his INR as well with a supratherapeutic INR that
required vitamin K to reverse. He was restarted on Coumadin
2.5 mg po q HS on [**2136-6-26**].
2. Infectious Disease - He was seen by interventional
radiology to manipulate his biliary drains which were
implicated in his high white blood cell count. They reported
the following: obstructive left biliary tree most likely
secondary to tumor extension to the left duct. Balloon
dilatation of the mid and distal left hepatic duct was
performed. Exchange of the previous 8 French biliary drainage
catheters for a new 8 French biliary drainage catheter with
post cholangiograms demonstrating optimal placement of the
proximal side holes. Both tubes were placed to internal
drainage.
His liver function tests and clinical exam was followed after
this and he remained stable. However the white blood cell
count which had been rising continued to stay elevated.
Clinically the patient remained afebrile and was hence not
treated with any antibiotics. Bile consistently grew multiple
organisms which again were not treated as the patient
remained clinically well appearing.
3. Gastrointestinal / Ascites - The patient's ascites
re-accumulated and was drained again on [**2136-6-24**]. The
analysis again was not consistent with infection. He was
started on Lasix and Spironolactone to prevent reaccumulation
and these doses were increased to Lasix 80 mg and
Spironolactone 200 mg.
4. Hyponatremia - The patient became hyponatremic. This was
attributed to his ascites. He was treated with a 1.0 liter
per day fluid restriction.
5. Hematologic - Thrombocytopenia - The patient's platelet
count was noted to be declining to as low as 80,000. It was
felt that this may be from disseminated intravascular
coagulation. A DIC panel was checked and was negative. Other
possibilities included Heparin induced thrombocytopenia
however the patient's platelet count remained stable in the
80,000 range and had no clinical signs of bleeding. It was
determined that Heparin will be continued while HIT antibody
is pending. Given the fact that Lovenox has less incidence of
Heparin induced thrombocytopenia, he was felt to be safe for
discharge on Lovenox in the interim while becoming
therapeutic on Coumadin.
6. Disposition - On [**2136-6-26**] the patient's affect seemed
more sad and the patient became less interested in his care.
It was felt the patient may be becoming more accepting of his
diagnosis and interested in going home. The patient had been
a DNR / DNI status. Since transfer from the Medical Intensive
Care Unit a discussion took place between the patient's
family, the palliative care team and the house officer on [**2136-6-26**]. During this conversation the patient made it clear
that he wishes to be discharged to home with Hospice care. He
does wish to continue Lovenox and Coumadin to treat his
pulmonary embolus and hypercoagulable state.
At this time he is being prepared for discharge to home with
visiting nurses and Hospice care.
DISCHARGE INSTRUCTIONS: He should continue to follow with his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6902**]. He should have a
Coumadin level check q OD while adjusting Coumadin and fax to
Dr. [**Last Name (STitle) 6902**]. Fax number [**Telephone/Fax (1) 6903**] who will adjust the
patient's Coumadin dose. He will continue on Lovenox until he
is therapeutic on his Coumadin.
DISCHARGE MEDICATIONS:
1. Docusate Sodium liquid 100 mg po bid.
2. Bisacodyl 10 mg po / pr [**Hospital1 **] prn.
3. Pantoprazole 40 mg po q day.
4. Furosemide 80 mg po q day.
5. Spironolactone 200 mg po q day.
6. Sodium Chloride nasal spray one to two sprays qid prn.
7. Oxycodone sustained release 80 mg po eight hours.
8. Oxycodone 10 mg po q four to six hours prn.
9. Warfarin 2.5 mg po q HS.
10. Enoxaparin Sodium 60 mg subcutaneous q 12 hours.
11. Morphine Sulfate elixir prn.
FINAL DIAGNOSIS:
1. Klatskin tumor.
2. Pulmonary embolus.
3. Hypoxia.
4. Ascites.
5. Hyponatremia.
6. Thrombocytopenia.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6904**] [**MD Number(4) 6905**]
Dictated By:[**Name8 (MD) 292**]
MEDQUIST36
D: [**2136-6-26**] 17:35
T: [**2136-6-27**] 10:56
JOB#: [**Job Number 6906**]
cc:[**Hospital3 6907**]
|
[
"789.5",
"401.9",
"250.00",
"276.1",
"576.2",
"415.19",
"287.5",
"156.1",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.98",
"87.54"
] |
icd9pcs
|
[
[
[]
]
] |
13709, 14178
|
14195, 14602
|
13291, 13686
|
1371, 8131
|
185, 747
|
769, 1349
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,643
| 144,664
|
4825
|
Discharge summary
|
report
|
Admission Date: [**2104-1-27**] Discharge Date: [**2104-2-1**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
fevers, hypotension and sepsis
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
64 yo M with Hx of CAD s/p NSTEMI, severe COPD with multiple
intubations on chronic steroids, who was recently admitted
between [**2104-1-17**] and [**2104-1-19**] with COPD exacerbation as well as
asymptomatic bacteruia and pyuria. Despite the positive UA, the
pt was only treated with one dose of ceftriaxone in the ED. The
abx was discontinued on the floor as he had a chronic
in-dwelling foley and he was asymptomatic. He now returns with
fevers, diarhea, and left lower quadrant abdominal pains since
this morning. The pt reports he ate some yellow rice three days
ago. Since then he has had fevers, chills, with abdominal
discomfort similar to gas pain and diaarheea. His stools were
described were as black, loose and watery. He reports having 6
BM/day. On occasion, he has some minimal incontinence with his
gas. Of note, he has also been on iron supplements. In addition,
the pt reports he has had burning with urination intermittently.
He has an indwelling foley catheter for >6 months which he has
changed once/month. The last time the catheter was changed was
in [**Month (only) **]. 20s. He reports he has had dark cloudy urine with white
chuncky matter in his stream intermittently. The dysuria occurs
when the urine flows around the catheter which occurs
occasionally. He started taking ciprofloxacin (unknown dose) at
one tab once daily on his own from prior prescriptions five days
ago with some improvement in his sx. However he is requesting a
foley change.
.
In the ED, the pt was febrile to 100.6, with HR of 94, and BP of
72/37. He was found to have pursed lipped breathing, upper
quadrant pain, and guaiac negative. He was given 5L of NS with
transient improvement in his SBP. Nonetheless, he had a central
line placed and started on IV Abx (Flagyl 500mg, Ceftriaxone 1g,
and Ceftazidime 1g) as well as stress dose steroids
(dexamethasone 10mg). He had an elevated WBC to 17.3 as well as
an elevated lactate to 3.6 (which decreased to 0.9 after fluid
resuscitation) and a positive UA. In addition, he developed
chest pain at [**2098**] at which time he was also given [**Year (4 digits) **] 325mg x1,
morphine 2mg x1. His BP decreased after the morphine and he was
started on levophed. In addition, he received calcium 1g x1, and
albuterol x3 and iprotroprium 3 through his ED stay. The pt was
transferred to the [**Hospital Unit Name 153**] for presumed sepsis.
Past Medical History:
1. COPD on 4 L O2 at home and s/p multiple admissions and
intubations for flares-FEV1 .47(19%) FEV1/FVC 36% on 4L home 02,
and BiPap QHS.
2. Chronic indwelling urethral catheter with hx of VRE UTI
3. hx of MRSA
4. CAD s/p NSTEMI ([**2101**]) [**4-9**] with cath normal, TTE with
preserved biventricular function.
5. Steroid induced hyperglycemia
6. Hypertension
7. Hyperlipidemia
8. Chronic low back pain L1-2 laminectomy from accident at work
9. Left shoulder pain for several months
10. Cataract
11. GERD
12. BPH
Social History:
Married with six children. Lives at home in [**Location (un) 16174**] with wife.
Retired [**Company 19015**] mechanic. Exposed to a lot of spray paint.
Former smoker. Quit 25 years ago. 20 pack year history.
Occassional EtOH Quit marijuana 3 years ago. Denies IV drug use.
Activity limited due to prior spine and current shoulder
problems.
Family History:
Mother with asthma and [**Name (NI) 2481**]
Father with [**Name2 (NI) 499**] cancer
Physical Exam:
VS: 98.6, 96/57, 72, 14, 99% on 4L NC
GEN: elderly AA male who appears chronically ill in NAD.
conversing fluently in full sentences. No accessory muscle use.
A+O x3
HEENT: EOMI, anicteric, mm dry, op clear
CV: distant heard sounds, very difficult to appreciate heart
sounds
CHEST: poor air movement with diffuse expiratory wheezing and
prolonged expiratory phase.
ABD: soft, NT, ND, BS+
EXT: wwp, no c/c/e. trace peripheral pulses bilaterally
Pertinent Results:
REPORTS:
ECG [**2104-1-27**]: poor baseline, NSR at 90, Nml axis, Nml intervals,
RSR' in V1, V2, V3, 0.5mm ST elevation in v3 only.
.
CXR [**2104-1-27**]: COPD. Linear atelectasis at the right lung base. No
focal pneumonia or CHF.
.
Abd CT [**2104-1-27**]:
"1. Emphysema.
2. Chronic bibasilar opacities, probably scarring.
3. Likely left renal cyst. However, an ultrasound would be
helpful for further characterization to exclude a mass.
4. Small calcific densities, which most likely are layering in
the bladder. However, this could be determined more definitively
with a bladder ultrasound examination to assess for bladder
stones.
5. Diverticulosis throughout the [**Month/Day/Year 499**].
6. Focus of bowel wall thickening in the sigmoid, which may be
artifactual. However, the presence of a mass cannot be excluded
by this study."
.
RENAL U.S. [**2104-1-30**] 10:56 AM
IMPRESSION:
No evidence of hydronephrosis or kidney stones. Limited
evaluation of the bladder secondary to decompression with Foley
catheter. Multiple smalool sub- centimeter echogenic foci with a
long thickened bladder wall. Difficult to assess whether these
lesions are intraluminal or intramural. If there is further
clinical concern, recommend reexamining with full bladder
without Foley catheter.
.
LABS:
.
[**2104-1-31**] 06:31AM BLOOD WBC-13.2* RBC-3.26* Hgb-8.3* Hct-25.9*
MCV-79* MCH-25.4* MCHC-32.0 RDW-17.3* Plt Ct-306
[**2104-1-30**] 07:11AM BLOOD WBC-16.7* RBC-3.37* Hgb-8.9* Hct-27.0*
MCV-80* MCH-26.4* MCHC-32.9 RDW-18.2* Plt Ct-340
[**2104-1-29**] 05:04AM BLOOD WBC-12.8* RBC-3.45* Hgb-8.7* Hct-27.0*
MCV-78* MCH-25.1* MCHC-32.1 RDW-16.8* Plt Ct-285
[**2104-1-28**] 02:30PM BLOOD WBC-12.6* RBC-3.73* Hgb-9.6* Hct-30.1*
MCV-81* MCH-25.7* MCHC-31.8 RDW-17.9* Plt Ct-308
[**2104-1-28**] 04:20AM BLOOD WBC-13.4* RBC-3.75* Hgb-9.5* Hct-29.7*
MCV-79* MCH-25.2* MCHC-31.9 RDW-16.9* Plt Ct-336
[**2104-1-28**] 12:00AM BLOOD Hct-28.6*
[**2104-1-27**] 10:00PM BLOOD WBC-17.8* RBC-3.56* Hgb-9.4* Hct-28.2*
MCV-79* MCH-26.5* MCHC-33.4 RDW-17.8* Plt Ct-306
[**2104-1-27**] 05:41PM BLOOD WBC-14.3* RBC-4.55* Hgb-11.6* Hct-36.5*
MCV-80* MCH-25.5* MCHC-31.8 RDW-17.1* Plt Ct-375
[**2104-1-28**] 04:20AM BLOOD Neuts-94.4* Bands-0 Lymphs-4.2*
Monos-1.3* Eos-0 Baso-0.1
[**2104-1-27**] 10:00PM BLOOD Neuts-92* Bands-1 Lymphs-3* Monos-1*
Eos-1 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2104-1-27**] 05:41PM BLOOD Neuts-82.7* Lymphs-10.8* Monos-4.6
Eos-1.6 Baso-0.3
[**2104-1-31**] 06:31AM BLOOD Plt Ct-306
[**2104-1-31**] 06:31AM BLOOD PT-12.2 PTT-45.0* INR(PT)-1.0
[**2104-1-30**] 07:11AM BLOOD Plt Ct-340
[**2104-1-28**] 04:20AM BLOOD PT-12.9 PTT-33.2 INR(PT)-1.1
[**2104-1-27**] 10:00PM BLOOD Plt Ct-306
[**2104-1-27**] 05:41PM BLOOD PT-12.6 PTT-29.5 INR(PT)-1.1
[**2104-1-31**] 06:31AM BLOOD Glucose-95 UreaN-18 Creat-0.6 Na-137
K-4.1 Cl-98 HCO3-36* AnGap-7*
[**2104-1-30**] 07:11AM BLOOD Glucose-112* UreaN-17 Creat-0.7 Na-136
K-4.3 Cl-97 HCO3-33* AnGap-10
[**2104-1-28**] 02:30PM BLOOD Glucose-158* UreaN-13 Creat-0.8 Na-131*
K-4.2 Cl-95* HCO3-27 AnGap-13
[**2104-1-28**] 04:20AM BLOOD Glucose-161* UreaN-14 Creat-0.7 Na-134
K-4.9 Cl-100 HCO3-31 AnGap-8
[**2104-1-27**] 05:41PM BLOOD Glucose-134* UreaN-20 Creat-1.1 Na-134
K-4.3 Cl-94* HCO3-32 AnGap-12
[**2104-1-28**] 08:00AM BLOOD CK(CPK)-40
[**2104-1-27**] 10:00PM BLOOD CK(CPK)-37*
[**2104-1-27**] 05:41PM BLOOD ALT-22 AST-17 AlkPhos-72 Amylase-114*
TotBili-0.5
[**2104-1-27**] 05:41PM BLOOD Lipase-30
[**2104-1-28**] 08:00AM BLOOD CK-MB-4 cTropnT-<0.01
[**2104-1-27**] 10:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2104-1-31**] 06:31AM BLOOD Calcium-8.2* Phos-2.4* Mg-2.0
[**2104-1-29**] 05:04AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
[**2104-1-28**] 04:20AM BLOOD Calcium-7.5* Phos-2.7 Mg-1.7
[**2104-1-27**] 05:41PM BLOOD Albumin-3.6
[**2104-1-27**] 10:00PM BLOOD Cortsol-1.9*
[**2104-1-27**] 10:00PM BLOOD CRP-49.2*
[**2104-1-27**] 10:00PM BLOOD HoldBLu-HOLD
[**2104-1-28**] 08:30AM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-60* pH-7.30*
calHCO3-31* Base XS-1 Intubat-NOT INTUBA
[**2104-1-28**] 08:30AM BLOOD Lactate-0.9
[**2104-1-28**] 04:40AM BLOOD Lactate-1.2
[**2104-1-28**] 02:22AM BLOOD Lactate-0.9
[**2104-1-28**] 01:20AM BLOOD Lactate-0.8
[**2104-1-27**] 11:59PM BLOOD Lactate-0.9
[**2104-1-27**] 11:20PM BLOOD Lactate-0.9
[**2104-1-27**] 10:09PM BLOOD Lactate-0.8
[**2104-1-27**] 06:15PM BLOOD Lactate-3.6*
[**2104-1-28**] 04:40AM BLOOD Hgb-9.6* calcHCT-29 O2 Sat-82
[**2104-1-28**] 08:30AM BLOOD freeCa-1.11*
[**2104-1-27**] 05:41PM URINE RBC-[**6-14**]* WBC-21-50* BACTERIA-MOD
YEAST-MOD EPI-0
[**2104-1-27**] 05:41PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2104-1-27**] 05:41PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
.
MICRO:
.
[**2104-1-27**] 5:41 pm URINE Site: CATHETER
**FINAL REPORT [**2104-1-30**]**
URINE CULTURE (Final [**2104-1-30**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 201-8797Q
[**2104-1-28**].
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 201-8797Q
[**2104-1-28**].
[**2104-1-28**] 5:56 am URINE
**FINAL REPORT [**2104-1-31**]**
URINE CULTURE (Final [**2104-1-31**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
INTERPRET RESULTS WITH CAUTION.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R
CHLORAMPHENICOL------- 8 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 32 S 128 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S =>32 R
.
Blood cultures x 3: no growth
.
C.diff x 3: negative
Brief Hospital Course:
64 year old M with PMH significant for NSTEMI, COPD with
multiple past intubations, HTN, and hypercholesterolemia
admitted with sepsis secondary to UTI. Pt was admitted to the
ICU, then subsequently transferred to the floor.
.
1. sepsis [**2-7**] [**Name (NI) 12007**] Pt with findings consistent with urosepsis on
admission including hypotension, positive UA, and urine cultures
which grew out MRSA and VRE. He was admitted to the ICU and
briefly placed on levophed to maintain his BP. He was then
weaned off pressors, and did not have further episodes of
hypotension.
- Pt was initially covered broadly with ceftazidime and
linezolid for presumed sepsis, but the ceftazidime was d/c'd
once urine cultures grew out MRSA and VRE. Blood cx's were
negative during the admission.
- Pt was on outpatient prednisone for his severe COPD so he was
started on stress dose steroids in the ICU. He received IV
hydrocortisone and fludrocort, which was then changed to
prednisone 60mg PO qd prior to discharge.
.
2. [**Name (NI) 3672**] Pt has severe COPD for which he has had multiple
hospitalizations and intubations. Given his acute infection and
possible adrenal insufficiency he was started on stress dose
steroids in the ICU, then changed to prednisone as stated above.
He did not require intubation during this admission.
- Continued inhalers including fluticasone and salmeterol.
- Continued PRN albuterol and atrovent nebs.
- Oxygen as needed to maintain sats in the low 90s. Continued
with BiPap at night per home regimen.
.
3. Cardiac:
[**Name (NI) 20190**] Pt's history is significant for a NSETMI with
preserved biventricular function. At home, he is on lipitor,
verapamil, and an [**Name (NI) **]. His verapamil and [**Name (NI) **] were held on
admission in the setting of his hypotension, but were then
restarted prior to discharge. He was started on a low dose [**Name (NI) **],
but this was d/c'd as pt did not have significant coronary
disease by prior cath and has iron deficiency anemia.
- Continued statin.
.
[**Name (NI) 9520**] Pt was in NSR during the entire admission.
.
4. [**Name (NI) 3674**] Pt has anemia with a baseline Hct in the high 20s to
low 30s. This was most likely due to both iron defeciency anemia
and anemia of chronic disease. He also had a decrease in his Hct
in the ED from 36.5 to 28.2 after receiving over 5 L of NS. This
was most likely hemodilutional. No signs of hemolysis on labs.
Pt's last iron studies were in [**12/2103**] and were consistent with
iron defeciency anemia.
- Continued iron supplementation.
- pt did not require transfusions during this admission.
- he should have GI f/u for consideration of [**Year (4 digits) 499**] ca screening
.
5. [**Name (NI) 20191**] Pt's hyperglycemia was thought to be due to
his chronic steroid use, and subseqent stress dose steroids
during this admission. Pt was initially on an insulin drip in
the ICU for optimal BS control in the setting of sepsis. He was
then changed to a RISS.
- [**Doctor First Name **] diet was switched to regular today per pt's request prior
to discharge.
.
6. Psych- Continued outpatient psych medications including
sertraline and lorazepam.
.
7. BPH- Continued on outpatient finasteride.
.
8. GU- CT scan obtained on [**1-27**] with concern for calcific
densities in the bladder and probable left renal cyst, although
this was not fully characterized. US confirmed L renal cyst and
also showed echogenic foci near the bladder wall, unclear
significance of these findings. Could consider repeating
ultrasound with full bladder and without foley cath for better
characterization.
.
9. Diarrhea: pt had diarrhea for 2 days during the admission,
subsequently improved after bowel regimen was d/c'd.
- c.dif negative x 1
.
9. FEN- Regular diet. Electrolyte replacement as needed.
.
10. Proph- SC heparin; PPI.
.
11. Access- Right IJ TLC, pulled prior to discharge.
.
12. Communication: Wife [**Name (NI) 19016**] [**Name (NI) 19017**] (HCP): [**Telephone/Fax (1) 19018**]
(home), [**Telephone/Fax (1) 19019**] (cell).
.
13. Code Status: Full code
Medications on Admission:
1. Fluticasone 110 mcg/Actuation Two Puff Inhalation [**Hospital1 **].
2. Salmeterol 50 mcg/Dose Disk Inhalation Q12H.
3. Ipratropium Bromide 0.02 % Inhalation Q4-6H.
4. Albuterol Sulfate 0.083 % Solution Sig: Q4H as needed.
5. Prednisone taper
6. Oxygen pt requires 4-5 L oxygen at home via NC.
7. Verapamil 240 mg PO Q24H.
8. Lisinopril 5 mg PO DAILY.
9. Atorvastatin 10 mg PO DAILY.
10. Sertraline 50 mg PO DAILY.
11. Finasteride 5 mg PO DAILY.
12. Lorazepam 0.5 mg PO BID
13. Oxycodone-Acetaminophen 5-325 mg PO Q6H as needed for pain.
14. Pantoprazole 40 mg PO Q24H.
15. Calcium Carbonate 500 mg PO TID W/MEALS
16. Cholecalciferol (Vitamin D3) 800 unit PO DAILY.
17. Ferrous Sulfate 325 PO DAILY.
18. Docusate Sodium 100 mg PO BID.
19. Senna 8.6 mg PO BID.
20. Bisacodyl 5 mg PO DAILY as needed.
Discharge Medications:
1. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
[**Hospital1 **]:*1 tube* Refills:*1*
2. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
[**Hospital1 **]:*20 Tablet(s)* Refills:*0*
3. Outpatient Lab Work
please have your CBC checked this [**Last Name (LF) 766**], [**2-4**].
4. Prednisone 10 mg Tablet Sig: as directed below Tablet PO once
a day: take 60mg daily x 3 days, then 50mg daily x 3 days, then
40mg daily x6 days, then 30mg daily.
[**First Name3 (LF) **]:*120 Tablet(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) INH
Inhalation Q12H (every 12 hours).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Finasteride 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).
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
[**Hospital1 **]:*90 Tablet, Chewable(s)* Refills:*2*
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
18. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
19. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
21. Erythromycin 5 mg/g Ointment Sig: One (1) application
Ophthalmic twice a day: apply OS/OD.
[**Hospital1 **]:*1 tube* Refills:*2*
22. Refresh Tears 0.5 % Drops Sig: One (1) Ophthalmic four
times a day as needed for eye dryness.
[**Hospital1 **]:*30 days* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Care Group
Discharge Diagnosis:
Primary diagnoss:
sepsis secondary to UTI
Secondary diagnes:
COPD exacerbation
CAD
HTN
Discharge Condition:
Stable. On O2, but without SOB.
Discharge Instructions:
Please seek medical attention immediately if you experience
chest pain, shortness of breath, nausea, vomiting, diarrhea,
cough, fever, chills, or dizziness.
Please attend all follow-up appointments. You will need a CBC
checked at a lab this [**Hospital1 766**], and you should follow-up with your
PCP in the next week.
Followup Instructions:
Please have a CBC drawn on [**Hospital1 766**], and follow-up with your PCP
in the next week.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2104-2-15**] 10:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2104-2-15**] 11:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2104-4-22**] 9:45
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2104-2-3**]
|
[
"414.01",
"600.01",
"251.8",
"041.04",
"280.8",
"038.9",
"272.4",
"753.10",
"787.91",
"785.52",
"995.92",
"276.51",
"E932.0",
"401.9",
"412",
"599.0",
"786.50",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.95",
"93.90",
"38.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
18139, 18180
|
10783, 14841
|
303, 328
|
18312, 18346
|
4224, 10760
|
18715, 19395
|
3658, 3744
|
15694, 18116
|
18201, 18291
|
14867, 15671
|
18370, 18692
|
3759, 4205
|
233, 265
|
356, 2744
|
2766, 3284
|
3300, 3642
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,885
| 151,467
|
4191+55551+55553
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2195-11-27**] Discharge Date:
Date of Birth: [**2145-8-22**] Sex: M
Service: [**Doctor Last Name 1181**]
CHIEF COMPLAINT: Unresponsiveness.
HISTORY OF PRESENT ILLNESS: The patient is a 50 year old man
with a history of polysubstance abuse including Cocaine,
Heroin and alcohol, hepatitis B, hepatitis C, restrictive
lung disease, chronic obstructive pulmonary disease, and
hypertension, who presented with hypotension, hypoxia and
unresponsiveness.
The [**Hospital 228**] medical course began when he was diagnosed with
mild pneumonia on [**2195-10-17**], after presenting to an outside
hospital with shortness of breath and productive cough. The
patient was found to have a right lower lobe infiltrate
thought to be aspiration. He was continued on antibiotics.
The patient then presented to the Emergency Department on
[**2195-11-2**], with chest pain and dysarthria. Neurology
consultation concluded that he had a toxic metabolic
encephalopathy as the workup included negative toxicology
screen, lumbar puncture and electroencephalogram. Swallow
study was done for aspiration which was normal. Head CT was
also negative as well as a CT of the spine. Right upper
quadrant ultrasound showed cirrhosis.
On [**2195-11-5**], the patient was found to have a distended acute
abdomen with an abdominal CT that showed portal venous air
and the patient was taken emergently to the operating room
where he was found to have toxic megacolon. The patient
underwent total colectomy with a mucous fistula and
ileostomy. The pathology showed pseudomembranous focal
hemorrhage as well as wall thickening and patchy ulceration
which suggested ischemia and possibly infectious etiologies,
although the findings seem to correlate with a vascular
pattern. The pathology was not thought to be consistent with
inflammatory bowel disease.
On postoperative day five, the patient developed copious
ostomy output four to five liters per day and progressive
volume depletion. The patient was given Ceftriaxone and
Flagyl and finally improved and was discharged to
rehabilitation.
At rehabilitation, the patient had frequent large volume
occult blood positive stool and intermittent clear nausea and
vomiting which improved with Nexium. Also, the patient was
restarted on Clozol. The patient had tarry stools on
[**2195-11-24**]. The patient was alert and oriented, however,
ambulating and comfortable at rehabilitation.
On [**2195-11-27**], at 7:15 a.m., the patient was found to be
unresponsive with coffee brown liquidy ooze around his mouth.
His oxygen saturation was 79% with a blood pressure of
88/60. The patient was transferred to [**Hospital1 190**] Emergency Department.
In the Emergency Department, his blood pressure was 60/42,
respiratory rate 24, oxygen saturation 98% with a nasogastric
lavage that was occult blood positive but negative for coffee
grounds. The patient was intubated for airway protection and
left subclavian vein line was placed. The patient was given
fluids, Ceftriaxone, Flagyl and transferred to the Medical
Intensive Care Unit. The patient was then switched to
Levofloxacin and Flagyl.
In the Intensive Care Unit, he grew four out of four blood
culture bottles positive for Methicillin resistant
Staphylococcus aureus. The patient was switched to
Vancomycin. He had a temporary pressor requirement but was
gradually weaned off pressors. The patient was given fluids.
The patient had a transthoracic echocardiogram in the
Intensive Care Unit that was negative. The patient was also
found to have pancreatitis.
PAST MEDICAL HISTORY:
1. Polysubstance abuse including alcohol, Cocaine and
Heroin. Last use within a year.
2. Hepatitis B.
3. Hepatitis C.
4. Schizophrenia versus schizo-affective disorder.
5. PPD positive.
6. Hypertension.
7. History of recurrent aspiration pneumonia.
8. Status post cholecystectomy.
9. Psoriasis.
10. Gastroesophageal reflux disease.
11. Urinary tract infection.
12. Mild restrictive lung disease.
13. History of staphylococcus endocarditis.
14. History of osteomyelitis.
15. Cirrhosis.
ALLERGIES: Sulfa.
MEDICATIONS ON ADMISSION:
1. Albuterol nebulizer.
2. Azmacort nebulizer.
3. Flovent.
4. Neurontin 300 mg p.o. b.i.d.
5. Prilosec.
6. Tramadol.
7. Zestril.
SOCIAL HISTORY: The patient lives with sister and is
unemployed. He smokes two packs per day for the last
thirty-five years. The patient admits to drinking alcohol.
In the past, the patient has been a heavy alcohol, Cocaine
and intravenous drug user.
FAMILY HISTORY: Hypertension and alcohol abuse.
PHYSICAL EXAMINATION: The patient had a temperature of 98.7
with a pulse of 105, respiratory rate 18, blood pressure
115/60 and oxygen saturation 100% while intubated.
Generally, the patient was intubated and sedated with
occasional chewing on his tube and myoclonic jerks. Head,
eyes, ears, nose and throat examination revealed pale
conjunctiva. The pupils are equal, round, and reactive to
light and accommodation. Extraocular movements are intact.
Anicteric sclera with green OGT drainage. The drainage was
occult blood positive. Cardiac examination revealed regular
rate and rhythm, normal S1 and S2, no murmurs, rubs or
gallops. The chest examination revealed lungs that had
decreased breath sounds on the left and clear to auscultation
on the right. Abdominal examination revealed a softly
distended abdomen with some discomfort to palpation and no
clear distribution. No bowel sounds were heard and no masses
were felt. The patient had a well healing incision with
mucous fistula that appeared noninfected. Colostomy was
pink. There was liquid brown stool that was occult blood
positive. Extremity examination revealed warm and well
perfused extremities with no edema.
LABORATORY DATA: The patient had a white blood cell count of
16.1, with a hematocrit of 26.0 and platelets of 307,000.
Urinalysis was negative. The patient had a Chem7 with a
potassium of 5.4, blood urea nitrogen 148, creatinine 8.0.
ALT was 147, AST 55, alkaline phosphatase 141, total
bilirubin 0.8. Initial CK was 58. Amylase was 301 with a
lipase of 402. Arterial blood gases on admission revealed pH
7.30/25/133.
Chest x-ray with left linear atelectasis versus infiltrate.
Endotracheal tube was 1.0 centimeter above the carina. There
was a left subclavian line in the mid superior vena cava.
Electrocardiogram revealed normal sinus rhythm at 83 beats
per minute with normal axis and intervals. There was a
biphasic T wave in V2 and mildly peaked T waves in V3 through
V6.
HOSPITAL COURSE: This 50 year old man with a history of
polysubstance abuse, hepatitis B, hepatitis C, question of
schizophrenia, restrictive lung disease, and chronic
obstructive pulmonary disease, presented in septic shock with
four out of four blood culture bottles positive for
Methicillin resistant Staphylococcus aureus but no documented
source. The patient also presented in acute renal failure
and with pancreatitis.
1. Pulmonary - The patient was intubated for hypoxic
respiratory failure and extubated on [**2195-11-30**]. The patient
was easily weaned to room air. There was question of
recurrent aspiration although the chest x-ray did not appear
to impressively suggest that. A speech and swallow
evaluation was done and video swallow test showed that the
patient does not aspirate. The patient was given incentive
spirometry and meter dose inhalers.
The patient was maintained in room air upon transfer to a
floor bed and continued to do well from a respiratory
standpoint. Repeated chest x-rays showed bilateral basilar
opacities which were thought to be aspiration pneumonia.
Initially, the patient was not treated for this but did
develop low grade fever and was eventually started on
Levofloxacin. The patient did not have a strong history for
aspiration and was not placed on antibiotics for aspiration
initially.
2. Infectious disease - The patient presented septic
requiring pressors with four out of four bottles positive for
Methicillin resistant Staphylococcus aureus without a clear
source. A transthoracic echocardiogram done in the Medical
Intensive Care Unit showed no evidence of vegetation,
however, was of suboptimal image quality. The patient
eventually had a transesophageal echocardiogram which
revealed a 4.0 millimeter vegetation on the noncoronary cusp
of the aortic valve. The patient was continued on Vancomycin
750 mg intravenous t.i.d. Vancomycin levels were within
therapeutic range.
Other sources of the positive blood cultures included
abdominal source since the patient had recently undergo
in-hospital abdominal surgery. An abdominal ultrasound and
renal ultrasound revealed no evidence of abscess or dilated
ducts. Cirrhosis was noted. There was patent portal vein,
however. No evidence of renal abscess and unremarkable
kidneys with no lower abdominal collections. An HIV test was
pursued and was found to be negative.
The patient had an esophagogastroduodenoscopy before the
transesophageal echocardiogram to rule out upper
gastrointestinal source of bleeding. Grade I varices were
seen in the esophagus. An abdominal CT was pursued which
revealed small pleural effusions and nonobstructing clot in
the SMV. There was no evidence of ischemia. No abscesses or
other abnormalities were noted. The pancreas was noted to be
normal. HCV PCR revealed nondetectable viral load.
Because the patient had persistent tenderness over his lower
back including L4-L5 and L5-S1, a magnetic resonance scan was
done of the back which revealed subtle T11 to T12 increase
intensity on the T2 images. Further evaluation with bone
scan was considered. The patient had wound cultures sent
from his abdominal wound which showed moderate growth,
coagulase positive Staphylococcus. Repeated chest x-rays
showed persistent bibasilar opacities consistent with
aspiration.
CT surgery was consulted for possible surgical management of
his endocarditis although they did not feel that there was a
need for surgical intervention at the time. The patient also
was found to have a patent foramen ovale which was found to
be small. CT surgery recommended evaluating the patient for
lower extremity sources of emboli. Lower extremity
ultrasound was negative bilaterally for deep vein thrombosis.
It was then thought that the source of possible embolic event
may have been from endocarditis.
3. Cardiovascular - The patient with transesophageal
echocardiogram revealing a 4.0 millimeter vegetation and a
patent foramen ovale. Paradoxical embolus was thought to be
unlikely given the size of the patent foramen ovale. Lower
extremity ultrasound looking for source of paradoxical emboli
was negative bilaterally. CT surgery followed the patient
while in the hospital and did not see any acute intervention
being indicated. The patient was only found to have 2+
aortic insufficiency on transesophageal echocardiogram and no
evidence of valve damage or paravalvular abscess.
4. Renal - The patient was found to have acute renal failure
upon presentation and upon examination of the urine was found
to have coarse muddy brown casts consistent with acute
tubular necrosis. The patient was also markedly dehydrated
because of high ostomy output. Thus, his renal failure was
thought to be secondary to acute tubular necrosis and
prerenal causes. He received fluid hydration and his
creatinine gradually resolved to baseline of 0.8 to 0.9.
5. Psychiatric - The patient with reported history of
schizophrenia versus schizo-affective disorder. Psychiatry
followed the patient while in hospital and felt there was no
current indication for antipsychotic pharmacology. The
patient also with a history of depression treated with
Prozac. He remained stable while in the hospital.
6. Gastrointestinal - The patient with pancreatitis with
increasing lipase and amylase but no evidence of inflammation
on abdominal CT. The patient was also found to be gastric
occult positive in the Intensive Care Unit but stable on the
floor. His hematocrit was found to be stable as well. An
esophagogastroduodenoscopy was performed before the
transesophageal echocardiogram which revealed grade I
varices. The patient was quickly started on proton pump
inhibitor and Propanolol which was titrated to keep his pulse
below 60. The patient's diet was advanced despite increase
in lipase and amylase. Gastroenterology followed the patient
while in the hospital.
CONDITION ON DISCHARGE: Good.
The rest of the discharge summary will be dictated closer to
the day of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36
D: [**2195-12-5**] 13:42
T: [**2195-12-5**] 14:00
JOB#: [**Job Number 18251**]
Name: [**Known lastname 2935**], [**Known firstname 63**] Unit No: [**Numeric Identifier 2936**]
Admission Date: [**2195-11-27**] Discharge Date: [**2195-12-6**]
Date of Birth: [**2145-8-22**] Sex: M
Service:
SUMMARY OF HOSPITAL COURSE: From a pulmonary standpoint the
patient had a negative swallow study making recurrent
aspiration less likely. He was continued on his Albuterol
and Flovent inhalers.
From an infectious disease standpoint, the patient had
recurrent bibasilar areas of consolidation and was started on
Levofloxacin 500 mg p.o. q. day. The patient remained
afebrile for 24 hours after starting the Levofloxacin. Per
recommendation of radiology and infectious disease, bone scan
was scheduled. Infectious disease felt that it might be
appropriate to increase the duration of antibiotics to eight
weeks based on a positive bone scan for osteomyelitis.
From a cardiovascular standpoint, the patient was found to
have bacterial endocarditis and a patent foramen ovale.
Cardiothoracic Surgery continued to follow. From a renal
standpoint the patient's renal failure completely resolved.
From a psychiatric standpoint, the patient remained
compensated without any need for antipsychotic medication.
From a gastrointestinal standpoint the patient had evidence
of chemical pancreatitis with an elevated lipase and amylase,
however, there is no pancreatic inflammation on computerized
tomography scan, nor were there any abdominal symptoms. In
consultation with the Gastroenterology Service it was felt
that the patient was not experiencing pancreatitis and that
following amylase and lipase would not be helpful in this
patient. The patient tolerated a regular diet without
difficulty and remained asymptomatic. The patient was
continued on Propranolol for his Stage 1 esophageal varices.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient was discharged with follow up
in the Infectious Disease Clinic and with follow up in his
primary care physician's office.
DISCHARGE MEDICATIONS:
1. Multivitamin one p.o. q. day
2. Vancomycin 750 mg intravenously q. 8 hours for six to
eight weeks
3. Prozac 100 mg p.o. q. day
4. Propranolol 40 mg p.o. b.i.d.
5. Trazodone 50 mg p.o. q.h.s.
6. Levofloxacin 500 mg p.o. q. day for a total of a seven
day course
7. Flovent 2 puffs b.i.d.
8. Neurontin 300 mg p.o. t.i.d.
9. Zestril 5 mg p.o. q. day
10. Thiamine 100 mg p.o. q. day
11. Protonix 40 mg p.o. q. day
12. Albuterol 2 puffs q. 4 prn shortness of breath
13. Tylenol 650 mg p.o./p.r. q. 4-6 hours prn
14. Cyclobenzaprine 10 mg p.o. t.i.d. prn pain
15. Ultram 50 mg p.o. q. 4 to 6 hours prn pain
DISCHARGE DIAGNOSIS:
1. Methicillin-resistant Staphylococcus aureus endocarditis
2. Cirrhosis with Grade 1 esophageal varices
3. Acute renal failure
4. Pancreatitis
5. Arteriosclerotic disease
6. Hepatitis B
7. Hepatitis C
8. Polysubstance abuse
9. Positive PPD
10. Hypertension
11. Gastroesophageal reflux disease
12. Restrictive and obstructive lung disease
13. History of osteomyelitis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**]
Dictated By:[**Last Name (NamePattern1) 2134**]
MEDQUIST36
D: [**2195-12-6**] 14:19
T: [**2195-12-6**] 14:36
JOB#: [**Job Number 2937**]
Name: [**Known lastname 2935**], [**Known firstname 63**] Unit No: [**Numeric Identifier 2936**]
Admission Date: [**2195-11-27**] Discharge Date: [**2195-12-9**]
Date of Birth: [**2145-8-22**] Sex: M
Service:
INTERNAL HOSPITAL COURSE:
Following most recent addendum on [**2195-12-6**], the patient has
done well in general. For his endocarditis, he was continued
on Vancomycin 750 IV q eight. He did have recurrent fever to
101 on [**2194-12-8**] however, he had no focal change in symptoms.
He had not been started on levofloxacin on [**12-6**] as had been
previously noted and this was added for persistent cough and
persistent areas of bibasilar consolidation. In addition, he
had stool culture which was negative, blood cultures x2 which
remain negative, urinalysis which was negative, and bone scan
which did show increased uptake at T11-12 level consistent
with osteomyelitis. He also had stable uptake at T9 as
previous area of osteomyelitis.
On [**2195-12-9**], the patient reported feeling well and had no
recurrent fevers. He had improving cough and persistent low
back pain, but no pain or tenderness at the thoracic spine.
Our discussion with the Medical and Infectious Disease team
thought the patient was stable for discharge to
rehabilitation. Should he have recurrent fever,
consideration should be given to re-imaging his thoracic
spine with MRI, white blood cell scan, or possibly repeat
echocardiogram. The patient will continue on Vancomycin for
a total of eight weeks for his methicillin-resistant
Staphylococcus aureus endocarditis with osteomyelitis.
DISCHARGE MEDICATIONS:
1. Multivitamin one po q day.
2. Vancomycin 750 mg IV q eight through [**2196-2-6**].
3. Prozac 100 mg po q day.
4. Propanolol 40 mg po bid.
5. Trazodone 50 mg po q hs.
6. Levofloxacin 500 mg po q day through [**2195-12-16**].
7. Flovent two puffs [**Hospital1 **].
8. Neurontin 300 mg po tid.
9. Zestril 5 mg po q day.
10. Thiamine 100 mg po q day.
11. Protonix 40 mg po q day.
12. Albuterol two puffs q four prn shortness of breath.
13. Tylenol 650 mg po PR q 4-6 hours prn.
14. Cyclobenzaprine 10 mg po tid prn pain.
15. Ultram 50 mg po q 4-6 hours prn pain.
DISCHARGE INSTRUCTIONS:
The patient will follow up with ID and Hepatology Clinics and
with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2950**].
