subject_id
int64 12
100k
| _id
int64 100k
200k
| note_id
stringlengths 1
41
| note_type
stringclasses 4
values | note_subtype
stringclasses 35
values | text
stringlengths 449
78.2k
| diagnosis_codes
listlengths 1
39
| diagnosis_code_type
stringclasses 1
value | diagnosis_code_spans
listlengths 1
21
| procedure_codes
listlengths 0
35
| procedure_code_type
stringclasses 1
value | procedure_code_spans
listlengths 1
5
| Discharge Disposition:
stringlengths 0
12
| Brief Hospital Course:
stringlengths 0
12
| Discharge Diagnosis:
stringclasses 1
value | Major Surgical or Invasive Procedure:
stringlengths 0
12
| Discharge Condition:
stringlengths 0
12
| Past Medical History:
stringclasses 1
value | History of Present Illness:
stringclasses 1
value | Social History:
stringclasses 1
value | Physical Exam:
stringclasses 1
value | Pertinent Results:
stringlengths 0
12
| Discharge Instructions:
stringclasses 1
value | Medications on Admission:
stringclasses 1
value | Followup Instructions:
stringlengths 0
12
| Family History:
stringlengths 0
12
| Discharge Medications:
stringclasses 1
value | DISCHARGE DIAGNOSES:
stringlengths 0
12
| PAST MEDICAL HISTORY:
stringclasses 1
value | DISCHARGE MEDICATIONS:
stringlengths 0
12
| [**Hospital 93**] MEDICAL CONDITION:
stringlengths 0
12
| DISCHARGE DIAGNOSIS:
stringlengths 0
12
| MEDICATIONS ON DISCHARGE:
stringclasses 983
values | MEDICATIONS ON ADMISSION:
stringlengths 0
12
| Cranial Nerves:
stringclasses 1
value | HOSPITAL COURSE:
stringlengths 0
12
| FINAL DIAGNOSIS:
stringclasses 974
values | CARE RECOMMENDATIONS:
stringclasses 32
values | DISCHARGE INSTRUCTIONS:
stringlengths 0
12
| PAST SURGICAL HISTORY:
stringclasses 1
value | DISCHARGE LABS:
stringclasses 1
value | Discharge Labs:
stringclasses 1
value | What to report to office:
stringclasses 286
values | Secondary Diagnosis:
stringclasses 1
value | ADMISSION MEDICATIONS:
stringclasses 204
values | DISCHARGE INSTRUCTIONS/FOLLOWUP:
stringclasses 212
values | Review of systems:
stringclasses 1
value | CARE AND RECOMMENDATIONS:
stringclasses 18
values | On Discharge:
stringclasses 1
value | Neurologic examination:
stringclasses 1
value | Discharge labs:
stringlengths 0
12
| Secondary Diagnoses:
stringclasses 1
value | On discharge:
stringclasses 1
value | [**Last Name (NamePattern4) 2138**]p Instructions:
stringclasses 138
values | HOSPITAL COURSE BY SYSTEM:
stringclasses 79
values | HOSPITAL COURSE BY SYSTEMS:
stringclasses 67
values | MEDICATIONS AT HOME:
stringclasses 429
values | MEDICATIONS ON TRANSFER:
stringclasses 1
value | Secondary diagnoses:
stringclasses 1
value | Secondary diagnosis:
stringclasses 1
value | TRANSITIONAL ISSUES:
stringclasses 1
value | PATIENT/TEST INFORMATION:
stringclasses 174
values | IMMUNIZATIONS RECOMMENDED:
stringclasses 1
value | -Cranial Nerves:
stringclasses 297
values | Transitional Issues:
stringclasses 1
value | Incision Care:
stringclasses 388
values | Past Surgical History:
stringlengths 0
12
| Discharge Exam:
stringclasses 1
value | DISCHARGE EXAM:
stringclasses 1
value | Labs on Discharge:
stringclasses 1
value | REGIONAL LEFT VENTRICULAR WALL MOTION:
stringclasses 171
values | PHYSICAL EXAM:
stringlengths 0
12
| Medication changes:
stringclasses 1
value | Physical Therapy:
stringclasses 313
values | Treatments Frequency:
stringclasses 226
values | SECONDARY DIAGNOSES:
stringlengths 0
12
| 2. CARDIAC HISTORY:
stringclasses 715
values | HOME MEDICATIONS:
stringclasses 441
values | Chief Complaint:
stringclasses 1
value | FINAL DIAGNOSES:
stringclasses 83
values | DISCHARGE PHYSICAL EXAM:
stringclasses 1
value | ACID FAST CULTURE (Preliminary):
stringclasses 214
values | Wound Care:
stringclasses 1
value | Blood Culture, Routine (Preliminary):
stringclasses 146
values | Discharge exam:
stringclasses 736
values | Neurologic Examination:
stringclasses 1
value | Discharge Physical Exam:
stringclasses 1
value | ACTIVE ISSUES:
stringclasses 1
value | CLINICAL IMPLICATIONS:
stringclasses 128
values | FUNGAL CULTURE (Preliminary):
stringclasses 365
values | FOLLOW UP:
stringclasses 645
values | PREOPERATIVE MEDICATIONS:
stringclasses 71
values | RESPIRATORY CULTURE (Preliminary):
stringclasses 133
values | SUMMARY OF HOSPITAL COURSE:
stringclasses 286
values | Labs on discharge:
stringclasses 1
value | MEDICATIONS PRIOR TO ADMISSION:
stringclasses 144
values | HOSPITAL COURSE BY ISSUE/SYSTEM:
stringclasses 131
values | SECONDARY DIAGNOSIS:
stringclasses 1
value | FOLLOW-UP APPOINTMENTS:
stringclasses 47
values | Cardiac Enzymes:
stringclasses 1
value | OUTPATIENT MEDICATIONS:
stringclasses 106
values | Review of Systems:
stringclasses 1
value | ADMISSION DIAGNOSES:
stringclasses 50
values | MEDICATION CHANGES:
stringclasses 1
value | Blood Culture, Routine (Pending):
stringclasses 88
values | TECHNICAL FACTORS:
stringclasses 60
values | PHYSICAL EXAMINATION:
stringlengths 0
12
| [**Last Name (NamePattern4) 4125**]ospital Course:
stringclasses 40
values | ADMISSION DIAGNOSIS:
stringclasses 115
values | Physical Exam on Discharge:
stringclasses 198
values | At discharge:
stringlengths 0
12
| RECOMMENDED IMMUNIZATIONS:
stringclasses 3
values | ON DISCHARGE:
stringlengths 0
12
| CHRONIC ISSUES:
stringclasses 1
value | Immediately after the operation:
stringclasses 71
values | Transitional issues:
stringclasses 965
values | FOLLOW-UP PLANS:
stringclasses 188
values | Changes to your medications:
stringclasses 809
values | Upon discharge:
stringclasses 1
value | REVIEW OF SYSTEMS:
stringlengths 0
12
| CARDIAC ENZYMES:
stringclasses 1
value | Cardiac enzymes:
stringclasses 361
values | Medication Changes:
stringclasses 665
values | [**Location (un) **] Diagnosis:
stringclasses 49
values | ACID FAST CULTURE (Pending):
stringclasses 59
values | Discharge PE:
stringclasses 99
values | General Discharge Instructions:
stringclasses 84
values | INDICATIONS FOR CATHETERIZATION:
stringclasses 54
values | WHEN TO CALL YOUR SURGEON:
stringclasses 31
values | Neurological Exam:
stringclasses 73
values | Exam on Discharge:
stringclasses 1
value | CHIEF COMPLAINT:
stringlengths 0
12
| REASON FOR THIS EXAMINATION:
stringlengths 0
12
| Relevant Imaging:
stringclasses 55
values | Active Issues:
stringclasses 353
values | [**Location (un) **] Condition:
stringclasses 42
values | RECOMMENDATIONS AFTER DISCHARGE:
stringclasses 2
values | [**Hospital1 **] Disposition:
stringclasses 38
values | TRANSITIONAL CARE ISSUES:
stringclasses 69
values | [**Hospital1 **] Medications:
stringclasses 41
values | [**Location (un) **] Instructions:
stringclasses 40
values | WOUND CULTURE (Preliminary):
stringclasses 63
values | DISCHARGE FOLLOWUP:
stringclasses 182
values | LABS ON DISCHARGE:
stringclasses 566
values | POST CPB:
stringclasses 1
value | URINE CULTURE (Preliminary):
stringclasses 70
values | Review of sytems:
stringclasses 249
values | Labs at discharge:
stringclasses 119
values | Immunizations recommended:
stringclasses 34
values | AEROBIC BOTTLE (Pending):
stringclasses 26
values | -Rehabilitation/ Physical Therapy:
stringclasses 39
values | FOLLOW UP APPOINTMENTS:
stringclasses 38
values | Mental Status:
stringclasses 1
value | Admission labs:
stringclasses 1
value | HOSPITAL COURSE BY PROBLEM:
stringclasses 131
values | [**Hospital 5**] MEDICAL CONDITION:
stringclasses 14
values | PHYSICAL EXAM UPON DISCHARGE:
stringclasses 47
values | WOUND CARE:
stringclasses 425
values | ANAEROBIC BOTTLE (Pending):
stringclasses 25
values | CURRENT MEDICATIONS:
stringclasses 82
values | FOLLOW-UP APPOINTMENT:
stringclasses 54
values | FINAL DISCHARGE DIAGNOSES:
stringclasses 23
values | TRANSFER MEDICATIONS:
stringclasses 76
values | Upon Discharge:
stringclasses 230
values | HISTORY OF PRESENT ILLNESS:
stringlengths 0
12
| CRANIAL NERVES:
stringlengths 0
12
| CT head:
stringclasses 1
value | Exam on discharge:
stringclasses 111
values | CT Head:
stringclasses 955
values | [**Location (un) **] PHYSICIAN:
stringclasses 130
values | Admission Labs:
stringclasses 1
value | secondary diagnosis:
stringlengths 0
12
| Head CT:
stringclasses 601
values | MRA OF THE HEAD:
stringclasses 48
values | INACTIVE ISSUES:
stringclasses 124
values | ADMISSION LABS:
stringlengths 0
12
| PROBLEM LIST:
stringclasses 49
values | PRIMARY DIAGNOSIS:
stringlengths 0
12
| OTHER PERTINENT LABS:
stringclasses 91
values | PROBLEMS DURING HOSPITAL STAY:
stringclasses 1
value | Medication Instructions:
stringclasses 48
values | IRON AND VITAMIN D SUPPLEMENTATION:
stringclasses 6
values | On admission:
stringlengths 0
12
| ANAEROBIC CULTURE (Preliminary):
stringclasses 227
values | MENTAL STATUS:
stringlengths 0
12
| ADMITTING DIAGNOSIS:
stringclasses 69
values | TRANSITIONS OF CARE:
stringclasses 92
values | Pertinent Labs:
stringclasses 205
values | 3. OTHER PAST MEDICAL HISTORY:
stringclasses 667
values | # Transitional issues:
stringclasses 71
values | [**Hospital1 **] Diagnosis:
stringclasses 24
values | Chronic Issues:
stringclasses 245
values | FOLLOW-UP INSTRUCTIONS:
stringclasses 101
values | CARE AND RECOMMENDATIONS AT DISCHARGE:
stringclasses 2
values | HOSPITAL COURSE: By systems:
stringclasses 1
value | NEUROLOGIC EXAMINATION:
stringclasses 339
values | Treatment Frequency:
stringclasses 26
values | Neurologic Exam:
stringclasses 63
values | DISCHARGE PLAN:
stringclasses 62
values | Active Diagnoses:
stringclasses 63
values | Medications on transfer:
stringclasses 568
values | Past medical history:
stringlengths 0
12
| SOCIAL HISTORY:
stringlengths 0
12
| CONDITION ON DISCHARGE:
stringlengths 0
12
| FLUID CULTURE (Preliminary):
stringclasses 112
values | Meds on transfer:
stringclasses 242
values | Exam upon discharge:
stringclasses 35
values | Other labs:
stringclasses 142
values | Discharge physical exam:
stringclasses 473
values | [**Hospital1 **] Instructions:
stringclasses 22
values | Imaging Studies:
stringclasses 111
values | Post CPB:
stringclasses 96
values |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
10,702
| 198,645
|
10786
|
Discharge summary
|
report
|
Admission Date: [**2140-4-4**] Discharge Date: [**2140-4-15**]
Date of Birth: [**2065-9-8**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Cephalexin
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
ventricular tachycardia, acute MI
Major Surgical or Invasive Procedure:
percutaneous coronary intervention
ventricular tachycardia mapping and ablation
History of Present Illness:
74M with ischemic CM EF~10-15%, PVD, prior VF arrest, s/p ICD
placement on mexilitine and dofetilide at home. Admitted to OSH
on [**3-31**] with complaints of feeling weak, found to be in
sustained VT @120bpm w/o ICD firing. En route the patient was
cardioverted in the ambulance with 100J. He was then admitted
to telemetry floor at [**Hospital 1474**] hospital but had VF arrest on
[**2140-4-2**], with successful shock from ICD. Trop 5.4, CPK's just
over 100. Mexilitine was discontinued and IV lido started at
2mg/kg/min.