DISCHARGE DIAGNOSES:
1. Methicillin-resistant Staphylococcus aureus endocarditis
with T11 osteomyelitis.
2. Cirrhosis with Grade I esophageal varices.
3. Acute renal failure now resolved.
4. Pancreatitis.
5. AFB.
6. Hepatitis B and C positive.
7. History of polysubstance abuse.
8. Pneumonia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**]
Dictated By:[**Last Name (NamePattern1) 2951**]
MEDQUIST36
D: [**2195-12-9**] 10:07
T: [**2195-12-9**] 10:14
JOB#: [**Job Number 2952**]
|
[
"456.21",
"518.82",
"421.0",
"038.11",
"276.5",
"730.28",
"507.0",
"571.5",
"070.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71",
"42.23",
"45.16",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4563, 4596
|
18636, 19186
|
17868, 18431
|
15567, 16479
|
4154, 4291
|
16496, 17845
|
18455, 18615
|
13150, 14724
|
4619, 6573
|
162, 181
|
210, 3590
|
3612, 4128
|
4308, 4546
|
14749, 14910
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,957
| 153,313
|
4493
|
Discharge summary
|
report
|
Admission Date: [**2161-5-28**] Discharge Date: [**2161-5-31**]
Date of Birth: [**2099-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD - [**2161-5-29**]
History of Present Illness:
Mr. [**Known lastname **] is a 61 yo male with HCV cirrhosis followed at the
[**Hospital1 756**] and chronic alcohol abuse with ESLD and history of
varices. He reports feeling dizzy yesterday and having one
episode of bright red bloody emesis. Then, last night he
developed abdominal discomfort, and today noticed much worsening
of his hematesis. He also passed out when bending over. He
denies preceeding presyncope, SOB, CP. he was out for only a
short time. He reports 2-3 days of chills and cough, but no
other focal infectious symptoms. EMS was called and saw clots.
They gave him 500cc IVF and brought him to the [**Hospital1 18**] ED.
In the ED, initial vs were: 98.6 135 113/80 16 100
His HCT was 22. His INR was 1.7. Lactate 6.4. BUN 25 with Cr
0.7. His BP was stable in the ED, but he remained tachycardic.
He received 3L IVF. He actively vomited clots. An NG lavage
was performed and showed bright red blood with clots and did not
clear. He had guaiac positive melena in ED. He was T/C x
several units, and was receiving one at the time of transfer.
He received 40mg of protonix and started on a drip, octreotide,
zofran, and 1g ceftriaxone. Prior to transfer, his last BP was
127/74, HR 117. He has 2 18G PIV.
On the floor, he was comfortable and not vomiting. He remained
tachy but his blood pressure was stable. 250cc x 3 of NG lavage
improved until a flash of bright red blood at the end of the
lavage.
Past Medical History:
Nadolol 40
Lasix 20 daily
PPI 40 [**Hospital1 **]
Thiamine
Folate 1mg
MVI
Iron Sulfate 325mg [**Hospital1 **]
Social History:
Reports 1-2 beers on the weekends. He lives with his wife. [**Name (NI) **]
has a history of IVDU, which is how he contracted HCV.
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam
Vitals: 98.4 131/78 105 100% on 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. NGT in place
with bright red blood
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1, pronounced S2, 3/6 SEM
loudest at apex, rubs, gallops
Abdomen: soft, non-distended, bowel sounds present. Mild TTP
diffusely, no rebound tenderness or guarding. Liver tip felt
below costal margin. Spleen not palpable.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
skin: diffuse psoriatic patches
Pertinent Results:
ADMISSION LABS
[**2161-5-28**] 09:36PM BLOOD WBC-7.4 RBC-2.32* Hgb-6.5* Hct-22.1*
MCV-95 MCH-28.2 MCHC-29.7* RDW-18.2* Plt Ct-152 Neuts-78.9*
Lymphs-13.0* Monos-7.8 Eos-0.1 Baso-0.2
[**2161-5-28**] 09:36PM BLOOD PT-18.9* PTT-32.0 INR(PT)-1.7*
[**2161-5-28**] 09:36PM BLOOD Glucose-165* UreaN-25* Creat-0.7 Na-142
K-4.2 Cl-106 HCO3-23 AnGap-17
[**2161-5-28**] 09:36PM BLOOD ALT-31 AST-51* AlkPhos-82 TotBili-1.1
EGD [**2161-5-29**]
Impression: [**Doctor First Name **]-[**Doctor Last Name **] tear; Varices at the lower third of
the esophagus and gastroesophageal junction; Erythema,
congestion, abnormal vascularity and mosaic appearance in the
whole stomach compatible with portal gastropathy; Erythema in
the antrum and stomach body compatible with gastritis; Erythema
and friability in the duodenal bulb and first part of the
duodenum compatible with duodenitis; Otherwise normal EGD to
second part of the duodenum
Recommendations: Esophageal varices without high risk stigmata.
Band ligation not performed. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear at GE junction
likely source of bleed without evidence of active bleeding.
Gastropathy, gastritis and duodenitis. Please continue IV PPI,
carafate, Octreotide overnight, abx.
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2161-5-29**] 11:19 AM
1. Echogenic and nodular liver, compatible with the history of
cirrhosis. Normal Doppler examination.
2. Trace perihepatic ascites. Pericholecystic fluid and wall
thickening is nonspecific in the setting of ascites.
Discharge Labs:
[**2161-5-31**] 06:50AM BLOOD WBC-5.4 RBC-3.27* Hgb-9.7* Hct-29.9*
MCV-92 MCH-29.5 MCHC-32.3 RDW-17.7* Plt Ct-69*
[**2161-5-31**] 06:50AM BLOOD Plt Ct-69*
[**2161-5-31**] 06:50AM BLOOD
[**2161-5-31**] 06:50AM BLOOD Glucose-101* UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-105 HCO3-26 AnGap-10
[**2161-5-31**] 06:50AM BLOOD ALT-24 AST-35 AlkPhos-77 TotBili-1.7*
[**2161-5-31**] 06:50AM BLOOD Albumin-2.7* Calcium-7.2* Phos-2.4*
Mg-2.0
.
Brief Hospital Course:
Mr. [**Known lastname **] is a 61 yo male with HCV cirrhosis and a history of
alcohol abuse who presents with hematemesis, tachycardia, and a
HCT of 22.
#. Hematemesis: Initially concerning for variceal bleed given he
has a history of HCV cirrhosis and alcohol abuse as well as a
possible history of varices. HCT 22 with unclear baseline. He
was matched for 8 units and received a total of 3U PRBCs.
Elevated lactate likely related to volume depletion from
bleeding, improved to 3.3 on recheck. Repeat HCT stablizized
after transfusion. Also given 2U FFP for reversal of
coagulopathy. On [**2161-5-29**] underwent EGD that revealed
[**Doctor First Name **]-[**Doctor Last Name **] tear and varices without evidence of variceal
bleeding. Treated with Octreotide gtt, Protonix gtt and
Ceftrixone for 24 hours. Was then continued on daily Protonix
and sucralfate. Ultrasound revealed trace perihepatic ascites
but normal doppler flow through the portal vein.
#. Syncope: Initially attributed to volume depletion. Also has a
history of aortic stenosis with loud murmur heard throughout
precordium and radiating to carotids and back. No further
episodes of lightheadedness after volume resuscitation.
#. Alcohol abuse: Per history was not overly significant in
recent past. Kept on CIWA scale and given thiamine / folate.
#. HCV cirrhosis: INR 1.7 on admission consistent with cirrhosis
and liver decompensation. Ultrasound as above consistent with
cirrhosis.
#. HTN: Initially held antihypertensives in setting of acute
bleeding. Restarted Nadolol [**2161-5-30**].
# Aortic Stenosis: Unknown severity and followed by outpatient
provider. [**Name10 (NameIs) **] not thought to be contributory to current
syncopal episode. Referred for continued outpatient management.
Medications on Admission:
Nadolol 40mg po daily
Lasix 20mg po daily
PPI 40mg po BID
Thiamine daily
Folate 1 mg daily
MVI daily
Iron Sulfate 325mg po BID
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
[**Doctor First Name **]-[**Doctor Last Name **] Tear
Acute Blood loss Anemia
EtOH Abuse
.
Secondary:
Hepatitis C cirrhosis
Severe Aortic Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for hematemesis which was found to be the
result of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**]-[**Doctor Last Name **] tear in your esophagus. You received 3
blood transfusions, IV fluids and medications to help stop the
bleeding. You also reported a syncope event in the setting of
the bleed which is felt due to a combination of your known
severe aortic stenosis and the bleeding.
.
Your home medications were restarted prior to your discharge.
.
Please follow up with your medical team at [**Hospital6 13185**] for further care of your cirrhosis and aortic stenosis.
.
It is very important that you stop drinking alcohol as this is
worsening your health and putting your life in danger.
Followup Instructions:
Please follow up with your gastroenterologist at [**Hospital1 3372**]. You missed your appointment on [**2161-5-29**]. This
should be rescheduled. Please call their office on Tuesday, [**6-2**] to reschedule.
|
[
"785.0",
"276.52",
"456.21",
"572.3",
"276.7",
"790.01",
"537.89",
"696.1",
"070.70",
"303.91",
"571.2",
"401.9",
"530.7",
"535.50",
"272.4",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7261, 7267
|
4865, 6648
|
326, 349
|
7467, 7467
|
2847, 4397
|
8374, 8586
|
2120, 2137
|
6826, 7238
|
7288, 7446
|
6674, 6803
|
7618, 8351
|
4413, 4842
|
2152, 2828
|
275, 288
|
377, 1821
|
7482, 7594
|
1843, 1954
|
1970, 2104
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,851
| 117,270
|
44302
|
Discharge summary
|
report
|
Admission Date: [**2125-11-15**] Discharge Date: [**2125-11-23**]
Date of Birth: [**2061-2-21**] Sex: M
Service: MEDICINE
Allergies:
Motrin / Codeine / Nortriptyline
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
fever and SOB at HD
Major Surgical or Invasive Procedure:
R femoral line placement
L femoral tunnelled line removal by IR
History of Present Illness:
64 yo M with multiple medical problems including Hep C, HIV,
ESRD on HD, CHF recently hospitalized in [**2125-8-8**] for MRSA
bacteremia as well as large thigh hematoma [**2-9**] supratherapeutic
INR.
.
Patient is a poor historian and gave several different accounts.
He was at HD earlier today, and he complained of fevers and
chills at HD. sats down to low 80s, tachy, temp 101.5, shaking,
SOB, tachy, couldn't talk in more than a few words. Got a full
session today. Had roughly 4 kg taken off. Per renal, will wait
until tomorrow to complete full dialysis. He was placed on CPAP
and got better. Got vanco at HD, BlCx drawn there. Per report,
[**4-11**] blood cultures positive for MRSA.
.
Notably, Pt with extensive h/o access problems, [**Name (NI) 94992**] occluded,
[**Name (NI) 94993**] thrombosed, IVC occlusion, R-AVgraft failed, Purulent
d/c from R chest. Consider reimaging R sided wound with purulent
discharge. At 3am, pt noted to be less responsive, triggered on
floor, transferred to MICU for ?bleeding, and mental status
changes.
.
Currently, he reports feeling unwell, but unable to clarify
exactly how. He reports having pain in LE (chronic) as well as
pain in R shoulder (old). He reports some mild SOB, but states
that his breathing is better than earlier, he is c/o
regurgitation. No fevers, chills. He does c/o nausea and 1
episode of diarrhea yesterday.
Past Medical History:
1) HIV: diagnosed in [**2106**], followed by Dr. [**Last Name (STitle) 1057**] at [**Hospital1 18**]; [**4-14**]
VL <50; CD4 614 in [**8-/2125**]
2) Diabetes Mellitus, type 2, since ~[**2106**] with neuropathy,
charcot foot, nephropathy, and ? mild retinopathy.
2) Chronic renal failure on Hemodialysis and graft infections,
thrombus: dx approx. [**2115**]. Started HD in 2/[**2118**].
On HD on tues, thurs, sat at [**Doctor Last Name **] hospital. Dialysis unit -
([**Telephone/Fax (1) 17592**] / Nephrologist - Dr. [**Last Name (STitle) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] -([**Telephone/Fax (1) 94994**]
3) [**Female First Name (un) 564**] esophagitis
4) Hepatitis C: genotype IB-> last viral load [**8-/2124**] 175,000
5) Congestive heart failure: last EF 50-55%, known ASD
6) Necrotizing Fasciitis: [**2112-10-17**]- [**2113**]: multiple surgeries and
circumcision during hospitalization.
7) hypertension
8) Hypercholesterolemia
9) LE Diabetic ulcers
10) Herpes zoster of the left mandibular distribution of the
trigeminal nerve. [**2115**]
11) R suprapatellar abscess: [**2115**].
12) IVDU (heroin and cocaine) [**2079**]-[**2102**], none since [**2102**]
13) Obesity
15) GI Bleed: [**2117**]. OB positive stool. No frank blood. Negative
scopes.
16) Anemia: [**2117**]. Started Epogen.
18) Colonic Polyps
19) Gastritis with large hiatal hernia.
20) Lipodystrophy
21) Charcot foot: dx in [**9-12**].
22) Colonic AVM: seen on [**3-8**] colonoscopy on the ileocecal
valve. Treated with thermal therapy. At that time was also
offerred hormonal therapy, but this was deferred.
23) positive AFB in sputum: [**2119-11-17**]. MYCOBACTERIUM GORDONAE. No
abnormalities on CT chest in [**2121**].
24) MRSA- grew out from culture from L ant chest wound
25) venous access problems as noted above
Social History:
lives alone. Hx of tobacco abuse (quit 20 yrs ago),
hx of alcohol abuse (quit >20 yrs ago), hx of heroin and cocaine
abuse (quit >20 yrs ago)
Family History:
non-contributory
Physical Exam:
On admission
VS: 102.5 136/59 116 24 93% 4LNC + face tent
GEN: awake, answering questions appropriately, appears
uncomfortable
HEENT: dry MM, OP clear
CV: Reg Nml S1, S2, no m/r/g
LUNGS: CTABL (ant and lat), No crackles or wheezing
ABDOMEN: Soft ND/NT +BS
EXT: Left HD line in place; R fem line in place,
Charcot foot, numerous ulcers
NEURO: A/OX3,
Pertinent Results:
[**2125-11-21**] 06:09AM BLOOD WBC-6.8 RBC-2.99* Hgb-9.0* Hct-28.2*
MCV-94 MCH-30.0 MCHC-31.8 RDW-19.7* Plt Ct-301
[**2125-11-21**] 06:09AM BLOOD Glucose-83 UreaN-34* Creat-6.1*# Na-141
K-4.5 Cl-99 HCO3-31 AnGap-16
[**2125-11-21**] 06:09AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.1
[**2125-11-21**] 06:09AM BLOOD Vanco-20.9*
.
CXR FINDINGS: In comparison with the study of [**11-18**], there is
still evidence of vascular congestion with some enlargement of
the cardiac silhouette. Prominence of the central pulmonary
vessels and mediastinum is again noted.
IMPRESSION: No significant change.
.
[**2125-11-23**] 07:23AM BLOOD WBC-8.1 RBC-2.88* Hgb-8.5* Hct-27.2*
MCV-95 MCH-29.4 MCHC-31.1 RDW-20.0* Plt Ct-335
[**2125-11-22**] 08:02AM BLOOD Glucose-78 UreaN-46* Creat-7.2* Na-140
K-4.7 Cl-99 HCO3-28 AnGap-18
[**2125-11-23**] 07:23AM BLOOD Calcium-9.8 Phos-3.2 Mg-2.0
Brief Hospital Course:
63 y/o M with HIV, HCV, IDDM, ESRD on HD recently s/p MRSA
bacteremia who is transferred from HD with fever, chills. He
was transferred to MICU with MRSA bacteremia then transferred
back to floor on [**2125-11-18**].
.
1. MRSA bacteremia - Pt has h/o recurrent bacteremia with MRSA
thought due to line infections but concerning for another
source. Pt has persistently refused MRI to evaluate for spine
osteo and refused TEE to r/o endocarditis. He also refused
right upper chest wall u/s to evaluate for abscess. Pt was
encouraged by PCP, [**Name10 (NameIs) **] and primary team to pursue these studies,
but he preferred to go back to NH and discuss proceeding with
further work up with his PCP at [**Name Initial (PRE) **] later date. During this
admission, pt had one set of blood cultures from [**2125-11-15**] that
was 2/2 bottles positive for MRSA. His femoral dialysis line was
removed on [**11-16**] and line tip was also +MRSA. All other blood
cultures have been no growth to date. Cultures from the right
anterior chest wound from OSH grew vancomycin resistant staph
aureus. A culture from the wound with results pending at time
of discharge. Please note, pt will need to be continued on
Vancomycin for another 7 days (ending on [**12-1**]).
It should be dosed at [**Location (un) **] dialysis center on tu/th/sa.
.
2. Resp distress - Upon admission, question of possible
aspiration pneumonia vs pulm effusion due to fluid overload on
initial CXR. Pt was treated empirically with Levofloxacin and
Vanco. Pt had no e/o respiratory distress on the floor, he
denied any SOB/cough/sputum production. WBC count was not
elevated and his lung exam was clear. Pt does not appear
clinically to have a pneumonia, he maintains normal oxygen
saturations on room air. However, he has a large neck
circumference and likely has obstructive sleep apnea, but does
not tolerate CPAP. At time of discharge, patient was saturating
well on room air without respiratory distress.
.
3. CHF- Recent echo showed an EF of 50% and pt likely has
chronic diastolic dysfunction. His BP remained stable on home
regimen of Metoprolol 25mg [**Hospital1 **] and he relies on dialysis to
help remove additional fluid & prevent pulm edema. Lung exam
was clear on the day of discharge.
.
4. Thrombosis - h/o multiple clots in grafts and IVC on chronic
coumadin. INR was therapeutic on the day of discharge at 2.1.
Coumadin should be continued at 5mg qhs and his INR should be
monitored and coumadin adjusted for a goal of INR of [**2-10**].
.
5. Hepatitis C: Hep C viral load was drawn and is currently
4,290. LFTs stable and pt has no documented h/o cirrhosis. A
RUQ U/S was unremarkable.
.
6. HIV: His last CD4 count was 614 ([**4-14**]). Pt maintained on
HAART, followed by Dr. [**Last Name (STitle) 1057**]. Pt was maintained on home regimen
of indinavir, ritonavir, lamivudine and there was no need for
PCP [**Name9 (PRE) **] with CD4>200. Pt will need to f/u with Dr. [**Last Name (STitle) 1057**] for
primary care of his HIV & HAART therapy.
.
7. ESRD on HD: Pt had a Left Femoral dialysis line placement on
[**11-18**] and has been maintained on dialysis Tu/Th/Sa. Pt was
continued on sevelamer & nephrocaps. Electrolytes stable on day
of discharge.
.
8. Diabetes-insulin dependent with peripheral neuropathy,
charcot foot, neuropathic ulcers and retinopathy. His last hgb
A1c was 6.3%. BS were well controlled with Insulin sliding
scale QID and a diabetic diet. He was continued on gabapentin
300mg q48hrs for neuropathy.
.
9. Wound care: dry dressing changes were performed twice daily
to both feet ulcers and to Right upper chest wall.
.
9. Anemia- h/o chronic anemia likely [**2-9**] ESRD, stable at
baseline hct throughout admission.
.
10. Access: Left femoral dialysis line.
Medications on Admission:
1. Albuterol Sulfate
2. Methadone 80 mg daily
3. Indinavir 800 mg Capsule [**Hospital1 **]
4. B Complex-Vitamin C-Folic Acid 1 mg
5. Gabapentin 300 mg [**Hospital1 **]
6. Quinine Sulfate 325 mg PO HS
7. Ritonavir 100 mg [**Hospital1 **]
8. Oxycodone-Acetaminophen 5-325 mg
9. Senna 8.6 mg [**Hospital1 **]
10. Docusate Sodium 100 mg [**Hospital1 **]
11. Stavudine 20 mg daily
12. Metoprolol Tartrate 25 mg [**Hospital1 **]
13. Sevelamer 800 mg TID
14. Ammonium Lactate 12 % [**Hospital1 **]
16. Lamivudine 150 mg Tablet QHD
17. Insulin
18. cymbalta
19. also taking coumadin, confirmed with rehab
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Inhalation Q6H (every 6 hours) as needed.
3. Indinavir 400 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID (2 times
a day).
4. Ritonavir 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times
a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
6. Stavudine 20 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q24H (every
24 hours).
7. Sevelamer 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
8. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q48H (every
48 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID
(2 times a day).
11. Insulin Regular Human Subcutaneous
12. Prednisolone Acetate 1 % Drops, Suspension [**Hospital1 **]: One (1) Drop
Ophthalmic QID (4 times a day).
13. Tobramycin-Dexamethasone 0.3-0.1 % Ointment [**Hospital1 **]: One (1)
Appl Ophthalmic QHS (once a day (at bedtime)).
14. Ciprofloxacin 0.3 % Drops [**Hospital1 **]: 1-2 Drops Ophthalmic [**Hospital1 **] (2
times a day).
15. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
16. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension [**Hospital1 **]:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
17. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
18. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
19. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime:
please adjust coumadin dosing for goal INR of [**2-10**].
20. Vancomycin 500mg IV -PLEASE NOTE-Vanc levels should be drawn
and pt should be dosed with Vancomycin at dialysis for another 7
days (completing course of antibiotics on [**12-1**]).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **] & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
MRSA Bacteremia
Line infection
Discharge Condition:
Good
Discharge Instructions:
You were admitted from hemodialysis with fever & chills. You
were diagnosed with an MRSA blood infection. You have been
receiving antibiotics for this infection and have been doing
well. You should continue with dialysis on tues/thurs/sat and
they will administer your Vancomycin at dialysis for a total of
2weeks of antibiotics.
If you experience any concerning symptoms including nausea,
vomiting, fever, chills, chest pain, shortness of breath or any
other general worsening of condition, please call your doctor or
return to the ER.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on Tuesday [**12-11**] at
6:40pm
You have an appointment with Dr. [**Last Name (STitle) 1057**] on [**1-2**] at 10am.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2126-1-9**] 9:30
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24,040
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Discharge summary
|
report
|
Admission Date: [**2180-4-7**] Discharge Date: [**2180-4-26**]
Date of Birth: [**2124-6-22**] Sex: M
Service: MEDICINE
Allergies:
Pentamidine Isethionate / Nevirapine / Sulfamethoxazole /
Amitriptyline Hcl / Imipramine / Clindamycin / Abacavir /
Gabapentin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Reason for MICU admission: Pressors, sepsis resussitation
Major Surgical or Invasive Procedure:
central line placement and removal
peripherally inserted central catheter placement, inadvertently
removed by patient
bone marrow biopsy
endoscopic retrograde cholangiography
History of Present Illness:
55 year old man with PMH of HIV, alcohol abuse, and PCP presents
with fever and diarrhea x 5 days. He reports that he was started
on HAART a few months ago, but had gone on an alcoholic binge
and decided not to take the HAART. Around Patriot's Day he had
some diarrhea which he attributed to HAART. He was very weak
during this period and stopped taking the HAART, after which he
felt significantly better for 2 days. Over the next few days,
the patient has had predominantly diarrhea with only [**12-14**] solid
BM's, subjective fevers and soaking night sweats, mild cough
productive of clear mucus. He is very weak and lethargic. His
friends told him that he looked [**Last Name (LF) 99136**], [**First Name3 (LF) **] he called his PCP's
office and came into the ED. [**Hospital1 112**] was on diversion so he came to
[**Hospital1 18**] instead.
.
In the ED, his initial BP was 88/54 and he had a temp of 100.9.
He was given 4L of NS with no improvement of his blood pressure
to 80/45. He received vanc/levo/flagyl and a code sepsis was
called. CT abdomen/pelvis showed no pathology, and CXR showed no
pneumonia. He received another 1L of fluid but CVP was >8 so he
was started on levophed and admitted to the [**Hospital Unit Name 153**] for sepsis.
.
[**Hospital Unit Name 153**] course: Initially on vanc/levo/flagyl. Stabilized and off
pressors within 12hrs. US with evidence of acute
cholecystitis(?) - added cefepime for broader GM NEG coverage.
On [**4-8**], he spiked to 103.3 and on [**4-9**]: Hemolysis noted on labs
-> marked hemolysis requiring 2 units transfusion overnight. Due
to ongoing temp spikes and hypoxia, cefepime was changed to
meropenem. Heme saw and ruled out TTP-HUS. He also had BMBX for
pancytopenia. MICRO studies sent in [**Hospital Unit Name 153**]: Cdiff, Blood cultures,
sputum for PCP, [**Name10 (NameIs) 1074**] VL, Stool O and P, galactomannin, B glucan.
.
A code purple was called in the [**Hospital Unit Name 153**] prior to transfer as
patient wanted to leave. Controlled with Haldol. Upon arrival to
the floor on [**4-19**], he trigerred for hypoxia, tachycardia, had a
fever of 100.8, tremors -> from anxiety. Treated with nebs,
ativan/haldol, bl/urine cx drawn.
.
ROS: Reports that stomach is distended. Has lost 20 pounds over
the last 6 weeks. Fever, chills, sweats, cough, diarrhea (mucus
watery stool) as per HPI. Has some associated abdominal pain
lasting less than 10 seconds, LLQ, crampy while in hospital.
Also has nausea and vomiting. Feels generally ill. Has some SOB
at baseline, variable. Denies chest pain. Hasn't been able to
hold much food down - last time was 2 days PTA, could eat a
little pasta down. Has been able to keep liquids down.
Past Medical History:
HIV, diagnosed in [**2166**], on and off various HAART regimens. Last
CD4 22 in [**11-16**] and VL > 500K
Pneumocystis pneumonia - multiple times (last time over a year
ago)
Alcohol abuse - last drink [**3-27**]
COPD
Social History:
Lives alone. Partnerl died in [**2168**], smokes 1 ppd from 2 ppd for
30 years. Drinks 12+ beers per day when drinking (in binges).
Worked as house painter.
Family History:
NC
Physical Exam:
PE: Tm 101.9 Tc 99.1 P 104 BP 115/66 R21 97% 2L NC CVP 8 SVO2
55%
Gen: Appears acutely ill, no respiratory distress, able to give
full history
HEENT: PERRLA, EOMI, MM dry, OP clear
Neck: right IJ in place
Resp: end expiratory wheezes all areas, no crackles
CV: tachy distant nl s1s2 no M
Ext: Soft NTND hyperactive bowel sounds
Neuro: CN 2-12 intact, strength intact in UE and LE.
Pertinent Results:
EKG: NSR at 83, NL axis, no ST/T wave changes. No previous for
comparison.
.
CXR: Two views of the chest demonstrate clear lungs, normal
cardiac and mediastinal contours, and unremarkable osseous
structures.
IMPRESSION: No pneumonia.
.
CT Abd:
IMPRESSION:
1. Splenomegaly.
2. Diffusely prominent mesenteric and retroperitoneal lymph
nodes which overall do not meet CT criteria for pathologic
enlargement.
3. Small amount of free fluid within the abdomen.
4. Fatty liver.
5. Equivocal cholelithiasis.
.
RUQ ULTRASOUND to evaluate "equivocal" cholelithiasis as source
of sepsis:
ADDENDUM: Upon re-evaluation of the son[**Name (NI) 493**] images, as well
as further clinical information, the findings are less
suggestive of acute cholecystitis. The patient has
hypoalbuminemia with an albumin level of 2.8 on [**2180-4-6**] (one day
prior to the ultrasound) and current albumin level of 1.7,
approximately four days later. Gallbladder wall edema and
pericholecystic fluid, as seen on the ultrasound, can be often
seen in patients with hypoalbuminemia. Additionally the
gallbladder is not tense and distended as is usually seen in
cholecystitis. Finally, the patient has a history of HIV and
could be presenting with AIDS related cholangiopathy to account
for his symptoms.
IMPRESSION:
1. Gallbladder wall edema, most likely secondary to acute
cholecystitis.
2. Common bile duct is mildly dilated, measuring 7 mm; however,
no stone is seen within the CBD.
3. The liver demonstrates increased echogenicity with
appearance of fatty
liver; however, other liver disease including cirrhosis and
fibrosis cannot be excluded.
.
MRCP to further evaluate cholecystitis:
1. Gallbladder wall thickening and pericholecystic fluid
consistent with
cholecystitis.
2. No evidence of intra- or extra-hepatic biliary ductal
dilatation or
pancreatic ductal dilatation.
3. Splenomegaly.
4. Moderate right pleural effusion and small amount of ascites.
.
ERCP:
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles, cystic duct, and gallbladder
were filled with contrast and well visualized. The course and
caliber of the structures are normal with no evidence of
extrinsic compression, no ductal abnormalities, and no filling
defects. Normal ERCP to the second part of duodenum.
.
BONE MARROW BIOPSY, for pancytopenia:
1. Hypercellular, erythroid dominant bone marrow with
megaloblastoid erythropoiesis, left-shifted myelopoiesis, and
megakaryocytic hyperplasia and dysplasia, see note.
Note: The morphologic changes [megaloblastic erythropoiesis,
dysplasia] are in keeping with a background HIV-related and/or
treatment-related myelopathy. No lymphoma is noted.
2. Small, non-necrotizing granulomata seen.
Special stain for infectious organisms are pending and will be
reported in an addendum.
BONE MARROW PATH REPORT ADDENDUM:
AFB and GMS stains are negative for acid-fast and fungal
organisms, respectively. Of note, the granulomas were no longer
present on deeper levels obtained for stains. By
immunohistochemistry, stain for [**Date Range 1074**] is negative. CD68 stains
abundant interstitial histiocytes.
Brief Hospital Course:
55yo male with h/o AIDS (CD4 51, VL >100,000), HCV, multiple
episodes of PCP, [**Name10 (NameIs) **] initially in shock with presumed
sepsis of biliary source, now with AFB in blood cultures and
stool cultures, likely disseminated MAC
# Disseminated MAC: High suspicion of MAC given constellation of
diarrhea, fevers with night sweats, mesenteric lymphadenopathy,
and pancytopenia with necrotizing granulomata on bone marrow in
an AIDS patient who was not taking MAC prophylaxis. AFB in blood
cultures from [**4-7**] and [**4-9**] and also in stool culture from [**4-12**].
Most likely MAC, less likely TB. Of note, smears of concentrated
sputum samples were negative x3 therefore patient does not have
infectious pulmonary tuberculosis. Started ethambutol 15mg/kg,
rifabutin 150mg every other day (dose adjusted for concurrent
ritonavir therapy, see below), and clarithromycin 500mg [**Hospital1 **];
will need prolonged course. Had opthalmologic exam on starting
high dose ethambutol and will need follow-up monitoring of
visual acuity and repeat optho exam in one month, as ethambutol
can cause color blindness and decreased visual acuity; he has
normal color vision and no visual complaints at the time of
discharge. Had limited but apparently normal hearing test, but
limited by impacted cerumen. Debrox otic drops x4 days and then
repeat hearing test, as high dose clarithromycin can be ototoxic
and patient will need long course.
# Biliary disease: cholecystitis, either bacterial or
acalculous, was aggressively pursued as source of sepsis, but
after extensive workup including ERCP, findings were ultimately
consistent with HIV cholangiopathy. During this work up, he did
complete 10 days of broad spectrum antibiotics, most recently
vancomycin and meropenem, empirically directed at biliary
source. GI consultant additionally recommended EGD and
colonoscopy because of mesenteric lymphadenopathy, which patient
refused; once AFB cultures turned positive, consistent with MAC,
further diagnostic procedures to evaluate this lymphadenopathy
seemed redundant, although if it does not improve with MAC
therapy, endoscopy should be re-considered.
# HIV: CD4 count 51, viral load >100,000 copies (checked this
admission); HIV genotype was sent to reference lab. Patient was
not taking HAART on admission, but after discussing with Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], patient's outpatient ID/Primary Care doctor, [**Hospital1 18**]
ID consultant recommended initiating HAART while treatment for
disseminated MAC was underway. Started Kaletra and lamivudine;
ID initially recommended Kaletra + Truvada, but patient reported
significant N/V with Truvada and refused to take it, so start
with lamivudine for now; patient will follow-up with Dr [**Last Name (STitle) **]
and likely add another ARV to regimen. Atovaquone for PCP
prophylaxis because it was possible that hemolysis observed
during was due to dapsone and patient reports allergies to
bactrim and pentamadine.
# Pancytoenia: likely [**1-14**] disseminated MAC
** Leukopenia: received Filgrastim with improvement in ANC
levels twice weekly with adequate WBC response. Will continue
with filgrastin 300mcg twice weekly x1 month; because MAC is
slow to respond to antibiotics, may need longer course of GM-CSF
support.
** Anemia - stable at 24 (same as admission), low retic,
elevated ferritin, low hapto. Course complicated by hemolysis in
ICU, resolved after stopping dapsone but exact cause not
certain, for which he received 3 units PRBCs.
** low platelets - could be either PHAT (primary HIV-associated
thrombocytopenia) or MAC infiltration of bone marrow. HIT Ab
(low suspicion) was negative.
# Tachycardia: CTA was negative for PE, possibly due to anemia;
also, AIDS patients have been reported to have persistent
tachycardia.
# COPD:
- nebs Q6H
# Delirium: Patient very disoriented near end of ICU stay, but
mental state cleared and had normal sensorium on the medical
[**Hospital1 **]. Avoid benzos; low dose atypical antipsychotic only if
needed.
# Depression: patient seems depressed when talking to him, very
frustrated with hospital stay and doesn't feel that he is
getting any better. Appreciate psychiatry input.
# Ascites: likely due to aggressive volume resuscitation early
in ICU course. Patient refused paracentesis; after diagnosis of
AFB bacteremia was established, thoracentesis was not likely to
add additional diagnostic information, so this was not
revisited.
# bilateral pleural effusions: again, likely due to volume
resuscitation; ICU team discussed diagnostic tap with patient,
who refused procedure. Once unifying diagnosis of AFB
bacteremia/disseminated MAC was made, this was not revisited.
Once patient was ambulatory, effusions decreased somewhat in
size with pulmonary toilet and he was weaned off oxygen
gradually.
#) code - DNR/DNI, confirmed with patient
#) FEN - received TPN for malnutrtion and [**Known lastname 6686**] po intake while
in ICU. Advanced to regular diet as tolerates, with Ensure
supplements and Megace for AIDS wasting.
#) proph - low platelets so pneumoboots only
Medications on Admission:
Dapsone
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily): prevents PCP [**Name Initial (PRE) 1064**].
Disp:*300 mL* Refills:*2*
2. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): for mycobacterium (MAC) infection.
Disp:*120 Tablet(s)* Refills:*2*
3. Ethambutol 400 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): for mycobacterium (MAC) infection.
Disp:*90 Tablet(s)* Refills:*2*
4. Rifabutin 150 mg Capsule Sig: One (1) Capsule PO EVERY OTHER
DAY (Every Other Day): for mycobacterium (MAC) infection.
Disp:*15 Capsule(s)* Refills:*2*
5. Lamivudine 300 mg Tablet Sig: One (1) Tablet PO once a day:
for HIV.
Disp:*30 Tablet(s)* Refills:*2*
6. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day): for HIV.
Disp:*120 Tablet(s)* Refills:*2*
7. Megestrol 40 mg/mL Suspension Sig: Twenty (20) mL PO DAILY
(Daily): for appetite.
Disp:*400 mL* Refills:*2*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*100 Tablet(s)* Refills:*2*
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*100 Tablet(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Cane
Please provide patient with a cane for walking
12. Filgrastim 300 mcg/0.5 mL Syringe Sig: Three Hundred (300)
mcg Injection twice every week for 1 months: for bone marrow
suppression.
Disp:*8 syringes* Refills:*0*
13. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO four
times a day as needed for fever or pain: do not take more than
4,000mg in a day.
14. Outpatient Lab Work
Please draw blood weekly for CBC. Please draw on same day as
neupogen will be given, before giving dose. Send result to Dr
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] phone [**Telephone/Fax (1) 3530**]/fax [**Telephone/Fax (1) 3528**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. HIV/AIDS with CD4 51, VL >100,000; complicated by PCP
pneumonia in the past
2. disseminated Mycobacterium avium-intracellulare complex
infection
3. chronic obstructive pulmonary disease
4. history of alcohol abuse
Discharge Condition:
good, tolerating regular diet, ambulatory, O2 Sats >90% on room
air while ambulating, but intermittently febrile due to
disseminated Mycobacterial infection
Discharge Instructions:
You have a very wide-spread infection caused by Mycobacterium
avium complex. You need to take the antibiotics rifabutin,
clarithromycin, and ethambutol for several months for this
infection. Talk to Dr [**Last Name (STitle) **] before stopping them, and be careful
not to miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**], because missing [**Last Name (Titles) 4319**] can make the
infection harder to treat in the future.
We started you on Truvada and lamivudine for HIV treatment. When
you see Dr [**Last Name (STitle) **], you may need another medicine for HIV, as
well.
Followup Instructions:
We have scheduled an appointment with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for you on
[**Last Name (LF) 2974**], [**4-22**]:30pm. His office number is [**Telephone/Fax (1) 3530**].
You should see Dr [**Last Name (STitle) **] in the [**Hospital1 18**] Opthalmology (Eye) Clinic
for a repeat screening vision exam in mid-[**Month (only) **], after one month
of ethambutol. Call [**Telephone/Fax (1) 253**] for an appointment.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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62,536
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42551+58539
|
Discharge summary
|
report+addendum
|
Admission Date: [**2125-3-23**] Discharge Date: [**2125-3-27**]
Date of Birth: [**2069-10-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
OSH transfer, inability to extubate
Major Surgical or Invasive Procedure:
Extubation (intubated at OSH)
PICC placement
History of Present Illness:
This is a 55 year old female with PMH of extensive psychiatric
disease including bipolar disorder and depression requiring
multiple psychiatric hospitalizations, polysubstance abuse,
hypothyroidism, hypertension, COPD, h/o pulmonary embolism in
[**2123-2-15**], rheumatoid arthritis vs. lupus, DM2, and obesity
presenting in transfer from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for failed attempt at
extubation. She originally presented on [**3-17**] to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with
altered mental status. Days prior to presentation, her husband
reported that he noted increased agitation and delirium at home.
He was suspicious that she had been drinking or using illicit
drugs. She was also noted to have repetitive movements, but was
still able to communicate and was aware of her symptoms. Her
husband said that she was using her inhalers more than usual and
had been vomiting at home. On the day of her admission she was
seen walking naked, was agitated, and combative. She was
intubated on admission [**3-17**] at OSH for airway protection. Tox
screen there was negative on admission, although going theory
was that she was intoxicated.
She developed fevers in the ICU shortly after admission up to
102.7 on [**3-18**]. She was initially started on vanco,
ceftriaxone, and acyclovir. An LP was performed and was negative
for signs of infection. Head CT on [**3-19**] revealed no
hemorrhage or infarction, but there was marked soft tissue
change filling the posterior aspect of the nasopharynx and
posterior aspect of the nasal cavity. There was marked mucosal
thickening in the ethmoid air cells.
Flu test was negative and one of two sets of blood cultures was
positive with coagulase negative staph species believed to be a
contaminant. On [**3-20**], patient was noted to have increased
secretions through ET tube and CXR showed LLL infiltrate.
Vanco/CTX was started for pneumonia and the patient remained
intubated.
On [**3-22**], she passed her SBT in the morning and seemed to be awake
and following commands. However, after extubation she was noted
to be obtunded and was having repetitive head movements and was
not following commands. Given that she was unable to clear
secretions, she was once again intubated for airway protection.
She continues to be febrile to 100.8 upon transfer and has been
hypotensive to 90s systolic and tachycardic to 110s. She was not
on pressors.
On the day of transfer, she once again passed her SBT with an
ABG on pressure support of 10 was 7.37/43/93 on FiO2 of 45%. She
had a CT chest prior to transfer showing LLL and posterior left
upper lobe alveolar infiltrates due to pneumonia and/or
pulmonary edema. Despite improvement in respiratory status,
there was concern for ongoing mental status change. She has been
off her psych meds and has been on propofol for 6 days. There
was concern for accumulating effects of propofol and the patient
was transferred due to shortage on benzodiazepines and inability
to change mode of sedation at OSH. An MRI could also not be
performed there because the vent was incompatible with their MRI
machine.
.
On arrival to the MICU, the patient appeared uncomfortable on
minimal sedation and was flailing her arms. She became more
comfortable once her propofol drip was restarted.
Past Medical History:
-Depression
-Bipolar disorder
-Polysubstance abuse
-Hypothyroidism
-Hypertension
-COPD
-Pulmonary embolism in [**2123-2-15**]
-Lupus
-Headaches
-DM2
-Obesity
Social History:
She grew up in [**Location (un) **] and [**Location (un) 7661**]. She lives with her husband
now in [**Name (NI) 20935**]. She has 11 years of education. She is a
[**Hospital1 **] minister and a housewife. She has 3 sons and a daughter.