On [**4-2**], he developed slurred speech and dizziness so lido was
held and then decreased to 1mg/min/kg. Since starting the lido
he has been arrhythmia free, pacing at a rate of 60. At 10:30
p.m., he had an episode of VT 160-170's. He would have a run of
this and then the nurse would see him pacing for about 10 beats
at a rate in the 120's, then he would go back into VT
160-170's... eventually shocked x 2.- back to V paced. Entire
event was about 2 minutes. The patient was asymptomatic except
for some palpitations. They then increased his lido to 2mg/min
after giving him a 50mg bolus.
Past Medical History:
1) Ischemic CM with an EF of [**9-24**]%
2) s/p vf arrest [**2132**] during his CEA s/p ICD placement [**2132**],
3) prior CVA's, CEA
4) PVD s/p fem [**Doctor Last Name **], right BKA
5) COPD
6) Hx of complete heart block
7) hx of amio pulmonary and liver toxicity in [**2134**].
8) unequal pupils trauma as child
Social History:
He lives alone in [**Hospital1 1474**]. He is a retired manual laborer. He
has no known drug allergies. He has two brothers, alive and
well.
Physical Exam:
VS: 146/55 HR 60 RR 18 Sat 99%3L NC
Gen: WN/WD man in bed in NAD.
HEENT: Pupils unequal (chronic, per patient) MMM, no icterus.
CV: +IV/VI HSM across precordium
Pul: CTA b/l, no wheezes or rales.
Abd: Soft, NT, ND +BS
Ext: R above-the knee amputation, LLE w/o edema.
Neuro: Alert & oriented x1 while on lidocaine gtt.
Pertinent Results:
[**2140-4-4**] 08:18PM BLOOD WBC-10.1 RBC-4.84 Hgb-14.5 Hct-42.8
MCV-88 MCH-30.1 MCHC-34.0 RDW-15.5 Plt Ct-215
[**2140-4-4**] 03:00PM BLOOD PT-15.7* INR(PT)-1.6
[**2140-4-4**] 08:18PM BLOOD Glucose-120* UreaN-21* Creat-0.8 Na-135
K-4.1 Cl-100 HCO3-26 AnGap-13
[**2140-4-9**] 06:03AM BLOOD ALT-17 AST-62* AlkPhos-70 TotBili-1.3
[**2140-4-4**] 08:18PM BLOOD Albumin-3.3* Calcium-8.2* Phos-2.6*
Mg-1.8
EKG: Dual chamber pacemaker in atrio-ventricular sequential
pacing mode. Compared to the previous tracing of [**2136-6-9**] no
diagnostic change.
Brief Hospital Course:
74M w/ischemic CM, PVD, prior VF arrest s/p ICD & on mexilitine
and dofetilide at home admitted to OSH w/VT @120 bpm and CP. At
OSH, found to have likely NSTEMI (Trop 5.4) & transferred to [**Hospital1 **]
for cath & EP study. Cath [**4-4**] w/80% RCA s/p 2 stents. Now
persistent VT and ICD firing, intubated on [**4-7**] electively to
sedate pt.
1. Cardiovascular:
a. Rhythm: Mr. [**Known lastname **] has an ICD that was initially placed in
[**2132**] after an episode of VF arrest during his carotid
endarterectomy. He was maintained on dofetilide, mexilitine
and metoprolol at home.
He presented to an OSH complaining of weakness and was found to
have an acute MI and episodes of VT. Mexilitine was held and
lidocaine drip was started but discontinued after PCI on [**4-5**]
due to confusion and disorientation. On [**4-7**], he received his
dofetilide dose somewhat late and developed persistent pulseful
VT. Lidocaine was re-started. The ICD settings were modified
and his heart rate was lowered back to 60bpm. The ICD would
attempt to pace him out of the VT with anti-tachycardia pacing
but 1/3 episodes would cause him to be shocked. He recieved
approximately 30 shocks. For patient comfort, he was intubated
and sedated electively. With the lower heart rate in addition
to switching lidocain to procainamide, the VT resolved. On
[**4-8**]- Went to EP and had ablation which was sucessful.
On [**4-10**], off of the dofetilide and procainamide, the patient was
still having NSVT. EP recommended starting quinidine 324mg po
tid. This was done, but then the pt developed severe diarrhea
and fever that was thought to be [**1-13**] quinidine. He was then
started on procainamide, which he will be discharged on. The
procainamide decreased the amount of NSVT to 1 or 2 runs of [**2-12**]
beats per 24 hours. He continues to have palpitations.
b. Ischemia: On admission here, he ruled in for MI and went
straight to cath. He was found to have lesions in his RCA. Two
drug-eluting stents were placed without complications. He will
continue aspirin, Plavix, and metoprolol. And
Post-op from the EP procedure, his ACEi moexipril was changed to
captopril.
c. Pump: EF 10-15% per echo in [**2125**], but the patient had no
signs or symptoms of decompensated heart failure. He was kept
on strict I/O's. Digoxin was discontinued as it is
arrythmogenic and he has been well-compensated. He was also
kept on Moexipril 15 [**Hospital1 **], aldactone 25mg qd for hypokalemia,
lasix 80 PO qd for now.
2. Pulm: intubated electively [**4-7**] during persistent VT &
ICD firings to allow sedation. Successfully extubated [**4-9**].
3. Mental Status: confused but redirectable in holding area;
?apparently some correlation with lido administration, which
were relatively high doses. Not hypotensive. A head ct was done
for ?unequal pupils post-op but on clarification, he has had
unequal pupils since childhood. This mental status change
improved when lidocaine was stopped.
4. Thrombocytopenia: His platelet count dropped slowly, heparin
dependent antibodies were sent and are neg.
5. Diarrhea: Pt developed severe diarrhea X 72 hours after one
dose of quinidine. Stool studies were neg for infectous
etiology including C.diff. This diarrhea was attributed to
quinidine and improved with holding of the medication.
6. Increasing Cr: The patient was noted on routine labs to have
an increasing creatinine on the day of discharge. His aldactone
was held, and he was discharged to follow up with Dr. [**Last Name (STitle) 35231**]
(general cardiology) in 1 week for re-check and follow up on
restarting aldactone.
Medications on Admission:
imdur
plavix
univasc
asa
tykosin
niaspan
lopressor
spivira inhaler
dig
protonix
Lido gtt.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Moexipril HCl 15 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
7. Procanbid 1,000 mg/12hr Tablet Sustained Release 12HR Sig:
One (1) Tablet Sustained Release 12HR PO twice a day.
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
8. 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*
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
Ventricular Tachycardia
Non-ST elevation MI
Diarrhea
Discharge Condition:
Good
Discharge Instructions:
If you have these symptoms, call your doctor:
- shortness of breath
- ICD firing (shocks)
- chest pain
- dizziness
- visual changes
Followup Instructions:
Please see Dr.[**Last Name (STitle) 7047**] within 1 week of discharge. [**Last Name (LF) **],[**First Name3 (LF) **]
M. [**Telephone/Fax (1) 3183**]
Please follow up with Dr. [**Last Name (STitle) **] in [**2-12**] weeks (Call
[**Telephone/Fax (1) 285**] to verify your appointment)
|
[
"041.85",
"401.9",
"458.8",
"997.1",
"428.0",
"780.6",
"414.01",
"427.1",
"V45.81",
"V12.59",
"599.0",
"V45.02",
"496",
"443.9",
"425.4",
"427.31",
"E942.0",
"287.5",
"787.91",
"410.71",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"37.34",
"88.53",
"37.26",
"96.04",
"36.07",
"96.09",
"37.22",
"38.91",
"88.56",
"96.71",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
8051, 8110
|
2975, 5628
|
315, 396
|
8207, 8213
|
2404, 2952
|
8393, 8682
|
6754, 8028
|
8131, 8186
|
6640, 6731
|
8237, 8370
|
2066, 2385
|
242, 277
|
424, 1554
|
5643, 6614
|
1576, 1892
|
1908, 2051
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,073
| 134,830
|
42013
|
Discharge summary
|
report
|
Admission Date: [**2190-1-21**] Discharge Date: [**2190-2-13**]
Date of Birth: [**2123-12-18**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Right paraganglionoma with presistent volatile blood pressures.
Major Surgical or Invasive Procedure:
Resection of right paraganglionoma.
Repair aorta
repair vena cava
History of Present Illness:
(Per endocrinology)
Mr. [**Known lastname **] is a 66-year-old man with a history significant for
paraganglionoma who was admitted for volume expansion the night
prior to resection of a right paraganglionoma.
.
To review his history, Mr. [**Known lastname **] is a 65-year-old man who as
part of the work up for a right inguinal hernia was found to
have a 7.7 cm retroperitoneal mass. He underwent a CT guided
core biopsy of the retroperitoneal mass at [**Hospital3 19345**] on [**2189-10-6**]. At that time, his blood pressure was noted
to be in the 210s and a nitro patch was given. Pathology was
consistent with a
paraganglioma. Pathology was reviewed at [**Hospital1 18**]. The features
were consistent with a paraganglioma. In addition, the submitted
immunostains showed that the tumor cells are stained strongly
positive for chromogranin and synaptophysin, and negative for
cytokeratins (AE1/AE3, CK7, and CK20), CD 68, and CD117.
.
Laboratory studies performed in [**Month (only) **] were significant for
increased plasma and urinary normetanephrine and metanephrine
catecholamines (see under labs).
.
He was seen on initial consolation by Dr. [**Last Name (STitle) **] at the
endocrinology clinic at [**Hospital6 3105**] on [**2189-12-10**].
At that time, he was clinically asymptomatic. But BP was found
to be high in the 190s (right 196/94--->left: 183/80). He was
not orthostatic. He was on amlodipine 5 mg daily, atenolol 50 mg
daily, and lisinopril 10 mg daily as outpatient. At that time,
he was started phenoxybenzamine 10 mg [**Hospital1 **] and the lisinopril was
stopped. Progressively, he was wean off the other BP meds and
the phenoxybenzamine dose was increased. Propanolol and
nicardipine were also added. He is currently on Phenoxybenzamine
40 mg po tid, Propranolol 10 mg po tid, and Nicardipine XR 60 mg
po bid with good BP control.
.
As part of the work up also, he underwent a MIBG, which was
performed on [**2190-1-13**] at [**Hospital1 18**]. The results demonstrated the
presence of an intense uptake of tracer seen within the
mid-abdomen, consistent with known paraganglioma. There was
normal physiologic uptake seen within the salivary glands,
thyroid, liver and lungs. There were no other foci concerning
for additional disease.
.
In addition, Mr. [**Known lastname **] was found to have an incidental thyroid
nodule on the chest CT performed in [**Month (only) **] as part of the
work up for the paraganglioma. A subsequent thyroid US showed a
dominant 3 cm solid nodule located on the left thyroid lobe.
Calcitonin level, which was WNL, was also checked to rule out
medullary thyroid carcinoma. He had also normal thyroid function
tests FNA biopsy has been postponed after the current surgery is
performed.