Family History:
Noncontributory
Physical Exam:
Admission Exam:
Vitals: T: 99.8, BP: 128/73, P: 102, R: 12, O2: 96% on PSV 5/5
40%
General: Intubated/sedated
HEENT: Sclera anicteric, MMM, ET tube in place, PERRL
Neck: supple
CV: Tachycardic
Lungs: Clear to auscultation anteriorly
Abdomen: soft, obese grimaces with palpation of stomach, non
distended, bowel sounds present
GU: Foley in place
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: Intubuated/sedated
Discharge Exam:
Vitals: Tm: 100.7, Tc: 100.7 BP: 108/62 (100s/60s) P: 108
(100-110s) R: 20 O2: 96%RA
FS: 100s, isolated 220 around dinner last night
General: A&Ox3, NAD but sitting anxiously, continuous foot
movements HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic but regular, no murmurs/rubs/gallops appreciated
Lungs: minimal wheezing in right lower lung base posteriorly,
otherwise CTAB. NC in place, not using accessory muscles
Abdomen: soft, obese, non-tender, non distended, bowel sounds
present
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema, 2+
pulses
Skin: superficial excoriation of buttocks bilaterally
Neuro: A&Ox3, no focal deficits, 5/5 strength throughout,
sensation intact to light touch throughout
Pertinent Results:
Admission labs:
[**2125-3-23**] 07:54PM WBC-7.4 RBC-3.51* HGB-9.7* HCT-28.3* MCV-81*
MCH-27.5 MCHC-34.2 RDW-15.2
[**2125-3-23**] 07:54PM NEUTS-77.4* LYMPHS-16.0* MONOS-2.9 EOS-3.3
BASOS-0.4
[**2125-3-23**] 07:54PM PLT COUNT-295
[**2125-3-23**] 07:54PM PT-10.8 PTT-28.1 INR(PT)-1.0
[**2125-3-23**] 07:54PM GLUCOSE-104* UREA N-5* CREAT-0.4 SODIUM-142
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-30 ANION GAP-9
[**2125-3-23**] 07:54PM ALT(SGPT)-20 AST(SGOT)-35 LD(LDH)-306* ALK
PHOS-70 TOT BILI-0.3
[**2125-3-23**] 07:54PM ALBUMIN-2.5* CALCIUM-8.0* PHOSPHATE-2.8
MAGNESIUM-2.2
[**2125-3-23**] 08:02PM TYPE-ART PEEP-5 O2-40 PO2-69* PCO2-45 PH-7.42
TOTAL CO2-30 BASE XS-3 INTUBATED-INTUBATED
[**2125-3-26**] 06:36AM BLOOD TSH-15*
[**2125-3-26**] 06:36AM BLOOD Free T4-1.0
Discharge labs:
[**2125-3-27**] 05:52AM BLOOD WBC-5.4 RBC-3.75* Hgb-10.3* Hct-29.7*
MCV-79* MCH-27.6 MCHC-34.8 RDW-15.4 Plt Ct-426
[**2125-3-27**] 05:52AM BLOOD Plt Ct-426
[**2125-3-27**] 05:52AM BLOOD Glucose-114* UreaN-7 Creat-0.5 Na-140
K-3.3 Cl-103 HCO3-29 AnGap-11
[**2125-3-27**] 05:52AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1
[**2125-3-26**] 06:36AM BLOOD calTIBC-255* Ferritn-187* TRF-196*
Notable OSH imaging:
CXR [**3-23**]- Right sided PICC in right atrium, could likely be
pulled back several centimeters. LLL infiltrate, bilateral
perihilar crowding. Evidence of volume overload.
.
CT chest w/ contrast [**3-23**]- Per OSH read: LLL and posterior left
upper lobe alveolar infiltrates due to pneumonia and/or
pulmonary edema. Small left and right pleural effusions. COPD.
Nonspecific mildy prominent mediastinal lymph nodes with a
slight interim increase in size of a subcarinal node compared to
the prior CT.
.
EKG: Sinus tachycardia at 103
Notable [**Hospital1 18**] imaging:
Admission CXR:
FINDINGS: No previous studies for comparison.
There is a right-sided PICC line with distal lead tip is in the
right atrium. This could be pulled back 3-4 cm for remarkable
placement. The side port of nasogastric tube is below the
gastroesophageal junction. The tip of the endotracheal tube is 3
cm above the carina. There is increase in pulmonary interstitial
markings suggestive of pulmonary vascular edema. There are more
confluent opacities within the left mid and lower lung fields,
which may represent asymmetric pulmonary edema or developing
consolidation.
ECHO: The left atrium is normal in size. 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 pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormalities.
ECG: Sinus tachycardia. Minor poor R wave progression. No
previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
119 146 76 310/413 65 2 43
Brief Hospital Course:
55 year old female with PMH of extensive psychiatric disease
including bipolar disorder and depression requiring multiple
psychiatric hospitalizations, polysubstance abuse,
hypothyroidism, hypertension, COPD, h/o pulmonary embolism in
[**2123-2-15**], lupus, DM2, and obesity who was transferred from
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with altered mental status s/p intubation for
airway protection for further management, now s/p extubation,
doing well.
.
#. Respiratory Failure: Patient was initially intubated for
altered mental status, then three days later had a LLL
infiltrate on CXR. Patient transferred because of difficulty to
extubate. On arrival her presumed ventilator-associated
pneumonia seemed to be improving on vanc/Ceftriaxone alone. She
was given one dose of 20mg IV lasix because of suspected mild
fluid overload. She was titrated down to minimal vent settings,
and with weaning of sedation or mental status improved to the
point that she was extubated [**2125-3-24**] without difficulty. She was
briefly on Precedex for sedation. At the time of discharge she
was satting 96% on RA. Denied dyspnea, breathing comfortably,
awake and alert. She completed an 8 day course of antibiotics
(vancomycin and ceftriaxone).
.
#. Toxic metabolic encephalopathy. Etiology remained unclear at
the time of discharge. Patient does have significant
psychiatric history with a history of psychiatric
hospitalizations as well as a history of polysubstance abuse.
Initial tox screen at OSH was negative, and patient denied any
ingestions. Husband does not believe she had access to anything
other than her prescribed medications. LP negative for infection
and HSV. Negative CT head. By the time of discharge, patient
had returned to baseline, per husband. Psychiatry was consulted,
who recommended we hold home psych meds except for restarting
wellbutrin. All benzos were held. She was on QHS and PRN
Seroquel until discharge, but this was not continued. Her QTc
interval was monitored and was not prolonged. She had a speech
and swallow evaluation after extubation and there were no signs
of aspiration.
.
#. Psychiatric disease. Patient has a history of bipolar and
depression requiring psychiatric hospitalization in the past.
She was on a considerable home psychiatric regimen including
Prozac, Seroquel, Trazodone, Abilify, and Klonopin. Denies she
has been taking Abilify at home. Patient does not appear to be
significantly depressed, but is very anxious at baseline. We
held her home trazodone, gabapentin, baclofen, abilify, and
Klonopin, and she was discharged on Wellbutrin alone. She will
see her PCP the day after discharge for re-evaluation of her
home medication regimen.
.
# Tachycardia: Patient was persistently tachycardic with a heart
rate in the 100s-110s, for which the reason was unclear. ECG
showed sinus tachycardia. Per husband, she has been tachycardic
for months and was noted to have a HR of 114 on [**2125-2-16**]
outpatient visit. Differential diagnosis includes: anxiety,
withdrawal (which didn't seem likely given chronic nature and
lack of hypertension), hyperthyroidism (TSH 15, Free T4
1.0-normal). Patient was not evaluated for pheochromocytoma, so
urine metanephrines may be indicated in the outpatient setting.
Patient was started on metoprolol and titrated up to 25mg [**Hospital1 **] to
prevent tachycardia induced cardiomyopathy.
.
# Fever: Patient was febrile to 100.7 on the morning of
discharge. This was felt to most likely be a drug fever as the
patient was completing for 8 day course of vancomycin and
ceftriaxone that day for treatment of VAP. WBC 5.4. These
antibiotics should cover for most UTIs, and patient was not
complaining of dysuria or increased frequency. Repeat UA was
contaminated. Site of PICC was mildly tender and erythematous
superficially, however patient is on vancomycin, which would
cover most skin infections. Blood cultures, UA and urine culture
was sent prior to discharge, however it was felt the patient was
stable for discharge at that time. She remained afebrile for the
remainder of the day, no tylenol was given. Fever was not felt
to be likely related to clot, as the patient has been on lovenox
at treatment doses throughout the admission.
.
# Anemia: Hct fluctuated from the high 20s to low 30s over
admission without signs of active bleeding. Patient was
asymptomatic. MCV 80. Iron studies suggest anemia of chronic
disease (iron 45, TIBC 255, Ferritin 187, TRF 196), which is
likely due to lupus.
.
#. Lupus: Confirmed from PCP visit note on [**2125-2-16**]. Patient is
on hydroxychloroquinoquine daily.
.
#. History of PE. Patient is on Coumadin 7.5mg at home for h/o
PE. INR was subtherapeutic on admission to OSH and so patient
was started on Lovenox 1mg/kg [**Hospital1 **] (weight 88.2kg) which was
continued as a bridge for warfarin therapy. Patient was
transferred on warfarin 3mg, for unclear reasons. This was
increased to 7.5mg the day prior to discharge, when dose was
confirmed with PCP's office. INR remained 1.0-1.1 over admission
and patient was discharged on Lovenox 120mg once daily for ease
of dosing (VNA to come to house, as patient and husband unable
to administer injection). PCP's office will continue to monitor
INR and dose warfarin accordingly, goal [**2-16**].
.
# Superficial ulcers, stage 1 over buttocks: Wounds were kept
clean and dry. Patient cleans area with antiseptic wipes
regularly.
.
#. COPD. Continued standing nebs. On atrovent at home, which was
continued on discharge.
.
#. DM2. Maintained on HISS with good control in-house.
Transitioned back to Metformin 500mg Qhs on the day of
discharge.
.
#. Hypothyroidism. TSH 15, but Free T4 1.0 (nml). Continued home
levothyroxine 75mcg.
Transitional Issues:
Patient is scheduled for appointment with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 19952**]
tomorrow morning ([**2125-3-28**]) at 10:30am.
Calcium and Vitamin D were started for bone health.
Per Psychiatry consult, home baclofen, gabapentin, clonazepam,
abilify (which patient states she does not take) were held on
discharge.
Patient was started on metoprolol for tachycardia. Please
consider further work up of this as an outpatient, including
urine metanephrines.
Blood cultures, urine culture were pending on discharge.
Patient requires warfarin/INR monitoring, which nurse from Dr. [**Name (NI) 92085**] office confirmed will be taken care of by Dr. [**Last Name (STitle) 19952**].
VNA has been instructed to draw coats on [**4-20**], [**4-2**] and
fax to Dr. [**Last Name (STitle) 19952**].
# CONTACT: [**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 92086**] [**Telephone/Fax (1) 92087**]
Medications on Admission:
MEDS:
Transfer meds-
-CTX 1 gm IV daily
-Vancomycin 2 gms IV q12 hours
-Lovenox 1 gm/kg SC q12 hours
-Folic acid 1 mg daily
-Humalog SS
-Propofol drip
-Thiamine 100mg daily
-Potassium 40meq PO BID
-Protonix 40mg IV daily
-Zofran 4mg IV q8 PRN N/V
-Ativan 2mg IV q4 PRN seizure/vent management
.
Home Meds-
Abilify 20mg PO Qday
Atrovent HFA 17mcg 2 puffs QID prn
Baclofen 20mg po QID
buproprion 150mg ER 1tab Q24
Butalbital-APAP-caffeine 50-325-40 1 tab Q6 prn HA
clonazepam 0.5 QID
gabapentin 600mg Qhs
hydroxychloroquine sulfate 400mg Qday with food
levothyroxine 75mcg Qday
metformin 500mg Qhs
wafarin 7.5mg Qday
fluticasone nasal spray 50mcg 2sprays each nostril Qday
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Disp:*30 Tablet(s)* Refills:*0*
3. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
4. metformin 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO QPM (once a day (in the
evening)).
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. cholecalciferol (vitamin D3) 1,000 unit 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. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO once
a day: Take with food.
9. Atrovent HFA 17 mcg/actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation every six (6) hours as needed.
10. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day: Each nostril daily.
11. Outpatient Lab Work
Please draw coagulation studies (PT, PTT, INR) on [**2125-3-29**],
[**2125-3-31**] and [**2125-4-2**] and fax results to Dr. [**First Name8 (NamePattern2) 56281**] [**Last Name (NamePattern1) 19952**]. Phone:
[**Telephone/Fax (1) 84402**]. Fax: [**Telephone/Fax (1) 79535**].
12. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 7 days: Continue this medication
until your PCP tells you to stop.
Disp:*14 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home Health of [**Location (un) 5028**]
Discharge Diagnosis:
Primary Diagnosis: Altered Mental Status, etiology unclear
Secondary Diagnosis:
Depression, Bipolar, hypothyroidism, COPD, history of PE, lupus,
DM2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 92086**],
It was a pleasure caring for you at [**Hospital1 827**]. You were transferred to our hospital because you
were having trouble breathing without the breathing tube in. You
spent a couple days in the ICU and were able to come of the
ventilator. It is unclear why you were initially so cunfused and
altered. You were treated for a pneumonia you developed while
intubated and have continued to improve. We watched you for a
couple of days on the regular medicine floor and you are now
well enough to go home. Our physical therapist recommended that
you have home physical therapy until you get stronger.
The following changes have been made to your home medications:
STOP taking Abilify, Baclofen, clonazepam (Klonopin), Fioricet
and gabapentin.
You have an appointment with your primary care provider
tomorrow, at which point he may decided to restart some of these
medications safely.
START taking Vitamin D 1000 units by mouth daily for your bone
health.
START taking Calcium 500mg by mouth three times a day.
CONTINUE taking warfarin 7.5mg daily. You will need to have
blood work drawn in two days and the results should be faxed to
your primary care doctor who may instruct you to alter your
dose, depending on the lab results.
START taking Lovenox injections 120mg daily until your primary
care doctor instructs your to stop.
START taking metoprolol 25mg by mouth twice daily. This will
slow down your heart rate.
Please discuss with your PCP why you are on baclofen; for now
please stop taking this medication.
You were noted to have a fast heart rate during this admission.
Studies of your heart and thyroid were normal. You were started
on a medication to decease your heart rate, however you should
discuss further work up with your primary care doctor. You
should also talk to him about arranging an outpatient sleep
study to evaluate if you have restless legs syndrome.
Please go to a lab to have your blood work drawn on [**2125-3-29**]. The
results should be faxed to your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 19952**].
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] [**Location (un) **]
Address: [**Doctor Last Name **], [**Location (un) **],[**Numeric Identifier 89216**]
Phone: [**Telephone/Fax (1) 84402**]
Appointment: WEDNESDAY [**3-28**] AT 10:30AM
Name: [**Known lastname 14481**],[**Known firstname 14482**] Unit No: [**Numeric Identifier 14483**]
Admission Date: [**2125-3-23**] Discharge Date: [**2125-3-27**]
Date of Birth: [**2069-10-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 310**]
Addendum:
Transitional Issue Continued:
Throughout admission, patient was noted to constantly be moving
her ankles and feet. Her husband mentioned this has been going
on for some time and it bothers her greatly. Consider outpatient
work up for restless leg syndrome (i.e. sleep study). Other
things to consider: iron deficiency anemia (patient's iron is 45
however) or withdrawal dyskinesia related to ability use
(depending on how long she was maintained on this medication.
Brief Hospital Course:
Transitional Issue Continued:
Throughout admission, patient was noted to constantly be moving
her ankles and feet. Her husband mentioned this has been going
on for some time and it bothers her greatly. Consider outpatient
work up for restless leg syndrome (i.e. sleep study). Other
things to consider: iron deficiency anemia (patient's iron is 45
however) or withdrawal dyskinesia related to ability use
(depending on how long she was maintained on this medication.
Discharge Disposition:
Home With Service
Facility:
Home Health of [**Location (un) 6451**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 314**] MD [**MD Number(2) 315**]
Completed by:[**2125-3-27**]
|
[
"V58.61",
"278.00",
"305.90",
"997.31",
"784.0",
"E879.8",
"707.05",
"707.21",
"349.82",
"427.89",
"250.00",
"244.9",
"518.81",
"496",
"V12.55",
"285.29",
"710.0",
"401.9",
"296.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
22000, 22225
|
21509, 21977
|
341, 388
|
18097, 18097
|
5469, 5469
|
20368, 21486
|
4199, 4216
|
16199, 17811
|
17925, 17925
|
15504, 16176
|
18248, 18933
|
6262, 8768
|
4231, 4660
|
18951, 20345
|
4676, 5450
|
14561, 15478
|
266, 303
|
416, 3748
|
18005, 18076
|
5485, 6246
|
17944, 17984
|
18112, 18224
|
3770, 3929
|
3945, 4183
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,327
| 147,129
|
41018
|
Discharge summary
|
report
|
Admission Date: [**2183-2-13**] Discharge Date: [**2183-2-22**]
Date of Birth: [**2100-12-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Keflex / Klonopin / Lipitor
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
acute myocardial infarction
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x4(LIMA_LAD, SVG-Ramus,Y to
OM,SVG-PDA) [**2183-2-18**]
left heart catheterization, coronary angiogram [**2183-2-13**]
History of Present Illness:
This 82 year old white male with no known cardiac disease who
was admitted to [**Hospital3 **] the night before transfer with
weakness, chills, and shaking in one arm. He reported fevers and
chills for 2days, since he started self catheterization. In the
ED, he was given Amikacin and levofloxacin, and levofloxacin was
continued on admission. Overnight, he began complaining of
indigestion, a burning sensation in his chest but no SOB or
radiation of the pain. His pain responded to Maalox, but he was
tachycardic to the 120s, and EKG showed diffuse ST depressions.
Troponin was 0.56. He was loaded with Plavix and given Lovenox.
He was transferred to [**Hospital1 18**] for cardiac catheterization.
.
REVIEW OF SYSTEMS:
+ for shaking, chills and fevers over the last few
weeks(associated with UTI), occasionally pt feels lightheaded,
dysuria
r/t self catheterization. Endorses some SOB with exertion, but
not until he walks about [**11-24**] a mile.
- for CP, memory problems, unintentional weight gain or loss,
dyyspnea, swelling in feet or ankles, orthopnea, claudication,
PND, headaches,vision changes, abdominal pain, change in bowel
pattern, N/V, skin changes or open wounds.
Past Medical History:
Dyslipidemia
Hypertension
s/p cerbrovascular accident (2-3 years ago)
h/o isolated Seizure
Neurogenic bladder.s/p bladder stimulator implant
s/p transurethral resection of the prostate
Vertigo
Rheumatoid arthritis
Diverticulitis
Hernia
s/p bilateral carotid endarterectomies
s/p evacuation of subdural hematoma [**2174**]
Social History:
Pt lives alone, wife passed away one year ago.
Has Partners [**Name (NI) 269**] once/week to help with foley care and assist
with medications. Pt is retired from computer business. Quit
smoking 15-20 years ago. Drinks 2-3 beers/ day, denies illicit
drug use. Is active -walks [**11-24**] miles/day and is president of a
senior group.
Family History:
Brother with pancreatic cancer passed away in his 60's, another
brother with CVA. No known coronary disease in the family.
Physical Exam:
Admission Exam:
VS: T=98.5 BP=115/62 HR=73 RR=18 O2 sat=96% RA
GENERAL: WDWN elderly male in NAD. Alert, talkative; mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Limited exam as pt laying flat after cath. LCTAB
anteriorly.
ABDOMEN: Soft, NTND
EXTREMITIES: Warm, no c/c/e
Pertinent Results:
[**2183-2-20**] 02:50AM BLOOD WBC-11.6* RBC-2.91* Hgb-10.0* Hct-28.4*
MCV-98 MCH-34.5* MCHC-35.4* RDW-13.4 Plt Ct-110*
[**2183-2-19**] 02:15AM BLOOD WBC-13.5*# RBC-3.07* Hgb-10.3* Hct-29.6*
MCV-96 MCH-33.4* MCHC-34.7 RDW-13.1 Plt Ct-138*
[**2183-2-13**] 03:00PM BLOOD WBC-24.2* RBC-3.74* Hgb-13.0* Hct-36.0*
MCV-96 MCH-34.8* MCHC-36.1* RDW-12.9 Plt Ct-163
[**2183-2-21**] 04:40AM BLOOD UreaN-19 Creat-0.9 Na-131* K-4.0 Cl-94*
[**2183-2-20**] 02:50AM BLOOD Glucose-124* UreaN-22* Creat-1.1 Na-133
K-4.1 Cl-97 HCO3-31 AnGap-9
[**2183-2-13**] 03:00PM BLOOD Glucose-138* UreaN-22* Creat-1.0 Na-138
K-3.8 Cl-104 HCO3-25 AnGap-13
[**2183-2-13**] 03:00PM BLOOD ALT-21 AST-19 AlkPhos-43 Amylase-231*
TotBili-0.9
Brief Hospital Course:
He was admitted to the Cardiology service. cathetreization
revealed triple vessel disease and LV function was preserved by
echocardiogram. Cardiac surgery was consulted and he was
prepared for revascularization
He was continued on Cipro given his fevers and chills on
presentation. He was afebrile and without urinary symptoms while
here.
On [**2-18**] he was taken to the Operating Room where coronary
revascularization was undertaken. He did well, weas weaned from
the ventilator easily and transferred tot he floor. CTs were
retained for three days due to serous drainage, but removed on
POD 3, along with his temporary pacing wires.
The Foley was removed and intermittent straight catheterization
was performed postop after the bladder stimulator was turned on.
He will follow up with his urologist after discharge.
He was begun on beta blockers and diuresed towards his preop
weight. He had transient atrial fibrillation, treated with
Amiodarone and convereted to sinus rhythm.
He was discharged to [**Location (un) **] of [**Hospital1 392**] for furhter rehabilitaion
prior to return home.
Arrangements were made for appropriate follow up with surgery,
cardiology and his primary care physician.
Medications on Admission:
From Home (records from CVS/[**Hospital1 392**])
Meclizine 12.5mg TID
Ciprofloxacin 250mg [**Hospital1 **]
Macrodantin 100mg [**Hospital1 **]
Tylenol #3 1-2 tabs PRN pain
Bethanechol 50mg QID
Prednisone 5mg daily
HCTZ 12.5mg QD
Atenolol 25mg daily
Diazepam 5mg daily
Aspirin 81mg daily
MVI 1 daily
.
From OSH:
- Meclizine 12.5 mg daily
- Levaquin 500 mg IV daily
- Bethenacol 25 mg daily
- Prednisone 5 mg daily
- HCTZ 25 mg daily
- Atenolol 25 mg daily
- ASA 81 mg daily
- MVI 1 daily
- Plavix 75 mg daily
- Lovenox 80 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day for 7 days.
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed for pain for 4 weeks.
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. diazepam 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for sleep.
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): two tablets twice daily for two weeks, then one tablet
twice daily for two weeks, then one daily.
10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 4 weeks.
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO BID (2
times a day).
14. bethanechol chloride 25 mg Tablet Sig: Two (2) Tablet PO QID
(4 times a day).
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever or pain.
17. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
18. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
19. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day for 7 days.
20. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab and Nursing
Discharge Diagnosis:
acute myocardial infarction
coronary artery disease
s/p coronary artery bypass grafts
rheumatoid arthritis
neurogenic bladder
s/p bladder stimulator implant
h/o remote seizure
s/p stroke
hypertension
vertigo
diverticulitis
s/p bilateral carotid endarterectomies
s/p transurethral prostatectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema- trace:1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2183-3-17**] at 1:15pm
Cardiologist:Dr.[**Last Name (STitle) **] on [**2183-3-28**] at 3:15pm
Wound check at [**Hospital1 18**] [**Last Name (un) 2577**] 2A on [**2183-2-25**] at 11:45Am
Please call to schedule appointments with your
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Name (STitle) **] (6-7-[**Telephone/Fax (1) **]in [**2-25**] 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:[**2183-2-22**]
|
[
"427.31",
"285.9",
"V45.89",
"410.71",
"V15.82",
"401.9",
"414.01",
"V13.02",
"V12.54",
"788.20",
"V58.65",
"V45.77",
"272.4",
"596.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"36.13",
"88.56",
"36.15",
"39.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7474, 7536
|
3747, 4960
|
321, 472
|
7874, 8105
|
3019, 3724
|
8945, 9709
|
2398, 2522
|
5540, 7451
|
7557, 7853
|
4986, 5517
|
8129, 8922
|
2537, 3000
|
1222, 1685
|
254, 283
|
500, 1203
|
1707, 2030
|
2046, 2382
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,310
| 146,367
|
20235
|
Discharge summary
|
report
|
Admission Date: [**2140-3-3**] Discharge Date: [**2140-3-6**]
Date of Birth: [**2069-6-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
This patient presented with what he described as weakness in his
legs and headaches.
Major Surgical or Invasive Procedure:
left craniotomy for tumor resection [**2140-3-3**]
History of Present Illness:
This patient presented with what he described as weakness in his
legs and headaches. The MRI scan showed a homogeneously
enhancing lesion in the left parietal lobe para medially which
completely occluded the sagittal sinus. There
is very little para focal edema. The tumor has a maximum
diameter of 3.4 cm already. The situation was discussed with him
and clearly primary radiosurgery is inappropriate due to the
size of the tumor. Also wait and see strategy given the size and
the inhomogeneity of the contrast enhancement, which was
suspicious for atypical features was not advisable. Mr. [**Known lastname **] [**Last Name (Titles) 54345**] for an at least partial resection to obtain histological
diagnosis and provide conditions that make radiosurgery of the
tumor parts and the sinus a possibility.
Past Medical History:
unknown
Social History:
lives with wife
Family History:
non-contributory
Physical Exam:
Exam upon discharge:
The patient was oriented x 3. PERRL, EOMs intact. Face
symmetric, tongue midline. He was moving all 4 extremities
spontaneously and was walking on his own. His sensation was
intact. No pronator drift.
Pertinent Results:
Post-op MRI [**2140-3-4**]:
FINDINGS: Postoperative changes are seen in the area of
partially resected
meningioma in the high left occipital lobe adjacent to the
sagittal sinus.
There are small foci of blood products in the operative bed, and
a tiny amount of left subdural blood. Some residual enhancing
mass remains adjacent to the superior sagittal sinus.
Signal change within the sinus itself is not significantly
changed from prior exam, allowing for technical factors. There
is high signal on T2W images within the portions of the sagittal
sinus inferior to the resection site suggestive of slow flow,
but normal enhancement within these areas on post-contrast
images, and no increased signal on precontrast T1W images to
suggest thrombus.
Ventricular size and configuration is unchanged. There is no
evidence of
acute ischemia. Mildly restricted diffusion signal at the
operative bed is
compatible with postsurgical change. Old infarct in the
brainstem is
unchanged.
IMPRESSION:
1. Postoperative change at the site of recently resected
meningioma, with
some residual enhancing tumor, and unchanged signal abnormality
within the
adjacent superior sagittal sinus which may represent tumoral
invasion or
thrombus. CTV or phase-contrast MRV could be performed to
further evaluate
this area if clinically indicated.
2. Findings most consistent with slow flow within the sagittal
sinus inferior to the resection site. No additional evidence of
sinus thrombosis.
3. No evidence of acute infarction.
CT Head [**2140-3-3**]:
FINDINGS: High left parietal meningioma has been resected via
left parietal
craniotomy. Expected postsurgical change is seen in the
resection bed. There is no sign of large intracranial
hemorrhage. Moderate amount of
pneumocephalus is present. There is no sign of mass effect, or
vascular
territorial infarction. Ventricles and sulci are unchanged in
size and
configuration, allowing for differences in modality.
IMPRESSION: Expected post-surgical change status post resection
of left
parietal meningioma. No large intracranial hemorrhage.
Pathology: pending at time of discharge but the frozen section
showed meningioma with atypical features
Brief Hospital Course:
The patient underwent elective craniotomy for tumor resection on
[**2140-3-3**]. The surgery went well. He did require intra-operative
platelets due to some bleeding. He had previously been on
aspirin but discontinued it 10 days before the surgery. The
patient went to the ICU post-operatively. His CT scan showed no
large hemorrhage with expected post-surgical changes in the
operative bed. The MRI showed some residual tumor as well as
some blood in the surgical bed and small amount of SDH.
Neurologically the patient was doing very well. He was
transferred to the floor on [**3-4**]. The patient was evaluated by
PT and was deemed safe to be discharged with his family. He was
ambulating, voiding, and taking in food without difficulty. He
was discharged on [**2140-3-6**].
Medications on Admission:
pioglitazone, glimepiride, atorvastatin, metoprolol tartrate,
omeprazole
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
4. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO daily ().
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
8. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 1 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours: Please follow up with pcp for BP
monitoring.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
meningioma with atypical features
Discharge Condition:
neurologically stable
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 have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed 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 haven 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:
??????Please return to the office in [**6-24**] days(from your date of
surgery) for removal of your 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 a Brain [**Hospital 341**] Clinic appointment with [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD
Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2140-3-21**] 4:00 pm on [**Hospital Ward Name 23**] 8 on
the [**Hospital Ward Name 516**].
Completed by:[**2140-3-9**]
|
[
"403.90",
"225.2",
"250.00",
"493.90",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
5753, 5759
|
3843, 4622
|
401, 454
|
5837, 5861
|
1646, 3820
|
7690, 8363
|
1370, 1388
|
4745, 5730
|
5780, 5816
|
4648, 4722
|
5885, 7667
|
1403, 1403
|
277, 363
|
482, 1290
|
1312, 1321
|
1337, 1354
|
1424, 1627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,606
| 105,840
|
49762
|
Discharge summary
|
report
|
Admission Date: [**2197-3-23**] Discharge Date: [**2197-3-29**]
Date of Birth: [**2120-8-17**] Sex: M
Service: [**Company 191**]
HISTORY OF THE PRESENT ILLNESS: This is a 76-year-old male
who was found to be rigoring after getting out of the pool on
the day of admission. The patient was overall feeling fine
and did not complain of a fever, cough, or general malaise.
The patient went to the Emergency Department and was found to
have a temperature of 101.1. During the patient's visit in
the Emergency Department, the patient's blood pressure fell
from a systolic blood pressure of 110 down to a systolic
blood pressure of 68. The patient was resuscitated with IV
fluids and pressors.
A workup of fever in the Emergency Department did not reveal
a source of fever. Chest x-ray was negative. Blood cultures
and urine cultures were collected. The patient was
empirically begun on levofloxacin and Flagyl. The patient
was stabilized and admitted to the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. CAD, status post CABG in [**2192**] with an EF of 30-40%.
2. Atrial fibrillation, currently taking Coumadin.
3. Depression.
4. Status post hernia repair.
5. Seizure disorder.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
101, blood pressure 110/80, heart rate 100, respiratory rate
15, breathing 98% on room air. General: The patient was an
ill-appearing male in no apparent distress. Skin: No
rashes. The membranes were moist. Neck: Supple with no
lymphadenopathy. Cardiac: Irregularly/irregular pulse with
a normal S1 and S2. There was a grade II/VI systolic murmur
best heard at the apex. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, nondistended, with no
tenderness. Extremities: The left extremity was very mildly
erythematous. Pulses were palpable bilaterally.
HOSPITAL COURSE: On the second day of the [**Hospital 228**] hospital
stay, the patient developed a cellulitis of his left lower
extremity. The cellulitis was felt to be the etiology of his
fevers and rigors. The patient was begun on oxacillin 2
grams IV q. six hours for the cellulitis. The cellulitis
improved dramatically over the next several days.
While in the ICU, the patient was mildly volume overloaded.
Diuretic therapy with Lasix and good results were achieved.
The patient became euvolemic and was transferred to the floor
for observation.
On the floor, the patient complained of a mild cough since
aspirating a small amount of water in the ICU. A chest x-ray
was performed and revealed pneumonitis secondary to
aspiration. The patient's cough resolved within a day.
The patient's chemistries on admission were a sodium of 140,
potassium 4.5, chloride 101, bicarbonate 26, BUN 20,
creatinine 1.0, glucose 98. Calcium was 7.5, phosphate 2.5,
magnesium 1.7. The patient's white count was 15 with a left
shift.
DISCHARGE CONDITION: The patient was discharged in good
condition.
DISCHARGE DIAGNOSIS:
1. Cellulitis.
2. Sepsis.
3. Congestive heart failure.
DISPOSITION: The patient was discharged home.
DISCHARGE MEDICATIONS:
1. Oxacillin p.o. to be taken for 14 days.
2. The patient was instructed to take all of the medications
he was taking previously before admission.
FOLLOW-UP: The patient is to follow-up with his primary care
physician within two weeks to monitor the compression and
resolution of his cellulitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. [**MD Number(1) 101646**]
Dictated By:[**Last Name (NamePattern1) 104024**]
MEDQUIST36
D: [**2197-4-3**] 12:01
T: [**2197-4-4**] 09:07
JOB#: [**Job Number 45493**]
|
[
"428.0",
"V58.61",
"682.6",
"V45.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2897, 2944
|
3095, 3676
|
2965, 3072
|
1861, 2875
|
1242, 1843
|
1022, 1227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,472
| 169,405
|
45745
|
Discharge summary
|
report
|
Admission Date: [**2124-7-10**] Discharge Date: [**2124-7-22**]
Date of Birth: [**2045-1-31**] Sex: M
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Mental status changes
Tailored [**First Name3 (LF) 1902**] therapy
Major Surgical or Invasive Procedure:
Right heart catheterization
Swan Ganz Catheter placement
History of Present Illness:
Mr. [**Known lastname 13972**] is a 79WM with PMH significant for CAD s/p [**2116**]
CABG, severe mitral [**Year (4 digits) **] regurgitation, h/o frontal/parietal
CVA's, and recent admission for [**Year (4 digits) 1902**] exacerbation, who presented
to Dr.[**Name (NI) 8664**] office today for a check-up. Since his discharge,
and over the last several months, Mr. [**Known lastname 13972**] has been
experiencing increasing fatigue and confusion. The psychiatry
team was consulted during his last admission in [**5-27**] for
possible contribution of depression, previous frontal CVAs, or
polypharmacy to his symptoms. An inpatient geripsych admission
was considered, but deferred, pending outpatient behavioral
neurology admission. Evaluation by a behavioral neurologist was
performed on [**7-4**] with an assessment that his decline in
mentation was likely secondary to encephalopathy due to chronic
hypoperfusion and recommendation that his Florinef dose was
increased to 0.1 mg PO qD.
.
Since his mental status declined in spite of medical
optimization of his fluid status, it was speculated that his
low-output state would be best addressed by MVR, given his low
EF and severe MR. This is likely to be a high-risk procedure in
Mr. [**Known lastname 97473**] decompensated state, however, and thus Dr. [**Last Name (STitle) **]
opted to admit Mr. [**Known lastname 13972**] to the CCU for tailored inotropic
therapy for his low-output [**Known lastname 1902**]. The goal of this admission is
to assess whether increased perfusion would improve his mental
status, prior to making a major decision about whether to
proceed with MVR. He was admitted directly to the CCU, and was
brought to the cath lab for placement of a Swan-Ganz catheter
under fluoroscopy.
Past Medical History:
1) CAD
- MI s/p CABG x3 [**2116**]
- presented in [**1-28**] in cardiogenic shock with ISR in the
setting of stopping ASA and coumadin for TURP, intubated and s/p
cardiac catheterization on [**1-28**] s/p minivision stent to OM1 and
s/p taxus stent to distal left main coronary artery on [**2124-2-2**]
2) [**Date Range 1902**] - EF 20-25% on [**5-27**] TTE. LV and RV moderately dilated
with severe global hypokinesis and inferior and inferolateral
wall akinesis. Recently hospitalized [**5-27**] for [**Month/Year (2) 1902**] exacerbation.
3) 3+ MR, 2+ AR
4) CRI baseline Cr around 1.3
5) CVA [**11/2116**]- left MCA infarct likely [**2-24**] embolism, source
uncertain
6) BPH s/p TURP
7) Inguinal hernia repair 40 years ago
8) Anxiety disorder
9) Autonomic dysfunction
10) Osteoporosis
11) T12 compression fx
12) epistaxis (on Coumadin) that was cauterized in [**5-26**]
13) Abdominal pain x3 years (Has had multiple dx tests, all
normal)
Social History:
He has been married for 52 years. He is retired.
Family History:
(+) FHx CAD: Sister had a CABG in her 50's.
Physical Exam:
VS: BP: 97/62 HR: 83 RR: 19 SaO2: 100% 2L NC
Gen: Lying comfortably in bed, NAD
HEENT: MMM, L eye with mild crusting, mild erythema around upper
lid, mild conjunctival injection
CV: RRR, IV/VI apical SEM, no r/g, JVP ~9cm
Chest: CTAB, no w/r/r
Abd: Soft, NT/ND, +BS
Extr: muscle wasting in all extremities, no LE edema, trace DPs
bilaterally
Neuro: A&Ox2, MMSE 11
Pertinent Results:
[**2124-7-10**] ECHO:
1. Right heart catheterization demonstrated severely elevated
filling
pressures with critically depressed cardiac output. The resting
mean
pulmonary capillary wedge pressure was severely elevated at
31mmHg, with
moderately elevated right atrial filling pressure of 16mmHg.
There was
moderate pulmonary hypertension with peak pulmonary artery
pressures of
55mmHg. Cardiac index was critically depressed at 1.4 L/min/m2
(normal
is 2.5 L/min/m2).
2. Coronary angiography was attempted unsuccessfully due to
inability
to engage coronary arteries with 4 French multipurpose catheter.
FINAL DIAGNOSIS:
1. Critically depressed cardiac index.
2. Severe diastolic ventricular dysfunction.
3. Moderate pulmonary hypertension.
.
.
[**2124-7-12**] ECHO:
1.The left atrium is moderately dilated. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. There is severe global
left ventricular hypokinesis. Overall left ventricular systolic
function is severely depressed. [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.]
3.The right ventricular cavity is moderately dilated. There is
severe global right ventricular free wall hypokinesis. 4.The
aortic [**Month/Day/Year **] leaflets (3) are mildly thickened. Moderate (2+)
aortic regurgitation is seen.
5. The mitral [**Month/Day/Year **] is normal. At least moderate to severe (3+)
mitral
regurgitation is seen.
6.There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2124-6-16**],
the LVEF is
probably unchanged while the MR is possibly more severe. The RV
function may be worse. TSI was performed. No significant
dyssnchrony was seen (60 ms).
.
[**2124-7-20**] 11:15AM BLOOD VitB12-1462* Folate-19.0
[**2124-7-10**] 06:30PM BLOOD TSH-6.5*
[**2124-7-11**] 04:00AM BLOOD Free T4-1.4
Brief Hospital Course:
Assessment: 79M with PMH significant for CAD s/p CABG, [**Month/Day/Year 1902**] (EF
20-25), severe MR, and h/o CVA, presenting for tailored
low-output [**Month/Day/Year 1902**] therapy.
.
Plan:
1) CARDIAC:
A) Pump: EF assessed to be 20-25% in context of severe MR. Upon
admission, a Swan-Ganz catheter placed for measurement of
hemodynamics and tailoring of low-output [**Month/Day/Year 1902**] therapy on
dobutamine. Tried on dobutamine and dopamine transiently, but
became tachycardic with no increase in MAP. Dopamine was d/c'ed,
and trial of vasopressin was initiated resulting in a slight
increase in BP, but significant decrease in CO and no notable
improvement in mental status. He subsequently underwent a trial
of Levophed which resulted in pulmonary edema and decreased
urine output. He was subsequently switched back to dobutamine
gtt only, with improvement in CO and clinical status but no
improvement in mentation. Thus, it was concluded that lack of
sustained improvement in his mentation indicated a failed trial
of inotropic support for the purposes of mediating his
encephalopathy secondary to hypoperfusion. He was gradually
titrated off the dobutamine and the swan ganz catheter was
removed. Off pressor support, Mr. [**Known lastname 13972**] was able to maintain
a systolic BP in the 90's-100's for the remainder of his
hospitalization, which is improved from SBP's in the 80's on
admission. He was evaluated by EP for placement of a BiV pacer;
however, due to lack of dyssynchrony on TTE, as well as
previously failed attempt to engage the CS, he was deemed to be
not a candidate.
In the context of his end-stage heart failure, agressive
diuresis was continued throughout the hospital course. His AceI
dose was titrated up to provide enhancement of the diuresis and
for known mortality and survival benefit. Both diuretics and his
AceI were titrated up to maximal levels tolerated while still
maitaining SBP in the high 90's to low 100's. He was not started
on a beta-blocker during this hospitalization due to report of
an adverse event in the past. He was discharged on a regimen
Lasix, Aldactone, and Lisinopril.
.
B) CAD: s/p CABG, likely has chronic hypoperfusion [**2-24**] low
output state, but no active ACS issues during this
hospitalization. Mr. [**Known lastname 13972**] was continued on chronic therapy
with ASA, plavix, and statin and will be discharged on this
regimen.