.
Of note, Chromogranin A was 1060 ng/mL (normal<=225)on
[**2189-12-15**] at LGH.
.
Today he denies any complaints.
.
REVIEW OF SYSTEMS:
General: no weight changes or fatigue. No fever or chills.
HEENT: no headaches, visual changes, or double vision. No neck
pain or tenderness.
Cardiovascular: no chest pain, no palpitations, no dyspnea on
exertion.
Lungs: no shortness of breath, no cough.
Gastrointestinal: no abdominal pain, nausea, vomiting, diarrhea,
or constipation.
Genitourinary: no dysuria, urgency, or frequency.
Musculoskeletal: no muscle or joints pain, muscular weakness, or
cramps.
Neurologic: no tremors, paresthesias, difficulties with memory,
sensory or motor disturbances.
Endocrine: as above. No polydipsia, polyuria, asthenia,
intolerance to cold or heat.
Psychiatric: denies depressed mood or anhedonia. No anxiety.
All other pertinent review of systems is negative.
Past Medical History:
PMH:
1. Newly diagnosed paraganglioma
2. Hypercholesterolemia
3. Hypertension
4. Hemorrhoid surgery [**98**] years in [**Country 11150**]
5. Inguinal hernia
6. Thyroid nodule
PSH:
CT guided biopsy of retroperitoneal mass
Social History:
Patient came to US in [**2173**] from [**Last Name (LF) 91211**], [**First Name3 (LF) 11150**].
Married with three grown children.
He lives with one of his sons.
[**Name (NI) **] is a retired former office worker.
No smoking (of any kind), alcohol, or other drugs.
Family History:
Both parents are hypertensive.
No history of any endocrine diseases or tumor syndromes.
Physical Exam:
ON DISCHARGE:
Vitals:
General: NAD
HEENT: NC/AT, no exophthalmus, no lid lag, EOMs intact, PERRL,
MMM
Neck: No bruits, small thyroid nodule on left side
Heart: RRR, no m/r/g, normal S1 and S2
Lungs: CTAB
Abdomen: bowel sounds present, soft, NT/ND, no abd bruits, no
CVAT
Extremities: no c/c/e, w/w/p, moves all
Neuro: No tremor noted. DTRs +2. [**Name2 (NI) 36**] and motor grossly intact
Pertinent Results:
PRE-OPERATIVE LABS:
[**2190-1-21**] 03:35PM BLOOD WBC-6.3 RBC-4.37* Hgb-13.5* Hct-37.8*
MCV-87 MCH-30.9 MCHC-35.8* RDW-14.0 Plt Ct-213
[**2190-1-21**] 03:35PM BLOOD PT-10.9 PTT-32.9 INR(PT)-1.0
[**2190-1-21**] 03:35PM BLOOD Glucose-143* UreaN-13 Creat-1.1 Na-138
K-4.3 Cl-105 HCO3-25 AnGap-12
[**2190-1-21**] 03:35PM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9
.
DAY OF SURGERY LABS:
[**2190-1-22**] 02:37PM BLOOD WBC-5.7 RBC-3.07*# Hgb-9.2*# Hct-26.4*#
MCV-86 MCH-30.1 MCHC-35.0 RDW-14.5 Plt Ct-141*
.
[**2190-1-22**] 01:04PM BLOOD PT-15.1* PTT-31.7 INR(PT)-1.4*
[**2190-1-22**] 02:37PM BLOOD PT-13.3* PTT-29.9 INR(PT)-1.2*
.
[**2190-1-22**] 01:04PM BLOOD Fibrino-108*
[**2190-1-22**] 02:37PM BLOOD Fibrino-144*
.
[**2190-1-22**] 09:52AM BLOOD Type-ART Rates-/8 Tidal V-68 FiO2-56
pO2-211* pCO2-40 pH-7.39 calTCO2-25 Base XS-0 Intubat-INTUBATED
Vent-CONTROLLED
[**2190-1-22**] 11:07AM BLOOD Type-ART Rates-/8 Tidal V-543 FiO2-51
pO2-193* pCO2-44 pH-7.34* calTCO2-25 Base XS--2
Intubat-INTUBATED Vent-CONTROLLED
[**2190-1-22**] 12:54PM BLOOD Type-ART pO2-226* pCO2-49* pH-7.27*
calTCO2-23 Base XS--4 Intubat-INTUBATED Vent-CONTROLLED
[**2190-1-22**] 02:39PM BLOOD Type-ART Tidal V-530 pO2-216* pCO2-46*
pH-7.34* calTCO2-26 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
[**2190-1-22**] 03:29PM BLOOD Type-ART Tidal V-530 pO2-238* pCO2-43
pH-7.36 calTCO2-25 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED
.
[**2190-1-22**] 09:52AM BLOOD Glucose-113* Lactate-1.9 Na-138 K-3.9
Cl-108
[**2190-1-22**] 11:07AM BLOOD Glucose-159* Lactate-1.5 Na-136 K-4.0
Cl-106
[**2190-1-22**] 12:54PM BLOOD Glucose-194* Lactate-2.4* Na-137 K-4.6
Cl-105
[**2190-1-22**] 02:39PM BLOOD Lactate-2.9* Na-137 K-4.4 Cl-102
[**2190-1-22**] 03:29PM BLOOD Glucose-202* Lactate-3.4* Na-136 K-4.2
Cl-100
.
[**2190-1-22**] 09:52AM BLOOD Hgb-12.1* calcHCT-36 O2 Sat-99
[**2190-1-22**] 11:07AM BLOOD Hgb-11.5* calcHCT-35
[**2190-1-22**] 12:54PM BLOOD Hgb-12.0* calcHCT-36
[**2190-1-22**] 03:29PM BLOOD Hgb-11.8* calcHCT-35
.
[**2190-1-22**] 09:52AM BLOOD freeCa-1.16
[**2190-1-22**] 11:07AM BLOOD freeCa-1.09*
[**2190-1-22**] 02:39PM BLOOD freeCa-0.75*
[**2190-1-22**] 03:29PM BLOOD freeCa-1.12
.
PRE-OP CXR [**2190-1-21**]: IMPRESSION -> No evidence of acute disease.
.
ECHO [**2190-1-29**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is dilated with borderline normal free wall function. The
number of aortic valve leaflets cannot be determined. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
.
IMPRESSION: Preserved left ventricular systolic function.
Dilated right ventricle with borderline normal free wall
function.
.
VIDEO SWALLOW [**2190-2-4**]:
FINDINGS: A mild-to-moderate amount of residue remained in the
valleculae
after all oral boluses, that was increased with increasing bolus
density.
Penetration was seen with nectar-thick liquids. There was
possible single
episode of trace aspiration of nectar-thick liquids as well.
.
IMPRESSION: Penetration with nectar-thick liquids and possible
single episode of silent aspiration of nectar thick liquids.
.
CT HEAD [**2190-2-5**]:
IMPRESSION: No evidence of acute intracranial process. If
clinical concern
persists for ischemic stroke, would recommend further evaluation
with an MRI.
.
EEG [**2190-2-6**]:
IMPRESSION: This is an abnormal routine EEG because of diffuse
background slowing and intermittent bifrontal slowing. These
findings
are indicative of a diffuse encephalopathy of non-specific
etiology. In
addition, there were intermittent triphasic waves in the second
half of
the recording which can be seen in metabolic encephalopathies
although
they are not specific as to pathology either. No epileptiform
discharges or electrographic seizures are present.
.
CXR [**2190-2-6**]:
FINDINGS: The feeding tube is in the first portion of the
duodenum. A
right-sided PICC line tip is in the right atrium. There is
plate-like
atelectasis in both lower lungs. There is no focal infiltrate.
.
MRI HEAD W/ AND W/O CONTRAST [**2190-2-7**]:
1. No evidence of acute infarct or hemorrhage.
2. Cystic lesion in the right middle ear/mastoid may represent
fluid. CT of the temporal bone can be obtained for further
evaluation.
3. Mucus retention cyst and mucosal thickening of the right
maxillary sinus and fluid in the bilateral mastoid air cells.
.
LABS PRIOR TO DISCHARGE:
[**2190-2-10**] 04:39AM BLOOD WBC-8.4 RBC-2.88* Hgb-8.7* Hct-25.1*
MCV-87 MCH-
30.2 MCHC-34.5 RDW-14.5 Plt Ct-382
[**2190-2-10**] 04:39AM BLOOD Glucose-137* UreaN-16 Creat-0.8 Na-134
K-4.2 Cl-101 HCO3-23 AnGap-14
[**2190-2-10**] 04:39AM BLOOD ALT-32 AST-28 LD(LDH)-200 AlkPhos-118
TotBili-0.5
[**2190-2-10**] 04:39AM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.5 Mg-2.1
Brief Hospital Course:
This 66 year-old male with a right paraganglionoma causing blood
pressures abnormalities was admitted [**2190-1-21**] for pre-operative
volume expansion. He underwent resection of the right
paraganglionoma on [**2190-1-22**]. His surgery was complicated by
volatile blood pressure due to the nature of the tumor itself,
as well as excessive bleeding requiring transfusion. The
patient's tumor had some attachment to the IVC which required
repair. His postoperative course was complicated by ileus,
delirium, and acute SOB/tachypnea and he transferred to SICU on
[**1-28**] for further monitoring. While in SICU, he was intubated for
3 days due to concern of ARDS and given lasix for volume
overload. Pt finally had a bowel movement. Urine and blood
culture on [**1-28**] grew pan sensitive pseudomonas. BAL on [**1-29**] grew
pan sensitive E. Coli and
psuedomonas. He was started on ciprofloxacin on [**1-30**] for 14 day
course (last day scheduled for [**2190-2-13**]). He was transfered to
floor on [**2190-2-2**]. Neurology was consulted due to persistent
aletered mental status on [**2190-2-5**]. A CT head and MRI were
obtained and essentially negative for acute process or signs of
infarct. An EEG was also performed which did not show any focal
seizure activity, Speech and swallow evaluated the patient,
with recommendations for aspiration precautions, honey thickened
liquids and pureed solids. Due to continued poor PO intake a
dobhoff tube was placed with the initiation of continuous tube
feeds for nutritional support. Patient was seen by ENT for
hypophonia, and found to have noted paralysis of his Left Vocal
Cord, thought to be most likely secondary to his intubation.
Patient did have elevated blood sugars postoperatively, he was
started on an insulin regmien and was given NPH 30 units in the
AM and 30 units in the PM. He achieved good blood sugar control
with this and was sent on home on this regimen with a sliding
scale. Patient had several consult services for which he will
need follow up with. He was discharged home in stable condition.
His pain was well controlled. He was ambulating with assistance.
He still had poor PO intake but was getting his tube feeds
cycled per nutrition recs. His component of hypoactive delirium
will likely take several weeks, possibly months to resolve.
TRANSITIONAL ISSUES:
1) f/u with Dr. [**Last Name (STitle) **] in 2 weeks
2) f/u with Endocrinlogy
3) f/u with ENT
4) home with PT, Med teachings, tube feeds
5) f/u with PCP regarding insulin regimen
Medications on Admission:
PHENOXYBENZAMINE 40'''
PROPRANOLOL 10'''
SIMVASTATIN 10'
Nicardipine XR 30''
Discharge Medications:
1. Tube Feedings
Tubefeeding: Two Cal HN Full strength;
Starting rate: 120 ml/hr; Do not advance rate Goal rate: 120
ml/hr
Cycle?: Yes, when at goal Cycle start: 2200 Cycle end: 0600
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 100 ml water q6h
2. Kangaroo [**Male First Name (un) 16917**] Feeding Pump
Patient needs Kangaroo [**Male First Name (un) 16917**] feeding pump and backpack.
3. Feeding bags
Patient will require one feeding bag per day dispense 30 with 6
refills.
4. Dobhoff Supplies
Patient will require dobhoff supplies dispense 1 month with 6
refills.
5. IV Pole
Patient will require an IV Pole.
6. Hospital Bed
Patient requires hospital-style bed
7. Lancets
Patient will need lancets to check his blood sugars. Please
provide at least a 90 day supply.
8. Syringes
Patient will require syringes to administer insulin. Please
provide at least a 90 day supply.
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
10. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*900 ML(s)* Refills:*0*
11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
12. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
Disp:*500 ml* Refills:*0*
13. simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
14. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: Thirty (30) units Subcutaneous twice a day: use 30 units in
the morning and 30 units in the evening.
Disp:*3360 units* Refills:*0*
15. Insulin Syringe 1 mL 29 x [**1-4**] Syringe Sig: One (1) syringe
Miscellaneous once a day: please provide 90 day supply of
inuslin syringes.
Disp:*270 syringes* Refills:*0*
16. insulin regular human 100 unit/mL Solution Sig: See scale
Injection every six (6) hours: Please refer to sliding scale
sheet.
Disp:*3600 units* Refills:*0*
17. glucometer
Patient will require a one touch glucomter or whatever is
covered by insurance to test blood sugars.
18. alcohol wipes
patient will need a 90 day supply of alcohol wipes to help with
fingersticks for checking blood sugars.
19. Glucometer test strips
Patient will need strips for his glucometer for his blood sugar
checks. Please provide at least a 90 day supply. Patient will be
checking blood sugars every 6 hours.
20. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: for high blood pressure.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Right paraganglionoma.
Hypertension
Post op respiratory failure and sepsis
Pneumonia
Wound seroma
Vocal cord paresis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the West 3 surgical service under Dr.
[**Last Name (STitle) **] after undergoing an extraction of your right
paraganglionoma on
[**2190-1-22**]. During the postoperative period you experienced some
issues with your breathing which required sending you to the
critical care unit and a tube being placed down your throat to
help you breath. We believe that you might aspirated some food
causing an infection in your lungs. Your blood was found to have
an infection with a bacteria which we treated with a medication
(antibiotic). You did well after being started on treatment for
your infection. You were seen by the Neurologists and found to
have a hypoactive delirium, we expect you to make a gradual
recovery from this. In addition, you were seen by the Ear,Nose
and Throat doctors who [**Name5 (PTitle) **] that one of your vocal cords was
not mobile, we believe this will also resolve over the next
several weeks. We have given you a number below to follow up
with Ear Nose and Throat doctors, please call to schedule an
appointment.
We have made the following changes to your medications:
STOP Phenoxybenzamine
STOP Propanolol
STOP Nicardapine
START Omeprazole take two tablets (total 40mg) by NGT once a day
START Lisinopril 5mg take one tablet by NGT daily
START Metoprolol tartrate take 100mg one tablet by NG tube twice
daily
START cholorhexidine gluconate use 15ml to rinse mouth twice
daily
START omeprazole 40mg take one tablet per NGT daily
START docusate sodium 50 mg/5 mL Liquid take up to 10ml by NGT
twice daily for softening stools
START insulin NPH inject 30 units in the morning and inject 30
units in the evening
START Insulin regular per your sliding scale after checking your
sugars every 6 hours, please see your attached sheet
Diet: You may resume your regular home diet.
.
Activity: No strenous activity (lifting greater than 20 pounds)
until you see Dr. [**Last Name (STitle) **] for follow-up in his clinic. You may
shower daily, but do not swim/bathe/soak your incision under
water until you see Dr. [**Last Name (STitle) **] for follow-up in his clinic.
.
Wound care: You will need to place a moistened gauze (use
sterile saline) into your wound once a day. This will need to be
changed on a daily basis.
Please follow up with your primary care provider to discuss your
insulin regimen and blood sugars. [**Last Name (un) **],[**Last Name (un) **]
[**Telephone/Fax (1) 7660**]
Followup Instructions:
Here are your following appointments:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2190-2-25**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital 18**] [**Hospital **] CLINIC (Endocrinology)
When: THURSDAY [**2190-3-4**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 1409**] [**Last Name (NamePattern4) 91212**], MD
We were unable to schedule an appointment with the Ear Nose and
Throat doctors. They would like to see you within 1-2 weeks of
your discharge for your vocal cords. Please call ([**Telephone/Fax (1) 21740**]
prior schedule a follow-up appointment with [**Hospital1 18**] laryngologist,
Dr. [**Last Name (STitle) **].
We were unable to schedule an appointment with your primary care
provider, [**Name10 (NameIs) **] do so after your hospital discharge.
TERJEE,[**Name10 (NameIs) **] [**Telephone/Fax (1) 7660**]. Please discuss your blood sugars
and insulin regimen with Dr. [**Last Name (STitle) 48970**].
|
[
"E878.8",
"790.29",
"599.0",
"038.43",
"241.0",
"995.92",
"401.9",
"235.4",
"478.31",
"997.49",
"998.51",
"997.32",
"293.1",
"272.0",
"518.52",
"211.8",
"998.11",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"39.31",
"96.6",
"54.4",
"96.04",
"96.71",
"39.32"
] |
icd9pcs
|
[
[
[]
]
] |
15509, 15559
|
10225, 12540
|
368, 435
|
15719, 15719
|
5152, 10202
|
18325, 19543
|
4639, 4728
|
12868, 15486
|
15580, 15698
|
12767, 12845
|
15870, 16956
|
4743, 4743
|
4757, 5133
|
12561, 12741
|
16985, 17979
|
3342, 4096
|
265, 330
|
17991, 18302
|
463, 3323
|
15734, 15846
|
4118, 4341
|
4357, 4623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,327
| 148,311
|
41521
|
Discharge summary
|
report
|
Admission Date: [**2158-10-9**] Discharge Date: [**2158-10-17**]
Date of Birth: [**2103-4-6**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
1.) pericardial window on [**2158-10-10**]
History of Present Illness:
55F w/ hx of small cell lung cancer s/p chemo/radiation w/
prophylactic cranial radiation s/p recent discharge after
undergoing pericardiocentesis c/b PEA arrest presents with
worsening dyspnea and light-headedness. Of note, no malignant
cells were identified from prior effusion. Discharged on
[**2158-10-5**], initially felt well at home but over the past day has
experienced signficant dyspnea with any exertion along with
light-headedness. No chest pain or syncope. Does have cough,
productive at times of frothy sputum but denies fever or chills.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Paroxysymal atrial fibrillation.
- S/p C section [**2139**]
.
ONCOLOGIC HISTORY:
- Presented with cough, dyspnea on exertion, wheezing and a
hoarse voice in [**2-/2157**]
- Imaging demonstrated a left upper lobe mass with mass effect
on the pulmonary artery and left upper lobe bronchus. CT-guided
biopsy of the mass and pathology revealed small cell lung
cancer. PET/CT scan prior to therapy demonstrated the large
FDG-avid left upper lobe mass with a hypodense nodular lesion in
the right thyroid.
- Began therapy for limited stage small cell lung cancer with
Cisplatin/Etoposide on [**2157-3-17**] and began radiation therapy on
[**2157-4-7**]. Therapy was completed [**2157-5-25**]. She underwent
prophylactic cranial irradiation, completed on [**2157-9-28**].
Social History:
Smoked 1 ppd for 25-30 years, quit [**1-22**]. Denies any alcohol of
IV drug abuse. Works as an elementary school librarian.
Family History:
Mother: deceased, long history of dementia
Father: died of asbestos-related lung cancer, possibly
mesothelioma
Sister: died of breast cancer at age 52
Brother with atrial fibrillations.
Physical Exam:
#ADMISSION PHYSICAL EXAM:
VS: 97.6 98/56 68 18 98% RA
GENERAL: NAD, AxOx3.
HEENT: No JVD. Sclera anicteric. PERRL, EOMI. MMM
CARDIAC: irregularly irregular. No m/r/g. No S3 or S4.
LUNGS: 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.
EXTREMITIES: No pretibial edema. No femoral bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
#DISCHARGE PHYSICAL EXAM:
VS: T 98.4, BP 110/76, HR 73, RR 18, O2 100% RA.
GENERAL: NAD, AxOx3.
HEENT: No discernable JVD, Sclera anicteric. PERRL, EOMI. MMM
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: 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.
EXTREMITIES: pretibial edema 1+. No femoral bruits.
Pertinent Results:
#ADMISSION LABS:
[**2158-10-9**] 04:26PM GLUCOSE-88 UREA N-11 CREAT-0.6 SODIUM-136
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
[**2158-10-9**] 04:26PM WBC-8.6 RBC-3.31* HGB-9.2* HCT-28.4* MCV-86
MCH-28.0 MCHC-32.6 RDW-14.3
[**2158-10-9**] 04:26PM NEUTS-75.8* LYMPHS-15.0* MONOS-6.2 EOS-2.6
BASOS-0.3
[**2158-10-9**] 04:26PM PLT COUNT-378
.
#PERTINENT LABS:
[**2158-10-17**] 04:25AM BLOOD WBC-6.2 RBC-3.12* Hgb-8.6* Hct-27.2*
MCV-87 MCH-27.4 MCHC-31.5 RDW-15.1 Plt Ct-382
[**2158-10-16**] 07:50AM BLOOD WBC-5.2 RBC-3.11* Hgb-8.7* Hct-26.9*
MCV-87 MCH-27.9 MCHC-32.3 RDW-14.4 Plt Ct-421
[**2158-10-15**] 06:30AM BLOOD WBC-4.2 RBC-3.18* Hgb-8.7* Hct-28.0*
MCV-88 MCH-27.3 MCHC-31.0 RDW-14.4 Plt Ct-494*
[**2158-10-14**] 06:20AM BLOOD WBC-4.1 RBC-3.00* Hgb-8.3* Hct-26.2*
MCV-87 MCH-27.8 MCHC-31.8 RDW-14.8 Plt Ct-418
[**2158-10-13**] 06:20AM BLOOD WBC-5.2 RBC-2.92* Hgb-7.9* Hct-25.6*
MCV-88 MCH-27.2 MCHC-31.0 RDW-14.6 Plt Ct-382
[**2158-10-12**] 01:52AM BLOOD WBC-9.2 RBC-2.86* Hgb-8.0* Hct-25.1*
MCV-88 MCH-28.1 MCHC-32.0 RDW-14.5 Plt Ct-393
[**2158-10-11**] 01:56AM BLOOD WBC-7.3 RBC-2.94* Hgb-8.3* Hct-25.6*
MCV-87 MCH-28.1 MCHC-32.2 RDW-14.4 Plt Ct-368
[**2158-10-10**] 05:19PM BLOOD WBC-7.3 RBC-3.19* Hgb-8.8* Hct-27.9*
MCV-87 MCH-27.6 MCHC-31.6 RDW-14.5 Plt Ct-376
[**2158-10-10**] 07:45AM BLOOD WBC-6.3 RBC-3.12* Hgb-9.3* Hct-27.3*
MCV-87 MCH-29.8 MCHC-34.1 RDW-14.3 Plt Ct-368
[**2158-10-14**] 06:20AM BLOOD Neuts-75.9* Lymphs-12.4* Monos-6.4
Eos-4.8* Baso-0.4
[**2158-10-12**] 01:52AM BLOOD PT-12.9* PTT-33.1 INR(PT)-1.2*
[**2158-10-10**] 07:45AM BLOOD PT-12.6* PTT-28.3 INR(PT)-1.2*
[**2158-10-17**] 04:25AM BLOOD Glucose-81 UreaN-5* Creat-0.6 Na-140
K-4.2 Cl-104 HCO3-25 AnGap-15
[**2158-10-16**] 07:50AM BLOOD Glucose-108* UreaN-6 Creat-0.6 Na-142
K-3.6 Cl-105 HCO3-26 AnGap-15
[**2158-10-15**] 06:30AM BLOOD Glucose-82 UreaN-5* Creat-0.5 Na-141
K-4.3 Cl-105 HCO3-28 AnGap-12
[**2158-10-14**] 06:20AM BLOOD Glucose-75 UreaN-9 Creat-0.6 Na-140 K-3.7
Cl-105 HCO3-29 AnGap-10
[**2158-10-13**] 06:20AM BLOOD Glucose-81 UreaN-10 Creat-0.8 Na-139
K-4.2 Cl-103 HCO3-28 AnGap-12
[**2158-10-12**] 01:52AM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-133
K-3.9 Cl-101 HCO3-26 AnGap-10
[**2158-10-11**] 01:56AM BLOOD Glucose-83 UreaN-7 Creat-0.5 Na-137 K-3.8
Cl-105 HCO3-25 AnGap-11
[**2158-10-10**] 07:45AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-141
K-3.7 Cl-104 HCO3-27 AnGap-14
[**2158-10-17**] 04:25AM BLOOD ALT-82* AST-109* AlkPhos-107* TotBili-0.3
[**2158-10-16**] 07:50AM BLOOD ALT-94* AST-145* CK(CPK)-91 AlkPhos-110*
TotBili-0.3
[**2158-10-17**] 04:25AM BLOOD Calcium-9.1 Phos-4.0 Mg-1.8
[**2158-10-16**] 07:50AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.6
[**2158-10-14**] 06:20AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9
[**2158-10-13**] 06:20AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.8
[**2158-10-11**] 01:56AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.2
[**2158-10-16**] 07:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2158-10-16**] 07:50AM BLOOD HCV Ab-NEGATIVE
[**2158-10-12**] 02:32AM BLOOD Type-[**Last Name (un) **] pH-7.42 Comment-GREEN TOP
[**2158-10-10**] 01:52PM BLOOD Type-ART pO2-367* pCO2-40 pH-7.40
calTCO2-26 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2158-10-10**] 01:52PM BLOOD Glucose-88 Lactate-0.9 Na-134 K-3.9
Cl-106
[**2158-10-10**] 01:52PM BLOOD Hgb-8.0* calcHCT-24
[**2158-10-12**] 02:32AM BLOOD freeCa-1.09*
[**2158-10-10**] 01:52PM BLOOD freeCa-1.08*
[**2158-10-14**] 06:20AM BLOOD B-GLUCAN-Test
[**2158-10-11**] 01:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2158-10-10**] 09:49AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2158-10-11**] 01:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2158-10-10**] 09:49AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
[**2158-10-10**] 09:49AM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE Epi-1
TransE-<1
[**2158-10-10**] 02:10PM OTHER BODY FLUID WBC-100* Hct,Fl-3* Polys-76*
Lymphs-20* Monos-3* Mesothe-1*
[**2158-10-10**] 02:10PM OTHER BODY FLUID TotProt-4.5 Glucose-78
LD(LDH)-713 Amylase-21 Albumin-2.6 Triglyc-66
.