.
C) Rhythm: Mr. [**Known lastname 13972**] remains in sinus rhythm with occasional
tachycardia to heart rates in the 90's. Later in the course of
his hospitalization, he began to have non-sustained runs of
PVC's.
.
D) MR: Patient is known to have severe MR; however, it is
doubtful that he would benefit from mitral [**Known lastname **] replacement,
given his high mortality risk for this procedure. Furthermore,
tailored therapy on dobutamine raises doubts whether increasing
CO would improve his MS.
.
2) Neuro/Psych: Mr. [**Known lastname 13972**] is intermittently sleeping and
lucid, with some improvement in his capacity for sustained
conversation. He does continue to confabulate with waxing and
[**Doctor Last Name 688**] alertness. His family does report some improvement in
cognitive status since prior to this admission. Given the
failure of improved cardiac output to improve his mental status,
we considered alternate etiologies for his delirium, including
depression and polypharmacy. Per Psychiatry consult, his
depression and anxiety were assessed to be stable. Patient was
started on Provigil 100 mg qday on [**7-14**]; however, this
medication was discontinued, per Psychiatry recommendations, as
it is known to be deliriogenic. His Lexapro dose was reduced to
a more age-appropriate dose. His digoxin dose was also reduced
to decrease its potential deliriogenic effects. Given the
moderate atrophy and multiple old infarcts on MRI performed in
[**Month (only) 547**], there is likely a baseline dementia contributing to his
decline in mental status. In work-up for alternate causes, his
folate level & vitamin B12 level were WNL. RPR was
non-reactive. In summary, his precipitous decline in mentation
is likely a multifactorial picture with chronic hypoperfusion,
h/o multiple infarcts, age-related atrophy, and possibly
depression.
.
3) FEN: He was maitained on a low-sodium diet and supplemented
with three chocolate Boost shakes per day. His electrolytes were
maintained with goals of K>4, Mg>2, but the need for repletion
was rare. It was necessary to encourage PO intake as he does not
self-feed without encouragement. A nutrition consult and 24
hour calorie count revealed that intake that meets only 40% of
caloric needs and 35% of protein requirements. In the setting of
heart failure and agressive diuresis with furosemide and
spironolactone, his fluid balance goals are even to 0.5 L
negative per 24 hour period.
.
4) Dispo: Long-term care planning has been discussed at length
with his wife [**Name (NI) 4134**] and children. Mr. [**Known lastname 97473**] code status
was changed to DNR/DNI during the course of the hospitalization.
He will be discharged to a nursing home selected by the
family, and all family members seem to be in agreement with this
plan. He will continued to be followed by his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**].
He will also continue to undergo Physical Therapy and has been
recommended for therapy to continue 3-5 times/week at Heathwood.
.
5) Code Status: DNR/DNI.
Medications on Admission:
All: NKDA
.
Meds (on [**5-27**] d/c):
1. Escitalopram 20mg PO qD
2. Fludrocortisone 0.1mg PO DAILY (recently increased per
behavioral neurology)
3. Simvastatin 40mg PO qD
4. Aspirin 325mg PO qD
5. Clopidogrel 75mg PO qD
6. Digoxin 125mcg PO qD
7. Levothyroxine 150mcg PO qD
8. Lisinopril 2.5mg PO qD
9. Furosemide 40mg POqD
Discharge Medications:
1. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
5. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Month/Year (2) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Month/Year (2) **]:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
[**Month/Year (2) **]:*60 Tablet(s)* Refills:*2*
9. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*15 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
13. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
14. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Month/Year (2) **]:*15 Tablet(s)* Refills:*2*
15. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*2*
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*0*
17. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
[**Month/Year (2) **]:*30 ML(s)* Refills:*1*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
End-stage congestive heart failure
Discharge Condition:
Guarded
Discharge Instructions:
Followup Instructions:
Follow-up with PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**] as needed.
|
[
"V45.81",
"458.9",
"294.8",
"V45.82",
"424.0",
"585.9",
"428.32",
"V58.83",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
13673, 13763
|
5658, 11157
|
358, 416
|
13842, 13852
|
3708, 4312
|
13900, 13997
|
3261, 3306
|
11532, 13650
|
13784, 13821
|
11183, 11509
|
4329, 5635
|
13877, 13877
|
3321, 3689
|
252, 320
|
444, 2210
|
2232, 3178
|
3194, 3245
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,642
| 107,013
|
37084+58126
|
Discharge summary
|
report+addendum
|
Admission Date: [**2119-12-7**] Discharge Date: [**2120-1-3**]
Date of Birth: [**2050-8-14**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Pollen Extracts
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Incidental finding of cystic neuroendocrine neoplasm.
Major Surgical or Invasive Procedure:
[**2119-12-7**]:
1. Distal pancreatectomy with splenectomy.
2. Ligation of intra-abdominal vessel for control of hemorrhage
(splenic arterial takeoff).
History of Present Illness:
Mr. [**Known lastname **] is a 69-year-old gentleman who has pulmonary issues
including COPD and chronic bronchitis and pulmonary infections.
In the workup of one of his recent bouts with this, a CT scan
was performed and cuts from this revealed a cystic lesion in the
pancreas. This was focused on the tail. He subsequently was
worked up with an endoscopic ultrasound and aspiration of this
tissue revealed a cystic neuroendocrine neoplasm. The features
of this were a size close to 3 cm in diameter along with some
enhancing features suggestive of solid tumor growth and
malignancy. Furthermore, a detailed CT scan the abdomen showed
that he had multiple cystic lesions throughout his liver and
kidneys; but that there was a suspicious-appearing lesion in the
superior pole of the left kidney that might also be a neoplastic
problem. [**Name (NI) **] was admitted for planned distal pancreatectomy.
Past Medical History:
PMHx: pancreatic neuroendocrine tumor, hyperlipidemia, HTN,
asthma, COPD, h/o CVA, HA, obesity, hiatal hernia, renal
insufficiency, renal cyst, liver cysts.
.
PSHx: [**2119-10-31**] EUS, [**2062**] appy; Umbilical hernia repair [**8-7**].
Social History:
Married.
Family History:
Non-contributory
Physical Exam:
Pre-Admission Examination [**2119-11-20**]:
His abdomen is soft, nontender, and nondistended with positive
bowel sounds. He has a well-healed umbilical hernia scar and
appendectomy incision. There is no evidence of recurrent
hernia. He is extremely rotund in the abdomen and would be
considered obese. There is no evidence of any hernias or masses
in his inguinal and genital region. A rectal exam is deferred
today. The rest of his physical exam is entirely normal with
the exception of coarse expiratory rhonchi bilaterally.
.
At Discharge:
AVSS/afebrile.
GEN: Well appearing male in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR; nl S1/S2 w/o m/c/r
ABD: Incision with steri-strips c/d/i. BSx4. Soft/NT/ND.
EXTREM: No c/c/e
NEURO: A+Ox3. Non-focal/grossly intact.
Pertinent Results:
On Admission:
[**2119-12-7**] 01:16PM freeCa-1.07*
[**2119-12-7**] 01:16PM HGB-13.5* calcHCT-41
[**2119-12-7**] 01:16PM GLUCOSE-142* LACTATE-1.1 NA+-141 K+-3.8
CL--106
[**2119-12-7**] 01:16PM TYPE-ART PO2-87 PCO2-40 PH-7.42 TOTAL CO2-27
BASE XS-0
[**2119-12-7**] 04:31PM freeCa-0.99*
[**2119-12-7**] 04:31PM HGB-11.7* calcHCT-35
[**2119-12-7**] 04:31PM GLUCOSE-156* LACTATE-2.0 NA+-138 K+-4.5
CL--108
[**2119-12-7**] 05:32PM freeCa-0.87*
[**2119-12-7**] 05:32PM HGB-11.7* calcHCT-35
[**2119-12-7**] 05:32PM GLUCOSE-168* LACTATE-3.1* NA+-139 K+-4.9
CL--114*
[**2119-12-7**] 05:32PM TYPE-ART PO2-311* PCO2-44 PH-7.27* TOTAL
CO2-21 BASE XS--6
[**2119-12-7**] 06:28PM freeCa-0.97*
[**2119-12-7**] 06:28PM HGB-13.7* calcHCT-41
[**2119-12-7**] 06:28PM GLUCOSE-169* LACTATE-3.0* NA+-140 K+-5.5*
CL--113*
[**2119-12-7**] 08:15PM FIBRINOGE-160
[**2119-12-7**] 08:15PM PT-15.1* PTT-29.1 INR(PT)-1.3*
[**2119-12-7**] 08:15PM PLT COUNT-152
[**2119-12-7**] 08:15PM WBC-18.4*# RBC-4.92 HGB-14.4 HCT-43.2 MCV-88
MCH-29.3 MCHC-33.4 RDW-14.9
[**2119-12-7**] 08:15PM estGFR-Using this
[**2119-12-7**] 08:15PM GLUCOSE-204* UREA N-17 CREAT-1.1 SODIUM-142
POTASSIUM-5.8* CHLORIDE-114* TOTAL CO2-22 ANION GAP-12
[**2119-12-7**] 08:58PM freeCa-1.04*
[**2119-12-7**] 08:58PM LACTATE-1.4
[**2119-12-7**] 10:25PM GLUCOSE-253* POTASSIUM-4.8
[**2119-12-7**] 10:38PM freeCa-1.38*
.
Prior to Discharge:
[**2119-12-27**] 06:05AM BLOOD WBC-30.9* RBC-2.78* Hgb-7.9* Hct-24.5*
MCV-88 MCH-28.5 MCHC-32.4 RDW-15.1 Plt Ct-1072*
[**2119-12-27**] 06:05AM BLOOD Glucose-132* UreaN-12 Creat-1.1 Na-136
K-4.2 Cl-100 HCO3-25 AnGap-15
[**2119-12-27**] 06:05AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9
.
IMAGING:
CTA ABD [**2119-11-20**] (Pre-Admit):
1. 2.6 x 2.4 x 2.7 cm predominantly cystic lesion in the body of
the
pancreas, with a thin periphery of enhancement, and 1.5 x 1.1 cm
nodular area of enhancement along its superior margin. Results
from recent endoscopic FNA biopsy are consistent with a
neuroendocrine lesion, which is concordant with the imaging
findings. No definite evidence of metastatic disease within the
abdomen.
2. Multiple bilateral renal cystic lesions, several of which are
hyperdense. The majority of these are consistent with renal
cysts, and are statistically most likely benign. However, 2.4-cm
left upper pole cystic lesion is more mass-like, enhances
substantially more from the other lesions, and is suspicious for
renal neoplasm. This lesion would be amenable to image-guided
biopsy.
.
[**2119-12-7**] CXR:
ET tube ends at the thoracic inlet, nasogastric tube passes into
the upper stomach, right jugular line tip is at the junction of
brachiocephalic veins. Heart size is normal. Mediastinal
vasculature is engorged but there is no pulmonary edema.
Bibasilar atelectasis is severe, worsened since [**11-20**].
.
[**2119-12-15**] Chest/ABD/PELVIC CT:
1. Post-surgical changes, status post partial pancreatectomy and
splenectomy with small amount of fluid at the pancreatic bed
just at the tip of drainage catheter.
2. Bilateral lower lobe consolidations may represent
aspiration,pneumonia,
or atelectasis.
3. Apparent air in the nondependent portion of the cecum and
proximal ascending colon is unlikely to represent pneumatosis
and likely represents air mixed with fecal material. There is no
portal venous air or free peritoneal air to suggest ischemia.
4. Dilated loops of small bowel with no definite transition
point most likely representing paralytic ileus. Clinical
correlation and follow-up is suggested.
5. Bilateral renal lesions, with the largest measuring 2.4 cm in
the left upper pole which is suspicious for renal neoplasm due
to soft tissue attenuation.
6. Multiple liver hypodensities, likely cysts.
7. Small hiatal hernia.
.
[**2119-12-17**] CHEST/ABD/PELVIC CT:
1. Multifocal bilateral lung consolidations compatible with
pneumonia. This has worsened in the interval.
2. Partial pancreatectomy and splenectomy changes with
inflammatory changes and fluid in the surgical bed. The drain
appears to be in appropriate position. No discrete or drainable
fluid collection is identified on this limited non-contrast
study.
3. Interval worsening small-bowel dilatation with bowel wall
thickening. These findings are concerning for developing partial
small-bowel obstruction, with a transition to normal caliber
near the surgical site. No pneumoperitoneum or portal venous air
is demonstrated.
4. Multiple hepatic cysts.
5. Bilateral renal lesions, some of them dense, which may
represent complicated cyst versus underlying mass lesion. The
need for further evaluation with ultrasound should be determined
on a clinical basis.
6. Diverticulosis with no signs of acute diverticulitis.
.
[**2119-12-19**] ECHO:
Image quality is very limited. The left atrium is elongated. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF 70%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. There are focal calcifications in the aortic arch.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. This is a nondiagnostic
study - no obvious intracardiac shunt seen during color flow
imaging and air buibble contrast injection, but cannot be
excluded with certainty on the basis of this study
.
[**2119-12-26**] CXR: Bibasilar opacities most consistent with
atelectasis although underlying infiltrate cannot be excluded.
.
PATHOLOGY:
SPECIMEN SUBMITTED: DISTAL PANCREAS, MIDDLE PANCREAS, SPLEEN:
DIAGNOSIS:
I. Middle pancreas (A-B): Benign pancreatic tissue.
II. Distal pancreas, distal pancreatectomy (C-H): Well
differentiated neuroendocrine tumor, See synoptic report.
III. Spleen (I-J): Spleen with congestion; no malignancy
identified.
Pancreas (Endocrine): Resection Synopsis
MACROSCOPIC
Specimen Type: Partial resection, pancreatic tail.
Tumor Site: Pancreatic tail.
Tumor focality: Unifocal.
Tumor configuration:
Circumscribed: Cystic and nodular, partially encapsulated.
Tumor Size
Greatest dimension: 2.5 cm. Additional dimensions: 2.3 cm
x 1.9 cm.
Other organs/Tissues Received: Spleen.
MICROSCOPIC
Functionality type: Pancreatic endocrine tumor, secretory
status unknown.
EXTENT OF INVASION
Primary Tumor: Tumor limited to pancreas.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 2.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins:
Uninvolved by tumor:
Distance from closest margin: 15 mm, microscopically .
Specified margin: Pancreatic parenchymal margin.
Lymphovascular invasion: Present.
Perineural invasion: Absent.
Mitotic activity: Absent.
Additional Pathologic Findings: None identified.
Comments: The tumor has been characterized previously by
immunohistochemistry (specimen S09-[**Numeric Identifier 83582**]; positive for AE1/AE3,
CAM5.2, Synaptophysin, and chromogranin). The tumor has a
mitotic index of 0-1/50 HPF. The tumor invades into adjacent
pancreatic parenchyma but does not invade peripancreatic soft
tissue.
Clinical: Pancreatic mass.
Gross:
The specimen is received fresh in three containers, all labeled
with the patient's name, "[**Known lastname **], [**Known firstname **]", and the medical record
number.
Part 1 is additionally labeled "middle pancreas." It consists of
an unoriented segment of pancreas with attached blood clot
measuring overall 5 x 3.1 x 2.1 cm. The pancreatic parenchymal
margins are inked in yellow and the outside surface of the
pancreas is inked blue. The specimen is serially sectioned to
reveal soft tan yellow lobulated cut surfaces with no obvious
lesions noted. The specimen is represented as follows: A =
sections of the parenchymal margin, B = representative sections
of pancreas.
Part 2 is additionally labeled "distal pancreas." It consists of
a distal pancreatectomy specimen measuring 4.5 x 3.5 x 2.7 cm
with attached peripancreatic adipose tissue measuring 5 x 1.6 x
1.1 cm. The parenchymal resection margin is inked yellow and
the outer surface of the pancreas is blue inked and the specimen
is sliced horizontally to reveal a solid-cystic mass measuring
2.5 x 2.3 x 1.9 cm, located 2 cm away from the parenchymal
resection margin at its closest approach. The cyst is filled
with a clear serous fluid and contains a focally solid area
measuring 2 x 1.2 x 0.2 cm. The specimen is represented as
follows: C = sections through the parenchymal resection margin,
D = section of the mass in relation to the normal pancreas and
the parenchymal resection margin, E-G = additional
representative sections of mass, H = sections of the
peripancreatic fat containing possible lymph nodes.
Part 3 is additionally labeled "spleen." It consists of a
splenectomy specimen with attached adipose tissue measuring
overall 14.5 x 12.8 x 3.5 cm and weighing 311 grams. The spleen
is serially sliced to reveal maroon brown cut surfaces with no
gross lesions identified. The specimen is represented as
follows: I = sections of hilar fat containing possible lymph
nodes, J = sections of spleen.
.
MICROBIOLOGY:
[**2119-12-26**] URINE URINE CULTURE: No Growth to date - PRELIM.
[**2119-12-26**] BLOOD CULTURE: No Growth to date - PRELIM.
[**2119-12-26**] BLOOD CULTURE: No Growth to date - PRELIM.
[**2119-12-24**] BLOOD CULTURE:No Growth to date - PRELIM.
[**2119-12-24**] CATHETER TIP: NO GROWTH.
[**2119-12-24**] BLOOD CULTURE: No Growth to date - PRELIM.
[**2119-12-21**] BLOOD CULTURE:NO GROWTH.
[**2119-12-21**] BLOOD CULTURE: NO GROWTH.
[**2119-12-19**] BLOOD CULTURE: NO GROWTH.
[**2119-12-19**] URINE URINE CULTURE:NO GROWTH.
[**2119-12-19**] BLOOD CULTURE:NO GROWTH.
[**2119-12-18**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST}
[**2119-12-17**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST:
POSITIVE FOR CLOSTRIDIUM DIFFICILE - FINAL.
[**2119-12-16**] BLOOD CULTURE: NO GROWTH.
[**2119-12-16**] URINE URINE CULTURE:NO GROWTH.
[**2119-12-16**] BLOOD CULTURE: NO GROWTH.
[**2119-12-15**] MRSA SCREEN MRSA: NEGATIVE.
[**2119-12-15**] URINE URINE CULTURE:NO GROWTH.
[**2119-12-15**] BLOOD CULTURE: NO GROWTH.
[**2119-12-15**] BLOOD CULTURE: NO GROWTH.
[**2119-12-11**] URINE URINE CULTURE: NO GROWTH.
[**2119-12-7**] MRSA SCREEN MRSA SCREEN: NEGATIVE.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2119-12-7**] for for planned distal pancreatectomy. On that date,
the patient underwent distal pancreatectomy with splenectomy,
which was complicated by major intraoperative hemorrhage
requiring additional ligation of intra-abdominal vessel for
control of hemorrhage (splenic arterial takeoff). During the
surgery, the patient required the administration of 7000 mL of
crystalloid, 1000mL of 5% albumin, two units of FFP, and 9 units
of packed red blood cells. He remained hemodynamically stable
throughout the procedure(reader referred to the Operative Notes
for details). After the surgery, the patient was admitted to the
TICU, where he arrived NPO with an NG tube, intubated on
mechanical ventilation and neomycin infusion, on IV fluids, with
a foley catheter and two JP drain in place, and a
Dilaudid/Bupivacaine epidural for pain control.
.
While in the TICU, he was treated for hyperkalemia with a return
of his potassium to a baseline of 3.8-4.6. On POD#1, the patient
was successfully extubated. Serial hematocrits remained stable.
He remained hemodynamically stable, and was transferred to the
inpatient floor later that day.
.
Post-operative pain was initially well controlled with the
epidural, which was converted to just a Dilaudid PCA on POD#4.
When tolerating a diet, the PCA was discontinued, and the
patient started on oral pain medications with continued good
effect. The NG tube was discontinued, and the patient started on
clears on POD#5. His diet was progressively advanced as
tolerated to fulls by POD#6. The foley catheter discontinued in
the afternoon of POD#4, six hours after the epidural was
discontinued. As he was unable to void, the foley was replaced,
and he was started on Flomax. Post-splenectomy immunizations
consisting of the Pneumovax, Meningicoccal, and Haemophilus B
vaccines were given on POD#5. At this point, the patient was
being prepared for discharge in the next 1-2 days.
.
On POD#8, the patient went into atrial fibrillation, which could
not be converted on the floor with Metoprolol and Lasix. The
patient was emergently transferred to the TICU for further
evalaution and care. He was intubated, placed on a neomycin
drip, and treated for hyperkalemia. He was able to be extubated
the next day. When hemodynamically stable, he was returned to
[**Hospital Ward Name 121**] 9 on [**2119-12-10**], at which point the NG tube was out, he was
NPO except medications, on IV fluids, the foley was still in
place, and the patient still on the Dilaudid/Bupivacaine
epidural for pain control. While on the floor, his diet had been
advanced to fulls, the epidural was discontinued, and the
patient started on a Dilaudid PCA, and JP amylase levels were
sent.
.
On [**2119-12-15**], the patient again experienced atrial fibrillation,
which could not be converted on the floor. He was cardioverted.
He was transfered back to the TICU, started on a Diltiazem drip,
which was converted to an Amiodarone drip due to hypotension.
Cycled cardiac enzymes were unremarkable. Chest CT revealed
findings consistent with aspiration pneumonia, for which patient
was started on IV Vancomycin and Cefepime. Abdominal/pelvic CT
revealed apparent air in the nondependent portion of the cecum
and proximal ascending colon is unlikely to represent
pneumatosis and likely represents air mixed with fecal material.
There is no portal venous air or free peritoneal air to suggest
ischemia. Dilated loops of small bowel with no definite
transition point most likely representing paralytic ileus. He
developed acute renal failure with a creatinine of 2.4, which
responded well to IV fluid boluses x2 with inproved urine
output. NGT was placed, and immediately 1L bilious fluid was
suctioned. Following the removal of fluid, his SaO2 improved to
low 90s, his nausea resolved, and his abdominal pain decreased
to a [**12-10**]. He required subsequent fluid boluses foe a FENA of
0.1. Repeat Chest/abdominal/pelvic CT on [**2119-12-17**] demonstrated
multifocal bilateral lung consolidations compatible with
pneumonia, which had worsened in the interval. Interval
worsening small-bowel dilatation with bowel wall thickening
concerning for developing partial small-bowel obstruction, with
a transition to normal caliber near the surgical site was also
noted. Also, the patient had been experiencing multiple loose
stools. [**2119-12-17**] C.diff was returned positive, and the patient
was started on PO Vancomycin and Flagyl in addition to IV
Vancomycin and Cefepime. The patient was started on TPN.
.
On [**2119-12-20**], the patient was again returned to [**Hospital Ward Name 121**] 9 in stable
condition. He was NPo with an NG tube, on IV fluids and TPN,
continued on IV Vancomycin, Flagyl, and Cefepime as well as PO
Vancomycin, a foley was in place, and he received acetaminophen
for pain control. Home medications were re-introduced after the
NG tube was discontinued, and the patient started on sips. He
experienced a transient low grade temperature on [**2119-12-25**], and he
was again cultured, but then defervesced. WBC did remain in the
24-30 range after splenectomy, but the WBC was stable. Diet was
advanced to low sodium/heart healthy regular diet by [**12-26**]. TPN
was discontinued on [**12-23**]. Foley was discontinued the morning of
[**12-24**]; the patient was subsequently able to void without problem.
[**Name (NI) **] had been removed, and steri-strips applied. Incision
remained clean and intact. By discharge, the aspiration
pneumonia was treated, and there was four days remaining of
treatment for C.diff.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care.
Physcial and Occupational Therapy were consulted. The patient
received subcutaneous heparin and venodyne boots were used
during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. He received glucose monitoring and
insulin administration teaching. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating his diet,
ambulating with assistance, voiding without assistance, and pain
was well controlled. He was discharged to an extended care
facility for rehabilitation and nursing care. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-5**]
hours as needed for fever or pain.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
4. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**12-2**] sprays in
each nostril Nasal once a day as needed for allergy symptoms.
5. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Buspirone 5 mg Tablet Sig: 1.5 Tablets PO QAM and 1 tablet PO
(by mouth) QPM.
7. Reglan 5 mg Tablet Sig: One (1) Tablet PO BID
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-2**]
puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-5**]
hours as needed for fever or pain.
3. Omeprazole 20 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:*11*
4. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**12-2**] sprays in
each nostril Nasal once a day as needed for allergy symptoms.
5. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Buspirone 5 mg Tablet Sig: 1.5 Tablets PO QAM and 1 tablet PO
(by mouth) QPM.
7. Reglan 10 mg Tablet Sig: One (1) Tablet PO QID with meals and
at bedtime.
Disp:*120 Tablet(s)* Refills:*0*
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-2**]
puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
13. One Touch Ultra Test Strip Sig: One (1) strips In [**Last Name (un) 5153**]
four times a day.
Disp:*100 strips* Refills:*2*
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Hold for loose stools.
18. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
20. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
21. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
22. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day): give 30 minutes before breakfast and dinner .
23. Insulin Regular Human 100 unit/mL Solution Sig: 4-12 units
Injection As directed per Regular Insulin Sliding Scale.
24. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days: Completion date: [**2120-1-1**].
25. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous every eight (8) hours for 4
days: Completion Date: [**2120-1-1**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
1. Neuroendocrine cystic tumor of the tail of pancreas.
2. Cystic lesion of the left kidney.
3. Intraoperative hemorrhage.
4. Acute on chronic renal failure
5. Atrial fibrillation
6. Bilateral aspiration pneumonia
7. CLOSTRIDIUM DIFFICILE
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-8**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have [**Month/Year (2) 14073**], they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2120-1-26**] 9:45. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 83583**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (PCP) in [**1-3**] weeks.
Completed by:[**2119-12-27**] Name: [**Known lastname **],[**Known firstname 33**] Unit No: [**Numeric Identifier 13303**]
Admission Date: [**2119-12-7**] Discharge Date: [**2120-1-3**]
Date of Birth: [**2050-8-14**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Pollen Extracts
Attending:[**First Name3 (LF) 2083**]
Addendum:
Just prior to discharge on [**2119-12-27**], the patient experienced a
temperature of 101.5 PO in the context of contuned eleavted WBC
in the 29-31 range. The planned discharge was cancelled. Blood
and urine cultures were sent, which ultimately revealed no
growth. A Legionella Urinary Antigen was negative. A
chest/abdominal/pelvic CT revealed gallbladder distension, fluid
collection increased in size at the proximal margin of distal
pancreas and in post-splenectomy bed, as well as small plueral
effusions. None of the collections were deemed drainable. The
patient was continued on IV Flagyl and PO Vancomycin. On
[**2119-12-28**], he continued experiencing temperatures with a Tmax of
102.3 PO. Aspirin 325mg daily was started for a platelet count
of greater than 1000K. The patient also received Lasix IV 20mg
daily for lower extremity edema with good effect. By [**2119-12-30**],
the patient defervesced into the 97-100.4 range. WBC had
decreased to 18.8.
.
During this time period, the patient continued to tolerate a low
sodium, heart healthy diet with Boost Glucose Control
supplements. Pain was well controlled on Ibuprofen and
acetaminophen. Plavix was restarted, and heart rate and BP were
well controlled on low dose Metoprolol. He voided adequate
amounts without problem, and moved his bowels regularly. He
ambulated with assistance, and was followed by Physcial Therapy.
He remained hemodynamically stable.
Major Surgical or Invasive Procedure:
[**2119-12-7**]:
1. Distal pancreatectomy with splenectomy.
2. Ligation of intra-abdominal vessel for control of
hemorrhage (splenic arterial takeoff).
Physical Exam:
At Actual Discharge:
VS: 99.8 PO, 102, 129/76, 18, 95% RA
GEN: Well appearing male in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR; nl S1/S2 w/o m/c/r
ABD: Incision with steri-strips c/d/i. BSx4. Soft/NT/ND.
EXTREM: 2+/4+ pitting edema (B) LE. Diffuse ecchymotic patch (R)
LE. No cyanosis, clubbing.
NEURO: A+Ox3. Non-focal/grossly intact.
Pertinent Results:
Additional Labwork:
[**2119-12-27**] 06:05AM BLOOD WBC-30.9* RBC-2.78* Hgb-7.9* Hct-24.5*
MCV-88 MCH-28.5 MCHC-32.4 RDW-15.1 Plt Ct-1072*
[**2120-1-1**] 06:45AM BLOOD WBC-18.8* RBC-2.78* Hgb-7.7* Hct-24.6*
MCV-89 MCH-27.8 MCHC-31.4 RDW-15.7* Plt Ct-1282*
[**2119-12-27**] 06:05AM BLOOD Plt Ct-1072*
[**2120-1-1**] 06:45AM BLOOD Plt Ct-1282*
[**2119-12-27**] 06:05AM BLOOD Glucose-132* UreaN-12 Creat-1.1 Na-136
K-4.2 Cl-100 HCO3-25 AnGap-15
[**2119-12-31**] 07:55AM BLOOD Glucose-110* UreaN-11 Creat-1.1 Na-137
K-4.3 Cl-99 HCO3-27 AnGap-15
[**2119-12-29**] 06:20AM BLOOD ALT-50* AST-56* AlkPhos-494* TotBili-0.6
[**2119-12-27**] 06:05AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9
[**2119-12-31**] 07:55AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.9
.
Additional Imaging:
[**2119-12-28**] Chest/ABD/PELVIC CT:
CT TORSO: Helical imaging was performed from the lung bases
through the pubic symphysis without IV contrast. Subsequently,
helical imaging was again performed from the thoracic inlet
through the pubic symphysis after uneventful administration of
intravenous contrast. Oral contrast was present for both
examinations. Sagittal, and coronal reformations were performed.
COMPARISON: CT torso from [**2119-12-17**].
CT CHEST: There remain bibasilar confluent opacities, slightly
more pronounced on the left. However, this appearance is
improved since the earlier examination. There remain small
bilateral pleural effusions, slightly enlarged compared to the
previous examination. No pneumothorax is present. There is no
axillary, hilar, adenopathy. There are scattered,
non-pathologically enlarged mediastinal, and prevascular nodes,
which may be reactive. There is minimal coronary artery vascular
calcification. Otherwise, the heart and great vessels appear
normal.
CT ABDOMEN: Patient is status post splenectomy, and distal
pancreatectomy. In the post-splenectomy bed is a 3.4 x 3.1 cm
(4:49) fluid collection with a minimally enhancing peripheral
rim. This appearance of the fluid is larger, and more organized
than on the prior examination. The wall of the stomach, adjacent
to this fluid collection, appears thickened. At the proximal
site of the pancreatectomy at the surgical margin is a more
apparent 4.6 x 4.7 cm fluid collection (4:58). The fluid
collection extends slightly anterior and inferiorly (4:62). The
head, uncinate, and neck of the pancreas appear normal. There is
fat stranding within the abdominal mesentery (4:72, 4:66), which
is likely related to post-surgical edema. The gallbladder is
slightly distended measuring 7.7 x 5.5 cm (4:64). The wall of
the gallbladder appears slightly thickened and there is slight
fat stranding around the gallbladder. There is minimal
peri-gallbladder fluid (4:61). No stones are present in the
gallbladder.
Throughout the right and left lobes of the liver are multiple
hypodense lesions, compatible with simple cysts. The largest in
the left lobe of the liver measures 4.5 x 4.2 cm, and the
largest in the right lobe of the liver measures 4.9 x 3.7 cm
(4:56). There is minimal intrahepatic biliary ductal dilation.
The hepatic vasculature appears normal. There are multiple
hyperdense cysts arising off both kidneys. The largest arising
exophytically off the superior pole of the left kidney measuring
3 x 2.1 cm (4:56), and the largest arising exophytically off the
lower pole of the right kidney measuring 13 x 15 mm (4:64). The
adrenals appear unremarkable. As described previously, the
posterior superior wall of the stomach is slightly thickened and
inflamed. The remaining pelvic loops of small and large bowel
appear normal without obstruction or dilation. There is no free
air within the abdomen. The abdominal aorta and its branches
appear widely patent. There are post-surgical changes of the
splenic artery (4:58). There are scattered, non-pathologically
enlarged mesenteric, and retroperitoneal lymph nodes.
CT PELVIS: Colonic diverticula, but no diverticulitis.
Otherwise, pelvic loops of small and large bowel appear normal.
The bladder appears normal. There are calculi within the
prostate. There is a small amount of simple fluid in the low
pelvis. There is no free air. There is a fat-containing right
inguinal hernia.
BONE WINDOWS: There are degenerative changes of the lower lumbar
spine. There are no suspicious-appearing sclerotic or lytic
lesions.
IMPRESSION:
1. Gallbladder distention, mild wall thickening,
peri-gallbladder fat stranding, and small amount of
peri-gallbladder fluid. Cholecystitis cannot be excluded and
would recommend right upper quadrant ultrasound if there is
focal pain at this site. There are no stones within the
gallbladder.
2. Fluid collection at the proximal margin of the distal
pancreatectomy, increased in size compared to the prior
examination.
3. Fluid collection in the post-splenectomy bed, increased in
size since the prior examination. The adjacent stomach appears
slightly inflamed.
4. Small bilateral pleural effusions. Persistent, but improved
bilateral basilar consolidations.
5. Stable multiple hepatic hypodensities and multiple bilateral
renal hyperdense cysts.
6. Stranding of the abdominal fat, likely postoperative.
7. Colonic diverticula without diverticulitis.
.
MICROBIOLOGY:
[**2119-12-27**] Blood Cx x2: N GROWTH - FINAL.
[**2119-12-27**] Urine Cx: NO GROWTH - FINAL.
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-5**]
hours as needed for fever or pain.
3. Omeprazole 20 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:*11*
4. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**12-2**] sprays in
each nostril Nasal once a day as needed for allergy symptoms.
5. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Buspirone 5 mg Tablet Sig: 1.5 Tablets PO QAM and 1 tablet PO
(by mouth) QPM.
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-2**]
puffs Inhalation four times a day as needed for shortness of
breath or wheezing.
12. One Touch Ultra Test Strip Sig: One (1) strips In [**Last Name (un) 6358**]
four times a day.
Disp:*100 strips* Refills:*2*
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Hold for loose stools.
15. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
every twelve (12) hours.
Disp:*60 Tablet(s)* Refills:*1*
18. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
19. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day): give 30 minutes before breakfast and dinner .
Disp:*60 Tablet(s)* Refills:*1*
20. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Until
edema resolved, and fluid balance even. Baseline weight: 106.6
Kg.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care Center
Discharge Diagnosis:
1. Neuroendocrine cystic tumor of the tail of pancreas.
2. Cystic lesion of the left kidney.
3. Intraoperative hemorrhage.
4. Acute on chronic renal failure
5. Atrial fibrillation
6. Bilateral aspiration pneumonia
7. CLOSTRIDIUM DIFFICILE
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:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-8**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**], MD Phone:[**Telephone/Fax (1) 13304**]
Date/Time:[**2120-1-26**] 9:45. Location: [**Hospital Ward Name **] 3, [**Hospital Ward Name 600**].
.
Please call ([**Telephone/Fax (1) 13305**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (PCP) in [**1-3**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2120-1-3**]
|
[
"236.91",
"782.3",
"403.90",
"E870.0",
"278.00",
"249.00",
"V58.67",
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"458.29",
"276.7",
"V05.8",
"997.1",
"491.20",
"507.0",
"272.4",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.52",
"96.71",
"38.86",
"03.90",
"99.15",
"38.93",
"99.55",
"41.5",
"52.52",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
35887, 35948
|
13276, 19915
|
27705, 27863
|
36231, 36231
|
28273, 33576
|
37518, 38040
|
1730, 1748
|
33599, 35864
|
35969, 36210
|
19941, 21040
|
36408, 36990
|
37006, 37495
|
27878, 28254
|
2312, 2569
|
248, 303
|
522, 1425
|
2603, 13253
|
36245, 36384
|
1447, 1688
|
1704, 1714
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,244
| 119,482
|
21473+57245
|
Discharge summary
|
report+addendum
|
Admission Date: [**2100-12-1**] Discharge Date: [**2101-1-4**]
Date of Birth: [**2029-8-10**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
impending resp failure
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
71 yo male w/ COPD, CLL s/p multiple hospitalizations since [**10-9**]
at OSH for SOB. First hosp for SOB, believed [**3-8**] COPD flare.
Developed R cavitary pulmonary nodules (ddx septic emboli vs PE
vs tumor). Bronch at OSH w/ plaques in airways, 1+ MRSA, and
giant cell inclusions on path. Completed full course of
Vanco/Acyclovir for MRSA/HSV PNA. CTA w/ PE, started on
heparin. Transferred to [**Hospital1 18**] [**12-1**] for poss lung nodule bx.
ROS: No CP, abdominal pain, diarrhea, headache, weight loss.
Past Medical History:
COPD
CLL
Diastolic Heart Failure
Social History:
Lives in [**Location 4628**] with wife.
Physical Exam:
T 98.4 110/58 (110-122/56-70) HR 67 RR 20 95%RA
Gen: comfortable cachectic male lying in bed, NAD.
HEENT: EOMI, MMM.
NECK: Supple. No masses or LAD. No JVD. No carotid bruits.
RESP: Diffuse exp wheezes, b/l basilar rales.
CV: Distant heart sounds, nl s1 s2, no mrg.
ABD: Tense and distended - unchanged from [**2101-1-1**], NT, +NABS.
No rebound or guarding.
EXT: 3+ pitting edema to thighs b/l
SKIN: rash unchanged
Pertinent Results:
ECHO: Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline
dilated. Due to suboptimal technical quality, a focal wall
motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal
(LVEF>55%). Right ventricular chamber size is normal. Right
ventricular
systolic function is normal. The aortic root is moderately
dilated. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Trivial mitral regurgitation is seen. There is a
trivial/physiologic
pericardial effusion. E:A 0.83.
.
CT chest ([**12-2**]):
IMPRESSION:
1) Bilateral upper [**Month/Year (2) 3630**] segmental and subsegmental pulmonary
emboli.
2) Cavitary nodules within the right lower [**Month/Year (2) 3630**] with extensive
lymphadenopathy involving the axilla, mesentery, and
retroperitoneum. Small hypodensity also seen within the spleen.
These findings raise the possibility of an infectious process,
particularly a fungal infection, tuberculosis, or atypical
organism. A less likely possibility accounting for the cavitary
nodules in the lung would be a neoplastic process. Dedicated CT
of the abdomen and pelvis with IV contrast was recommended for
further evaluation of the lymphadenopathy and to assess for
extensive disease.
3) Small right pleural effusion.
4) Left hydronephrosis vs. peripelvic cyst. Again, a dedicated
CT of the abdomen and pelvis would be helpful in further
evaluation of this finding.
.
[**2100-12-3**] LE doppler:
IMPRESSION: Normal bilateral lower extremity DVT study.
.
[**2100-12-3**]: CT Abd
CT ABDOMEN WITH IV CONTRAST: Again demonstrated within the right
lower [**Month/Day/Year 3630**] are three cavitating lesions with central areas of
low attenuation, likely representing necrosis, unchanged since
the prior exam. A small right pleural effusion persists.
Additionally, in the lingula and left lower [**Month/Day/Year 3630**] are two tiny,
less than 5 mm, pulmonary nodules seen, present in the prior
study, which are nonspecific findings.
The liver, gallbladder, pancreas, spleen, adrenal glands, and
stomach are all within normal limits. In the left kidney, there
is a large parapelvic cyst which measures approximately 3.9 x
4.2 cm in greatest tranverse dimensions. Within the right kidney
interpolar region, there is a low attenuation well circumscribed
simple cyst present measuring 1.9 cm. Both kidneys enhance
symmetrically and excrete normally. The ureters appear
unremarkable. There is no hydronephrosis.
Within the fourth portion of the duodenum, there is a fat
containing well defined defect measuring approximately 1.7 cm,
most likely representing a lipoma. Additionally, on series 2,
image 37, there is a second fat containing well defined lesion
which appears to be in the wall of the duodenum which measures
approximately 5 mm, which may represent a second duodenal
lipoma. The remainder of the small and large bowel appears
unremarkable without evidence of wall thickening, bowel
obstruction, or surrounding fat stranding.
There are multiple enlarged lymph nodes within the mesentery and
retroperitoneum. Largest lymph node is identified within the
aorta caval region and measures approximately 2.5 x 3.7 cm.
There are multiple fat containing lesions/nodes throughout the
mesentery and retroperitoneum. The largest fat containing lesion
seen on series 2, image 38, which appears to have a thin wall,
measuring 4.0 x 2.9 cm. Several other of the fat containing
lesions appear to be surrounded by soft tissue density, and may
represent lymph nodes with central areas of fat. One of these
lesions is seen within the left periaortic region, best seen on
series 2, image 55, which measures 3.5 x 3.3 cm.
There is no free air or free fluid. There is no evidence of
bowel obstruction. The aortic wall is heavily calcified. There
is no evidence of aneurysmal dilatation. The abdominal
vasculature is patent throughout.