#MICROBIOLOGY:
[] **FINAL REPORT [**2158-10-13**]**
Staph aureus Screen (Final [**2158-10-13**]):
STAPH AUREUS COAG +.
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
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[][**2158-10-10**] 9:49 am URINE Source: CVS.
**FINAL REPORT [**2158-10-12**]**
URINE CULTURE (Final [**2158-10-12**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
.
[][**2158-10-10**] 5:40 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2158-10-13**]**
MRSA SCREEN (Final [**2158-10-13**]): No MRSA isolated
.
[][**2158-10-10**] 2:20 pm TISSUE PERICARDIAL TISSUE.
**FINAL REPORT [**2158-10-16**]**
GRAM STAIN (Final [**2158-10-10**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2158-10-13**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2158-10-16**]): NO GROWTH
.
[][**2158-10-10**] 2:10 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final [**2158-10-10**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2158-10-17**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2158-10-12**] @
10:15 AM.
Fluconazole AND VORICONOZOLE REQUESTED BY DR.[**Last Name (STitle) **],G
#[**Numeric Identifier 90315**]
[**2158-10-16**].
SENT TO [**Hospital1 4534**] FOR SENSITIVITIES [**2158-10-17**].
Refer to sendout/miscellaneous reporting for results.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16437**]. SPARSE GROWTH.
[**Female First Name (un) **] PARAPSILOSIS. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2158-10-16**]): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2158-10-11**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2158-10-10**]):
Test cancelled by laboratory.
PATIENT CREDITED.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
[][**2158-10-11**] 1:10 pm URINE Source: Catheter.
**FINAL REPORT [**2158-10-12**]**
URINE CULTURE (Final [**2158-10-12**]): NO GROWTH.
.
#REPORTS:
[][**2158-10-13**] TTE
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild to moderate ([**2-13**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
moderate sized pericardial effusion with the largest collection
around the right atrium. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. There are
no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2158-10-5**],
the effusion has increased (particularly around the RA).
.
[]ECG Study Date of [**2158-10-9**] 2:16:50 PM
Arial fibrillation with a rapid ventricular response. Low
precordial lead voltage. Delayed precordial R wave transition.
Compared to the previous tracing of [**2158-10-4**] the ventricular
response has slowed. Otherwise, no diagnostic interim change.
TRACING #1
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
95 128 82 [**Telephone/Fax (2) 90316**] 71
.
[]ECG Study Date of [**2158-10-9**] 9:13:36 PM
Sinus rhythm. The limb leads appear misattached. Low precordial
lead voltage. Compared to the previous tracing of [**2158-10-9**] no
apparent diagnostic interim change.
TRACING #2
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 0 84 [**Telephone/Fax (2) 90317**] 70
.
[]CHEST (PA & LAT) Study Date of [**2158-10-9**] 4:40 PM
IMPRESSION: Unchanged mild cardiomegaly. Underlying pericardial
effusion is better assessed with echo. No superimposed acute
process.
.
[]Pathology Examination [**2158-10-13**]
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 90318**],[**Known firstname **] [**2103-4-6**] 55 Female [**-1/3811**]
[**Numeric Identifier 90319**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd
SPECIMEN SUBMITTED: pericardial tissue.
Procedure date Tissue received Report Date Diagnosed
by
[**2158-10-10**] [**2158-10-10**] [**2158-10-13**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/vf
Previous biopsies: [**-1/2854**] GI BIOPSIES (3 JARS).
[**Numeric Identifier 90320**] Immunophenotyping, LUNG
[**Numeric Identifier 90321**] RUSH...TRANSTHORACIC BIOPSY OF MEDIASTINAL MASS (1
JAR)
DIAGNOSIS:
Pericardial tissue (A-F):
Dense fibrous tissue, adipose tissue and muscle with acute and
chronic inflammation.
No malignancy identified.
.
[]PERICARDIAL FLUID Procedure Date of [**2158-10-10**]
DIAGNOSIS: Pericardial fluid:
ATYPICAL.
A few atypical epithelioid cells, likely reactive
mesothelial cells.
.
[]ECG Study Date of [**2158-10-10**] 3:11:48 PM
Atrial fibrillation versus atrial flutter with rapid ventricular
response. Compared to the previous tracing of [**2158-10-9**] the atrial
fibrillation/flutter is new and the arm leads are cotterly
applied. Clinical correlation is suggested.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
122 0 90 346/454 0 78 -116
.
[]CHEST (PORTABLE AP) Study Date of [**2158-10-12**] 10:40 AM
FINDINGS: As compared to the previous radiograph, the
pericardial drain has been removed. There is no evidence of
interval recurrence of larger pleural effusions. No evidence of
pericardial effusion. Known and unchanged left hilar mass with
subsequent areas of perihilar fibrotic changes.
.
[][**2158-10-10**] TTE
Pre Drainage:
No thrombus is seen in the left atrial appendage. There is mild
symmetric left ventricular hypertrophy. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
free wall is hypertrophied, there is evidence of fibrinous
organization in the pericardial space with a thickness of 0.8
cm. There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. Moderate (2+) aortic regurgitation is seen. Moderate
(2+) mitral regurgitation is seen. There is a moderate sized
pericardial effusion. Stranding is visualized within the
pericardial space consistent with organization as previously
noted. There are no echocardiographic signs of tamponade. There
is a moderate left pleural effusion visualized. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**2158-10-10**]
at 1400.
Post Drainage:
There is a reduction in the size of the pericardial effusion.
There is preserved left ventricular function that is unchanged
from preoperative levels. There is a persistent left pleural
effusion.
.
[]ECG Study Date of [**2158-10-13**] 8:28:44 AM
Atrial fibrillation with a controlled ventricular response. Low
limb lead
voltage. Aberrantly conducted ventricular complex versus
ventricular premature beat. Cannot exclude prior anteroseptal
myocardial infarction of indeterminate age. Non-specific
anterolateral ST segment flattening. Compared to the previous
tracing of [**2158-10-10**] the ventricular response is slower,
ventricular ectopy is absent.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 0 76 400/456 0 70 128
.
[]LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2158-10-16**]
7:01 PM
IMPRESSION:
1. Normal examination of the liver. No intra- or extra-hepatic
bile duct dilation.
2. Adherent sludge at the gallbladder fundus without evidence
of acute
cholecystitis.
3. Bilateral pleural effusions.
.
[]ECG Study Date of [**2158-10-17**] 11:56:30 AM
Sinus rhythm. Low limb lead voltage. The previously mentioned
abnormalities
recorded on [**2158-10-17**] persist without diagnostic interim change.
TRACING #2
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
66 156 74 [**Telephone/Fax (2) 90322**] 127
Brief Hospital Course:
[]BRIEF CLINICAL COURSE:
55F w/ hx of small cell lung cancer s/p chemo/radiation w/
prophylactic cranial radiation s/p recent discharge after
undergoing pericardiocentesis c/b PEA arrest presents with
worsening dyspnea and light-headedness. Patient had pericardial
window procedure performed by cardiac surgery; pericardial fluid
sample grew non-candidal fungus, and the patient was placed on
antifungals, first micafungin then voriconazole, pending
sensitivities. Patient will follow up with infectious disese,
heme-onc, and cardiac surgery.
.
[]ACTIVE ISSUES:
# Pericardial Effusions: During the last admission, the patient
underwent a diagnostic and therapeutic pericardiocentesis which
revealed no evidence of malignancy, and returned with
symptomatic recurrent pericardial effusion 3 days post
discharge. There was initial concern for viarl pericarditis and
the patient was prophylactically placed on 600mg Ibuprofen TID
and 0.6mg [**Hospital1 **] colchicine for empiric attenuation of any
inflammatory component. Given the acuity of the fluid build up,
cardiac surgery was consulted and they performed a pericardial
window procedure. Pericardial fluid studies revealed growth of
two non-candidal fungus species and the patient was initially
placed on micafungin per Infectious Disease recs. Upon
speciation, the patient was placed on PO voriconazole with plan
for ID follow up as an outpatient for antifungal regimen
adjustment pending send out sensitivities on the fungal strains.
Pathology from the pericardial window tissue did not reveal
malignancy and ID is conferring with pathology to examine the
tissue for fungal infiltrates. Clinically, the patient
progressed well post operatively, was afebrile, ambulatory, and
in good spirits. The patient underwent baseline RUQ u/s and had
LFTs drawn; u/s was normal and LFT's were slightly elevated,
downtrended the next day. The patient has scheduled follow up
with infectious disese for antifungal regimen adjustments.
.
# Paroxysmal Atrial Fibrillation: Patient with CHADS2 score of
0. She was discharged from her last admission with metoprolol
and on increased dose of verapamil. The patient presented in
afib with rvr with intermittent paroxysmal episodes. Her
systolic blood pressures were consistently between 90-110;
therefore, the verapamil dose was lowered initially, then
discontinued entirely once voriconazole was started in favor of
atenolol. The patient had no further episodes of afib while on
the atenolol and she was stable on the new regimen.
.
# Limited small lung cancer: Cisplatin/Etoposide on [**2157-3-17**] and
began radiation therapy on [**2157-4-7**]. Therapy was completed
[**2157-5-25**]. Serial CT chest has not shown any recurrence of cancer.
The cytology from her pericardial fluid was negative for
malignant cells. She will follow up with her [**Month/Day/Year 5564**] for
further surveillance.
.
[]CHRONIC ISSUES:
.
# Anemia: Likely of chronic disease. At baseline throughout
this hospitalization.
.
# Anxiety: The patient was maintained on prn ativan throughout
this hospitalization.
.
[]TRANSITIONAL ISSUES:
-the patient will have LFTs drawn by VNA and the results faxed
to her PCP and ID given that the patient is on voriconazole.
-the patient will go home with KOH monitor and send in
daily/symptomatic reports.
-ID will follow up with the patient regarding laboratory
sensitivity results on her pericardial fluid and tissue
pathology exam for fungal infiltration into the tissue.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY
2. Senna 1 TAB PO BID:PRN constipation
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
please avoid operating any heavy machinery or driving while
taking this medication
4. Verapamil SR 480 mg PO Q24H
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
please avoid operating any heavy machinery or driving while
taking this medication
2. Senna 1 TAB PO BID:PRN constipation
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
hold for SBP < 90, HR < 55
RX *atenolol 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth up to three times a
day Disp #*30 Capsule Refills:*0
6. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice daily Disp
#*30 Tablet Refills:*0
7. Voriconazole 200 mg PO Q12H
RX *voriconazole 200 mg 1 tablet(s) by mouth every 12 hours Disp
#*30 Tablet Refills:*0
8. Outpatient Lab Work
Please draw blood for routine LFTs
(AST/ALT/Tpro/Alb/Tbili/Dbili/Alkphos) and fax results to [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] @ [**Telephone/Fax (1) 17769**], and fax to [**Last Name (LF) 5302**],[**First Name3 (LF) **] B @
[**Telephone/Fax (1) 10274**].
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure taking care of you.
You were admitted to the [**Hospital1 69**]
for increasing shortness of breath after your recent discharge.
You were found to have a new build up of fluid in the sac that
surrounds your heart which was causing your symptoms. You were
taken to surgery by the cardiac surgeons who removed a part of
that sac around the heart to allow for the fluid to drain. This
will also help prevent new fluid from accumulating. Some yeast
grew in the lab from the fluid that was drained and the
infectious disease doctors placed [**Name5 (PTitle) **] on antifungal medication
while we waited to see exactly what kind of fungus was growing.
You will be sent home with a course of antifungal medication and
you will follow up with the infectious disease doctors. You
will also follow up with your primary care doctor, your cardiac
surgeon, and your [**Name5 (PTitle) 5564**]. You are also being sent home with
a cardiac holter monitor that will record any abnormal cardiac
event which will then be transmitted to your cardiologist for
review. We wish you all the best.
Followup Instructions:
Name: [**Last Name (LF) 5302**],[**First Name3 (LF) **] B.
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] OF [**Location (un) **]
HEIGHTS
Address: [**Apartment Address(1) 31234**], [**Location (un) **],[**Numeric Identifier 14512**]
Phone: [**Telephone/Fax (1) 31235**]
Appointment: Friday [**2158-10-20**] 9:00am
Department: CARDIAC SURGERY
When: TUESDAY [**2158-10-24**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 170**]
Building: LM [**Hospital Unit Name **] [**Location (un) 551**]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Department: CARDIAC SERVICES
When: FRIDAY [**2158-10-27**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2158-11-7**] at 2:00 PM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: MONDAY [**2158-10-30**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
|
[
"V87.41",
"285.9",
"423.8",
"250.00",
"427.32",
"V15.3",
"300.00",
"420.90",
"V10.11",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
21996, 22045
|
17096, 17645
|
329, 374
|
22110, 22110
|
3304, 3305
|
23416, 25090
|
2124, 2311
|
20968, 21973
|
22066, 22089
|
20612, 20945
|
22261, 23393
|
2352, 2849
|
1087, 1163
|
10136, 10468
|
10501, 17073
|
20209, 20586
|
282, 291
|
17660, 19996
|
402, 958
|
3321, 3661
|
22125, 22237
|
3677, 10100
|
1194, 1964
|
20012, 20188
|
1002, 1067
|
1980, 2108
|
2874, 3285
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,632
| 156,728
|
13236
|
Discharge summary
|
report
|
Admission Date: [**2135-11-5**] Discharge Date: [**2135-11-16**]
Date of Birth: [**2070-11-14**] Sex: F
Service: MEDICINE
Allergies:
Nsaids / Sulfa (Sulfonamide Antibiotics) / Morphine
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"Hypotension and tachycardia."
Major Surgical or Invasive Procedure:
-Right internal jugular central venous line
-Intubation
-Surgical incision in the left thenar muscle
-Percutaneous gallbladder drainage
-PICC line placement in left arm
History of Present Illness:
MICU ADMISSION NOTE
64 yo F with DM and history of seizures (last one was 10 years
ago) admitted from the ED with hypotension, tachycardia,
requiring pressors.
.
Patient reports that she was in her normal state of health until
beginning of the week. She says that after she helped someone
move, she was having band like abdominal discomfort on Tuesday
(4 days PTA). By Wednesday (3 day PTA), she noticed more of a
back pain and right sided flank pain. She was also having
dysuria, which prompted her to start pyridium. By Thursday, she
was having persistent back pain and was noticing swelling of her
left hand. She came to the ED and was discharged with Percocet
for pain. Since then, she had 1x emesis and 1x diarrhea on
Friday. She reported subjective fever and chill. Per ED
report, patient rolled out of bed overnight, unable to get up
and was on the ground for 3 hours, without losing consciousness.
She took percocet prior to arrival to the ED.
.
In the ED, triggerred immediately at triage for hypotension
73/38. triggerred for hypotension 70s/30s, tachy in the 130s.
She got 1 L of NS immediately with subsequent HR in the 120s.
RIJ was placed and patient got 2.7 more liters prior to arrival
to the MICU. She was started on levophed. Her CVP prior to
transfer was reportedly 20 with SVO2 94%, lactate around 12.9,
WBC 14.1, CK 1800, Crt 2.0 from 0.5. ABG pH was 7.15/39/99/14.
EKG showed sinus tachy. UA + nitrate but no neuks and few
bacteria. Blood culture and urine culture were sent. CXR
showed pulmonary vascular congestion. Left hand swelling
appears stable per ED. Prelim CT head without acute process.
She got oxycodone for pain. Got vanc and ceftriaxone in the ED
at 8AM. VS upon transfer HR 121, HR 24, O2Sat 96% on 4L, BP
93/54, lactate 11.1.
.
On the floor, patient appears uncomfortable, complains of back
pain and left wrist pain, but reports redness has improved.
.
HPI ONTO GENERAL MEDICINE FLOOR
64yoF nun (goes by Sister [**Name (NI) **] [**Name (NI) 6382**]) with h/o DM, seizures,
admitted to MICU Green on [**2135-11-5**] for hypoTN, tachycardia,
and pressor requirment. History is gathered from notes and
verbal s/o, pt tired and trying to sleep.
.
Pt was in usual state of health until 4 days before admission at
which point she began having band like abdominal discomfort,
back pain, R-sided flank pain, dysuria, subjective fevers and
chills, and L hand swelling; she also had some emesis x1 and
diarrhea x1. She had been seen in the ED at some point and
discharged with Percocet, and she has also at some point fallen
out of bed without LOC, but was on the ground for 3 hrs.
.
In the ED she was hypotense and got a RIJ and was given 3.7L,
started on Levophed. WBC 14.1 with 27% bands, Cr 2.0, lactate
12.9. She was started on Vanc/CTX and admitted to MICU. In the
MICU, pt was treated with Cefepime/Vanc/Flagyl. She was
resuscitated and WBC count, lactate, and ARF resolved. Urine and
blood cultures have grown [**2-23**] Group B Strep sensitive to [**Doctor Last Name **]
and subsequent cultures have come back negative; she is
currently being treated with [**Doctor Last Name **]. She was intubuated for
hypoxia, and eventually extubated on [**11-7**]; pressors were then
weaned uneventfully [**11-8**]. She was minimally diuresed with IV
Lasix for hypoxia after fluid resuscitation, [**11-9**] got 20 IV
Lasix, she's about 4L LOS positive at this point (2L negative on
[**11-9**]) and is autodiuresing. CVL was pulled, PIV placed, and
PICC order placed.
.
[**2135-11-5**] had perc chole tube placed for distended GB seen on
CT abd/pelvis, it is still currently in place. She is getting an
MRI tonight to rule out osteomyelitis/discitis given c/o back
pain; however there was also a report of her being found down
next to her bed. Tomorrow she is slated for a TEE to r/o
endocarditis; TTE was negative.
.
Plastic surgery was consulted for possibility of necrotizing
fasciitis given reported L hand pain, however a bedside
exploration of her L hand didn't see any necrosis. It was closed
it back up and the suture needs to come out this Sunday, and if
still in house Plastics will do it.
.
ROS otherwise currently unobtainable. The pt received some
sedation for her MRI and is very sleepy, but answering
questions.
Past Medical History:
- Group B Strep sepsis, presumed urinary source from
pyelonephritis, course complicated by pressor need, intubation,
development of right L3 pedicle osteomyelitis; large distended
gallbladder s/p percutaneous gallbladder drain
- HTN
- HLD
- DMT2 c/b peripheral neuropathy
- history of seizures, last one 10 years ago
- OA
- History of SVT, status post AV nodal ablation
procedure(radiofrequency) in [**8-/2121**]
- h/o Dengue fever
- thrombocytopenia
- history of right shoulder tendonitis in [**3-/2132**]
- history of mildly low vitamin D
- History of mild ALT elevation with ultrasound on [**2133-8-21**] in [**Location (un) **], [**State 531**] revealing
increased echogenicity of the liver consistent with fatty
infiltration of the liver.
Social History:
- Is a Catholic nun, and lives with 2 other sisters, goes by
Sister [**Name (NI) **] [**Name (NI) 6382**], has a pet cat and dog. Is ambulatory and
very independent with her ADL's at baseline. She is from [**Location (un) **].
Family History:
per [**Name (NI) **]
Father had Alzheimer's disease and died of complications of
coronary disease and strokes at age 84. Mother had HTN,
hyperlipidemai, type 2 diabetes and died at age 70 possibly of
MI. PGM with HTN and stroke. Maternal cousin (male) died [**Name (NI) 40342**]
age 65 y. There is no other noted family history of cancer,
diabetes, sudden death, or psychiatric illness.
Physical Exam:
Physical Exam upon arrival to MICU
Vitals: T:98 BP: 111/48 P: 135 R:23 O2: 96% NRB
General: Alert, oriented, uncomfortable
HEENT: Sclera anicteric, mucous membrane dry
Neck: supple, JVP not elevated, no LAD
Lungs: diffused crackles mostly in the lower bases bilaterally,
wheeze or rhonchi
CV: Tachycardia, regular, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Back: tenderness in the R CVA, not on the spine
GU: + foley
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema. Left hand swollen and tender in the thenar muscle.
Scattered erythema macules in the palm.
.
PHYSICAL EXAM ON DISCHARGE:
Afebrile for numerous days, SBP 110-120's, pulses in the
90-100's, O2 sat high 90's to 100% on RA.