CT PELVIS WITH IV CONTRAST: Again seen within the pelvis are
several enlarged lymph nodes along the iliac chains. The largest
lymph node is located along the right iliac chain and measures
2.2 x 3.8 cm. Some of these lymph nodes appear to have tiny
amounts of fat within them. The rectum, sigmoid colon, prostate,
bladder, and distal ureter are unremarkable. There is no free
fluid.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Multiple enlarged mesenteric and retroperitoneal lymph nodes,
likley related to the known chronic lymphocytic leukemia.
However, some of the nodes appear to contain fat within them.
Additionally, there are several predominantly fat containing
lesions scattered throughout the mesentery and retroperitoneum
as well as possible duodenal lipomas. cause of the fat within
the nodes and mesenteric lesions is uncertain. Low
density(necrotic0 nodes can be seen in [**Doctor First Name **] or tuberculosis
infection. The presence of fat containing lymph nodes, however,
is unusual for these atypical infections. Another, but unlikley
consideration would be metastatic liposarcoma. Fat containing
lymph nodes can be seen in Whipples disease but this is not
relevant to this patient and the small bowel is normal. Given
the patient's cavitary lesions within the right lower [**Last Name (LF) 3630**], [**First Name3 (LF) **]
atypical infectious process is favored in a setting of CLL.
2. Possible small lipomas within the duodenum.
3. Small right pleural effusion, stable since the prior exam.
4. Bilateral renal cysts.
.
[**2100-12-9**]: bronchial bx
Right lower [**Month/Day/Year 3630**] bronchial biopsy:
a. Ulcerated bronchial mucosa with viral inclusions
consistent
with herpes simplex infection.
b. No malignancy identified.
.
[**2100-12-9**]: bronchial brushings
NEGATIVE FOR MALIGNANT CELLS.
Reactive bronchial epithelial cells, squamous epithelium,
neutrophils, red blood cells, pulmonary macrophages and
proteinaceous debris.
No viral cytopathic effect identified.
No organisms identified on silver stains
.
[**2100-12-13**]: CTA
CT CHEST WITHOUT/WITH CONTRAST: There are residual small filling
defects within the left upper [**Month/Day/Year 3630**] segmental pulmonary artery,
as well as within the right upper [**Month/Day/Year 3630**] and mid [**Month/Day/Year 3630**] segmental
and subsegmental pulmonary arteries, markedly decreased in size
in the interval. No other filling defects are seen within the
pulmonary arterial vasculature. Calcified atheromatous changes
are seen again within the aortic arch and descending aorta, and
unchanged. Otherwise the great vessels, heart, and pericardium
are within normal limits. A small pleural effusion is again
demonstrated on the right side, and unchanged. The right lower
[**Month/Day/Year 3630**] cavitary lesions are unchanged. There is centrilobular
emphysema unchanged. There are new ill-defined nodular opacities
within the right upper and mid lobes that were not seen in the
prior scan.
Again is seen extensive axillary lymphadenopathy bilaterally and
multiple small mediastinal lymph nodes, consistent with the
known diagnosis of CLL, unchanged.
Bone windows reveal no suspicious lytic or sclerotic bony
lesions.
CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were
essential in delineating the pathology described above.
IMPRESSION:
1) New ill-defined nodular non-specific opacities within the
right upper and middle [**Month/Day/Year 3630**].
2) Regression in size and number of filling defects within the
pulmonary arterial vasculature, improved PE.
3) Small right pleural effusion and posterior right lower [**Month/Day/Year 3630**]
cavitary lesion unchanged.
4) Lymphadenopathy consistent with the known diagnosis of CLL.
.
[**2100-12-15**] bronchial washings:
Highly atypical squamous cells, pulmonary macrophages,
inflammatory cells, and fungal spores.
.
[**2100-12-19**]: KUB
HISTORY: Respiratory distress, distended abdomen. Evaluate for
obstruction.
Gas filled loops of large and small bowel are present. Gas is
seen as far as the rectum suggesting an ileus pattern rather
than obstruction.
IMPRESSION: Gas filled loops of large and small bowel.
.
[**2100-12-20**] CT abd/pelvis
CT THORAX W/CONTRAST
Extensive air space consolidation is identified in the right
upper [**Month/Day/Year 3630**]. Given the patient's history, this is most in keeping
with aspiration pneumonia. But consideration to other forms of
infection, or secondary to the patient's recent BAL procedure is
given. A right-sided subclavian line is in-situ, but there is no
evidence of perivenous abnormality to suggest extravasation. No
pneumothorax is seen.
Background changes of extensive pan-lobular and inter-lobular
emphysema are identified. Bibasilar pleural effusions are
identified, larger on the right. In addition, atelectasis is
identified bibasilarly , p[articularly within the right. Within
these areas of atelectasis in the right lower [**Month/Day/Year 3630**], is again
identified a focal rounded hypo-intense areas consistent with
either pulmonary infarcts or cavity formation.
The patient's pulmonary emboli were not visualized, but the
examination was not targeted to evaluate for this.
There is evidence of multiple moderate-to-large axillary lymph
nodes, that are consistent with the patient's history of CLL.
Multiple mediastinal lymph nodes are also identified.
CT ABDOMEN W/CONTRAST
There is evidence of large and small bowel dilatation. The
distal colon is partially decompressed, but the more proximal
colon is dilated. There is no evidence of an obvious transition
point. No evidence of bowel ischemia is identified, and no bowel
masses are identified. The patient's proximal celiac axis is
identified, but the celiac axis, SMA, and pelvic vessels are
patent. In addition, the SMV appears patent.
As before, multiple fat-filled lymph nodes are identified, as is
a general haziness in the patient's mesentary consistent with
lymphoma. The spleen is not enlarged. The pancreas is a little
atrophic, but otherwise normal.
CT PELVIS W/CONTRAST
Multiple intraperitoneal fat-filled lymph nodes are identified.
Multiple parapelvic cysts are identified bilaterally, unchanged
from previously.
The descending aorta is normal. A small amount of free fluid is
identified.
CT BONES W/CONTRAST
No suspicious lytic or sclerotic abnormality is identified.
CONCLUSION
1. Interval development of significant air-space consolidation
in the right
upper [**Month/Day/Year 3630**], worrisome for aspiration pneumonia, although
consideration to
other causes is also given.
2. Background bibasilar atelectasis/infarction with reactive
pleural
effusions is seen as before.
3. Interval development of significant large and small bowel
dilatation,
without evidence of a significant transition point, most
consistent with
ileus. In particular, the hernial orifices do not contain bowel,
and the
visualized vessels appear normal.
The findings were discussed with the team at the time of
reporting.
.
[**12-23**] transfusion reaction
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS:
Mr. [**Known lastname **] experienced an increase in respiratory rate, blood
pressure,
and heart rate 75 minutes following a test dose of IVIG. He also
experienced chills/rigors and flushing. The differential
diagnosis
includes side effects from IVIG vs. underlying illness.
Common side effects of IVIG include mild-to-moderate headahces,
which
respond to anti-inflammarotyr drugs. Chills, chest discomfort
may occur
in the first hour of the infusion and respond to cessation of
the
infusion for 30 minutes and resumption at a slower rate.
Fatigue,
fever, or nausea after infusion may last up to 24 hours. Other
side
effects include dizziness, leg or muscle cramps, difficulty
breathing,
shortness of breath and wheezing.
The most likely cause of Mr. [**Known lastname **]' symptoms is the test dose of
IVIG.
However, given his complex medical history and respiratory and
cardiac
status, his underlying illness as a component cannot be entirely
excluded.
For future infusions of IVIG, pre-medication with steroids and
possible infusion at a slow rate are recommended.
.
[**2100-12-25**] CT chest
FINDINGS: There has been interval worsening of the right upper
[**Month/Day/Year 3630**] pneumonia with new involvement of the anterior segment. In
addition, there are cavitary areas within this air-space
opacity. The superior segment of the right lower [**Month/Day/Year 3630**] continues
to be involved. There is a moderate-sized right pleural effusion
and a small left pleural effusion with bibasilar compressive
atelectasis. No definite lower [**Month/Day/Year 3630**] cavitary lesions are
identified.
There is a stable appearance of multiple moderate to large
axillary lymph nodes, consistent with the patient's history of
CLL. Multiple mediastinal lymph nodes are also stable.
The right subclavian central venous line terminates in the
superior vena cava. There is an NG tube terminating within the
stomach. The visualized portion of the unenhanced upper abdomen
demonstrates an unremarkable appearance of the visualized
portion of the liver, spleen, adrenal glands.
CT BONES WITHOUT CONTRAST: No suspicious lytic or sclerotic
abnormalities identified.
IMPRESSION:
Interval worsening of the air-space consolidation in the right
upper [**Month/Day/Year 3630**] with areas of cavitation. Unchanged bilateral pleural
effusions with compressive atelectasis at the bases.
.
[**2100-12-29**]: skin bx
Subcorneal/intraepidermal pustule with associated keratinocyte
necrosis and overlying scale-crust (see note).
Note: Gram stain and PAS stains are negative for bacteria and
fungi. The changes are not specifically diagnostic, however the
presence of individual cell necrosis of keratinocytes raises
the possibility of an herpetic infection.
.
[**2101-1-2**] Chest CT
CT CHEST W/IV CONTRAST: A left subclavian venous access catheter
is in place with the tip terminating in the distal SVC. The
previously seen right central venous catheter has been removed.
There are numerous enlarged mediastinal and hilar lymph nodes
again seen. These are located within the prevascular, right
paratracheal, precarinal, subcarinal, and right and left hilar
distributions. The largest of these, located in the right
paratracheal region (series 102-B,
image 88) measures 1.9 x 1.3 cm (previously 1.9 x 0.9 cm). A
right hilar node measures 1.3 x 1.9 cm (previously 1.2 x 1.9
cm). In comparison with the previous examination, the degree of
mediastinal and hilar lymphadenopathy appears stable-to-slightly
increased in prominence. There are again seen bilateral and
axillary lymph nodes. The largest of these, located in the left
axilla, measures 1.6 x 2.1 cm (previously 1.8 x 2.5 cm), and
contains internal hypodensity suggestive of necrosis.
The heart and pericardium appear unremarkable. The central
airways are patent. There is prominent calcification of the
thoracic aorta, consistent with atheromatous disease. Small
bilateral pleural effusions are again seen, right slightly
greater than left. The right pleural effusion appears decreased
in size from the previous examination. The left pleural effusion
is stable. Again seen within the right upper [**Month/Day/Year 3630**], is a large
area of cavitary pneumonia. In comparison with the previous
examination, this appears stable- to-slightly-decreased in size.
There are multiple scattered nodular densities within the
anterior segment of the right upper [**Month/Day/Year 3630**] (series 102-B, images
96 and 102), which appear unchanged from the previous
examination. Within the posterior aspect of the superior segment
of the right lower [**Month/Day/Year 3630**], there is again seen a focus of cavitary
pneumonia, as well as additional peripheral nodular densities.
These are possibly consistent with additional foci of
consolidation and infection, or, alternatively, necrotic areas
of pulmonary parenchyma related to the patient's known prior
pulmonary emboli. There is slight improvement in the compressive
atelectasis of the right lower [**Month/Day/Year 3630**] adjacent to the decreased
right pleural effusion.
Heterogeneous linear opacity at the left base is consistent with
compressive atelectasis, although pneumonic consolidation within
this area cannot be entirely excluded. Additional pleural-based,
peripheral opacities within the superior segment of the left
upper [**Month/Day/Year 3630**] medially (series 102-B, image 84) may be consistent
with peripheral atelectases vs. small foci of consolidation. A
nodular density within the left upper [**Month/Day/Year 3630**] laterally (series
102-B, image 92) appears unchanged.
No pneumothorax. The surrounding osseous structures appear
unchanged. Limited images of the upper abdomen, including
limited images of the liver, spleen, and adrenal glands appear
unremarkable.
.
IMPRESSION
1. Stable-to-slightly increased mediastinal, hilar, and axillary
lymphadenopathy, consistent with the patient's history of CLL.
2. Stable-to-slight improvement in cavitary pneumonia within the
right upper
[**Month/Day/Year 3630**] and superior segment of the right lower [**Month/Day/Year 3630**].
3. Peripheral based densities within the posterior aspect of the
right lower
[**Month/Day/Year 3630**], possibly consistent with areas of pneumonia vs. pulmonary
infarcts
related to prior PE.
4. Decreased size of right pleural effusion. Stable small left
pleural
effusion.
.
[**2101-1-3**]: KUB
dilated loops of colon. no free air in abdomen.
Brief Hospital Course:
Pt is a 71 yo man with pmh significant for CLL and COPD who
originally developed SOB after discharge from OSH where was
treated for COPD flare, was re-admitted to that hospital and
found by CT to have pulmonary nodules with cavitation and
multiple pulmonary emboli and by bronchoscopy to have lesions
consistent with HSV. Pt was transferred to [**Hospital1 18**] for further
care and work up of pulmonary nodules. Here he was treated
initially for HSV with Acyclovir. Ultimately pt had a
bronchoscopy here with BAL positive for aspergillus and
pseudomonas; bronchial biopsy with HSV; and gram stain with gram
positive cocci. He was started on Voriconazole, Vancomycin,
Ciprofloxacin and Flagyl for presumed aspiration pneumonia.
Pulmonary nodules were not biopsied as it was felt that it would
not change management. Pt was transferred to MICU on [**2100-12-18**]
with worsening respiratory status, never required intubation and
was felt ready for transfer back to the floor on [**2100-12-22**].
Unfortunately, while on the floor pt had a transient hypoxia,
became tachypnic and agitated and was transfered back to the
MICU within that same day where his respiratory status improved
to baseline after diuresis. After this stabilazation patient
was felt again ready for transfer back to the floor on [**2100-12-24**]
but after having some respiratory distress during infusion of
IVIG (which he routinely receives for CLL treatment) it was
decided that pt should stay in the MICU. He subsequently
recieved IVIG without incidence. Shortly after this the patient
developed a distended abdomen. GI was consulted and colonoscopy
was performed with diagnosis of ileus and treatment with
decompression with rectal tube. During this period the patient
also developed a rash on his left lower extremity which
Dermatology consultants biopsied and felt was associated with
either bacterial or fungal infection. Also during this period
pt developed marked lower extremity edema thought secondary to
increased IV fluid load on background of diastolic CHF.
Throughout the hospitalization pt was on heparin drip to treat
the pulmonary emboli and was ultimately transitioned to
coumadin. He was transferred to the floor on [**2101-1-1**].
.
Floor course and continuing management issues:
1. Resp distress-Etiology of pt's respiratory distress is
multifactorial [**3-8**] COPD, pseudomonas and aspergillus PNA, and
PE. Repeat Chest CT performed on [**1-2**] showed stable to slightly
increased lymphadenopathy consistent with CLL and stable to
slight improvement in cavitary PNA of RUL and superior segment
of RLL. Pt was treated for his respiratory distress as outlined
by issues listed below.
2. PNA:Chest CT performed on [**1-2**] showed stable to slight
improvement in cavitary PNA of RUL and superior segment of RLL.
Antibiotics were discontinued one by one. Aztreonam was
discontinued on [**1-3**]. Pt received a total antibiotic course of:
vanco (20 days), Voriconazole (20 days), Aztreonam (18 days, d/c
[**1-3**]), Cipro (12 days, d/c [**1-1**]), Flagyl (11 days, d/c [**12-31**]),
Pt is to continue vancomycin (for corynebaterium in BAL gram
stain) and voriconazole (for aspergillus) until he follows up in
[**Hospital **] clinic. Pt needs to follow up in [**Hospital **] clinic in 4 weeks with Dr
[**First Name (STitle) **]. He should get a repeat chest CT several days prior to the
visit.
.
2. COPD: Continue to treat COPD flare with albuterol, atrovent,
Flovent, Spiriva, salmeterol. Continue slow steroid taper. Pt is
to get Prednisone 30mg po qd for 3 days. Change to 20mg po qd on
[**1-7**]. Continue on Prednisone 20mg qd daily. Continue chest PT.
Pt should follow up in pulmonary clinic.
.
3. PE: Recent chest CT from [**1-2**] showed peripheral based
densities within the posterior aspect of the right lower [**Month/Year (2) 3630**],
possibly consistent with areas of pneumonia vs. pulmonary
infarcts, related to prior PE. Pt is being anticoagulated with
heparin and coumadin (since [**1-1**]). Continue heparin until pt is
therapeutic on coumadin with goal INR [**3-9**].
.
5. Diastolic heart failure and LE edema - Pt became fluid
overloaded after bronchoscopy with 3+ lower edema bilaterally.
Pt was given IV Lasix with goal negative 1 L per day. Pt has
been diuresing well. Continue gradual diuresis with Lasix 80mg
po qd.
.
6. Abd distention/Ileus: On [**12-19**], pt had KUB c/w ileus, NGT
placed. [**12-20**] Abd CT scan showed diffuse dilated small and large
bowel. No clear transition point. No masses. No evidence bowel
wall ischemia. Surgery consulted for question of [**Last Name (un) 3696**]
Syndrome. Rectal tube placed for decompression, pt was made NPO
w/ NGT for some time. Pt improved w/decompression from above and
below. GI was also consulted, recommended conservative
treatment. On [**12-29**], had recurrent ileus, but passing stool. On
[**12-30**] started reglan for bowel motility. Pt is improved overall
clinically: passing stool through rectal tube and tolerating po
diet. Rectal tube fell out and was not replaced on [**1-3**].
.
7. Seizure disorder-Pt was continued on phenytoin. Levels were
monitored while on voriconazole as it interferes w/metabolism.
On [**2024-12-31**], levels were found to be subtherapeutic; pt was
given phenytoin boluses and maintenance dose was increased. Last
dilantin level was 4.6 on day of discharge. He was given
additional bolus prior to discharge. Pt should be continued on
maintenance dose of Phenytoin 200mg tid. Please check phenytoin
level on [**1-7**]. Goal level is [**11-19**]. Please have pharmacist
adjust phenytoin dose as needed. Of note, pt's dilantin levels
are affected by his hypoalbuminemia and voriconazole.
.
8. Anemia/CLL- No evidence of GIB or hemolysis. Pt is on IVIG q2
months per oncologist. On [**12-23**], pt developed respiratory
distress during dose of IVIG requiring him to stay in MICU. Pt
received another infusion thereafter, without incident.
Respiratory distress was most likely secondary to pt's other
medication issues. For future infusions of IVIG, pre-medication
with steroids and
possible infusion at a slow rate are recommended. Please see
pertinent data section for more details on the transfusion
reaction investigation.
.
9. Discoid erythematous rash: Located primarily on left lower
extremity. Derm biopsied it and felt it is a dermatomal
eruption. Skin biopsy showed HSV. Pt was not restarted on
acyclovir given improving rash. If it worsens consider starting
acyclovir for treatment of HSV.
.
10. Hyponatremia- Likely due to SIADH given pulm processes. He
became hypernatremic on fluid restriction w/TPN. Sodium has now
normalized.
.
11. ACCESS- PICC line placed on [**12-31**].
.
12. FEN: tolerating full diet well
.
13. PPx: PPI, boots, Heparin SS
.
11)[**Name (NI) 56667**], pt
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (family friend) [**Telephone/Fax (1) 56668**]
Dr. [**Name (NI) 5448**] (pt's PCP): office- [**Telephone/Fax (1) 56669**], cell: [**Telephone/Fax (1) 56670**]
12)Code: full
Medications on Admission:
dilantin 400mg [**Hospital1 **]
theophylline SA 300mg [**Hospital1 **]
Advair 500-50 [**Hospital1 **]
Bactrim DS [**Hospital1 **]
Valacyclovir 1gm [**Hospital1 **]
Vancomycine 1gm [**Hospital1 **]
Tiotropium qd
Prednisone 40mg [**Hospital1 **]
Albuterol neb
xanax 0.25 tid prn
IVIG q8-10weeks.
Discharge Medications:
1. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Five
(5) Puff Inhalation [**Hospital1 **] (2 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): Per sliding scale.
6. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed
for constipation.
11. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
12. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days: Last day is [**1-6**].
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Trazodone HCl 50 mg Tablet Sig: 0.25 Tablet PO HS (at
bedtime) as needed.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
18. Phenytoin Sodium Extended 100 mg Capsule Sig: Two(2) Capsule
PO BID (2 times a day). NOTE: DOSE REDUCED FROM ADMISSION DUE
TO ANTIFUNGAL/ANTIBIOTICS, HYPOALBUMINEMIA, ETC. WILL NEED CLOSE
OUTPATIENT MONITORING.
19. Voriconazole 200 mg Solution Sig: 2.5 Solutions Intravenous
Q12H (every 12 hours).
20. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) Intravenous ASDIR (AS DIRECTED): Until
therapeutic on coumadin with INR of [**3-9**].
please use weight based protocol for target PTT of 60-100sec.
21. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day.
22. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day:
Start on [**1-7**].
23. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
24. Chest CT
Pt needs to get a chest CT 3 weeks later, prior to being seen in
[**Hospital **] clinic
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
pulonary embolus
COPD
chronic lymphocytic leukemia
Aspergillosis Pneumonia
Pseudomonas Pneumonia
Congestive Heart Failure
Discharge Condition:
stable
Discharge Instructions:
Contact your physician if you develop any more trouble
breathing, chest pain, leg pain.
Take your coumadin and have your physician check your "INR"
regularly. You may need a hypercoagulable workup by your
oncologist.
Followup Instructions:
Follow up with your primary care doctor Dr. [**Last Name (STitle) 5448**]
([**Telephone/Fax (1) 56669**]) after discharge from [**Hospital **] rehab.
Follow up with your oncologist Dr. [**Last Name (STitle) 54533**] ([**Telephone/Fax (1) 56671**]) within
2 weeks of discharge.
Follow up in [**Hospital **] clinic ([**Telephone/Fax (1) 4170**]) with [**First Name8 (NamePattern2) **] [**Doctor Last Name **] on [**2-10**], 11am. Located on [**Doctor First Name **], basement.
Follow up in pulmonary clinic as follows:
Provider PULMONARY BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2101-1-24**]
7:45
Provider PULMONARY EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2101-1-24**] 8:00
Provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 5091**] Date/Time:[**2101-1-24**] 8:00
Pt is scheduled for Chest CT on [**1-19**], in [**Hospital 191**] clinic of
[**Hospital1 18**] [**Hospital Ward Name **] building.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Name: [**Known lastname **],[**Known firstname 1340**] Unit No: [**Numeric Identifier 10590**]
Admission Date: [**2100-12-1**] Discharge Date: [**2101-1-4**]
Date of Birth: [**2029-8-10**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**First Name3 (LF) 1472**]
Addendum:
HPI:
71 y/o man with prior history of CLL s/p 1 month of cytoxin and
five cycles of fludaribine (year [**2096**]) on chronic oral steroids
for CLL and COPD developed progressive SOB beginning 2 months
prior to admission. At that time it was felt he had a COPD
flair and was admitted to the hospital for observation and
management. CT showed new infiltrates in the right lower lobe
largest measuring 4x2.5cm with an "infectious appearance". He
was started on levoquin and his prednisone was increased to 40mg
[**Hospital1 **] from 20mg [**Hospital1 **]. Prior to his discharge he developed a fever,
but left for home AMA as opposed to a rehab hospital. OVer the
next few days he worsened and was readmitted to another hospital
where repeat CT showed cavitations of the right lower lobe
nodules. Bronch with biopsy demonstrated a white plaque that
could not be washed off. Biospy of the lesion deomonstrated
atypical cells with intranuclear inclusions classic for HSV. No
biopsy of the right lower lobe infiltrate was obtained as it was
too distal. BAL grew 1+MRSA, 1+ stenotrophomonas, (-) PCP, (-)
fungal culture and (-) AFB smear. He was started on empiric
therapy: VAncomycin for MRSA cavitary pneumonia, acyclovir ? HSV
pneumonia, and bactrim for PCP coverage given his
immunosuppression from CLL and chronic steroids. No antifungals
were initiated. Blood cultures x2 sets were negative.
The patient improved on the drug regimen however after several
days deteriorated with progressive DOE. CTA at that time
demonstrated multiple PE's. HE was started on lovenox then
transferred to [**Hospital1 8**] for management and diagnosis of the
cavitary lesions/dyspnea.
On admission he was afebrile with a normal WBC, and dyspneic
after walking 10'. He does not complain of SOB at rest. He has
a significant travel history and has been across the U.S., South
East [**Female First Name (un) **], Europe, [**Country **], [**Country 10591**] as he is a Federal Express
worker. He has no travel over the last year. He has no pets at
home. He denies a history of TB, though does not know his PPD
status. PPD was not placed at the outside hospital b/c of
concern that he would be anergic anyhow. Denies weight loss,
hemoptysis, drenching night sweats. Denies visual disturbances,
or RUQ pain. Denies chest pain or chest tightness.
He is a 80 pack year smoker however quit 10 years ago after
being diagnosed with COPD. He is followed by a pulmonologist
who has treated him with Tio, albuterol nebs/MDI, salmeterol,
fluticasone, and chronic steroids. He has been unable to be
weaned from steroids secondary to exacerbations of his COPD. He
has never been intubated for exacerbations. At baseline he is
able to walk several blocks without becoming dyspneic.
In regards to his CLL, he was diagnosed in [**2093**] and with an
elevated WBC. Imaging results at that time are unknown to me.
He was seen by Oncology, Dr. [**Last Name (STitle) **], who started him on
chemotherapy and radiation. He completed 5 cylces of
fludaribine which was stopped secondary to granulocytopenia. He
then underwent 1 month of cytoxin which was discontinued
secondary to hemolytic anemia. Since that time he has been on
chronic steroids for dual management of his CLL and COPD. He
was recently started on IVIG earlier this year when he started
developing more frequent URI under the premise that he might
benefit from greater iimmune function. He normally receives it
when his IgG is 300-400. He has a known reaction to IVIG (known
after discussion with his nurse following his reaction to IVIG
in the MICU hereat [**Hospital1 8**]) and gets premedicated with benadryl
and decadron. He has not had any history of blastic
transformation. He had a colonoscopy 2 yrs ago which was
normal.
Hospital Course:
He was admitted to the medicine service and started on a heparin
drip for anticoagulation of his PE. All antibiotics except for
bactrim (PCP [**Name Initial (PRE) 2515**]) were discontinued given the lack of
support for any particular organism and his stable respiratory
function. Repeat CT showed stable appearance of the cavitations
compared with films taken at the outside hospital.
Interventional pulmonology was consulted who felt that the
cavitary lesion was too distal to biopsy on bronchoscopy. Given
it's pleural base we consulted Interventional Radiology.
However, given the size of his pleural blebs, his tenuous
respiratory function, and their history of obtaining poor yields
on micro studies from bx, they were reluctant to biopsy him
pending. He remained afebrile and began to improve from a
pulmonary standpoint able to ambulate down the halls without
desaturating or stopping to catch his breath. It was then felt
that rather than have an infectious process, the cavitary
lesions may have represented pulmonary infarcts that were the
typical wedge shaped pleural based lesions. He initially
improved off antibiotics, on anticoagulation only. Steroids
were tapered. However after several days, he decompensated with
worsening DOE with fevers up to 102.7. Minimal activity
resulted in desaturation into the low 80??????s. Repeat CT chest
showed new opacities in the right lower and middle lobes,
resolving PE and stable right lower lobe cavitations. Repeat
bronch by pulmonology grew out aspergillus, sparse pseudomonas
and GPR consistent with oral microbes. Over the next few days,
he continued to spike fevers with persistently negative blood
cultures and unchanged sputums. Another CT chest showed
worsening effusion and right lung infiltrates. He was started
on voriconazole and cipro for treatment of invasive aspergillus
and nosocomial pseudomonas pneumonia. He was transferred to the
MICU for treatment. Further hospital course as outlined by
discharge summary.
Chief Complaint:
see d/c summary
Major Surgical or Invasive Procedure:
see d/c summary
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**]
Completed by:[**2101-1-27**]
|
[
"482.1",
"484.6",
"251.8",
"507.0",
"511.9",
"780.39",
"562.10",
"491.21",
"695.4",
"204.10",
"428.0",
"054.9",
"518.81",
"415.19",
"E932.0",
"117.3",
"560.1",
"214.8",
"484.8",
"054.79",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"45.23",
"86.11",
"38.93",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
37070, 37302
|
19144, 26191
|
37030, 37047
|
29288, 29296
|
1429, 19121
|
29562, 34940
|
26535, 29020
|
29143, 29267
|
26217, 26512
|
34957, 36958
|
29320, 29539
|
992, 1410
|
36975, 36992
|
345, 864
|
886, 920
|
936, 977
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,588
| 133,228
|
9117
|
Discharge summary
|
report
|
Admission Date: [**2197-5-31**] Discharge Date: [**2197-6-14**]
Date of Birth: [**2143-12-3**] Sex: M
Service: Liver Transplant Surgery Service
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
male status post orthotopic liver transplant on [**2195-8-2**] by
Dr. [**First Name (STitle) **] who is recently noted to have an elevation of
liver enzymes. Ultrasound today, on the day of admission was
unable to detect hepatic artery flow. The patient was taken
of severe stenosis verses clot and possibility of
intervention. Angiography showed severe stenosis of the
artery through which a small catheter was advanced beyond the
narrowing and the artery was found to be clotted. It was
decided that TPA should be infused into the vessel and
imaging should be repeated in the morning.
1. End-stage liver disease secondary to Hepatitis B and C
and alcohol.
2. Orthotopic liver transplantation [**7-/2195**].
3. Status post pontine hemorrhagic stroke.
4. Transient seizure disorder.
MEDICATIONS ON ADMISSION:
1. Multivitamin.
2. Bactrim one tab q day.
3. Prednisone 20 mg p.o. b.i.d.
4. Prilosec 40 mg p.o. q day.
5. Diflucan 1 tab p.o. q day.
6. Rhabdomyicn 3 mg p.o. q day.
7. Ambien 10 mg p.o. q h.s.
8. Zestril 20 mg q day.
9. Prograf 1 mg p.o. q day.
10. Aspirin 81 mg p.o. q day.
11. Colace p.r.n.
ALLERGIES: Roxicet and Vicodin.
SOCIAL HISTORY: Tobacco: The patient currently a smoker,
occasional ETOH use. No recreational drugs per patient.
PHYSICAL EXAMINATION: On examination the patient was
afebrile, heart rate was 76, blood pressure 111/61. The
examination revealed a middle aged male alert, oriented in no
distress. Lungs were clear to auscultation bilaterally.
Heart exam revealed regular rate and rhythm. Abdominal exam
revealed abdomen which was soft, nontender, nondistended.
There was no swelling in the area of the groin where the
catheter had previously been introduced. There was no
hematoma. The extremities were warm and well perfused with
no edema.
LABORATORY VALUES: White blood cell count 13.6, hematocrit
47.7, platelets were 126, prothrombin time was 11.1, PTT
30.6, INR is 0.9. Fibrinogen was 171. Sodium 136, potassium
4.4, chloride 98, bicarbonate 24. BUN 32, creatinine 1.1.
glucose 145. ALT 137, AST 106, alk phos 130. Total
bilirubin 1.1, direct bilirubin 1.4. SK 506 level was 2.5.
Robimycin level was 14.3.
IMAGING: Ultrasound as referenced in the history of present
illness was significant for the inability to document hepatic
artery wave forms by ultrasound. Angiography, global
arteriogram demonstrated mild atherosclerotic disease of the
renal abdominal aorta. There was a high aortic bifurcation
noted. Selective celiac arteriogram demonstrated patent
celiac access. The common Hepatic artery occluded abruptly
and no distal branches were visualized. On portal venous
phase the portal vein and splenic vein appeared widely
patent. Hepatic arteriogram demonstrated partially occluded
common hepatic arterial lumen with multiple filling defects
most consistent with thrombus. There was reflux of contrast
present.
HOSPITAL COURSE: As previously stated the patient was
admitted and placed in the surgical Intensive Care Unit. The
plan was to return on hospital day two for repeat
angiography. On the morning of hospital day two, the patient
was taken back to the angiography suite. At angiography
initially a successful thrombolysis of the hepatic artery
occlusion was performed. There was evidence of a short but
significant hepatic artery stenosis. The stenosis was unable
to be crossed with a balloon angioplasty catheter. During
the procedure the recurrence of a partially obstructing
thrombi in hepatic artery both up and down stream of the
hepatic artery stenosis. TPA and Heparin infusions were
restarted.
On hospital day three the patient was again taken to
angiography. A patent donor hepatic artery with a very slow
flow across focal anastomotic stenosis was again observed.
Also there was luminal irregularity following the anastomosis
which was interpreted as greater on the previous day with a
widely patent vessel beyond the anastomosis.
On that evening the patient was taken to the O.R. for hepatic
artery repair of the saphenous vein interposition graft.
Postoperatively the patient was transferred back to the
Surgical Intensive Care Unit intubated, was subsequently
extubated without incident. Perioperative antibiotics
consisted of Unasyn.
On hospital day four this was the morning following the
operation, the patient was taken back to angiography and a
the saphenous vein graft was seen and there was noted to be
patent anastomosis with swift flow however, there seemed to
be a looped complex in the left hepatic artery with no flow
past that area.
The patient continued in the surgical Intensive Care Unit and
an insulin drip was started for an elevated blood glucose
control. The patient was hypotensive and not responding to
fluid boluses and albumin so a Dobutamine drip was started.
A Swann-Ganz catheter was inserted for hemodynamic
monitoring. The was transfused four units on this day for
hematocrit drop. He was also transfused three units of
platelets. The Unasyn was discontinued, Vancomycin and Zosyn
was started for antibiotics. The Cell-Cept, Prograf and
Prednisone were restarted. On postop day one, the patient
was hypertensive, a Nitroglycerin drip was started and then
subsequently weaned off. The patient was transfused another
two units of platelets. A heme consult for thrombocytopenia
was obtained, the recommendations including stopping the
Heparin. There was a question of whether the patient had
Heparin induced thrombocytopenia. They also recommended
switching the proton pump inhibitor as well as brought up the
issues were thrombocytopenia is likely secondary to a
consumptive process verses decreased thrombopoietin. The
ultrasound showed patent hepatic artery on this day.
On postop day two large amount of drainage was observed from
the left groin wound. The patient was hypertensive and
Zestril was restarted. The patient received an additional
three units of packed red cells and two units of platelets.
Repeat ultrasound showed patent hepatic artery and the
patient remained in the surgical Intensive Care Unit.
On hospital day seven, which is postop day three, the patient
was transfused an additional two units of platelets for a
platelet count of 77,000. A CT scan was obtained which
showed right hepatic artery flow with no flow on the left,
with a question of a change in the left lobe suggestive of
infarction.
On postop day four the Swann line was discontinued as well as
the cortise line which had been inserted for resuscitation.
The tips were sent for culture and central venous line was
placed. The patient was transferred to the floor on this day
and TPN was started.
On postop day five the patient was on the floor and
improving. It was noted at this time that there was scrotal
ecchymosis present. The platelet count was followed and had
initially risen to above 100,000 but was now trending down
and was actually 78,000 on this day. Also noted on this day
there was a left eye hematoma.
On postop day six, the patient's platelets were noted to be
54,000 in the morning. Also of note this day the patient's
Prograf was held secondary to a level of 15.6. Pain
medication was changed to p.o. Dilaudid from intravenous
medications at this time. The patient was transfused a unit
of platelets on the evening of this day.
On postop day seven, the antibiotics were discontinued.
Ultrasound showed both of the right and left hepatic artery
and the common duct was also evaluated and measured 2.5 mm.
On hospital day 12, postop day eight, the patient had a new
complaint of calf tenderness. An ultrasound was obtained
which was negative for deep vein thrombosis. On this day the
patient was transfused two additional units of platelets for
a platelet count of 63,000.
On postop day nine, a CT scan was repeated to evaluate the
hepatic artery and again flow was seen both in the right and
left hepatic arteries.
On postop day 10 the patient's Plavix was restarted and the
patient continued to improve with ambulation, was tolerating
a regular diet, was feeling generally well.
On postop day 11, which is hospital day 15, on [**6-14**] the
patient was noted to be doing quite well, had no complaints,
was afebrile, was tolerating p.o.'s and had not required any
additional platelet transfusions for two days and was
discharged home with a plan to follow-up in clinic with Dr.
[**Last Name (STitle) **] as well as with Dr. [**Last Name (STitle) 497**].
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Discharged to home.
DISCHARGE DIAGNOSIS:
1. Status post orthotopic liver transplant.
2. Hepatic artery thrombosis.
3. Thrombocytopenia.
4. Hypotension.
5. Hypertension.
DISCHARGE MEDICATIONS:
1. Mycophenolate Pofetil 500 mg p.o.b.i.d.
2. Prograf 1 mg p.o. b.i.d.
3. Plavix 75 mg p.o. q day.
4. Zestril 20 mg p.o. q day.
5. Prednisone 10 mg p.o. b.i.d.
6. Ambien 10 mg p.o. h.s. p.r.n.
7. Dilaudid 2 mg p.o. q 4 to 6 hours p.r.n.
8. Bactrim one tab p.o. q day.
9. Fluconazole 200 mg p.o. q day.
FOLLOW-UP PLANS: The patient was to follow-up in [**Hospital 1326**]
Clinic with Dr. [**Last Name (STitle) **] as well as with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] from
the Hepatology service.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 31419**]
MEDQUIST36
D: [**2197-10-9**] 20:03
T: [**2197-10-9**] 20:20
JOB#: [**Job Number 31420**]
|
[
"998.12",
"996.82",
"070.54",
"570",
"287.5",
"286.6",
"458.2",
"444.89",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"50.12",
"88.47",
"38.46",
"38.93",
"38.91",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
8923, 9235
|
8766, 8900
|
1044, 1383
|
3148, 8673
|
1523, 3130
|
9253, 9736
|
192, 1018
|
1400, 1500
|
8698, 8745
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,643
| 120,280
|
3982
|
Discharge summary
|
report
|
Admission Date: [**2117-11-17**] Discharge Date: [**2117-11-20**]
Date of Birth: [**2060-9-27**] Sex: M
HISTORY OF PRESENT ILLNESS: This is a 57-year-old male who
presented to his outpatient physician's office with complaint
of intermittent chest pain with exertion for the past three
days. He had electrocardiogram changes, and so was sent to
arrival, he noted that his pain was similar to his previous
angina. this pain/pressure radiated to both his arms and was
not associated with nausea, vomiting, diaphoresis, or
dyspnea. He received 325 mg of aspirin in his primary
doctor's office.
In the Emergency Department of [**Hospital3 417**] Hospital he was
then transferred to [**Hospital1 69**] for
catheterization with possible intervention given the ST
changes on his electrocardiogram; namely, ST depressions in
leads II and aVL, and ST elevations in II, III, and aVF.
He was pain free on arrival here and was taken to the
catheterization laboratory via Med-Flight. He had an episode
of transient hypotension in the catheterization laboratory,
and so was admitted to the Coronary Care Unit for monitoring.
He required one dose of atropine to which his blood pressure
responded well.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Coronary artery disease with a myocardial infarction
in [**2112**]; at which time a catheterization revealed an ejection
fraction of 55% with an 80% right coronary artery lesion, a
90% left anterior descending artery lesion that was stented,
and a 90% first obtuse marginal lesion that was
angioplastied.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg p.o. q.d.
2. Folic acid.
3. Lipitor 40 mg p.o. q.d.
4. Vitamin B12.
5. Aspirin 325 mg p.o. q.d.
6. Multivitamin.
7. Heparin drip.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: His father died of coronary artery disease.
His mother has dementia.
SOCIAL HISTORY: He has a 30-pack-year history of smoking and
quit six years ago. No calcium or cocaine use. He lives
alone.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed a middle-aged man in no acute distress who was pain
free and afebrile. He had a blood pressure of 114/72, and a
pulse of 71. His oxygen saturation was 100% on 2 liters
nasal cannula. His head, ears, nose, eyes and throat
examination was unremarkable. His lungs were clear with no
rales. He had no jugular venous distention. His heart was
regular with distant heart sounds and no appreciable murmurs.
The abdomen was benign. His extremities were warm and with
no edema. His neurologic examination was nonfocal.
PERTINENT LABORATORY DATA ON PRESENTATION: His laboratory
data revealed a white blood cell count of 8.3, hematocrit
of 45.9, and platelet count of 324. His blood urea nitrogen
was 16. His creatinine was 1.4. His potassium was 3.8.
RADIOLOGY/IMAGING: His catheterization revealed a 90% left
circumflex lesion that was stented, an 80% stenosis of his
first obtuse marginal that was stented, a 40% mid left
anterior descending artery lesion, and an 80% mid right
coronary artery lesion. He also had mild pulmonary arterial
hypertension with a pulmonary artery pressure of 33/22. He
had mild increased left-sided filling pressures with a
pulmonary capillary wedge pressure of 18.
Electrocardiogram at [**Hospital3 417**] Hospital showed normal
sinus rhythm at 75 beats per minute, with normal axis and
normal intervals. He had T wave flattening in V1. He had
1-mm ST depressions in V1 and V2. He had 2-mm ST depressions
in aVL. He had ST elevations in II, III, and aVF. There was
no fascicular block.
HOSPITAL COURSE: Mr. [**Known lastname 17437**] did well in the Coronary Care
Unit with no further episodes of hypotension. His creatine
kinases peaked at 820 and then trended down. He had no
recurrent chest pain, or shortness of breath, or arrhythmias
noted on telemetry. He ambulated well on hospital day two.
He was continued on his aspirin, and Plavix, and Lipitor. A
cholesterol panel showed a total cholesterol of 151,
triglycerides of 8, HDL of 42, and an LDL of 107. He was
restarted on his beta blocker which he tolerated well, but
his blood pressures on the low end with systolics in the 90s
to 100s. A low-dose ACE inhibitor (namely lisinopril 2.5 mg
q.d.) was started with no further decrease in his blood
pressure. This can be increased as an outpatient as
tolerated.
An echocardiogram was obtained on [**2117-11-19**] which
revealed an ejection fraction of 45%. He had a normal left
atrial and left ventricular size. He had normal right
ventricular function. He had mild symmetric left ventricular
hypertrophy. He had basal and mid inferior hypokinesis.
There was no pericardial effusion.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: To home.
DISCHARGE FOLLOWUP: To follow up with his primary
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in the next 7 to 10 days,
who will set him up for cardiac rehabilitation.
DISCHARGE DIAGNOSES:
1. Hypercholesterolemia.
2. Coronary artery disease, status post acute inferior
posterior myocardial infarction.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Atenolol 25 mg p.o. q.d.
3. Lipitor 40 mg p.o. q.d.
4. Vitamin B12.
5. Folate.
6. Multivitamin.
7. Lisinopril 2.5 mg p.o. q.d.
8. Plavix 75 mg p.o. q.d. (until [**2117-12-19**]).
[**Name6 (MD) **] [**Name8 (MD) 17633**], M.D. [**MD Number(1) 17634**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2117-11-20**] 15:41
T: [**2117-11-24**] 08:18
JOB#: [**Job Number 17635**]
cc:[**Last Name (NamePattern4) 17636**]
|
[
"414.01",
"416.8",
"V45.82",
"410.31",
"412",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"36.06",
"36.05",
"99.20",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
1807, 1877
|
5044, 5160
|
5186, 5681
|
1595, 1789
|
3624, 4733
|
4748, 4811
|
4833, 5023
|
149, 1211
|
1233, 1569
|
1894, 3606
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,484
| 151,071
|
40966
|
Discharge summary
|
report
|
Admission Date: [**2101-7-5**] Discharge Date: [**2101-7-16**]
Date of Birth: [**2021-4-6**] Sex: M
Service: NEUROLOGY
Allergies:
Valium / Penicillins
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
Neck pain and L arm weakness
Major Surgical or Invasive Procedure:
lung biopsy [**2101-7-8**]
C-spine stabilization [**2101-7-11**]
History of Present Illness:
Mr [**Known firstname **] [**Known lastname 60013**] is an 80yo RHM with a history of atrial
fibrillation, HTN, HLD and elevated PSAs on finasteride therapy
who is being admitted for the work up of a C-spine bony mass
with
associated cord compression. He reports that he has been
experiencing neck pain, weakness, unsteadiness. He describes
stiffness located on the right side of his neck that radiates to
his shoulder. It also radiates up to the back of the head,
consistent with occipital headaches. He did do a course of
physical therapy for what was thought to be muscle spasms, but
it
was not at all helpful. Two after developing neck pain patient
started have weakness on the left upper extremity. He also
complains of some clumsiness with his left hand more so than his
right. He says that his left hand is "useless" he reports
dropping things and a general lack of coordination. He also
reports having lost [**10-8**] pounds. Today he denies any
incontinence.
He also describes a generalized unsteadiness that has caused him
to be much less active on his feet. "When I stand, I fall back",
and is very concerning to him.
He had MRI/ cervical spine at Health Alliance MRI/center on
[**2101-6-18**] which showed a large mass is best appreciated on the T1
and T2 Weighted sequence and appears to arise from the posterior
elements of C2. [**2101-6-22**] CT/Head at Health Alliance MRI center
that showed a hypodensity within the brainstem. We do not have
an
official report.
Review of Systems: Negative for dysarthria, dysphagia, increased
phlegm production without increased shortness of breath or
fevers/chills, no diarrhea/constipation, no bowel/bladder
incontinence, no double vision.
Past Medical History:
1. Atrial fibrillation: On coumadin therapy, noted to have an
elevated INR of 7.5 yesterday. He reports at least two prior
admissions for epistaxis requiring holding of his warfarin. He
is
normally followed at the [**Hospital **] hospital.
2. HTN
3. HLD
4. CAD: told that he had an EKG which showed evidence of old
infarct
5. Elevated PSA: was told by his physician that he had a
elevated/borderline (?) PSA, has not had a biopsy. Apparently,
they are watching and waiting, and since his last test, the PSA
has not elevated.
6. COPD: on daily nebs at home, through the VA.
Surgical History: Low back, lumbar spine fusion on [**2094-10-6**], rotator cuff repair, right knee arthroscopic procedure,
hernia repair, tonsillectomy, and gallbladder removal.
Social History:
He is retired. He is accompanied by his wife
and two sons today, one of the sons did undergo surgery with Dr.
[**Last Name (STitle) **] previously. He does not smoke. He formerly smoked a
pack a day for 40 years. He has one drink of alcohol a week.
He
is married.
Family History:
Significant for diabetes, heart disease, asthma,
and blood disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Examination: Temperature is 97.8 F. His blood
pressure
is 112/80. Heart rate is 82. Respiratory rate is 16. His skin
has full turgor.
GEN: Well appearing, elderly male in no apparent distress
HEENT is unremarkable.
Neck: ROM is decreased with right rotation, there is no bruit.
Cardiac examination reveals regular rate and rhythms.
Lungs: Clear to auscultation bilaterally
Abd: Soft without tenderness, tympanic to percussion without
fluid wave
Extremities: No edema, generalized muscle wasting
Neurological Examination:
Mental Status: Alert, awake and oriented x 4, able to [**First Name8 (NamePattern2) **] [**Doctor Last Name 1841**]
backwards, spell WORLD backwards, [**2-24**] object recall in 5
minutes,
speech is fluent without paraphasic errors, comprehension is
intact
Cranial nerves: Pupils to light are R ([**4-26**]), L([**4-25**]), EOMI
without
nystagmus, visual acuity is 20/200 uncorrected, 20/50 corrected,
VFF. Facial sensation is symmetric without ptosis or facial
droop. SCMs are strong bilaterally with a midline tongue.
Motor: [**4-28**] in RUE with 4-/5 in left biceps, triceps, wrist
flexors/extensors, intrinsic hand muscles. Bilateral thenar
atrophy noted. Tone and bulk are symmetrically increased and
decreased respectively.
Reflexes: 2+ throughout
Sensation: Intact to light touch in upper extremities without
patches of numbness, intact JPS and vibration sense in toes
bilaterally
Gait: Not tested due to instability
Coordination: FTN is full bilaterally
DISCHARGE PHYSICAL EXAM:
Physical Examination:
Temperature is 95.0 axillary F. His blood pressure is 137/81.
Heart rate is 84. Respiratory rate is 22. His skin has full
turgor.
GEN: Well appearing, elderly male in no apparent distress
HEENT is unremarkable.
Neck: ROM is decreased with right rotation, there is no bruit.
Cardiac examination reveals regular rate and rhythms.
Lungs: Clear to auscultation bilaterally
Abd: Soft without tenderness, tympanic to percussion without
fluid wave
Extremities: No edema, generalized muscle wasting
Neurological Examination:
Mental Status: Alert, awake and oriented x 4, able to [**First Name8 (NamePattern2) **] [**Doctor Last Name 1841**]
backwards, spell WORLD backwards, [**2-24**] object recall in 5
minutes,
speech is fluent without paraphasic errors, comprehension is
intact
Cranial nerves: Pupils to light are 3->2mm bilat, EOMI without
nystagmus, visual VFF. Facial sensation is symmetric without
ptosis or facial
droop. SCMs are strong bilaterally with a midline tongue.
Motor: [**4-28**] in RUE with 4-/5 in left biceps, triceps, wrist
flexors/extensors, intrinsic hand muscles. 4+ on L IPand 4 on L
hamstrings Bilateral thenar atrophy noted. Tone and bulk are
symmetrically increased and decreased respectively.
Reflexes: 2+ throughout
Sensation: Intact to light touch
Gait: Deferred
Coordination: FTN is full bilaterally
Pertinent Results:
ADMISSION LABS:
[**2101-7-5**] 03:45PM BLOOD WBC-12.8* RBC-4.42* Hgb-13.5* Hct-39.8*
MCV-90 MCH-30.7 MCHC-34.1 RDW-13.9 Plt Ct-305
[**2101-7-5**] 03:45PM BLOOD PT-79.9* PTT-49.3* INR(PT)-9.2*
[**2101-7-5**] 09:25PM BLOOD ESR-68*
[**2101-7-5**] 03:45PM BLOOD Glucose-143* UreaN-21* Creat-1.1 Na-137
K-4.0 Cl-98 HCO3-28 AnGap-15
[**2101-7-5**] 03:45PM BLOOD ALT-16 AST-26 LD(LDH)-394* AlkPhos-100
TotBili-0.6
[**2101-7-5**] 03:45PM BLOOD Albumin-3.9 Calcium-9.7 Phos-3.3 Mg-2.1
[**2101-7-5**] 03:45PM BLOOD TSH-0.10*
[**2101-7-5**] 03:45PM BLOOD CEA-387* PSA-6.0*
[**2101-7-5**] 03:45PM BLOOD b2micro-2.4*
DISCHARGE LABS:
138 / 101 / 35
-------------< 132
4.5 / 30 / 0.6
Ca: 8.9 Mg: 2.2 P: 2.9
11.6
19.0>---< 290
35.3
MICROBIOLOGY:
Time Taken Not Noted Log-In Date/Time: [**2101-7-6**] 4:53 am
BLOOD CULTURE #1.
**FINAL REPORT [**2101-7-12**]**
Blood Culture, Routine (Final [**2101-7-12**]): NO GROWTH.
REPORTS:
CXR [**2101-7-5**]: IMPRESSION: Large size central pulmonary
right-sided hilar mass. No previous chest examinations available
for comparison. Described findings would benefit from a chest CT
for further delineation of the process.
CT ABD/PELVIS/CHEST [**2101-7-6**]: IMPRESSION:
1. Lung mass measuring 3.1 x 6.0 x 6.8 cm proximal to the right
hilum with a single adjacent enlarged hilar lymph node
concerning for primary malignancy.
2. 10 mm hypodense/hypoenhancing focus Segment VIII in the right
liver lobe is not completely characterized on this exam.
Small/early metastasis can not be excluded.
3. 7 mm arterial hyperenhancing nodule in the body of the
pancreas.
Differential includes a primary pancreatic tumor (such as a
neuroendocrine
tumor) or metastasis.
4. 8 mm soft tissue nodule in the mesentery in the left upper
quadrant
concerning for metastasis.
MRI L-SPINE [**2101-7-5**]: IMPRESSION: Heterogeneous signal intensity
mass involving the lateral mass of C2 vertebra, likely a bony
metastasis. Visualized lung parenchyma reveals multiple
rim-enhancing lesions in the right cerebral hemisphere and
brainstem likely metastasis. Further evaluation with brain MRI
is recommended.
CT HEAD W/OUT CONTRAST [**2101-7-7**]:
IMPRESSION:
1. Stable-appearing metastatic disease with no evidence of any
new
hemorrhage.
2. Mucosal thickening of left maxillary sinus.
FNA [**2101-7-8**] R HILAR MASS:
DIAGNOSIS: FNA, Right hilar mass:
POSITIVE FOR MALIGNANT CELLS,
consistent with poorly-differentiated non-small cell
carcinoma with extensive necrosis.
C-2 LESION PATH [**2101-7-12**]: DIAGNOSIS:
C2 lesion (A-D):
Metastatic large cell carcinoma consistent with lung origin, see
note.
Note: Tumor cells are positive for [**Last Name (un) **]-31, Keratin 7, focally
positive for chromogranin an synaptophysin and negative for
TTF-1, CK5-6, CK20 and p63.
CXR [**2101-7-11**]: IMPRESSION:
No abnormalities to explain patient's symptoms within the
limitations of this study technique. If clinically warranted,
correlation with cross-sectional imaging might be considered.
C-SPINE [**2101-7-11**]: FINDINGS: The patient is status post fusion of
the occiput down to the level of C4. There are no signs of
hardware-related complications. There is generalized
demineralization. Pre-vertebral soft tissues are grossly normal.
Cervical spine is not well seen below the level of C4.
CT HEAD W/OUT CONTRAST [**2101-7-12**]: IMPRESSION: No overt interval
change on noncontrast head CT. MRI would be more sensitive for
an acute infarction, if clinically indicated.
CT C-SPINE [**2101-7-12**]: IMPRESSION:
1. Status post posterior occipital-C4 fusion without evidence of
hardware
migration into the spinal canal or neural foramina.
2. Large right lateral paravertebral mass at C2 and C3 levels,
completely
destroying the right aspect of C2, similar to the prior exams.
3. Multilevel cervical DJD is better assessed on the [**2101-7-5**]
cervical spine MRI.
MRI SPINE [**2101-7-12**]: Impression:
1. Enhancing mass involving the right aspect of C2 vertebral
body/lateral mass engulfing the right vertebral artery and
obstructing the right neuroforamina. No evidence of involvement
of the spinal canal at this level.
2. Degenerative changes as described above worse at c5-6 and
c6-7 with
posterior osteophytes indenting and flattening the spinal cord
but no evidence of spinal cord signal abnormality.
Brief Hospital Course:
This is an 80yo man with a history of atrial fibrillation, HTN,
HLD, likely coronary artery disease and significant smoking
history with COPD who was admitted for the
work up of a large C2 verterbral body mass with associated
c-spine compression and radicular weakness. Ultimately, by
imaging, we have been able to show the presence of a mediastinal
mass associated with abdominal metastasis as well as evidence of
multiple CNS metastases with evidence of internal hemorrhage.
Preliminary pathology shows high grade poorly differentiated
squamous cell. He will be followed by hematology/oncology,
orthopedics and radiation oncology.
# NEURO: Patient with L arm weakness that was likely related to
his spinal met, but could also have been effected by his CNS
mets. He underwent C-spine stabilization and biopsy of his
C-spine mass which showed metastatic lung pathology. He will
need
radiation of his lesions, which is planned for 5-10 days of
treatment with simulation and first treatment on Monday [**2101-7-18**] at 1030hrs. In addition, we started him on keppra 1000mg
[**Hospital1 **] to help prevent seizures related to his CNS lesions. In
addition we started pt on dexamethasone 4mg Q6H to prevent
swelling and further CNS damage. He will continue this dose
until his oncologist decided otherwise. We controlled his pain
on oxycodone 5mg Q6H PRN, but this does sedate patient, so we
tried to avoid it as much as possible. Patient is being sent to
rehab to regain as much functionality as possible over the
coming weeks.
# HEM/ONC: Mediastinal mass biopsy returns as a poorly
differentiated squamous cell cancer, and C-spine biopsy returned
as lung pathology making pt's sx likely related to metastatic
lung cancer. Patient will be seen in thoracic oncology clinic
on [**7-28**] for possible chemotherapy treatment. Plan for
treatment to be determined prior to clinic visit, but after pt
has completed his radiation course. Plan to send tissue for
mutational analysis re: EGFR, KRAS mutations, etc.
# ORTHO: Pt s/p c-spine stabilization on [**7-11**], biopsy was
obtained intraoperatively. Drain removed, dressing in place. Pt
may use a C-collar for comfort, but currently does not wish to.
Will f/u with orthopedics (Dr. [**Last Name (STitle) 1007**] in two weeks.
# CARDS: Pt with afib with rates at 100-120, but we decided to
not anticoagulate at this time as pt's CNS mets are hemorrhagic.
His diltiazem can be increased if her continues to have
elevated rates. We started him on metoprolol 12.5mg [**Hospital1 **] to help
control his tachycardia that we felt may have been related to
his hyperthyroidism (see below). He has been normotensive
during this admission.
# ENDO: Pt shown to have elevated free T3 with low TSH, likely
worsening his atrial fibrillation. Endo consult felt that his
hyperthyroidism could not be evaluated while pt was acutely ill
as thyroid studies are not accurate for inpatients. This will
need to be followed as pt recovers from his acute illness
# PULM: Pt with known COPD, so we put him on albuterol and
ipratropium nebs. We were unable to continue his mom[**Name (NI) 6474**],
because we do not have this on formulary.
# CODE/CONTACT: DNR/[**Name2 (NI) 835**]; Call son, physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 89389**]
Medications on Admission:
CYCLOBENZAPRINE - (Prescribed by Other Provider; Dose
adjustment
- no new Rx) - 10 mg Tablet - 1 Tablet(s) by mouth once a day as
needed for and PRN
DILTIAZEM HCL - (Prescribed by Other Provider) - 240 mg
Capsule,
Ext Release 24 hr - 1 Capsule(s) by mouth once a day
FINASTERIDE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
FLUOXETINE - (Prescribed by Other Provider) - 20 mg Capsule - 1
Capsule(s) by mouth daily
FORMOTEROL FUMARATE [FORADIL AEROLIZER] - (Prescribed by Other
Provider) - 12 mcg Capsule, w/Inhalation Device -
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
GABAPENTIN - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 300 mg Capsule - 1 Capsule(s) by mouth three times a
day
GEMFIBROZIL - (Prescribed by Other Provider) - 600 mg Tablet -
1
Tablet(s) by mouth twice a day before meals
HYDROCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5
mg-500 mg Tablet - Tablet(s) by mouth
MOM[**Name (NI) **] [[**Name2 (NI) **] TWISTHALER] - (Prescribed by Other
Provider)
- 220 mcg (60 doses) Aerosol Powdr Breath Activated - twice a
day
POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - 17
gram/dose Powder - 1 by mouth daily
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg Tablet
- 1 Tablet(s) by mouth twice a day
WARFARIN - (Prescribed by Other Provider) (On Hold from
[**2101-7-5**] to unknown per order of PCP for for [**Name9 (PRE) 89390**] of 7.5 on
[**7-4**]) - 5 mg Tablet - 1 Tablet(s) by mouth once a day 5 mg on
Sat, Mon, Wed 2.5 mg Sun, Tuesday, Thurs, Fri
Medications - OTC
ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (Prescribed by Other
Provider) - Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
MULTIVITAMIN, STRESS FORMULA [STRESS 500] - (Prescribed by
Other
Provider) - Dosage uncertain
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED).
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for folds.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) as needed for constipation.
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
11. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
12. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
14. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
15. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours).
17. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
18. mom[**Name (NI) 6474**] 220 mcg (60 doses) Aerosol Powdr Breath Activated
Sig: One (1) dose Inhalation twice a day.
19. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
20. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO once a
day.
21. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Primary: Lung cancer metastatic to brain and spine.
Secondary: Atrial Fibrillation, CAD, COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
NEURO EXAM: Notable for 2-3/5 left bicep/tricep/WrE/WrF without
sensory/reflex loss. Some diffuse weakness of lower extremities
bilaterally
Discharge Instructions:
Dear Mr. [**Known lastname 60013**],
You were admitted to the hospital for neck pain. While here, we
determined that you had lung cancer which had metastasized to
your C2 vertebrae and your brain. Your C2 vertebrae was
stabilized, and you were able to be sent to rehab to further
recover. You will be treated with radiation therapy for [**5-3**]
days after you go to rehab.
We made the following changes to your medications:
1) We STOPPED your WARFARIN, because your brain metastases are
hemorrhagic and it would be dangerous to thin your blood at this
time.
2) We STOPPED your PERCOCET.
3) We STOPPED your FLEXERIL.
4) We STARTED you on a REGULAR INSULIN SLIDING SCALE because you
are taking high dose steroids.
5) We STARTED you on MICONAZOLE POWDER applied twice a day as
needed for groin rash.
6) We STARTED you on DOCUSATE 200mg twice a day as needed for
constipation.
7) We STARTED you on OXYCODONE 5mg every 6 hours as needed for
pain.
8) We STARTED you on KEPPRA 1gram twice a day. This is to
prevent seizures.
9) We STARTED y ou on DEXAMETHASONE 4mg every 6 hours. Do not
stop this medication unless instructed to do so by your
oncologist.
10) We STARTED you on ALBUTEROL NEBS every 6 hours.
11) We STARTED you on IPRATROPIUM NEBS every 6 hours.
12) We STARTED you on METOPROLOL TARTRATE 12.5mg twice a day.
Please continue to take you other medications as previously
prescribed.
If you experience any of the following below listed Danger
Signs, please call your doctor or go to the nearest Emergency
Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2101-7-28**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 831**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2101-7-28**] at 9:00 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30
| 104,557
|
11594
|
Discharge summary
|
report
|
Admission Date: [**2172-10-14**] Discharge Date: [**2172-10-19**]
Service: [**Hospital Unit Name 196**]
IDENTIFICATION/CHIEF COMPLAINT: This is a [**Age over 90 **]-year-old male
with a history of coronary artery disease, re-do coronary
artery bypass grafting and hypertension, who presented to an
outside hospital with unstable angina.
PAST MEDICAL HISTORY:
1. Coronary artery disease:
a) The patient had coronary artery bypass grafting with a
saphenous vein graft to the left anterior descending artery,
a saphenous vein graft to the first obtuse marginal artery, a
saphenous vein graft to the third obtuse marginal artery and
a saphenous vein graft to the right coronary artery.
b) He had re-do coronary artery bypass grafting in [**2170**]
with a saphenous vein graft to the left anterior descending
artery with no bypass grafts to total occlusions of right
coronary artery and obtuse marginal artery grafts.
c) In [**2172-3-5**], the patient had a stent of the
saphenous vein graft to the left anterior descending artery
with a cardiac catheterization showing a left ventricular end
diastolic pressure of 17, an ejection fraction of 42% and mid
inferior akinesis and anterolateral akinesis/hypokinesis.
d) In [**2172-6-2**], the patient had a percutaneous
transluminal coronary angioplasty of a saphenous vein graft
to the left anterior descending artery with a left
ventricular end diastolic pressure of 19.
2. Hypercholesterolemia.
3. Hypertension.
4. Chronic renal insufficiency with a baseline creatinine of
1.9.
5. Hernia repair.
MEDICATIONS ON ADMISSION:
Aspirin 325 mg p.o. q.d.
Enalapril 10 mg p.o. b.i.d.
Metoprolol 25 mg p.o. b.i.d.
Lipitor 20 mg p.o. q.d.
Amlodipine 5 mg p.o. q.d.
Sublingual nitroglycerin p.r.n.
ALLERGIES: There were no known drug allergies.
HISTORY OF PRESENT ILLNESS: The patient was doing well post
percutaneous transluminal coronary angioplasty in [**2172-6-2**].
On [**2172-10-11**], he developed back pain while sitting.
This involved radiation to his left arm and also some
retrosternal chest pain. He also described some slight
shortness of breath with nausea and diaphoresis. This
episode of chest pain was not initially relieved with
sublingual nitroglycerin and the patient presented to [**Hospital6 18075**].
At [**Hospital6 2561**], the patient was found to have no
acute electrocardiogram changes and laboratory investigation
showed a CBC with a white blood cell count of 10.7, a
hematocrit of 36.6, a platelet count of 291 and a Chem 7
which was within normal limits with a BUN of 50 and a
creatinine of 1.9. His CK, MB and troponin I were noted to
be 64, 2.6 and 0.2. His second set of enzymes were also
normal. The patient was admitted and his chest pain was
treated with nitroglycerin and heparin drips. He was also
noted to have an asymptomatic run of ventricular tachycardia
of 27 beats without any hemodynamic compromise. The patient
was started on a lidocaine infusion at that time.
The patient was transferred to [**Hospital1 188**] on [**2172-10-14**] and was taken straight to the
cardiac catheterization laboratory. There, he was found to
have a cardiac output and cardiac index of 3.1 and 1.8
respectively. His right ventricular end diastolic pressure
was 16 and his pulmonary artery pressures were 48/28 with a
mean of 39. His wedge pressure was noted to be 29 and his
mixed venous oxygen saturation was 42. No left ventricular
angiography was done.
Examination of the coronary arteries showed a right dominant
system with a normal left main coronary artery. There was a
99% lesion at the first obtuse marginal artery and a 100%
lesion at the second obtuse marginal artery. His
posterolateral ventricular branch was noted to be occluded at
30%. The right coronary artery, which had a previous known
occlusion, was not injected. The patient's saphenous vein
graft to left anterior descending artery stent was found to
be 98% occluded and the patient underwent balloon
percutaneous transluminal coronary angioplasty and subsequent
brachytherapy with a residual occlusion of 10%.
SOCIAL HISTORY: The patient denied any history of tobacco
use. He consumed alcohol socially and currently lived alone
without support. The patient was capable of doing his own
shopping, cooking, cleaning and driving. He did have a
health care proxy by the name of [**Name (NI) 1743**] [**Name (NI) 7049**], who resided
at 74 [**Hospital1 36830**]in [**Hospital1 2436**].
FAMILY HISTORY: The family history was noncontributory.
PHYSICAL EXAMINATION: On examination, the patient was in no
apparent distress with vital signs showing a temperature of
96.9??????F, a blood pressure of 138/63, a heart rate of 87, a
respiratory rate of 20 and an oxygen saturation of 96% on a
nonrebreather mask. The neurological examination was
unremarkable. The patient was awake, alert and oriented
times three. On head and neck examination, the pupils were
equal and reactive to light. The extraocular movements were
intact. The oropharynx was moist.
On cardiovascular examination, the patient's jugular venous
pressure was 8-10 cm above the sternal angle. He had a
normal S1 and S2 with an S3 and S4. He did not have any
audible murmurs. The respiratory examination showed diffuse
crackles half way up his chest bilaterally with no wheezes.
The abdominal examination was unremarkable. The extremities
showed palpable bilateral dorsalis pedis pulses with no
edema. He had a right groin pulmonary artery catheter line
in place and his arterial sheath site was clean, dry and
intact with no bruit or hematoma.
LABORATORY DATA: The patient's cardiac care unit laboratory
values showed a white blood cell count of 14,200, hematocrit
of 27.6 and platelet count of 211,000. Chem 7 showed a
sodium of 129, potassium of 4.1, chloride of 97, bicarbonate
of 18, BUN of 46, creatinine of 2.1 and glucose of 217. CK
was 555, calcium was 9.0 and magnesium was 1.6. Arterial
blood gases showed a pH of 7.33, a pCO2 of 29 and a pO2 of
90.
ELECTROCARDIOGRAM: The patient's electrocardiogram on
[**2172-10-12**] showed him to be in sinus rhythm at 60
with a prolonged P-R interval, a normal P wave and a QRS axis
of -60 to -90. He also had a right bundle branch block with
a left anterior hemiblock. He had Q waves noted in leads III
and aVF. He also had some premature ventricular
contractions. There were T wave inversions in leads V1 to
V4, which appeared unchanged from his electrocardiogram from
[**2172-7-1**].
RADIOLOGY DATA: The patient's chest x-ray showed significant
pulmonary vascular redistribution cephalad.
HOSPITAL COURSE: Following cardiac catheterization, the
patient was continued on Plavix and received aggressive
diuresis for his elevated pulmonary capillary wedge pressure.
On [**2172-10-15**], the patient was noted to have
continued runs of nonsustained ventricular tachycardia and an
echocardiogram was done, which showed the patient to have a
moderately depressed left ventricular function with 1+ aortic
insufficiency, 2+ mitral regurgitation and 1+ tricuspid
regurgitation. He also was noted to have inferior and
inferoseptal hypokinesis. The pulmonary artery catheter was
removed along with the introducer on that day.
On [**2172-10-16**], the patient was noted to be in atrial
bigeminy in the morning and also continued to have short runs
of nonsustained ventricular tachycardia of three to four
beats. The patient continued with his intravenous diuresis
with 80 mg of Lasix q.d. and was subsequently transferred to
the floor. On [**2172-10-17**], the electrophysiology
department was informally consulted and the patient's
metoprolol dose was increased. The patient's rhythm
continued to be monitored.
On [**2172-10-19**], the patient was in stable condition
with adequate diuresis. His nonsustained ventricular
tachycardia continued to improve and the patient continued to
show no further episodes of nonsustained ventricular
tachycardia.
The patient was discharged home on [**2172-10-19**] in
stable condition.
DISCHARGE MEDICATIONS:
Plavix 75 mg p.o. q.d.
Enteric coated aspirin 325 mg p.o. q.d.
Lipitor 20 mg p.o. q.d.
Metoprolol 37.5 mg p.o. q.d.
Enalapril 10 mg p.o. q.d.
Amlodipine 5 mg p.o. q.d.
Lasix 40 mg p.o. q.d.
Colace 100 mg p.o. b.i.d.
Nitroglycerin 0.4 mg sublingual every five minutes p.r.n.
times three.
Protonix 40 mg p.o. q.d.
FOLLOW UP: The patient was instructed to follow up with his
primary cardiologist, Dr. [**Last Name (STitle) 1391**], at [**Hospital3 **] in the
upcoming week.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 26201**]
MEDQUIST36
D: [**2172-10-20**] 14:46
T: [**2172-10-20**] 14:59
JOB#: [**Job Number 36831**]
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
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4492, 4533
|
8075, 8388
|
1602, 1816
|
6637, 8052
|
8400, 8815
|
4556, 6619
|
149, 351
|
1845, 4099
|
373, 1576
|
4116, 4475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,116
| 119,214
|
50470
|
Discharge summary
|
report
|
Admission Date: [**2129-1-24**] Discharge Date: [**2129-2-15**]
Date of Birth: [**2077-11-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Macrobid / Betadine
Attending:[**Doctor First Name 2080**]
Chief Complaint:
OSH transfer for bilateral pulmonary embolism.
Major Surgical or Invasive Procedure:
Central Venous Catheter placement
Arterial Line placement
IVC filter placement
History of Present Illness:
This is a 51-year-old female status-post recent bilateral breast
reduction surgery complicated by infection status-post recent
discharge from OSH for chest pain presented to OSH in PEA arrest
with PE on CT scan status-post thrombolytics.
.
Patient underwent bilateral breast reduction surgery several
weeks ago prior to this admission. Per report from [**Location (un) 620**] this
course was complicated by infection. Patient was recently
admitted and discharged day prior to admission from
[**Location (un) 745**]-Wellesly for left sided chest pain, which was attributed
to neuropathic post surgical pain.
.
On night of admission, patient's husband heard her fall
upstairs. She was alert and orientated complaining of left leg
pain. EMS were called and she reportedly arrested in front of
EMS. In the field EMS performed CPR for 20 minutes, she received
3 rounds of Epi and Atropine and responded with a rhythm of
sinus tachycardia. In the ED she went into PEA arrest again and
was given another round of Epi/Atropine and 3 minutes of CPR.
She again responded with sinus tachycardia. She then coded again
and received CPR for another 2 minutes with a round of epi. She
was intubated in the ED with gases showing pH 6.80, pCO2 77, pO2
243. A CTA was performed, which showed a large PE. Patient was
given tPA at 725 and finished at 925am. She was noted to have
some oozing at her surgical site of her right breast with tPA
and was binded with a strap. She was also started on Levophed
given hypotension to 70s. Ms. [**Known lastname **] was started on Heparin gtt
at 930am. She was noted to have non-focal movement of her upper
extremities. Her labs were noted to be remarkable for a
+d-dimer, elevated Creatinine 1.4, trans. ABG showing acidosis
of 6.80 likely mixed given CO2 of 77, CO2 17. Prior to her
transfer to the [**Hospital Unit Name 153**] vital signs were 90/50 on 20 of Levophed,
HR 120, RR 20-25 intubated, Sat 100%.
.
REVIEW OF SYSTEMS:
Unable to obtain [**3-1**] intubation status.
Past Medical History:
PAST MEDICAL HISTORY:
Migraine
.
PAST SURGICAL HISTORY
s/p bilateral breast reduction [**2128-12-16**]
s/p excicion dermatofibroma [**2116**]
Social History:
Unable to obtain [**3-1**] intubation status
Family History:
Unable to obtain [**3-1**] intubation status
Physical Exam:
Admission:
BP= 114/101, HR=119, RR=19, O2= 100%
GENERAL: Obese Caucasian Female intubated in NARD.
HEENT: Intubated. PERRLA/EOMI.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. 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:
TTE [**1-24**]: Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
right ventricular cavity is mildly dilated with focal basal free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: The right ventricle is mildly dilated with free wall
hypokinesis. The RV apex is contractile ([**Doctor Last Name 97772**] sign).
These findings are consistent with a pulmonary embolus. Normal
regional and global LV function without significant valvular
abnormality.
.
CXR [**1-24**]:
1. Low-lying endotracheal tube, only 1.2 cm above the carina.
Tube could be withdrawn several centimeters for more optimal
positioning.
2. Pneumomediastinum.
3. Moderate interstitial pulmonary edema.
4. Cardiomegaly, with abnormal left ventricular contour. This is
worrisome
for development of left ventricular aneurysm, and
echocardiography is
recommended for correlation. Alternatively, this could represent
a lung mass projecting over the left heart border. If
echocardiography is not revealing, further evaluation with chest
CT is recommended.
5. Abnormal catheter or wire like fragment projecting over the
right heart
border, extending into the liver. If there is no wire or
catheter fragment
external to the patient which could project in this position,
this finding is worrisome for a retained catheter or wire
fragment, possibly located within the SVC, extending into a
hepatic vein. Lateral chest radiograph is
recommended for correlation.
[**2129-1-25**]
1. No evidence of retroperitoneal hematoma.
2. Persistent nephrograms bilaterally, consistent with ATN.
There is a
heterogeneous appearance of the kidneys, left greater than right
with wedge-shaped areas of decreased density. These could
represent areas of infarct versus differential function.
3. Colonic distention and focal wall thickening of the
transverse colon,
which may be infectious, inflammatory, or ischemic (particularly
given recent cardiac arrest). Distention may be due to stool
retention.
[**2129-1-30**] Bleeding scan
Final Report
RADIOPHARMACEUTICAL DATA:
14.4 mCi Tc-[**Age over 90 **]m RBC ([**2129-1-30**]);
HISTORY:51 yo F with ongoing bloody bowel movements and falling
Hct.
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-99m, blood flow and dynamic
images of the abdomen for 90 minutes were obtained. A left
lateral view of the pelvis was not obtained secondary to lack of
patient cooperation. Blood flow images show no areas of abnormal
tracer activity.Dynamic blood pool images show increased tracer
activity within the first 90 minutes in the region of the
pelvis, overlying the left iliac vessels and progressing more
centrally and inferiorly within the pelvis, likely corresponding
to the sigmoid colon or rectum. The patient refused additional
delayed images.
IMPRESSION: Findings consistent with probable active hemorrhage
in the region of the sigmoid colon or rectum.
.
[**2129-1-31**] Doppler U/S LExt
HISTORY: PE and GI bleed, on anticoagulation. Question DVT.
FINDINGS: The bilateral common femoral veins demonstrate normal
spectral
waveforms symmetric bilaterally. There is normal
compressibility, color flow and response to augmentation in the
bilateral common femoral, superficial femoral and popliteal
veins. The bilateral calf veins demonstrate normal flow.
IMPRESSION: No evidence of DVT.
.
LENIs [**2129-2-8**]:
BILATERAL UPPER EXTREMITY ULTRASOUND: Grayscale, color, and
Doppler images of
the bilateral internal jugular, subclavian, axillary, brachial,
basilic, and
cephalic veins demonstrate normal compressibility, flow, and
augmentation. A
PICC line is present in the left cephalic vein. Targeted
ultrasound of the
area of discomfort in the medial left acromioclavicular fossa
demonstrates no
subcutaneous edema.
IMPRESSION: No DVT in right or left upper extremity.
.
Discharge Labs:
.
5.7 \ 10.2/ 298
/30.9 \
.
PT: 22.5 PTT: 89.7 INR: 2.1
Brief Hospital Course:
Middle Aged Female status-post recent bilateral breast reduction
c/b infection s/p recent discharge for MSK chest pain p/w PEA
arrest s/p multiple cycles of Atropine/Epi likely [**3-1**] PE s/p
thrombolytics on pressors, intubated, heparin gtt.
.
#. OBSTRUCTIVE CARDIOGENIC SHOCK: Cariogenic shock likely
secondary to clot burden, as CT scan showed PE with RV
dilatation. TTE performed showed areas of hypokinesis, dilated
RV with LV systolic function intact. Patient was supported
initially with pressors including levophed and neosynephrine.
She was felt to be preload dependent and was aggressively
treated with IV fluids. Clot was busted with TPA, then patient
was supported on heparin ggt. Pressors were slowly weaned, and
patient maintained her own blood pressures. She was even
hypertensive to 170s/90s upon transfer from [**Hospital Unit Name 153**] to general
medical floor. She was monitored on telemetry without further
incidence thereafter.
.
#. LARGE PE STATUS-POST THROMBOLYTICS: Patient noted to have a
large PE on CT scan likely [**3-1**] immobile status s/p surgery with
poor wound healing followed by cervical disc herniation where
she was immobile. Due to her PEA arrest she underwent
thrombolytic therapy which ended at 9:25 Am on the day of
admission. Thereafter, she was started on heparin gtt, but had
bleeding complications which subsided off heparin in the ICU
during which time an IVC filter was placed. She was eventually
moved to warfarin therapy. Low molecular weight heparin therapy
was not given because of the uncertain absorption and
therapeutic benefit in obese patients, which she is, as well as
need for observation on anticoagulation considering patient's
bleeding complications (GI bleed and breast surgical sites).
She is discharged with an INR of 2.1 after 48hrs. She is
referred to hematologist Dr. [**Last Name (STitle) 3060**] to determine the optimal
length of therapy on warfarin, given her cardiac arrest, and 13
PRBC bleed experienced. She will follow up in [**Hospital 3052**] for evaluation of duration of anticoagulation and timing
of IVC filter retrieval. She was also discharged with lovenox
to take if her INR is <2.
.
#. PEA ARREST: Secondary to vascular collapse due to pulmonary
embolism. Per OSH reports pt had 3 episodes of PEA arrest with
response to several rounds of epi and atropine. Mental status at
admission was difficult to obtain as pt was intubated but she
was noted to have non-focal movement of her upper extremities.
Unclear as to how long patient was unreponsive prior to EMS
arrival. The patient's mental status improved as sedation was
decreased, and she was awake following commands on the evening
of admission. She made a full recovery in hospital. She was
monitored on telemetry without further incident.
.
#. ALTERED MENTAL STATUS: Pt noted to be unresponsive initially
on examination with no sedation on board. At OSH she was
reported to have non-focal movement of her upper extremities.
However during her central line placement she was localizing
pain. Ddx for AMS included anoxic brain injury from PEA arrest,
cerebral hypoperfusion from her persistent hypotension. As
sedation was weaned and patient was extubated, she regained
mental status. However, patient continued to be confused and
would perseverate on minor details. She had trouble remembering
why she was in the hospital, and repeated the same questions
throughout the day. However, it did appear as if her mental
status was improving throughout her [**Hospital Unit Name 153**] course. By the time she
was transferred to medical floor, her mental status had
completely recovered.
.
# ACUTE BLOOD LOSS ANEMIA/GI BLEED: Patient's hct continued to
drop throughout [**Hospital Unit Name 153**] admission. Hemolysis labs were negative.
CT of abdomen/pelvis and left thigh (patient had an ecchymosis
in this area) were unrevealing for source of bleeding. She was
initially transfused 6 units PRBC for Hct<24 and moved to the
medical floor. The next day she has bright red blood per rectum
and heavy clots at the breast reduction surgical sites. A
retained tampon was noted and removed, though no heavy vaginal
bleeding was noted. She was transferred back to the ICU where
she recieved another total 7 units PRBCs tranfusion. A bleeding
scan [**2129-1-29**] showed questionable upper GI bleeding. Another scan
[**2129-1-30**] showed definite sigmoid/rectal bleeding. Heparin was held
while an IVC filter was placed, her blood count stabilized, and
heparin was re-initiated given high risk complications from PE.
GI was consulted in the ICU but recommended holding off scoping
because she was stable, and would not want to biopsy, due to
resumption of heparin, and high risk of bleeding. Also, she had
a normal colonoscopy in [**4-5**]. Her hematocrit remained stabled
and she was moved back out to the medical floor. Continued
observation on heparin alone demonstrated stable HCT without
further bleeding. Warfarin was initiated slowly so as not to
overshoot the INR. She will need a repeat colonoscopy in the
future, either if she is ever off the warfarin, or as an
elective procedure well after stabilization from this
hospitalization.
.
#. ACUTE RENAL FAILURE: On admission her Cr was 1.6, but rose
to a zenith of 3.0 in the ICU. This was thought due to
hypoperfusion with cardiac arrest. It subsequently decreased to
normal levels daily with supportive care, and was baseline on
discharge.
.