Large F in no distress, able to get to bedside chair and eat on
her own. Appears very well, in good spirits, conversant,
pleasant, much improved
Mouth normal, moist, EOMI, no scleral icterus
L sided PICC in place, well placed
Lungs CTAB no w/c/r
RRR without m/g
Abdomen obese but soft NT ND, RUQ perc chole drain in place and
with stopcock to off
No BLE edema, extremities warm, well perfused, no mottling. L
hand with sutures removed, no longer swollen
CN2-12 intact, no focal neuro deficits
Pertinent Results:
ADMISSION LABS:
[**2135-11-5**] 07:22AM BLOOD WBC-14.1*# RBC-3.26* Hgb-9.3* Hct-29.5*
MCV-91 MCH-28.7 MCHC-31.7 RDW-14.6 Plt Ct-64*
[**2135-11-6**] 03:50AM BLOOD WBC-22.4*# RBC-3.50* Hgb-9.9* Hct-30.0*
MCV-86 MCH-28.2 MCHC-33.0 RDW-15.0 Plt Ct-75*
[**2135-11-7**] 04:12AM BLOOD WBC-18.4* RBC-3.40* Hgb-9.6* Hct-30.1*
MCV-89 MCH-28.3 MCHC-31.9 RDW-14.9 Plt Ct-110*
[**2135-11-8**] 04:01AM BLOOD WBC-12.3* RBC-3.15* Hgb-9.0* Hct-27.9*
MCV-89 MCH-28.7 MCHC-32.4 RDW-14.8 Plt Ct-85*
[**2135-11-5**] 07:22AM BLOOD Neuts-60 Bands-27* Lymphs-4* Monos-5
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-0
[**2135-11-6**] 03:50AM BLOOD Neuts-75* Bands-11* Lymphs-3* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-2*
[**2135-11-7**] 04:12AM BLOOD Neuts-82* Bands-0 Lymphs-9* Monos-7 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2135-11-5**] 07:22AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Burr-OCCASIONAL
[**2135-11-7**] 04:12AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
[**2135-11-5**] 07:22AM BLOOD PT-17.9* PTT-46.0* INR(PT)-1.6*
[**2135-11-6**] 03:50AM BLOOD PT-18.7* PTT-49.5* INR(PT)-1.7*
[**2135-11-7**] 04:12AM BLOOD PT-16.1* PTT-44.8* INR(PT)-1.4*
[**2135-11-15**] 05:45AM BLOOD ESR-14
[**2135-11-15**] 08:54PM BLOOD Ret Aut-2.4
[**2135-11-5**] 05:05PM BLOOD Glucose-229* Na-136 K-3.9 Cl-100 HCO3-22
AnGap-18
[**2135-11-5**] 10:15PM BLOOD Glucose-178* UreaN-31* Creat-1.4* Na-137
K-4.0 Cl-103 HCO3-22 AnGap-16
[**2135-11-7**] 04:12AM BLOOD Glucose-215* UreaN-44* Creat-0.7 Na-133
K-4.1 Cl-100 HCO3-25 AnGap-12
[**2135-11-5**] 07:22AM BLOOD ALT-53* AST-120* CK(CPK)-1884* AlkPhos-78
TotBili-0.8
[**2135-11-6**] 03:50AM BLOOD ALT-186* AST-340* LD(LDH)-441*
CK(CPK)-1504* AlkPhos-77 TotBili-0.8
[**2135-11-7**] 04:12AM BLOOD ALT-248* AST-336* CK(CPK)-450* AlkPhos-90
TotBili-1.0
[**2135-11-5**] 07:22AM BLOOD Lipase-23
[**2135-11-5**] 07:22AM BLOOD CK-MB-12* MB Indx-0.6
[**2135-11-5**] 07:22AM BLOOD cTropnT-0.05*
[**2135-11-6**] 03:50AM BLOOD CK-MB-23* MB Indx-1.5 cTropnT-0.16*
[**2135-11-7**] 04:12AM BLOOD CK-MB-5 cTropnT-0.13*
[**2135-11-10**] 06:08AM BLOOD CK-MB-1 cTropnT-0.10*
[**2135-11-5**] 10:15PM BLOOD Calcium-8.5 Phos-4.5 Mg-2.6
[**2135-11-6**] 03:50AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.4
[**2135-11-7**] 04:12AM BLOOD Calcium-8.3* Phos-2.4*# Mg-2.6
[**2135-11-8**] 04:01AM BLOOD Calcium-8.5 Phos-1.7* Mg-2.6
[**2135-11-15**] 08:54PM BLOOD Hapto-63
[**2135-11-7**] 04:12AM BLOOD Cortsol-16.2
[**2135-11-15**] 05:45AM BLOOD CRP-3.1
[**2135-11-5**] 07:22AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2135-11-5**] 07:34AM BLOOD Glucose-148* Lactate-12.9* Na-141 K-3.2*
Cl-108 calHCO3-10*
[**2135-11-5**] 10:06AM BLOOD Glucose-159* Lactate-9.5* Na-140 K-3.4
Cl-107 calHCO3-14*
[**2135-11-5**] 02:15PM BLOOD Lactate-7.9*
[**2135-11-5**] 03:45PM BLOOD Lactate-7.6*
[**2135-11-5**] 04:22PM BLOOD Lactate-7.7*
[**2135-11-5**] 07:34AM BLOOD Hgb-10.7* calcHCT-32
[**2135-11-5**] 10:06AM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-90
[**2135-11-5**] 10:33PM BLOOD freeCa-1.22
.
MICROBIOLOGY DATA:
[**2135-11-5**] 7:22 am BLOOD CULTURE (2/2 bottles)
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP B
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
[**11-5**] urine cx: GBS 10,000-100,000 cfu/ml
[**11-6**] wound cx: No PMNs, org, neg culture
[**2135-11-5**] 8:56 pm BILE
**FINAL REPORT [**2135-11-12**]**
GRAM STAIN (Final [**2135-11-6**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2135-11-8**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2135-11-12**]): NO GROWTH.
.
5 blood cultures after initial positive were negative
.
[**2135-11-14**] 2:02 pm URINE Source: CVS.
**FINAL REPORT [**2135-11-15**]**
URINE CULTURE (Final [**2135-11-15**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
.
IMAGING DATA:
[**11-5**] CT abd/pelvis:
IMPRESSION:
1. Significantly distended gallbladder without additional signs
to suggest acute cholecystitis such as pericholecystic fluid or
gallbladder wall thickening. No cholelithiasis. However, given
the degree of GB distension acute cholecystitis remains a
consideration.
2. Nonspecific stranding around bilateral kidneys with no
hydronephrosis or renal calculi. Pyelonephritis cannot be
excluded on this non-contrast examination.
3. Small bilateral pleural effusions and bibasilar
atelectasis/consolidation.
4. Nonspecific fat stranding around celiac axis, SMA, and
pancreas unlikely on the account of pancreatitis given normal
lipase.
5. Left adnexal soft tissue density likely represents left
ovary. Uterus appears to be surgically absent. Correlate with
history
[**11-5**] CXR:
FINDINGS: Interval placement of endotracheal tube with tip
terminating just above the thoracic inlet, about 5.5 cm above
the carina. Advancement may be helpful for standard positioning.
Nasogastric tube terminates below the diaphragm, and right
internal jugular vascular catheter is unchanged in position.
Persistent cardiomegaly and worsening pulmonary edema, now
moderate in severity. Small bilateral pleural effusions.
.
[**11-7**] TTE: suboptimal imaging: The left atrium is normal in
size. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No valvular
pathology or pathologic flow identified
.
[**11-7**] CXR:
IMPRESSION:
1. Increasing pulmonary edema and bibasilar atelectasis, now
moderate.
2. Probable small increasing layering pleural effusions.
3. High endotracheal tube, advancement by at least 2-3 cm
recommended.
4. Standard unchanged position of right central venous and
nasogastric catheters.
.
[**11-9**] MRI C/T/L spine IMPRESSION:
1. No evidence of abnormal signal or abnormal enhancement in the
vertebral
bodies or discs to suggest osteomyelitis/discitis.
2. Moderate degenerative changes in the cervical and thoracic
spine as
described above.
3. Moderate degenerative changes in the lumbar spine with mild
spinal canal stenosis at L3-L4 and L4-L5 levels.
4. Severe facet degenerative changes in the lumbar spine from
L3-L4 to L5-S1 levels.
5. Hyperintense signal in the posterior paraspinal muscles with
mild
enhancement from L2-L4 levels which likely represents edema due
to
inflammation.
.
[**11-11**] TEE IMPRESSION: No valvular mass, vegetations, or
significant regurgitation identified. Mildly thickened aortic
leaflets.
.
[**11-14**] MRI L spine IMPRESSION:
1. L2/L3 septic facet with inflammation/infection in the
adjacent soft
tissues and osteomyelitis at the L3 right pedicle.
2. No evidence of intraspinal enhancement or epidural abscess.
.
DISCHARGE LABS
[**2135-11-15**] 08:54PM BLOOD WBC-7.4 RBC-3.55* Hgb-9.6* Hct-30.9*
MCV-87 MCH-27.1 MCHC-31.0 RDW-15.1 Plt Ct-133*
[**2135-11-15**] 05:45AM BLOOD WBC-8.9 RBC-3.77* Hgb-10.5* Hct-32.3*
MCV-86 MCH-27.8 MCHC-32.4 RDW-15.1 Plt Ct-137*
[**2135-11-13**] 06:19AM BLOOD WBC-9.6 RBC-3.72* Hgb-10.1* Hct-32.1*
MCV-86 MCH-27.0 MCHC-31.3 RDW-14.8 Plt Ct-129*
[**2135-11-15**] 08:54PM BLOOD Neuts-62.6 Lymphs-33.5 Monos-2.8 Eos-0.7
Baso-0.4
[**2135-11-15**] 08:54PM BLOOD PT-16.3* PTT-48.0* INR(PT)-1.4*
[**2135-11-15**] 08:54PM BLOOD Glucose-130* UreaN-11 Creat-0.5 Na-136
K-4.3 Cl-106 HCO3-25 AnGap-9
[**2135-11-15**] 05:45AM BLOOD Glucose-128* UreaN-14 Creat-0.4 Na-139
K-4.1 Cl-106 HCO3-25 AnGap-12
[**2135-11-12**] 06:03AM BLOOD Glucose-131* UreaN-16 Creat-0.5 Na-139
K-4.4 Cl-106 HCO3-25 AnGap-12
[**2135-11-10**] 06:08AM BLOOD Glucose-136* UreaN-20 Creat-0.5 Na-141
K-4.4 Cl-105 HCO3-29 AnGap-11
[**2135-11-9**] 04:22AM BLOOD Glucose-131* UreaN-24* Creat-0.5 Na-142
K-4.0 Cl-108 HCO3-28 AnGap-10
[**2135-11-15**] 08:54PM BLOOD ALT-67* AST-82* LD(LDH)-224 CK(CPK)-33
AlkPhos-76 TotBili-0.9
[**2135-11-15**] 05:45AM BLOOD CK(CPK)-32
[**2135-11-13**] 06:19AM BLOOD ALT-76* AST-96*
[**2135-11-12**] 06:03AM BLOOD ALT-72* AST-86* AlkPhos-70 TotBili-1.0
[**2135-11-10**] 06:08AM BLOOD ALT-108* AST-121* CK(CPK)-105 AlkPhos-75
TotBili-0.8
[**2135-11-15**] 08:54PM BLOOD CK-MB-1 cTropnT-0.02*
[**2135-11-15**] 05:45AM BLOOD CK-MB-1 cTropnT-0.03*
[**2135-11-15**] 08:54PM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7
[**2135-11-15**] 05:45AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.9
[**2135-11-12**] 06:03AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.6
[**2135-11-12**] 04:38PM BLOOD Lactate-1.4
[**2135-11-7**] 05:07PM BLOOD Lactate-1.8
[**2135-11-7**] 06:49AM BLOOD Lactate-2.0
[**2135-11-6**] 04:41PM BLOOD Lactate-2.5*
[**2135-11-12**] 04:38PM BLOOD O2 Sat-95
[**2135-11-7**] 08:06PM BLOOD O2 Sat-93
[**2135-11-5**] 07:45AM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-100 Ketone-TR Bilirub-SM Urobiln-8* pH-7.0 Leuks-NEG
[**2135-11-5**] 07:45AM URINE Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.023
[**2135-11-5**] 07:45AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
Brief Hospital Course:
64 yo F with type 2 DM, history of seizure, thrombocytopneia and
arthritis admitted to MICU for hypotension, tachycardia,
requiring pressor support and intubated for hypoxia who was
found to have Group B strep sepsis, felt likely from urinary
source, course complicated by development of osteomyelitis
(likely seeded during bacteremia) at L3 right pedicle, and s/p
percutaneous gallbladder drain.
.
1. Septic shock, due to group B strep bacteremia, suspected
source possibly pyelonephritis. Upon presentation had
subjective fever, recent nausea, vomiting, dysuria as well as R
CVA tenderness and left hand tenderness/swelling on exam. She
was admitted with leukocytosis and 27% bandemia, lactate of 13,
hypotense and started on pressors.
.
There was initial concern for nacrotizing fasciitis of left
hand, which was evaluated by hand surgery by bedside evaluation.