#. BREAST REDUCTION COMPLICATED BY INFECTION: Patient's breast
surgery was complicated by bilateral infections. She was
treated with a course of levaquin given that outside cultures
grew: strep faecalis, proteus and pseudomonas. Her plastic
surgeon was aware of her admission, and plastic surgery was
consulted here. A supportive bra was used for patient comfort.
Levofloxacin was later tapered to Keflex for prophylaxis per
Plastics request, which she tolerated well (completed 10 day
course). There were no further signs of infection. She was
discharged on WTD dressings daily, and should follow up with
plastic surgery as soon as possible.
.
#. Cervical radiculopathy: She was started on neurontin and
tramadol to help control arm pain related to her cervical
radiculopathy with improvement.
Medications on Admission:
Levofloxacin 500mg daily
Hydromorphone 2-4mg q3hr PRN
Diazepam 5mg q6hr PRN
Lisinopril 20mg daily
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
[**Date Range **]:*60 Tablet(s)* Refills:*2*
2. Rizatriptan 10 mg Tablet Sig: One (1) Tablet PO PRN (as
needed) as needed for migraine.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Date Range **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
[**Date Range **]:*60 Tablet(s)* Refills:*0*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Date Range **]:*60 Capsule(s)* Refills:*2*
6. Outpatient [**Name (NI) **] Work
PT/INR check [**2129-2-16**], and continually thereafter for goal INR
[**3-2**]. Adjust coumadin accordingly.
- fax results to:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Address: [**Street Address(2) 25171**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 25161**]
Fax: [**Telephone/Fax (1) 105143**]
7. Warfarin 2 mg Tablet Sig: Four (4) Tablet PO once a day:
according to your INR, goal [**3-2**], to adjusted by your PCP.
[**Name Initial (NameIs) **]:*120 Tablet(s)* Refills:*2*
8. Lovenox 100 mg/mL Syringe Sig: One (1) injection Subcutaneous
every twelve (12) hours: Subcutaneously. While your INR is less
than 2.
[**Name Initial (NameIs) **]:*14 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Cardiac Arrest
Bilateral Pulmonary Embolism
Lower GI Bleed, acute blood loss anemia
Hypertension, benign
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 hospital (ICU) after cardiac arrest due to
bilateral pulmonary embolism for which you were treated with
clot busting medications at an outside hospital. You were
continued on anticoagulants, but experienced episodes of
bleeding from your surgical breast wounds and from your GI
tract, which required you to be in ICU on several occasions. All
in all, you received 13 units of red blood cells (6 the first
ICU admission, and 7 the second ICU admission), and 2 units of
cryoprecipitate (the first ICU admission). The bleeding in the
GI tract was most likely from the rectal or sigmoid colon area
as per a bleeding scan done at the time. For this, the
anticoagulant was held, and an IVC filter was placed. The
bleeding stablized by itself and the anticoagulation was
re-initiated, without colonoscopy. It was confirmed with your
PCP that [**Name Initial (PRE) **] colonoscopy done [**2128-3-28**] was normal. You were
moved back out to the medical floor, where warfarin therapy was
begun. You will need to be monitored for therapeutic
effectiveness of the warfarin by an [**Hospital 2786**] clinic
and/or your PCP. [**Name10 (NameIs) **] Plastic surgery consult service followed
you in the hosptial, and you will need to follow-up with your
surgeon. Because of the complexities of your case, you have
been referred to a hematolgy thrombus specialist to help
determine the length of your therapy and whether your IVC filter
should come out at all. Your PCP is aware of your hospital
course, and you have been given a follow-up appointment with
her. You will need home PT to continue to help you recover your
strength. Please note the medication changes on discharge, and
the danger signs listed below for which you should seek
immediate evaluation.
.
START:
--Coumadin 8mg daily. Please have your INR checked 1 day after
discharge and fax to your PCP, [**Name10 (NameIs) **] thereafter at the discretion
of your doctors
-- Lovenox shots will be given to you to take home (100mg). If
your INR goes below 2, you will need to take this shot
subcutaneously twice daily until your INR is greater than 2.
Followup Instructions:
Appointment #1
MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 69800**]
Specialty: Primary Care
Date/ Time: [**Last Name (LF) 2974**], [**2129-2-18**]
Location: [**Street Address(2) 25171**], [**Location (un) **],[**Numeric Identifier 3002**]
Phone number: [**Telephone/Fax (1) 25161**]
Special instructions for patient:
.
Appointment #2
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**]
Specialty: Hematology
Date/ Time: [**Last Name (NamePattern1) 2974**], [**4-1**] at 10am
Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) 3387**]
Phone number: [**Telephone/Fax (1) 91089**]
.
Please make an appointment with Plastic surgery to ensure your
wounds heal:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20932**] ([**Telephone/Fax (1) 105144**]
|
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71,083
| 146,227
|
44275
|
Discharge summary
|
report
|
Admission Date: [**2181-3-20**] Discharge Date: [**2181-4-5**]
Date of Birth: [**2099-2-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
recent fall, possible shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Difficult to obtain history due to language barrier.
.
This is an 82 yo Cantonese speaking female with a hx of CHF,
DM2, and afib who presents from rehab after an unwitnessed fall
4 days ago. Noted to right neck echymosis today, extending onto
the left side. There may have also been some dyspnea per report.
However, per her son in the [**Name (NI) **], she had no complaints but seemed
more confused on the day of admission.
.
On presentation to the ED, initial vitals were 97.9 84 156/123
24 85% on RA. However, pleth on her O2 sat was very difficult to
obtain throughout her stay and likely unreliable. CT Head was
negative and CT c-spine showed spinous process fractures. CXR
showed old cardiomegaly and questionable LLL infiltrate. U/A
showed a UTI. She received ceftriaxone, azithromycin, and
vancomycin to treat UTI and ? PNA. She was maintained on a NRB
and per report desatted when taken off NRB. However, her pleth
remained very irregular. Due to hypoxia requiring a NRB, she was
admitted to the ICU for further care.
.
Review of systems is not able to further be obtained due to
language.
Past Medical History:
diastolic CHF with severe TR
AFib on coumadin
CKD baseline Cr approx 2.4
Type 2 DM
Chronic Hep B
gout
glaucoma
Monoclonal gammopathy, suspected multiple myeloma. Pt/family
have declined workup. Seen by Heme/Onc at [**Hospital1 3278**]
Social History:
[**Hospital1 4273**] any history of smoking, EtOH, or other drug use
Was born in [**Location (un) 6847**] and has been living in the United States
for the past 30 years. She is married; her husband is 88, lives
with her, and is in good health. She has three sons.
Family History:
Significant for DM and HTN.
Physical Exam:
GENERAL: Pleasant, chronically ill appearing female in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck with diffuse
ecchymosis.
CARDIAC: Irregular rhythm, normal rate. Normal S1, S2. No
murmurs, rubs or gallops.
LUNGS: Coarse breath sounds diffusely but no wheezes
ABDOMEN: NABS. Soft, NT, distended, tympanitic
EXTREMITIES: [**12-15**]+ LE edema, 2+ dorsalis pedis/ posterior tibial
pulses.
SKIN: No rashes/lesions; ecchymoses on neck as above
NEURO: alert, interactive, no focal abnormalities
Pertinent Results:
[**2181-3-20**] 07:15PM GLUCOSE-83 UREA N-75* CREAT-2.8* SODIUM-133
POTASSIUM-5.2* CHLORIDE-96 TOTAL CO2-28 ANION GAP-14
[**2181-3-20**] 07:15PM CK(CPK)-60
[**2181-3-20**] 07:15PM cTropnT-0.07*
[**2181-3-20**] 07:15PM CK-MB-NotDone
[**2181-3-20**] 07:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2181-3-20**] 07:15PM WBC-4.1 RBC-2.66* HGB-8.7* HCT-27.3* MCV-103*
MCH-32.6* MCHC-31.7 RDW-21.9*
[**2181-3-20**] 07:15PM NEUTS-62.5 LYMPHS-22.7 MONOS-9.5 EOS-4.5*
BASOS-0.8
[**2181-3-20**] 07:15PM PLT COUNT-108*
[**2181-3-20**] 07:15PM PT-22.4* PTT-46.8* INR(PT)-2.1*
CT head [**3-20**]:
1. No acute intracranial abnormality.
2. Chronic small vessel ischemic disease.
3. Sinus disease, likely inflammatory in etiology.
CT C-spine [**3-20**]:
1. Transverse fractures through the spinous processes of C2
through C6. Right posterior neck hematoma, incompletely
assessed.
2. Severe multilevel degenerative disease with moderate central
canal stenosis, which predisposes this patient to spinal cord
injury with minor trauma. In the appropriate clinical context,
consider MR for further characterization.
3. Large multinodular goiter.
MRI c-spine [**3-26**]:
1. Large linear fluid collection within the epidural space,
beginning at approximately C3-C4 extending into the visualized
upper thoracic spine is most suggestive of epidural hematoma.
2. Multilevel cervical spondylosis as described above. There is
moderate-to-severe canal narrowing at the C6-C7 interspace
related to a combination of disc osteophyte complex and more
focal component of epidural hematoma at this level. No definite
cord edema is identified, although the exam is somewhat limited
on the fluid-sensitive sequences.
3. Slightly increased signal within the C7 and T1 vertebral
bodies in conjunction with mild anterior soft tissue swelling at
this level is concerning for traumatic vertebral body fractures.
No significant loss of vertebral body height or retropulsion of
bony fragments is noted at the levels.
4. Diffuse edema within the posterior spinal tissues related to
known spinous process fractures. Limited ability to assess the
anterior and posterior longitudinal ligaments related to motion
artifact on current study, however, no definite discontinuity is
identified.
5. Moderate canal stenosis at the C4-C5 interspace,
predominantly related to disc osteophyte complex and focal
ossification of the posterior longitudinal ligament at this
level.
CXR
IMPRESSION:
1. Marked cardiac enlargement, unchanged, likely reflecting a
combination of cardiomegaly and pericardial effusion, as seen on
prior CT from [**2180-9-19**]. No evidence of pulmonary edema.
2. Retrocardiac opacity, which may reflect atelectasis. An
infectious
etiotoly is not excluded and clinical correlation is
recommended.
3. No displaced fractures identified.
TTE
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is markedly
dilated with mild global free wall hypokinesis. There is
abnormal diastolic septal motion/position consistent with right
ventricular volume overload. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. Severe
[4+] tricuspid regurgitation is seen. There are torn tricuspid
valve chordal structures seen prolapsing across the valve and
into the right atrium. The pulmonary artery systolic pressure
could not be determined due to the severity of tricuspid
regurgitation. There is a small pericardial effusion.
IMPRESSION: Severe tricuspid regurgitation with evidence of
right ventricular volume overload. Markedly dilated right
ventricle with mild global hypokinesis. Preserved left
ventricular systolic function. Small circumferential pericardial
effusion.
Compared with the prior study (images reviewed) of [**2180-9-19**],
the findings are similar.
Brief Hospital Course:
AP: 82F with chronic dCHF, severe TR, DM2, and CKD who presents
from rehab s/p fall with confusion, hypoxia, C-spine fractures,
pyuria
.# Cervical spine Fractures: Per trauma, no acute management
needed. MRI also shows cervical spine epidural hematoma but
neurologically remains intact. Per Dr. [**Last Name (STitle) 1352**], it is okay for
pt to be on coumadin as long as she is not supratherapeutic.
Plan is for soft collar x 4 weeks. She has follow-up in spine
clinic next week with plain films ordered.
# Confusion: Initially presented with confusion s/p fall and
?hypoxia vs. UTI. The true etiology is unclear at this point as
pt got broad spectrum abx in ICU initially. Currently pt knows
she is in a hospital and thinks it is [**2180-3-14**], she recalls
recent events accurately and does not appear confused/delirious.
She likely has underlying dementia. Per family, pt is much
clearer than when she first presented to hospital
#. ? Hx of Hypoxia: Unclear if hypoxia was true or a measurement
artifact. ABGs in the ICU support good oxygenation. Sometimes
difficult to get accurate O2 [**Location (un) 1131**] on finger; much more
reliable with a forehead monitor. No evidence of infection.
Stable on RA now. No clinical signs of PNA
.
.#. Acute on chronic renal failure: exact etiology of
exacerbation? Thought possibly due to Bactrim (given for pyuria)
or low-flow state with SBP low 100s. She has known underlying
CKD stage 4, due to combination of DM and suspected multiple
myeloma. Has known monoclonal gammopathy which has been
documented at [**Hospital1 3278**]. No hydronephrosis on CT scan, urine eos
neg, renal U/S no acute hydronephrosis. She was followed
closely by renal and her Cr is now improving. Cr peaked at 4.1,
now 3.2 Appears her baseline is Cr 2.4 range. She will need
weekly Cr check until her Cr normalizes to her baseline. She
should follow-up with her renal physician sometime within the
next 2-3 weeks.
# Anemia - labs show no sign of Fe deficiency. likely from CKD
and anema chronic disease. Renal recommended increasing Epo to
8000 units three times week.
.#. Afib: Currently rate controlled.
coumadin held for several days due to supratherap levels. She
is now resumed on coumadin. Will need close monitoring of INR.
Should not allow further supratherap levels due to cervical
hematoma. INR on day of discharge was 2.2 Continue digoxin
#. Type 2 DM uncontrolled with complications: had a hypoglycemic
episode early in hospitalization, may have been due to reduced
Cr clearance of insulin. With [**Last Name (un) **] consult services'
assistance, her insulin regimen has been changed to NPH and ISS.
.
#. Chronic diastolic heart failure: she has known severe
tricuspid regurgitation, RV overload, on [**Hospital1 3278**] echo as well as
echo here. Records from [**Hospital1 3278**] shows that she has been admitted
there for CHF exacerbation several times requiring diuresis.
Her family reports she is chronically edematous. She has signs
of anasarca here but breathing was stable. Her lopressor dose
was decreased this admission and imdur held to increase overall
blood pressure and improve forward flow to her renal perfusion.
.
#. Possible UTI vs contaminated specimen - Dirty U/A in ED. Has
hx of proteus sensitive to all except cipro.
-she was initially tx with bactrim, urine culture grew E. coli
ESBL but then final [**Hospital1 **] result returned and showed signs of
contamination. Second UCx showed flora. Third UCx showed
10,000-100,000 VRE but clinically pt not exhibiting signs of a
UTI, is afebrile, nl wbc, no change in MS [**First Name (Titles) **] [**Last Name (Titles) **] dysuria,
other urinary sx. A final UA from [**3-30**] shows 2 wbcs, neg Leuk,
neg nit, no bacteria or yeast. Bactrim discontinued as given
concerns over renal failure and monitor.
# Hx of Gout: Cont colchicine and allopurinol
.
#. Glaucoma: Cont xalatan eye drops.
.
FEN: Low salt cardiac dysphagia diet w thin liquids
.PPX:
-DVT ppx with coumadin
-Bowel regimen
-pureed diet w thin liquids
.
CODE STATUS: DNR/DNI confirmed
.
EMERGENCY CONTACT: [**Name (NI) **] (son), [**Telephone/Fax (1) 94949**]
.
.
Medications on Admission:
acetaminophen
coumadin 0.5mg T/Th/Sat/Sun 1mg MWF
digoxin 0.125mg qod
colchicine 0.6mg qod
Metoprolol 75mg PO qam 50mg at 2pm and 10pm
INSULIN:
-- Novolin SS modified
-- Novolog 70/30 34 units with breakfast, 10 units with dinner
Procrit 10K units qWK
Imdur 30mg PO daily
Atrovent 2 Puffs INH [**Hospital1 **]
torsemide 40mg [**Hospital1 **]
xalatan eye gtt 1 gtt OU qHS
ranitidine 150mg qHS
Prevacid 30mg PO daily
Allopurinol 100mg PO daily
Neurontin 300mg PO daily
Phoslo 2 tabs PO TID
FeSulfate 325mg PO daily
KCl 40 mEq daily
senna
colace
fleets enema prn
MoM prn
Dulcolax prn
Discharge Medications:
1. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Colchicine 0.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO EVERY OTHER DAY
(Every Other Day).
3. Insulin NPH Human Recomb 100 unit/mL Suspension [**Hospital1 **]: Eighteen
(18) units Subcutaneous qam.
4. Novolin R 100 unit/mL Solution [**Hospital1 **]: per sliding scale
Injection four times a day.
5. Atrovent HFA 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
6. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
8. Allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
9. Gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q48H (every
48 hours).
10. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
12. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
13. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
14. Torsemide 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day).
15. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
16. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
17. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: one and a half Tablet
PO three times a day: hold for SBP <110, HR <60.
18. Epoetin Alfa 4,000 unit/mL Solution [**Last Name (STitle) **]: 8000 (8000) units
Injection QMOWEFR (Monday -Wednesday-Friday).
19. Oxycodone-Acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed: total tylenol not to exceed 4
g/day.
20. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO BID (2 times a day).
21. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day).
22. Atrovent HFA 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) puffs
Inhalation twice a day.
23. Coumadin 1 mg Tablet [**Last Name (STitle) **]: half Tablet PO Tues/Thurs/Sat/Sun.
24. Coumadin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Mon/Wed/Fri.
25. Outpatient [**Name (NI) **] Work
Pt will need her INR checked 2-3 times this week to ensure it
does not become supratherapuetic.
Please check Cr, electrolytes twice this coming week to monitor
renal function and ensure it continues to improve
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
Acute renal failure
Cervical spinal fracture
Hypoglycemia resolved
Chronic kidney disease
Atrial fibrillation
Chronic diastolic heart failure
Anemia
Discharge Condition:
stable
Discharge Instructions:
If you have fevers, chills, worsening neck pain, focal weakness,
numbness or tingling of your extremities, please seek medical
attention
Followup Instructions:
Please follow with orthopedic spine at [**Hospital1 18**] as below:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2181-4-9**] 12:40
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2181-4-9**] 1:00
Follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-15**] weeks. Call
Dr.[**Last Name (STitle) 17650**] office at [**Telephone/Fax (1) 8236**] for an appointment.
Follow up with your kidney doctor Dr. [**Last Name (STitle) **]. S. Balakrishnan at
[**Hospital 3278**] Medical Center in the next 2-3 weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2181-4-6**]
|
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"V58.67",
"427.31",
"250.42",
"496",
"070.32",
"428.32",
"799.02",
"250.82",
"294.8",
"276.1",
"423.9",
"274.9",
"273.1",
"041.04",
"041.4",
"293.0",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14642, 14712
|
6946, 11118
|
356, 363
|
14915, 14924
|
2680, 6923
|
15109, 15953
|
2053, 2082
|
11750, 14619
|
14733, 14894
|
11144, 11727
|
14948, 15086
|
2097, 2661
|
275, 318
|
391, 1494
|
1516, 1755
|
1771, 2037
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,279
| 124,728
|
34409
|
Discharge summary
|
report
|
Admission Date: [**2101-8-8**] Discharge Date: [**2101-8-12**]
Date of Birth: [**2053-8-2**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48 year-old left-handed man with a reported history of a
traumatic subdural hematoma s/p left parietal craniotomy in
[**2079**], no reported prior seizure history, and alleged distant
alcohol abuse who presents as a direct transfer to the [**Hospital1 18**]
Neuro-ICU from [**Hospital6 2561**] for further evaluation and
management of refractory seizures. He was apparently in his
USOH until last evening at 11:30 pm, when he was "noted to be
talking incoherently", and subsequently rolled from bed to the
floor. He was then witnessed by his significant other to have
"shaking arms and legs in a fetal position," approximately [**12-8**]
minutes in duration. His girlfriend immediately called EMS.
The patient apparently suffered a laceration to his left
forehead from the fall and bit his tongue, but did not
experience any form of incontinence. Blood glucose on the scene
was 98, heart rhythm is normal. He remained in a "post-ictal"
confusional state and was brought to the [**Hospital6 2561**]
ED, where he was noted to be amnestic for the event.
He was brought to [**Hospital3 **], where he regained "full
consciousness" in the ED. His initial mental status was
described as "lucid," as well as "alert and oriented x 3, no
evidence of acute psychoses; normal mood." He had "normal
cranial nerves [pupils equal at 4 mm and reactive, fundi
"benign"]. Sensation was "normal to fine touch or pin
throughout" and strength was described as "[**4-11**]+ all 4
extremities." Cerebellar examination revealed "normal
finger-to-nose" and gait was "normal." A Romberg was negative.
Given resolution and return to baseline, the plan was for
discharge. However, he had another generalized tonic-clonic
seizure "within several hours" in the emergency room
(description unavailable), from which he "never regained full
consciousness." Even after he received four pushes of lorazepam
2 mg IV (8 mg total), he remained very agitated, requiring
security guards to restrain him. There was apparently a concern
that he was "not able to protect his airway" and was therefore
intubated without complication after receiving succinylcholine
and etomidate. He was sedated on Propofol and loaded with 1
gram of Dilantin. He was also documented as having received
vecuronium 10 mg at 3 am, about one-half hour after intubation,
though the indication is unclear (possibly to facilitate LP).
Clinical data included a CBC (WBC normal at 7.5), Chem 10
(glucose 136), LFTs (elevated AST of 84), cardiac enzymes
(elevated CPK 1325 and MB 10.8, normal Trop I less than 0.04).
Urinalysis revealed trace ketones, [**4-16**] wbc, [**4-16**] rbc, [**1-11**] epis,
and [**1-11**] hyaline casts. Amylase, lipase, TSH were normal.
Phenytoin level at drawn at 4:30 am was 5.9 (albumin 3.6). He
was ultimately given an additional 500 mg IV dilantin load.
Serum and urine drug screens were negative. Of note, the
patient received an LP; no opening pressure was recorded. Tube
1 had 1240 RBC that clear to 6 RBC by Tube 4. There were 9 WBC
on Tube 1 (21 polys, 26 lymphs, 13 monos), but 0 in Tube 4.
Protein was 44 and glucose was 69. A urine culture, two blood
cultures, and a CSF culture were pending. On imaging, the
patient had a non-contrast head CT that revealed that he was
"status post left parietal craniotomy" but was otherwise
unremarkable and without evidence of acute infarct or
hemorrhage. C-spine plain film and CT revealed no fracture;
however, there were degenerative changes including
"intervertebral disk space narrowing at multiple levels, worst
at the C3-4, C4-5 and C5-6 vertebral levels." CXR showed
appropriate placement of the ETT and NGT, though no comment is
made regarding infiltrates or possible pneumonic processes. An
MRI of the head with and without contrast was ordered, but not
performed.
Records indicate that he was brought to the ICU in "stable"
condition. There, he reportedly had several episodes of full
body shaking described as rigor-like for ~30 seconds, and
associated with pupillary dilation. These episodes resolved as
Propfol was increased. As there was a concern for subclinical
seizures with a need for LTM monitoring, the patient was
transferred to [**Hospital1 18**] for further evaluation and management.
Review of Systems:
Patient unable to provide at this time due to intubation and
sedation. Per documentation from [**Hospital3 **], there was "no
recent trauma, no fevers, chills, headaches, rashes, sick
contacts, travel. [**Name2 (NI) **] recent illness of any kind." While lucid,
the patient also denied neck pain or photophobia.
Past Medical History:
Traumatic subdural hematoma in the setting of a motor vehicle
accident, s/p left parietal craniotomy in [**2079**] (reportedly at
[**Hospital 912**] Hospital in [**Hospital1 1474**])
Alcohol Abuse
Social History:
He lives at home in [**Location 4288**] with his significant other and her
child. He works in credit card processing and she is reportedly
a pharmacist. He is apparently quite active and has
participated in triathalons. He reportedly never smoked, and
had a drinking problem prior to [**2092**]. He was sober for some
time, though his son states that he may have had alcohol 3 weeks
ago. He had a history of possible MJ and cocaine use many years
ago. He has had personal difficulties in the form of financial
stress.
Family History:
Brother had seizures after recent motor vehicle accident and is
now on medications for treatment
Physical Exam:
Vitals: T not yet available BP 113/76 P 67 RR 17 SaO2 100 on
FiO2 50%, f 17, Vt 483
General: NAD, well nourished
HEENT: small laceration above left eye and s/p left-sided
craniotomy, sclerae anicteric, MMM, orally intubated
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, + SEM over precordium
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, no edema, pedal pulses appreciated
Skin: no rashes
Neurologic Examination (conducted off Propofol for ~15 minutes):
Mental Status:
Slowly awakens off Propofol, opens eyes to voice, but remains
inattentive and sleepy, able to follow some commands such as
open and closing eyes and moving extremities, no evidence of
neglect
Cranial Nerves:
Optic disc margins sharp; blinks to threat bilaterally. Pupils
equally round and reactive to light, 6 to 3 mm bilaterally.
Intact Doll's can track examiner laterally, no nystagmus.
Corneals intact. Facial appears symmetric. Intact Gag.
Motor:
Normal bulk and tone throughout. No tremor noted. Moves all
four extremities anti-gravity and symmetrically.
Sensation: Withdraws all four extremities to noxious in
symmetric fashion and with a grimace.
Reflexes: B T Br Pa Pl
Right 1 1 1 3 1
Left 1 1 1 3 1
Toes were downgoing bilaterally.
Coordination and Gait: unable to perform at this time.
Brief Hospital Course:
48 year-old man with a reported history of a traumatic subdural
hematoma s/p left parietal craniotomy in [**2079**] and no reported
prior seizure history who presents as a direct transfer to the
[**Hospital1 18**] Neuro-ICU from [**Hospital6 2561**] for further
evaluation and management of refractory seizures and concern for
subclinical seizure activity. A limited examination after his
prior intubation and sedation is unrevealing at this time. The
description of initial incomprehensible speech could represent a
partial seizure from a focus near the prior craniotomy site with
secondary generalization. An initial evaluation at the outside
hospital was notable for the presence of RBC and WBC in the CSF
that cleared, elevated CPK and MB that may have risen due in
some part to the fall, subsequent seizure activity, or forced
restraint by security. In the setting of a history of alcohol
abuse and possible recurrence, an elevated AST/ALT ratio could
reflect alcoholic hepatitis. Thus an indetectable serum alcohol
level could suggest a withdrawal seizure. The patient had a a
full toxic, metabolic, and infectious evaluation.
He received dilantin 100mg TID during ICU; was then started on
keppra on transfer to Neurology floor. Patient was extubated
successfully on [**8-9**].
-MRI head showed no evidence of acute abnormalities, left
anterior temporal encephalomalacia/gliosis, likely postsurgical;
focal encephalomalacia/gliosis in the medial left occipital
lobe, of unknown etiology.
EEG showed an epileptiform focus on L temporal lobe
and will continue on keppra and taper dilantin.
Medications on Admission:
OUTPATIENT MEDICATIONS:
None
MEDICATIONS ON TRANSFER:
Propofol 40 mcg/kg/min.
Dilantin 1 g, then 500 mg bolus
Prevacid
NS with 40 mEq KCL at 100 cc/hour
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
twice a day for 12 doses: Please take 1 tab twice a day for 4
days, then 1 tab daily for 4 days, then stop.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital trabsferred from At. [**Hospital1 **]
after two long seizures. You were in ICU and after good response
to treatment you were transferred to the Neurology wards. You
are on two anti-epileptic medications; one is called dilantin
which will be slowly tapered off over time, the other is keppra
which you will continue taking.
You will follow-up in the clinic for adjustment of medications.
Completed by:[**2101-8-15**]
|
[
"V60.2",
"345.90",
"V15.5",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
9369, 9375
|
7232, 8834
|
322, 329
|
9427, 9434
|
5717, 5816
|
9039, 9346
|
9396, 9406
|
8860, 8860
|
9458, 9910
|
5831, 6375
|
8884, 8890
|
4625, 4940
|
275, 284
|
357, 4606
|
6599, 7209
|
6390, 6583
|
8915, 9016
|
4962, 5160
|
5176, 5701
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,890
| 146,474
|
37242
|
Discharge summary
|
report
|
Admission Date: [**2108-11-25**] Discharge Date: [**2108-11-30**]
Service: MEDICINE
Allergies:
Codeine / Oxycodone
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
OSH transfer for ERCP
Major Surgical or Invasive Procedure:
ERCP with stent [**2108-11-26**]
History of Present Illness:
[**Age over 90 **] yo F with history of CAD, subdural hematoma who presented to
[**Hospital3 3583**] on [**2108-11-24**] with epigastric abdominal pain,
vomiting, and abnormal LFTs. She is known to be s/p
cholecystectomy over 30 years ago. She initially received CT abd
and pelvis with contrast ([**2108-11-24**]) which showed pneumobilia
consistent with post-cholecytectomy changes. Received an MRCP on
[**2108-11-25**] at [**Hospital3 3583**], which showed dilated intra and
extrahepatic bile ducts as well as multiple filling defects
suspicious for stones and debris. She was noted on medical floor
to spike a fever to 104 and subsequently had SBP in the 70s and
HR up to the 140s. She was started on piperacillin/tazobactam.
Patient was given a small IV fluid bolus (~250 mL) and
transferred to the [**Hospital3 3583**] ICU. Central access was
obtained with a triple lumen catheter (unintentionally placed in
the patient's femoral artery), norepinephrine drip was started,
and patient was transferred to [**Hospital1 18**] for ERCP and ongoing ICU
care of sepsis.
In the ICU, the patient reports feeling fine. She is denying any
abdominal pain at rest, current nausea, or vomiting. She also
denies fever or chills. Notes that she has not had a bowel
movement in the last day, so she is unsure about having diarrhea
or constipation. She denies any chest pain or difficulty
breathing.
REVIEW OF SYSTEMS: *somewhat limited by patient's somnolence*
(+)ve: fever, nausea, vomiting, episgastric abdominal pain
(-)ve: chills, night sweats, loss of appetite, fatigue, chest
pain, palpitations, rhinorrhea, nasal congestion, cough, sputum
production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, +
diarrhea, constipation, hematochezia, melena, dysuria, urinary
frequency, urinary urgency, focal numbness, focal weakness,
myalgias, arthralgias
Past Medical History:
1) CAD with stents in place - on plavix
2) Diabetes mellitus
3) Hypertension
4) Vertigo wih falls
5) Subdural hematoma seconary to fall in [**3-22**] - evacuated
6) Anxiety
7) Osteoarthritis
8) s/p cholecystectomy
9) s/p left hip replacement
Social History:
Patient lives alone. Ambulates with a walker.
Tobacco: Denies
EtOH: Denies
Illicits: Denies
Family History:
Non-contributory
Physical Exam:
VS: T 95.4, HR 72, BP 112/55, RR 15, O2Sat 97% 2L NC
GEN: Elderly patient appearing younger than stated age, though
looking comfortable
HEENT: PERRL, EOMI, oral mucosa slightly dry
NECK: Supple, no JVP elevation
PULM: CTAB anteriorly
CARD: RR, nl S1, nl S2, III/VI SEM heard best at RUSB
ABD: BS+, soft, tender diffusely which was evidenced by
grimacing
EXT: Triple lumen catheter in patient's right groin, Patient's
right lower extremity is cooler than left
NEURO: Oriented x 3, CN II-XII intact
PSYCH: Affect flat
Pertinent Results:
[**Hospital3 3583**] on [**2108-11-25**]:
WBC 14.3
ALT 255, AST 221, Bili 3.2, Aphos 200
CK 85, Trop 0.15
.
[**Hospital3 3583**] on [**2108-11-25**]:
WBC 9.4, HCT 35.4
Na 129, K 3.9, Cl 94, CO2 24, BUN 18, Cr 0.74
ALT 252, AST 265, Bili 2.5, Aphos 199, INR 0.99
CK 92, Trop 0.03
.
STUDIES:
[**Hospital3 3583**] MRCP [**2108-11-25**]:
IMPRESSION:
"Dilated intra and extrahepatic bile ducts. The common bile duct
measures about a centimeter in diameter and contains multiple
filling defects of mixed signal intensity suspicious for common
duct stones and debris. There may also be stones in the right
hepatic duct though this area is limited due to metallic
surgical clips."
[**Hospital3 3583**] CT Abdomen and Pelvis [**2108-11-24**]:
IMPRESSION:
"Pneumobilia with assoicated postoperative change in the
gallbladder fossa and dilated extrahepatic ducts. This may be a
chronic finding reflecting prior instrumention."
.
[**2108-11-26**]: ECG: Normal sinus rhythm, rate 94. Leftward axis at
minus 5 degrees. Early transition. Slight diffuse non-specific
ST-T wave changes. No previous tracing available for comparison.
These slight ST-T wave changes are non-specific and
non-diagnostic.
.
[**2108-11-26**]: CXR: The right internal jugular line tip is at the
proximal right atrium and might be pulled back for approximately
3 cm to secure its position at the low SVC. The heart size is
top normal. Mediastinal position, contour and width are
unremarkable. Lungs are essentially clear except for potentially
present left retrocardiac opacity that might represent area of
atelectasis. No appreciable pleural effusion is demonstrated and
there is no pneumothorax.
.
[**2108-11-27**]: CXR: Status post placement of a left-sided PICC
terminating within the mid SVC.
.
[**2108-11-28**] TTE:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is
seen. 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.
.
.
[**2108-11-26**] ERCP:
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: The anatomy was unusual at the major papilla.
Either the patient has had previous biliary intervention that
she does not recall, or a biliary-enteric fistula is present.
Cannulation: Cannulation of the biliary duct was successful
and deep with a 5-4-3 tapered catheter using a free-hand
technique. Contrast medium was injected resulting in partial
opacification (biliary tree only partially opacified due to the
presence of cholangitis)
Biliary Tree: Multiple biliary stones that were causing partial
obstruction were seen at the biliary tree. Sludge and pus was
released from the bile duct during cannulation. A 7cm by 10FR
Cotton [**Doctor Last Name **] biliary stent was placed successfully.
Impression:
* The anatomy was unusual at the major papilla - either the
patient has had previous biliary intervention that she does not
recall, or a biliary-enteric fistula is present
* Cannulation of the biliary duct was successful and deep
with a 5-4-3 tapered catheter using a free-hand technique.
* Contrast medium was injected resulting in partial
opacification (biliary tree only partially opacified due to the
presence of cholangitis)
* Multiple biliary stones that were causing partial
obstruction were seen at the biliary tree.
* Sludge and pus were released from the bile duct during
cannulation.
* A 7cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed
successfully
* Otherwise normal ercp to third part of the duodenum
Recommendations: Depending on clinical status, patient can have
clear fluids today
Continue supportive ICU care as needed
ERCP in one month when off plavix for 7 days for stone
extraction
Should remain on antibiotics for a total of 7 days
.
.
[**2108-11-25**] 11:44PM BLOOD WBC-12.1* RBC-3.27* Hgb-9.9* Hct-29.9*
MCV-91 MCH-30.2 MCHC-33.0 RDW-13.4 Plt Ct-112*
[**2108-11-26**] 02:15PM BLOOD WBC-9.9 RBC-3.14* Hgb-9.6* Hct-28.0*
MCV-89 MCH-30.7 MCHC-34.3 RDW-13.2 Plt Ct-128*
[**2108-11-28**] 03:44AM BLOOD WBC-6.1 RBC-2.82* Hgb-8.5* Hct-25.6*
MCV-91 MCH-30.1 MCHC-33.1 RDW-13.2 Plt Ct-128*
[**2108-11-30**] 05:46AM BLOOD WBC-7.2 RBC-3.20* Hgb-9.6* Hct-29.2*
MCV-91 MCH-30.1 MCHC-32.9 RDW-13.1 Plt Ct-229
[**2108-11-25**] 11:44PM BLOOD Neuts-90.1* Lymphs-6.3* Monos-3.4 Eos-0
Baso-0.1
[**2108-11-26**] 05:19AM BLOOD Neuts-86.4* Lymphs-9.3* Monos-4.1 Eos-0.2
Baso-0
[**2108-11-30**] 05:46AM BLOOD Plt Ct-229
[**2108-11-25**] 11:44PM BLOOD PT-14.6* PTT-29.1 INR(PT)-1.3*
[**2108-11-26**] 05:19AM BLOOD PT-14.7* PTT-28.8 INR(PT)-1.3*
[**2108-11-27**] 03:05AM BLOOD PT-12.6 PTT-25.5 INR(PT)-1.1
[**2108-11-25**] 11:44PM BLOOD Glucose-180* UreaN-21* Creat-1.0 Na-136
K-3.7 Cl-102 HCO3-22 AnGap-16
[**2108-11-27**] 03:05AM BLOOD Glucose-82 UreaN-22* Creat-0.7 Na-142
K-3.5 Cl-110* HCO3-20* AnGap-16
[**2108-11-29**] 06:00AM BLOOD Glucose-195* UreaN-8 Creat-0.4 Na-137
K-3.6 Cl-100 HCO3-29 AnGap-12
[**2108-11-30**] 05:46AM BLOOD Glucose-155* UreaN-7 Creat-0.4 Na-141
K-3.7 Cl-101 HCO3-33* AnGap-11
[**2108-11-25**] 11:44PM BLOOD ALT-167* AST-83* LD(LDH)-190 CK(CPK)-104
AlkPhos-172* TotBili-4.4*
[**2108-11-27**] 03:05AM BLOOD ALT-94* AST-34 AlkPhos-140* TotBili-2.2*
[**2108-11-29**] 06:00AM BLOOD ALT-56* AST-23 AlkPhos-189* TotBili-1.7*
[**2108-11-30**] 05:46AM BLOOD ALT-52* AST-27 AlkPhos-208* TotBili-1.2
[**2108-11-25**] 11:44PM BLOOD CK-MB-3 cTropnT-0.03*
[**2108-11-26**] 05:19AM BLOOD CK-MB-4 cTropnT-0.03*
[**2108-11-25**] 11:44PM BLOOD Albumin-3.1* Calcium-7.6* Phos-3.3 Mg-2.1
[**2108-11-30**] 05:46AM BLOOD Calcium-8.3* Phos-2.1* Mg-1.5*
[**2108-11-28**] 03:44AM BLOOD calTIBC-225* Ferritn-87 TRF-173*
[**2108-11-26**] 04:16AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2108-11-26**] 04:16AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-NEG pH-5.5 Leuks-MOD
[**2108-11-26**] 04:16AM URINE RBC-5* WBC-66* Bacteri-NONE Yeast-NONE
Epi-3
[**2108-11-26**] 04:16AM URINE CastGr-1*
[**2108-11-26**] 04:16AM URINE Mucous-RARE
.
.
MICRO:
[**2108-11-28**] 9:47 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2108-11-29**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2108-11-29**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
.
[**2108-11-26**] 4:18 am BLOOD CULTURE Site: A LINE
Source: Line-art rt fem.
**FINAL REPORT [**2108-12-2**]**
Blood Culture, Routine (Final [**2108-12-2**]): NO GROWTH.
.
.
[**2108-11-26**] 4:16 am URINE Source: Catheter.
**FINAL REPORT [**2108-11-27**]**
URINE CULTURE (Final [**2108-11-27**]): NO GROWTH.
.
.
[**2108-11-26**] 2:08 am BLOOD CULTURE
**FINAL REPORT [**2108-12-2**]**
Blood Culture, Routine (Final [**2108-12-2**]): NO GROWTH.
Brief Hospital Course:
[**Age over 90 **] year old female with history of CAD and subdural hematoma who
presented to [**Hospital3 3583**] on [**2108-11-24**] with epigastric
abdominal pain, vomiting, and abnormal LFTs.
#. Cholangitis and GNR bacteremia (from [**Hospital3 3583**]): She
presented with symptoms (fevers, bandemia, and abdominal pain)
consistent with cholangitis and sepsis, and OSH cultures grew
gram negative rods. She was maintained on Zosyn which had been
started at [**Hospital3 3583**]. Vancomycin was [**11-25**] for additional
empiric coverage for presumed cholangitis and sepsis of unclear
etiology but was stopped on [**11-27**] after clinical improvement and
no further growth in cultures. ERCP was performed on [**11-26**]
which revealed pustular exudates, stones and sludge. A common
bile duct stent was placed. LFTS were initially elevated and
trended down. PICC was placed on [**11-27**] for planned 2 weeks of
antibiotics (Zosyn).
.
Upon arrival to the medical floor, her sensitivities confirmed
quinolone sensitive klebsiella bacteremia. she was therefore
switched to oral ciprofloxacin to complete a total of 14 days.
Her PICC line was discontinued. Blood cultures from [**Hospital1 18**]
showed NGTD at time of discharge.
.
she will need to have repeat ERCP in [**3-19**] weeks (provided pt
information to call to schedule), with plavix discontinuation 7d
prior to procedure. discussed this plan with PCP on the day of
discharge, who is aware, and will see pt in [**1-17**] weeks (pt
instructed to call PCP to schedule appt).
.
#. Hypotension: Ms. [**Known lastname **] was hypotensive to SBPs 70-80 at the
OSH. She arrived with pressors running through a femoral
arterial line. CVL in right IJ was placed on [**11-26**]. She was
started on levophed in the ICU which was stopped at 230am on
[**11-27**]. She was also given gentle IVF boluses as she continued
to have good UOP, good mentation and good peripheral warmth.
.
Upon arrival to the medical floor, her hypotension had resolved.
.
# hypoxia - pt with 2L O2 requirement upon arrival to the
medical floor. this was felt likely [**1-16**] ARDS physiology in
setting of sepsis, and was weaned off on the night of her
arrival to the medical floor.
.
#. Coronary artery disease: Troponins were increased at OSH but
were unchanged here. Her Plavix was continued and home
medications of isosorbide mononitrate, lisinopril, atenolol were
held given hypotension. Her troponin leak was felt most likely
[**1-16**] demand.
.
#. Femoral arterial line: Was meant to be a central line placed
at OSH. It was discontinued on [**11-26**] without complication. She
reported no pain and there was no bruit or hematoma. Initially
the right foot was cooler vs left but this resolved after line
was removed. Upon arrival to the medical floor, her distal
pulses remained 2+ bilaterally at DP/PT.
#. Thrombocytopenia: She had stable thrombocytopenia (128)
during this admission.
#. Diabetes: Glipizide was held and HISS was used.
#. Goals of care: She expressed a desire to be DNR, no CPR,
though would allow short term intubation for a short period of
time for procedures such as ERCP.
#. Communication: With patient and [**Name (NI) **] son, [**Name (NI) 2251**]
[**Name (NI) **]: [**Telephone/Fax (1) 83839**]
Medications on Admission:
HOME MEDICATIONS:
1) Ezetimibe 10 mg PO daily
2) Paroxetine 20 mg PO daily
3) Isosorbide mononitrate 60 mg PO daily
4) Atenolol 25 mg PO daily
5) Plavix 75 mg daily
6) Glipizide 5 mg PO daily
7) Lisinopril 5 mg PO daily
8) Xanax PRN anxiety
TRANSFER MEDICATIONS:
1) Protonix 40 mg IV Q24H
2) Motrin 600 mg PO Q6H:PRN pain or fever
3) Morphine PRN
4) Isosorbide mononitrate 60 mg PO daily
5) Xanax PRN anxiety
6) Lisinopril 5 mg PO QAM
7) Plavix 75 mg PO daily
8) Zosyn 3.375 g Q8H
9) Levophed titrated to keep systolics > 90
10) NS IVF @ 200 mL/hr
ALLERGIES:
Codeine / Oxycodone
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for gi upset.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
Partners[**Name (NI) 269**]
Discharge Diagnosis:
primary:
acute cholangitis
klebsiella bacteremia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
you were admitted to the hospital with an infection of your
bile ducts. this was treated with an ERCP procedure at which
time multiple stones, and pus were seen. a stent was placed to
help facilitate drainage.
.
you will need a repeat ERCP procedure in [**3-18**] weeks to have the
stent removed, and the stones treated.
.
the following changes were made to your medications:
1. you were placed on a 14 day course of ciprofloxacin.
Followup Instructions:
you will need to have a repeat ERCP with Dr. [**Last Name (STitle) **] in 4 weeks
to remove the stones seen during this admission. we were unable
to schedule this appointment for you today. please call Dr. [**Name (NI) 83840**] office at ([**Telephone/Fax (1) 10532**] to schedule this appointment
within 4-6 weeks of your discharge.
.
please stop your plavix 7 days before the scheduled date of the
above procedure.
.
upon arriving home please contact your primary care physician,
[**Name (NI) **],[**Name11 (NameIs) 640**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 25821**], and arrange for an appointment
within 2-3 weeks for routine follow-up. we have spoken with dr.
[**First Name (STitle) **] to inform him of your course, and he should receive a
faxed copy of your discharge summary within 24 horus of
discharge (FAX [**Telephone/Fax (1) 83841**]).
|
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62,402
| 172,850
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2783
|
Discharge summary
|
report
|
Admission Date: [**2168-1-6**] Discharge Date: [**2168-1-22**]
Date of Birth: [**2099-1-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
body aches/cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt's a 68 year old male h/o HTN, COPD, with recent admission for
LE swelling with renal failure and transaminitis - found to have
dx of amyloid (by renal bx) now presenting today with bodyaches
and cough. Per pt and daughter pt was feeling his own baseline
recently till just yesterday when his baseline mild sob (had
since [**9-25**]) started to worsen, new productive cough, +chills
but no sub fevers, and full body myalgias. No rhinorrhea, HA,
does have c/o mild dizziness and non-specific intermittant CP in
bilat lower rib region - (non-pleuritic per pt). Pt states also
had mild diffuse lower ab pain - no changes in stool or n/v, no
urinary changes/dysurea, has no recent change in LE swelling,
and no new rashes/arthralgias. Of note, pt has had flu shot
this year, but pt's granddaughter in house has had been told she
had the flu earlier this week.
<br>
In ED vitals of 97.9 96/58 15 100 and 96% on RA - pt treated
with 1L NS IVF and given dose of ceftaz 1g and 1g vanc, 1 set
blood cx done in ED. Pt with his t max on floor at 101.5 - pt
states feels mildly better since prior though subjectively.
<br>
Note pt's last cytoxan dose was on [**2167-12-29**] as confirmed with
clinical pharmacist.
<br>
ROS: noted as above, also with +mild chronic constipation, has R
eye blindness.
Past Medical History:
-Amyloidosis - on cytoxan now for tx, (dx [**12-28**] by renal bx),
initially had bone marrow bx - 20-30% plasma cells found, tx
initially with velcade - had transaminitis - now on tx for
chronic Hep B, amyloid being treated with cytoxan - last dose
[**12-29**]
-Hyperlipdemia
-Chronic back pain
-COPD
-Gastritis
-HTN - off metoprolol since last admissin
-Tension headaches
-NASH
-H/O Hepatitis B per serologies on OMR - now with dx chronic Hep
B on treatment
-R Eye Blindness
Social History:
Originally from [**Country 3587**]. Now lives with his daughter in
[**Location (un) 686**]. Quit smoking cigarettes. No ETOH or recreational
drugs.
Family History:
No family history of renal disease.
Physical Exam:
Exam
VS T max 101.5 T current 101.5 BP 104/55 HR 97 RR 20
O2sat: 94% RA
Gen: In NAD.
HEENT: PERRL, EOMI. No scleral icterus. Mucous membranes
moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: +crackles/course BS in LLL throughout, no wheezing.
Normal respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT at time of exam, mild-mod distensions, +bs
Extremities: +anasarca with +4 pitting LE edema
Neurological: alert and oriented X 3, CN II-XII intact.
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
GU: deferred.
Pertinent Results:
[**2168-1-6**] 04:20PM URINE HOURS-RANDOM
[**2168-1-6**] 04:20PM URINE GR HOLD-HOLD
[**2168-1-6**] 04:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2168-1-6**] 04:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
[**2168-1-6**] 04:20PM URINE RBC-0-2 WBC-[**1-21**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2168-1-6**] 04:20PM URINE GRANULAR-0-2 HYALINE-0-2
[**2168-1-6**] 04:20PM URINE MUCOUS-OCC
[**2168-1-6**] 12:38PM GLUCOSE-108* LACTATE-2.1* NA+-140 K+-5.1
CL--108 TCO2-24
[**2168-1-6**] 12:35PM GLUCOSE-114* UREA N-47* CREAT-3.0* SODIUM-143
POTASSIUM-5.1 CHLORIDE-111* TOTAL CO2-26 ANION GAP-11
[**2168-1-6**] 12:35PM estGFR-Using this
[**2168-1-6**] 12:35PM ALT(SGPT)-96* AST(SGOT)-93* ALK PHOS-571* TOT
BILI-0.3
[**2168-1-6**] 12:35PM ALT(SGPT)-96* AST(SGOT)-93* ALK PHOS-571* TOT
BILI-0.3
[**2168-1-6**] 12:35PM LIPASE-76*
[**2168-1-6**] 12:35PM ALBUMIN-1.9*
[**2168-1-6**] 12:35PM NEUTS-88.7* LYMPHS-7.6* MONOS-1.9* EOS-1.5
BASOS-0.4
[**2168-1-6**] 12:35PM NEUTS-88.7* LYMPHS-7.6* MONOS-1.9* EOS-1.5
BASOS-0.4
[**2168-1-6**] 12:35PM PLT COUNT-162
[**2168-1-6**] 12:35PM PT-13.2 PTT-26.2 INR(PT)-1.1
<br>
[**1-6**] CXR: FINDINGS:
There is atelectasis and an infiltrate in the left lower lobe.
This is new
since the prior examination and likely represents infection. The
cardiomediastinal silhouette is stable. Right lung is clear.
CONCLUSION:
An infiltrate in the left lower lobe suggestive of infection.
Please ensure followup to clearance.
<br>
Echo:[**Known lastname **], [**Known firstname 13679**] [**Hospital1 18**] [**Numeric Identifier 13680**]Portable
TTE (Complete) Done [**2168-1-13**] at 11:31:41 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Hospital6 **] Center
[**Location (un) 13681**], [**Numeric Identifier 6425**] Status: Inpatient DOB: [**2099-1-6**]
Age (years): 69 M Hgt (in): 66
BP (mm Hg): 115/65 Wgt (lb): 170
HR (bpm): 92 BSA (m2): 1.87 m2
Indication: Left ventricular function. Amyloid. Congestive heart
failure.
ICD-9 Codes: 428.0, 424.0
Test Information
Date/Time: [**2168-1-13**] at 11:31 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: East MICU
Contrast: None Tech Quality: Adequate
Tape #: 2009E007-0:45 Machine: Vivid [**5-19**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.4 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: 0.31 >= 0.29
Left Ventricle - Ejection Fraction: >= 75% >= 55%
Left Ventricle - Stroke Volume: 87 ml/beat
Left Ventricle - Cardiac Output: 7.97 L/min
Left Ventricle - Cardiac Index: 4.26 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 15 < 15
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Arch: 2.7 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 25
Aortic Valve - LVOT diam: 2.1 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A ratio: 0.73
Mitral Valve - E Wave deceleration time: 250 ms 140-250 ms
Findings
This study was compared to the prior study of [**2167-12-16**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
Normal IVC diameter (<2.1cm) with <35% decrease during
respiration (estimated RA pressure indeterminate).
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Normal regional LV systolic function. Hyperdynamic LVEF >75%.
Estimated cardiac index is high (>4.0L/min/m2). TDI E/e' >15,
suggesting PCWP>18mmHg. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The right atrial pressure is
indeterminate. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). The estimated cardiac index is high
(>4.0L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2167-12-16**],
the heart rate is higher and the left ventricular systolic
function is more vigorous.
CLINICAL IMPLICATIONS:
Based on [**2165**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
MRA/MRI Small hyperintensity seen only on the diffusion-weighted
sequence
which is too small to fully characterize. This may represent
artifact but a tiny acute infarct cannot be excluded. If
neurologic abnormalities are
referred to this area, followup study could be performed for
further
evaluation.
US Upper extremity Nonocclusive thrombus surrounding the PICC in
one of the proximal right brachial veins. This vein is expanded
related to the nonocclusive thrombus.
[**1-16**] MRI/MRA abd: Celiac artery and its major branches are
widely patent. The SMA is patent over the proximal 6 cm. More
distally/inferiorly, the distal SMA as well as the [**Female First Name (un) 899**] are not
imaged due to lack of anatomic coverage.
[**2168-1-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2168-1-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2168-1-10**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL;
FECAL CULTURE - R/O E.COLI 0157:H7-FINAL INPATIENT
[**2168-1-8**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2168-1-8**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2168-1-7**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2168-1-7**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2168-1-6**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL INPATIENT
[**2168-1-6**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2168-1-6**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
.
[**2167-12-18**]: SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
BONE MARROW INVOLVEMENT BY PLASMA CELL DYSCRASIA.
VASCULAR DEPOSITION OF CONGOPHILIC BIREFRINGENT MATERIAL
CONSISTENT WITH AMYLOIDOSIS. SEE NOTE.
Note: By immunohistochemistry, CD138 highlights numerous plasma
cells comprising 20-30% of marrow cellularity. By Kappa/Lambda
light chain immunostaining, the plasma cells are kappa
restricted. CD20 stain highlights rare scattered interstitial B
cells. Bcl-1 is coexpressed within a subset of plasma cells (at
edge, where immunoreactivity appears greater). By in situ
hybridization (Kappa, lambda), the majority of the plasma cells
contain kappa light chain [**Medical Record Number 13682**]. The combined morphologic and
immunophenotypic findings are consistent with a plasma cell
dyscrasia with immunoglobulin light chain associated systemic
amyloidosis.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate. Erythrocytes show mild
anisopoikilocytosis and hypochromasia. Suggestion of red cell
agglutination is noted. Abnormal red blood cells are seen,
including spherocytes, schistocytes, and target cells. The
white blood cell count appears mildly increased. Platelet count
appears normal. Large forms are seen. Giant forms are present.
Differential count shows 82% neutrophils, 0% bands, 3%
monocytes, 13% lymphocytes, 2% eosinophils.
Aspirate Smear:
The aspirate material is adequate for evaluation and shows
numerous cellular spicules. The M:E ratio is 2.6:1. Erythroid
precursors are decreased and show normoblastic maturation.
Myeloid precursors appear normal in number and show full
spectrum maturation. Megakaryocytes are present in normal
numbers; abnormal forms are not seen. Numerous small,
cytologically typical plasma cells, occurring singly and in
large clusters are present. Differential shows: 0% Blasts, 0%
Promyelocytes, 2% Myelocytes, 10% Metamyelocytes, 33%
Bands/Neutrophils, 25% Plasma cells, 13% Lymphocytes, 17%
Erythroid. Numerous small plasma cells with vacuolated
cytoplasm are present focally in clusters.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation and shows
variably cellular bone marrow (10-20%) overall, 15%. Amorphous
eosinophilic deposition is present in the thickened blood vessel
wall, consistent with amyloid. The M:E ratio estimate is
normal. Erythroid precursors are decreased in number and
exhibit full spectrum of maturation. Myeloid elements are
decreased and exhibit full spectrum of maturation.
Megakaryocytes are present in mildly decreased numbers. There
is an interstitial infiltrate of plasma cells occurring singly
in small clusters occupying 20-30% of marrow cellularity.
[**Last Name (un) 13683**] bodies are noted. Marrow clot section is similar to the
biopsy. Touch prep is not submitted.
Special Stains:
Special stain for amyloid ([**Country 7018**] Red) are positive and
birefringent under polarized light.
ADDITIONAL STUDIES:
Cytogenetics (please refer to separate report)
Brief Hospital Course:
68 year old male h/o HTN, COPD, with recent admission for LE
swelling with renal failure and transaminitis - found to have dx
of amyloid (by renal bx) and multiple myeloma presented LLL PNA.
.
# LLL PNA - Presented with SOB in the setting of recent cytoxan
tx. Found to have a LLL infiltrate and completed a course of
vancomycin and cefepime. No pathogen was isolated. Was negative
for flu.
.
# Multiple myeloma - Previously started Velcade on [**12-24**] however
this was discontinued secondary to transaminitis. This admit he
was given cytoxan with poor response. In addition Velcade was
restarted on [**2168-1-18**]. After a though case review and
multidisiplinary meeting in was determined that with the
complication of amyloid, nephrotic syndrome, and complications
seen with velcade it was not possible to make significant
improvement in his condition. After multiple discussions with
the patient and family meetings regaurding goals of care it was
decided by the patient to become DNR/DNI, CMO and transition to
home hospice. Acyclovir has been continued with his recent
chemotherapy and should be continued in hospice to prevent
painful mouth lesions.
.
# amyloid/nephrotic syndrome- Amyloid noted on [**12-18**] Bone marrow.
[**12-21**] Renal biopsy showed global glomeruli distruction. The
patient remains anasarcic from the nephrotic syndrome associated
with this finding. Renal was consulted and diuresis was
attempted with some success with 160mg lasix IV and
chlorthiazide 500mg IV. However diuresis resulted in repeated
hypotension and was therefore discontinued. His renal function
was acutley worsened with hypotension however improved to
baseline with fluids and dialysis was not need.
.
# Metabolic acidosis: treated with PO Bicarb while in the
hospital
# Chronic Hepatitis B - continued lamivudine. This should be
continued at hospice to prevent a painful hepatitis.
# Constipation - Resolved with Colace, senna, miralox, bisacodyl
ICU course:
Mr. [**Known lastname **] was transferred to the ICU on [**1-11**] after an episode of
hypotension on the floor in the setting of PNA, possible colitis
and BRBPR. Surgery was consulted with ischemic colitis in
setting of hypotension as well as infectious colitis incl C diff
on differential. He was continued on flagyl, cefepime and vanco.
Lactate was initially 3.7 but quickly normalized and pts abd
pain and BRBPR quickly resolved as well. Initially, his
hypotension resolved with fluids. He was briefly hypotense
overnight [**1-12**] to SBP 70s and MAPs 40 while sleeping but once
awaked, BP normalized. Exact etiology of hypotension was never
determined. C diff was negative x1. Surgery in the end did not
this ischemic colitis likely but did think a 10-14D course of
abx would be appropriate. GI did not want to do colonoscopy due
to risk of bowel perforation. He recieved 5 units of PRBCs with
normalization of his Hct. At time of transfer to floor, his
hypotension had been resolved x 36 hrs and he was tolerating a
clear liquid diet. While pt was in ICU, he did have a bedside
TTE which showed EF 75% with mild LVH suggestive of possible
diastolic dysfunction.
Renal continued to consult during ICU course and thought
amyloidosis likely [**12-21**] multiple myeloma was the continuing cause
of his renal failure. They did not think HD was yet indicated.
Also per their recs, Lasix used for peripheral edema and pt was
put on PO bicarb.
Transaminitis persisted and thought to be [**12-21**] velcade toxicity,
chronic hep B or amyloid infiltration. Lamivudine was continued
for chronic Hep B.
In ICU, patient had waxing and [**Doctor Last Name 688**] mood and mental status.
[**Month (only) 116**] represent depression vs disorientation in setting of
hospitalization vs primary neurological process. We recommended
BMT team consider head MRI once stabilized.
.
#Ischemic colitis: As mentioned above surgical invervention was
avoided and HCT remained stable with transfusions. The bloody
bowel movements stoped with improved blood pressure and the HCT
remained stable for days prior to discharge
.
# AMS: In the setting of infection and hypotension in the unit.
Improved on the floor, remaining alert and oriented with the
exception of occacional disorientation to date. He had good
insight to his condition and was able to articulate well his
decision to transition to hospice care
Medications on Admission:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
Disp:*60 Capsule(s)* Refills:*2*
2. Lamivudine 5 mg/mL Solution Sig: Five (5) PO once a day.
Disp:*150 mL* Refills:*2*
3. Furosemide 160mg qdaily (new medication for pt - started
recent admission)
4. omeprazole 20mg qdaily
5. colace
(prior on simvastatin - d/c last admission with transaminitis)
Discharge Medications:
1. Lamivudine 10 mg/mL Solution Sig: 2.5 ml PO DAILY (Daily):
25mg daily.
Disp:*75 ml* Refills:*2*
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Disp:*1 bottle* Refills:*2*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas, bloating.
Disp:*120 Tablet, Chewable(s)* Refills:*2*
5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Roxanol Concentrate 20 mg/mL Solution Sig: Two (2) mg PO q2h
prn as needed for pain.
Disp:*36 ml* Refills:*3*
9. Methadone 5 mg/5 mL Solution Sig: 0.5 to 5 mg PO three times
a day as needed for pain: [**Month (only) 116**] take PO or SL if unable to
swallow.
Disp:*450 ml* Refills:*3*
10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO
DAILY (Daily) as needed for constipation.
Disp:*30 packet* Refills:*2*
11. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
prn as needed for thrush.
Disp:*1 bottle* Refills:*2*
12. 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*
13. Lorazepam 2 mg/mL Concentrate Sig: 0.5 mg PO q4h prn as
needed for anxiety: [**Month (only) 116**] take SL.
Disp:*50 ml* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 13684**] Hospice
Discharge Diagnosis:
Multiple myeloma
amyloidosis
nephrotic syndrome, chronic renal failure
ischemic colitis
chronic hepatitis B
Hospial acquired pneumonia
.
secondary dx: HTN, COPD
Discharge Condition:
Stable, discharge to hospice
Discharge Instructions:
You were admitted to the hospital for Lower extremity edema. You
were found to have many medical problems including a cancer
called multiple myeloma, amyloidosis, kidney failure and
neprhotic syndrome. You were also in the Intensive care unit for
hypotension and altered mental status complicated by
gastrointestinal bleeding. Your hypotension, GI bleeding, and
mental status improved with fluids
.
You received chemotherapy for the multiple myeloma, however this
has been ineffective and we are unable to cure your cancer. In
addition your kidney damage is perminant making removal of your
excess fluid impossible. After long discussions with your
primary oncologist, hospital oncology team, kidney doctor,
primary care doctor, and hospice you have discided to return
home with hospice and transition care to comfort measures.
.
You will be followed at home by the hospice program.
.
The following changes were made to your medication regimen:
.
Please contact the hospice team for any symtpoms you are
experiencing such as pain, shortness of breath, nausea,
diarrhea, fever, headache, or any other worrsisome symptoms.
Followup Instructions:
You will continue to be followed by hospice
Completed by:[**2168-1-22**]
|
[
"203.00",
"564.09",
"277.39",
"403.90",
"486",
"557.0",
"996.74",
"070.32",
"583.81",
"584.9",
"276.2",
"453.8",
"496",
"571.8",
"272.4",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20381, 20440
|
13784, 18150
|
330, 336
|
20645, 20676
|
2998, 8855
|
21845, 21920
|
2346, 2383
|
18572, 20358
|
20461, 20624
|
18176, 18549
|
20700, 21822
|
2398, 2979
|
8878, 13761
|
274, 292
|
364, 1664
|
1686, 2164
|
2180, 2330
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,882
| 100,981
|
22170
|
Discharge summary
|
report
|
Admission Date: [**2148-6-24**] Discharge Date: [**2148-6-28**]
Date of Birth: [**2117-7-10**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Fevers/chills/dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30 yo female with no PMH in good health who noticed 3 days of
subjective fevers and chills PTA. Pt had intermittent dysuria
for last week. + HA and myalgias. + constipation and no BM in
last 3 days.
Of note, pt developed pruritic rash about 1 week ago while
painting a room in bilateral antecubital areas, 'spreading' to
right lateral thorax and inguinal folds. No new fabrics or
detergents. Room was warm but not excessively.
ROS: No cough, no abd pain, no diarrhea, no sore throat, no
sinus pain, no ear pain. No bug bites, recent exposure to the
forest. Pt is sexually active monogamously with fiancee. No
vaginal itching or discharge. No photophobia or sick contacts.
In [**Name (NI) **], pt hypotensive with SBP in 70's, tachycardic to 130's.
Given 4L NS with response of SBP to 90-100's. Given Levo 500mg
IV x 1. Febrile to 104.5.
Pt admitted to MICU for urosepsis. Her blood pressure responded
to IVFs; no pressors were given. She defervesced on
Levofloxacin for sensitive E. Coli urosepsis, and is begining to
auto-diuresed.
Past Medical History:
None
Social History:
In monogamous relationship with fiancee, with whom she lives.
Denies smoking or alcohol. Currently unemployed.
Family History:
Father has HTN.
Physical Exam:
98.9, 118/76, 100, 25, 97%4L NC 380-IN/3930-OUT
Gen: comfortable nice young woman, pleasant and conversant, NAD,
supine
HEENT: PERRLA, EOMI, MMM, OP clear, NC/AT
Neck: Supple, 8cm JVP, right IJ bandage C/D/I with sl tenderness
Chest: decreased BS bilateral bases with associated dullness to
percussion, no egophany
Back: no vertebral tenderness, c/o 'ache' on palpation of both
CVA's
Cor: increased HR, nl S1 S2, no M/R/G
Abd: NABS, soft, slight suprapubic tenderness, no HSM, no
tenderness over liver/GB
Ext: MAE, no C/C/E
Neuro: A&Ox3, CN II - XII intact,
Skin: blanching papular slightly erythematous rash on bilateral
antecubital fossa, right lateral thorax, and bilateral inguinal
folds
Pertinent Results:
[**2148-6-24**] 03:50PM LACTATE-2.4* K+-4.8
[**2148-6-24**] 03:51PM NEUTS-70 BANDS-11* LYMPHS-9* MONOS-9 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2148-6-24**] 03:51PM GLUCOSE-122* UREA N-8 CREAT-1.0 SODIUM-136
POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-21* ANION GAP-20
[**2148-6-24**] 04:20PM URINE RBC-[**1-26**]* WBC-[**5-2**]* BACTERIA-MANY
YEAST-NONE EPI-[**1-26**]
[**2148-6-24**] 04:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-1 PH-8.0 LEUK-TR
[**2148-6-24**] 06:40PM PT-12.9 PTT-35.3* INR(PT)-1.1
[**2148-6-24**] 08:15PM CRP-9.52*
[**2148-6-24**] 08:15PM CORTISOL-21.5*
[**2148-6-24**] 08:15PM PHOSPHATE-1.8* MAGNESIUM-1.4*
[**2148-6-24**] 08:15PM ALT(SGPT)-3 AST(SGOT)-10 TOT BILI-0.3
Renal U/S:
1. Normal renal ultrasound without evidence of stones, renal
masses, or
hydronephrosis. No perinephric abscess is identified.
2. Gallbladder wall edema without gallstones, sludge, or
pericholecystic
fluid collections. No biliary duct dilatation is identified.
These findings
are nonspecific and clinical correlation is recommended to
exclude the
possibility of acalculus cholecystitis. Follow-up with a
dedicated right upper
quadrant ultrasound is also recommended.
3. Trace amount of free fluid within Morison's pouch.
Abd/Pelvis CT:
1) Left-sided pyelonephritis with no hydronephrosis, perinephric
fluid
collection, or abscess.
2) Bilateral pleural effusions with associated atelectasis.
3) Equivocal wall thickening within the transverse colon which
may be related
to underdistention by contrast; however, clinical correlation
would be helpful
and if necessary delayed scanning to evaluate
contast-filledcolon.
CXRay (after IVFs)
IMPRESSION: Interval development of bibasilar infiltrates which
could
represent atelectasis vs. aspiration pneumonitis. Recommend
follow-up chest
x-ray for monitoring progression.
Brief Hospital Course:
30 yo previously healthy woman presenting with fevers, chills,
and dysuria, found to be hypotensive and tachycardic with fever
to 104.5 in ED.
Urosepsis/Pyelonephritis: Pt initially admitted to MICU and
responded to IVF's and IV Levofloxacin 500mg qd. Pt felt much
better, remained afebrile, and was transfered to floor on HD #3.
Pt was d/c'd on Levofloxacin 500mg PO, which is to be continued
for a total of 14 days.
Bilateral Pleural Effusions: d/t IVF's in MICU. Pt
self-diuresed until she was euvolemic, and her Foley was d/c'd.
She had >95% O2 sat on RA.
Rash: Likely contact dermatitis, which appears to be resolving.
No evidence of tic bite or meningitis. Sarna and benedryl prn.
Normocytic Anemia: Low iron and low TIBC. Not classic for
iron-deficiency. Bili normal. Iron supplements after pt done
with Levofloxacin.
FULL CODE
Medications on Admission:
None
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
Disp:*1 bottle* Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Take for 10 more days.
Disp:*10 Tablet(s)* Refills:*0*
3. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for pruritis: Take as needed for
itchiness.
Disp:*30 Capsule(s)* Refills:*0*
4. Iron 325 (65) mg Tablet Sig: One (1) Tablet PO once a day:
Start taking in 10 days after you are done taking Levofloxacin.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Urosepsis
Iron-deficiency
Discharge Condition:
Pt was in good and stable condition
Discharge Instructions:
Please call your doctor or return to the hospital if you
experience flank pain, acute abdominal pain, discomfort or
burning with urination, blood in urine, shaking chills,
shortness of breath or difficulty breathing.
You may have some residual fever cycles which should improve.
If your fevers get worse or more frequent, call your doctor or
come to the hospital.
You have low blood iron. After completing 10 more days of
antibiotics, start taking iron supplements daily. (Don't take
iron and Levofloxacin concurrently)
To prevent recurrent urinary tract infections:
1. Don't use spermacide-containing products for contraception
2. Early post-intercourse urination
3. Ample fluid intake
4. Cranberry juice
5. Wipe front to back after bowel movements
If you continue to have recurrent urinary tract infections,
please speak with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]
prevention.
Followup Instructions:
Follow up with your primary care doctor as needed.
|
[
"692.9",
"041.4",
"511.9",
"590.10",
"275.41",
"038.42",
"280.9",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5763, 5769
|
4243, 5092
|
330, 336
|
5854, 5891
|
2334, 4220
|
6863, 6917
|
1589, 1606
|
5147, 5740
|
5790, 5833
|
5118, 5124
|
5915, 6840
|
1621, 2315
|
269, 292
|
364, 1416
|
1438, 1444
|
1460, 1573
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,410
| 120,015
|
24359
|
Discharge summary
|
report
|
Admission Date: [**2135-5-1**] Discharge Date: [**2135-5-12**]
Date of Birth: [**2064-4-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Aortic Stenosis
Major Surgical or Invasive Procedure:
Redo Sternotomy, AVR(23mm St. [**Male First Name (un) 923**]) [**2135-5-3**]
History of Present Illness:
The patient is a 71 year old man.
He was approximately 19 years status post coronary bypass
grafting. All the grafts are patent, including the left
internal mammary artery to the left anterior descending
artery. He had a 70% lesion of the proximal circumflex graft.
He has, however, severe aortic stenosis, aortic
insufficiency, and recent onset atrial fibrillation. It was
proposed to perform re-do sternotomy, aortic valve
replacement and possible bypass grafting to the circumflex
artery.
Past Medical History:
Myocardial infarction [**2109**]
CABGx4 [**2115**]
Atrial fibrillation [**9-6**]
Failed cardioversion [**1-7**]
S/P TURP
Past Pneumonia/sepsis
Hyperlipidemia
Hypercholesterolemia
Social History:
40 pack year smoking history quit in [**2092**]. Drinks 2-3 drinks
nightly. Married and lives in [**Location 3320**]
Family History:
Notable for coronary artery disease.
Physical Exam:
Gen: elderly gentleman in no acute distress
HEENT: Normocephalic/atraumatic, Pupils equal, round and
reactive. Oropharynx benign.
LUNGS: CLear
Heart:III/VI systolic murmur, irregular rate and rhythm
Abd: soft, nontender, nondistended, normal active bowel sounds/
EXT: no clubbing, cyanosis or edema. Right leg saphenectomy
partial left leg saphenectomy. Pulses 2+ femoral, 1+ DP/PT.
Neuro: nonfocal
Pertinent Results:
[**2135-5-1**] 11:51PM PT-13.4* PTT-47.3* INR(PT)-1.2
[**2135-5-1**] 05:16PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2135-5-1**] 05:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2135-5-1**] 03:54PM GLUCOSE-107* UREA N-22* CREAT-1.0 SODIUM-139
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
[**2135-5-1**] 03:54PM ALT(SGPT)-33 AST(SGOT)-22 ALK PHOS-92
AMYLASE-39 TOT BILI-1.0
[**2135-5-1**] 03:54PM WBC-5.3 RBC-4.33* HGB-13.4* HCT-39.0* MCV-90
MCH-30.9 MCHC-34.4 RDW-13.7
[**2135-5-7**] 05:15AM BLOOD WBC-4.8 RBC-2.51* Hgb-7.5* Hct-23.3*
MCV-93 MCH-30.0 MCHC-32.3 RDW-13.9 Plt Ct-132*
[**2135-5-7**] 01:00PM BLOOD Hct-24.7*
[**2135-5-11**] 06:10AM BLOOD Glucose-114* UreaN-12 Creat-1.1 Na-139
K-5.0 Cl-103 HCO3-26 AnGap-15
[**2135-5-1**] 03:54PM BLOOD ALT-33 AST-22 AlkPhos-92 Amylase-39
TotBili-1.0
EKG
-[**2135-5-1**]
Atrial fibrillation
Consider prior inferior myocardial infarction although is
nondiagnostic
Modest right ventricular conduction delay
Left ventricular hypertrophy by voltage
Since previous tracing of [**2135-4-25**], limb lead QRS voltage more
prominent
-[**2135-5-3**]
Sinus tachycardia
Consider prior inferior myocardial infarction although is
nondiagnostic
Nonspecific ST-T abnormalities
Since previous tracing of [**2135-5-1**], atrial fibrillation absent
and sinus
tachycardia with ST-T wave changes now seen
CXR
-[**2135-5-3**]
1) Tiny right apical pneumothorax; no other acute
cardiopulmonary process.
2) Multiple lines and tubes as described above; NG tube could be
advanced several cm
-[**2135-5-11**]
No pleural effusions are identified.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2135-5-1**] for preoperative anticoagulation and surgical
management of his aortic valve disease. Heparin was started and
he was worked-up in the usual preoperative manner. On [**2135-5-3**],
Mr. [**Known lastname **] was taken to the operating room where he underwent a
redo sternotomy with an aortic valve replacement utilizing a
23mm St. [**Male First Name (un) 923**] mechanical valve. Postoperatively he was taken to
the cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. He was then transferred to the cardiac
surgical step down unit for further recovery. He was gently
diuresed towards his preoperative weight. Coumadin was started
for anticoagulation for his mechanical valve and atrial
fibrillation. Mr. [**Known lastname **] had pain with swallowing and his
medications were changed to elixirs. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. The otolaryngology service was consulted
who noted a mucosal irregularity on the posterior pharyngeal
wall. Saline gargles were recommended and bactroban nasal
ointment for epistaxis prophylaxis. Follow-up was recommended in
3 weeks to assess resolution of the lesion. Mr. [**Known lastname 61693**] sore
throat slowly improved so that he was able to adequately take in
sufficient nutrition. As his INR was subtherapeutic, heparin was
started until his INR was within range. Ultimately, his INR rose
above 2.0 and his heparin was discontinued. Mr. [**Known lastname **]
continued to make steady progress and was discharged home on
postoperative day ten. He will follow-up with Dr. [**Last Name (STitle) **], his
cardiologist and his primary care physician as an outpatient.
Medications on Admission:
Zocor 20mg daily
Digoxin 0.25mg daily
Atenolol 12.5mg daily
Coumadin
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 doses.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day: Take as
directed by Dr. [**First Name (STitle) **] for INR goal of 2.5-3.
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Aortic stenosis
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Do not use creams, lotions, or powders on wounds.
Call our office if you have sternal drainage, temp>101.5.
Followup Instructions:
With [**Hospital **] clinic [**Telephone/Fax (1) 41**] in [**1-6**] weeks
Make an appointment with Dr. [**First Name (STitle) 10733**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2135-5-13**]
|
[
"414.00",
"V45.81",
"424.1",
"427.31",
"401.9",
"412",
"462",
"428.0",
"272.4",
"427.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.22",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7118, 7191
|
3471, 5451
|
336, 415
|
7251, 7258
|
1762, 3448
|
7609, 7858
|
1290, 1328
|
5570, 7095
|
7212, 7230
|
5477, 5547
|
7282, 7586
|
1343, 1743
|
281, 298
|
443, 937
|
959, 1140
|
1156, 1274
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,500
| 127,625
|
49068
|
Discharge summary
|
report
|
Admission Date: [**2200-11-14**] Discharge Date: [**2200-11-19**]
Service:
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname 95655**] is a
[**Age over 90 **]-year-old female presenting to [**Hospital1 190**] Emergency Room status post fall.
PAST MEDICAL HISTORY:
1. Cerebrovascular accident.
2. Coronary artery disease with myocardial infarction.
3. Hypertension.
4. Ulcerative colitis.
5. Peripheral vascular disease.
6. Hypercholesterolemia.
7. Cervical spondylosis.
The patient presented on [**2200-11-13**] status post fall in her
bathroom at 7 PM. The patient denied fainting or any other
symptoms prior to the fall. The fall is believed to be a
mechanical fall. So, the patient is not aware of why she
fell. The patient denies any head trauma or LSE. The patient
hit the left flank. The patient denies any loss of
consciousness. The patient was complaining of left sided
pain, worse with cough and movement. The patient denies any
neck pain, numbness, or weakness.
ADMISSION MEDICATIONS:
1. Zestril.
2. Plavix.
3. Norvasc.
4. Spironolactone.
5. Detrol.
6. Prilosec.
7. Colace.
8. Tylenol.
9. Quinine.
SOCIAL HISTORY: The patient lives alone and ambulating with
minimal assistance. The patient lives in the level 1
apartment with elevator access. Son lives nearby and is
supportive in the patient's care.
ALLERGIES: The patient reports allergies to SULFA, ASPIRIN,
AND PENICILLIN.
PHYSICAL EXAMINATION: On admission, the patient had a
temperature of 96.2, pulse 76, blood pressure 138/60,
breathing at a rate of 20. GENERAL: The patient is a
pleasant, elderly female in moderate distress. HEENT:
Normocephalic, atraumatic. Pupils equal, round, and reactive
to light. Extraocular muscles are intact. NECK: Supple
without any C-spine tenderness. No JVD appreciated. CHEST:
Chest was clear to auscultation bilaterally. There were good
bilateral breath sounds. CARDIOVASCULAR: The patient had
regular rate and rhythm, no murmurs, rubs, or gallops.
ABDOMEN: Soft, nondistended, nontender. The patient's flank
examination was notable for possible left sided back and CVA
pain and large hematoma on the left flank. The patient was
able to move both legs with minimal pain. Skin was devoid
any rash, petechiae, clubbing, cyanosis, or edema.
LABORATORY DATA: Laboratory data revealed the white count of
7.2, hematocrit 31.5, platelet count 251,000, INR 1.2. The
patient had large blood, dipstick negative, greater than 50
RBCs and yellow urine. The patient's sodium was 130,
potassium 4.7, chloride 97, CO2 22, BUN 25, creatinine 1.0,
glucose 103. The patient ruled out with troponin I of 0.9,
0.7, and 1.3. CKMB of 65 and unrecorded. The patient had a
chest x-ray, which was negative. The patient was given CT of
the abdomen and pelvis with and without IV contrast. CT scan
showed mild stranding of the left kidney without evidence of
parenchymal hemorrhage or contusion. Also, notable for
fracture of the lower posterior ribs of left posterior ribs,
10, 11, and 12. CT was also remarkable for left transverse
process fracture of L1 and L2, right femoral hernia, right
adrenal enlargement without interval change from MRI of the
abdomen dated [**2199-8-13**], stable in size.
HOSPITAL COURSE: The patient was admitted to the Trauma Team
for observation. Secondary to patient's age and multiple rib
fractures with associated morbidity, the Anesthesia
Department was consulted to perform epidural anesthesia on
the patient to aid in the aggressive pulmonary toilet. The
patient declined this. The patient was treated with morphine
until the morning. Secondary to patient's persistent flank
and back pain, the Department of Orthopedics was consulted,
L1-L2 transverse processes fractures with stable injuries
that required symptomatic treatment and recommended patient
being fitted with thoracolumbar corset for comfort. The
patient also received CT imaging of the cervical spine.
Findings were notable for multiple areas of anterolisthesis
of a mild degree at C3-C4, C4-C5, and C6-C7, C7-T1. No
fractures were identified. Spinous process of C3 was
displaced slightly forward. DENS intact. Lateral masses of
C1 were well lined on C2 without any soft tissue swelling.
The patient also received Flex X plain radiograph and plain
film trauma series of the cervical spine, which were
negative.
The patient continued to improve during the remainder of the
hospital stay under good pain management with morphine and
dilaudid. The patient worked with PT and continued to make
an improvement.
Now, the patient is stable with improved pain control. The
patient will be discharged to rehabilitation to progress with
independence in mobility. The patient should followup with
the Trauma Clinic in two weeks' time.
DISCHARGE DIAGNOSES:
1. Posterior left rib fractures, #10, 11, and 12.
2. Transverse process fracture of L1 and L2.
3. Significant left flank contusion with ecchymosis.
DISCHARGE MEDICATIONS:
1. Hydromorphone 2 mg to 4 mg PO q.4h. to 6h. p.r.n.
2. Epogen 4000 units subcutaneously once a week.
3. Zolpidem 5 mg PO q.h.s.p.r.n.
4. Quinine 260 mg PO q.h.s.p.r.n.
5. Vioxx 25 mg PO q.d.p.r.n. pain.
6. Heparin 5000 units subcutaneously q.12h.
7. Spironolactone 25 mg PO q.d.
8. Lisinopril 2.5 mg PO q.d.
9. Docusate 100 mg PO b.i.d.
10. Pantoprazole 40 mg PO q.24h.
11. Detrol 2 mg PO q.d.
CONDITION ON DISCHARGE: The patient was stable at the time
of discharge.
DISCHARGE STATUS: The patient will be discharged to [**Hospital3 1761**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-912
Dictated By:[**Last Name (NamePattern1) 5924**]
MEDQUIST36
D: [**2200-11-19**] 10:11
T: [**2200-11-19**] 10:22
JOB#: [**Job Number **]
|
[
"922.1",
"805.4",
"807.03",
"443.9",
"401.9",
"272.0",
"412",
"E885.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4812, 4964
|
4987, 5392
|
3269, 4791
|
1027, 1150
|
1458, 3251
|
280, 1004
|
1167, 1435
|
5417, 5767
|
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