A small laceration was performed which did not show any evidence
of necrosis and stitches were placed that were removed by
discharge. Abdominal/pelvic CT was obtained which was concerning
for pyelonephritis, but also showed distended GB, and a
percutaneous drain was placed by IR given the size and the
difficulty to evaluate for wall thickness.
.
Her blood culture and urine culture then grew out Group B strep
presumed from urinary source and pt was started on Penicillin G
IV. Other workup for seeding/source included TTE and TEE which
were negative, MRI of her C/T/L spine (given complaints of back
pain) which initially was negative except for non-specific
paraspinal muscle inflammation; a repeat L-spine days later then
showed evidence of right L3 pedicle osteomyelitis and PCN course
was decided on 6wks after last negative blood culture, so to end
on [**12-22**]. She had a left PICC placed and should get
weekly CBC with differential, BMP, LFT's, ESR, and CRP and fax
to [**Telephone/Fax (1) 17715**], attn: [**Last Name (un) **] [**Last Name (un) **]. She has infectious disease
follow up scheduled.
.
Her hemodynamics improved, pressors weaned, and pt was afebrile,
with decrease in WBC's to normal range, clearance of bands,
normalization of lactate for numerous days before discharge.
.
2. Gallbladder distention s/p perc chole drain: Still in place
by discharge, with plan by Interventional Radiology to remove in
[**5-27**] wks to allow for a track to form such that it can be removed
without leakage. Her bile culture came back negative and
therefore not thought to be the source. Pt should follow up with
interventional radiology for drain removal and this can be
achieved by paging [**First Name5 (NamePattern1) 636**] [**Last Name (NamePattern1) 40343**] by calling [**Telephone/Fax (1) 22727**] and
paging [**Numeric Identifier 40344**] and setting up follow up.
.
3. Tachycardia: After call out from MICU, pt noted to have
elevation of sinus tachycardia to 110-120. It was noted that
when the GB drain was open, it was putting out 2-3L per day of
non-purulent, clear brown bile fluid. She was clinically so
improved, FeNa and urine lytes were consistent with dehydration
and pt was aggressively fluid resuscitated, with improvement in
rates to 90-100's. Other workup for tachycardia was negative,
i.e. infectious etc. The GB drain was capped and did not put any
further fluid out; there was no worsening of abdominal symtpoms
either.
.
4. Elevated cardiac enzymes: Pt had elevation in Troponins to
0.16 without MB elevation, felt likely demand ischemia during
sepsis, and possibly signifying underlying fixed coronary
stenosis. This should be followed up as outpt with ? stress test
when pt farther out from acute illness. No chest pain during
admission.
.
5. Thrombocytopenia: Pt with chronic thrombocytopenia previously
worked up by H/O and felt ? due to Keppra medication; she was
admitted with plt count 64 that steadily rose by discharge to
133 and stable. Pt should be followed up by H/O as outpatient.
.
6. Acute renal failure: Cr 2.0 on admission likely due to
sepsis, quickly improved to normal by discharge.
.
7. CK elevation: to 1884 on arrival likely due to being found
down and acute inflammation of sepsis, this trended down to
normal by discharge.
.
8. Transaminitis: to peak of mid 200's through course while
septic, and improved to 60-80 by discharge. Likely due to acute
inflammation of sepsis.
.
9. H/o seizure: on admission, on Keppra 1.5g [**Hospital1 **]; this was
continued and was not an
active issue this admission.
.
10. Medication reconciliation: Pt admitted with medication list
including ASA 81, Diovan, Lipitor and Janumet; these were held
during admission but ASA, Lipitor, and Janumet were restarted;
Diovan can be added back as appropriate.
.
Full code this admission.
Transitional issues: Pt needs f/u with ID which is already
scheduled; needs maintenance labs as above. She will need to
have follow up for her gallbladder drain with contact
information as above.
Medications on Admission:
- calcium and vitamin D 600/400, [**Hospital1 **]
- ASA 81 mg daily
- Levetiracetam 750 mg 2 tabs, [**Hospital1 **]
- omega 3/Krill oil 90/300 QHS
- Janumet 50/1000 mg 2 tab twice a day
- diovan 160 mg qAM
- Lipitor 20 mg qPM
- MVI/multimineral daily
Discharge Medications:
1. Outpatient Lab Work
Please check weekly CBC with differential, BMP, LFT's, ESR, and
CRP and fax to [**Telephone/Fax (1) 17715**], attn: [**Last Name (un) **] [**Last Name (un) **]
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
4. Penicillin G Potassium 4 Million Units IV Q4H
5. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
6. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO twice a
day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
8. Omega 3 Fish Oil Oral
9. Janumet 50-1,000 mg Tablet Sig: Two (2) Tablet PO twice a
day.
10. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: For back pain, should be stopped if
not needed.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 686**]
Discharge Diagnosis:
Primary diagnosis this admission:
1. Group B Streptococcus urosepsis
2. Osteomyelitis of L3 likely seeding
3. Gallbladder distention s/p percutaneous cholecyst drain but
without evidence of acute cholecystitis
Secondary diagnoses, and past medical history:
- History of SVT, status post AV nodal ablation procedure
(radiofrequency) in [**8-/2121**]
- HTN
- HLD
- DM2 c/b peripheral neuropathy
- history of seizures, last one 10 years ago
- OA
- h/o Dengue fever
- thrombocytopenia
- history of right shoulder tendonitis in [**3-/2132**]
- history of mildly low vitamin D
- History of mild ALT elevation with ultrasound on [**7-31**] in [**Location (un) **], [**State 531**] revealing increased
echogenicity of the liver consistent with fatty infiltration of
the liver.
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:
Mrs. [**Known lastname 40345**],
You were admitted to [**Hospital1 69**] after
you were found down and were found to be in sepsis with bacteria
(Group B Streptococcus) in your blood. You were treated with
antibiotics, intubated, given medications to maintain your blood
pressure, had a bedside exploration of your left hand, had a
percutaneous drain placed in your gallbladder, and had a PICC
line placed for long term antibiotics.
The following changes were made to your medication list:
1. START Penicillin 4 million units IV q24 hrs for 6 weeks after
last negative blood culture (Last day will be [**2135-12-22**])
2. HOLD Diovan 160 mg daily for now; this was held initially
when your blood pressures were low. This should be re-evaluated
at the rehab and if appropriate should be restarted
3. START Oxycodone 5mg every 6 hours as needed - this is for
back pain (osteomyelitis) and should be given only as needed and
can be stopped when you no longer need it
4. START a bowel regimen with Docusate and Senna - due to the
constipating effects of Oxycodone, can also be stopped if not
needed
5. START subcutaneous Heparin 5000 units three times a day until
you are ambulating on a very consistent basis
Followup Instructions:
You have the following appointments scheduled. However, please
also call [**Telephone/Fax (1) 1247**] to follow up with your listed primary
care [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **].
You will need to schedule a follow up appointment with
Interventional Radiology to have your percutaneous gallbladder
drain removed in [**5-27**] weeks. This can done by calling [**Telephone/Fax (1) 40346**] and paging [**First Name5 (NamePattern1) 636**] [**Last Name (NamePattern1) 40343**] at [**Numeric Identifier 40344**] and setting up follow up.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2135-11-29**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: THURSDAY [**2135-12-22**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 32437**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: FRIDAY [**2136-2-3**] at 9:40 AM
With: [**Name6 (MD) 10160**] [**Name8 (MD) 10161**], NP [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2135-11-22**]
|
[
"287.5",
"575.8",
"401.9",
"599.0",
"272.4",
"V43.65",
"276.51",
"729.81",
"038.0",
"V70.7",
"357.2",
"518.81",
"V58.67",
"112.1",
"410.71",
"584.9",
"250.60",
"345.90",
"730.28",
"995.92",
"785.52",
"728.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.01",
"38.91",
"38.97",
"96.71",
"96.04",
"86.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
23534, 23601
|
17172, 20508
|
345, 516
|
24415, 24415
|
7554, 7554
|
25831, 27418
|
5845, 6236
|
22361, 23511
|
23622, 23858
|
22085, 22338
|
24591, 25808
|
6251, 6913
|
6941, 7535
|
21883, 22059
|
20525, 21862
|
275, 307
|
544, 4817
|
7570, 17149
|
24430, 24567
|
23880, 24394
|
5601, 5829
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,479
| 194,882
|
47053
|
Discharge summary
|
report
|
Admission Date: [**2175-2-10**] Discharge Date: [**2175-2-15**]
Date of Birth: [**2104-2-3**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Lumbar spine spondylosis with scoliosis and stenosis
Major Surgical or Invasive Procedure:
Posterior Lumbar spinal decompression with fusion L1-L5
History of Present Illness:
Longstanding back pain with claudication and radiculopathy,
trunk imbalance
Past Medical History:
Hypertension
Social History:
Lives with husband
Family History:
non-contributory
Physical Exam:
wound healing primarily
Neuro intact
abdomen benign
Pertinent Results:
[**2175-2-10**] 09:50AM HGB-10.1* calcHCT-30
Brief Hospital Course:
Underwent surgical procedure without complications, extensive
intraop fluid replacement and upper airway edema necessitated
maintenance of endotracheal airway until evening of surgery
when extubated uneventfully. Further replacement of blood
volume loss (continued oozing from drain) and stabilized Hb 10.
No neurologic sequelae and hemodynamically stable
perioperatively.
Ambulatory POD # 2 and wound healing primarily. Resumed normal
bladder function POD#3 and Bowel function POD#4.
Ambulatory without aids using LSO Brace.
Medications on Admission:
HCTZ
Lisinopril
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Oxycodone HCl 20 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
4. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Spinal stenosis
Discharge Condition:
Stable, ambulatory, wound healing primarily
Discharge Instructions:
Keep wound clean and dry
Leave steri-strips in place
Brace when ambulating for comfort
No bend, lift twist 12 weeks
Followup Instructions:
as planned Dr. [**Last Name (STitle) 363**] [**Telephone/Fax (1) **]
|
[
"721.3",
"401.9",
"285.1",
"E849.7",
"E878.1",
"998.11",
"782.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"81.63",
"99.04",
"81.08"
] |
icd9pcs
|
[
[
[]
]
] |
2354, 2444
|
816, 1348
|
389, 447
|
2504, 2549
|
745, 793
|
2713, 2785
|
640, 658
|
1414, 2331
|
2465, 2483
|
1374, 1391
|
2573, 2690
|
673, 726
|
279, 351
|
475, 552
|
574, 588
|
604, 624
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,701
| 167,723
|
51652
|
Discharge summary
|
report
|
Admission Date: [**2167-1-8**] Discharge Date: [**2167-1-22**]
Date of Birth: [**2117-2-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Gadolinium-Containing Agents / Aztreonam
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
Mental status changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49 year old female vasculopath with multiple medical problems
including [**Name (NI) 11398**] on insulin pump, ESRD on HD, CAD s/p CABG [**2158**]
(LIMA to LAD, SVG to OM1, D1 and RCA) complicated by infection
of L saphenectomy site, last cath [**5-5**] with LAD 50% mid and TO
distal, patent SVG to D1 with 90% distal lesion, LCx with
diffuse dz and 90% stenosis, and patent grafts, recent P-MIBI
[**12-26**] with moderate reversible anterior defect (unchanged from
[**3-5**]) prior to L 5th metatarsal amputation for osteomyelitis,
presents with 5 days of fever (to 101.2), chills, cough with
sputum and no blood, DOE and generalized weakness. Her sugars
have also been difficult to control on her insulin pump. Pt fell
down 2 days ago secondary to weakness and loosing balance, no
LOC, head trauma or back/hip pain. Denies CP, palpitations,
nausea, vomiting, weight gain, presyncope, orhtopnea, or PND.
Past Medical History:
1. CAD: as above. Dr.[**Last Name (STitle) **] is cardiologist.
2. ESRD: [**2-4**] diabetes. On HD X 3 years.
2. [**1-16**]--neck exploration, thyroid and parathyroidectomy for
secondary hyperparathyroidism
3. [**12-27**]--gangrenous left toe/osteomyelitis
4. s/p bilateral fem-[**Doctor Last Name **] bipass [**2160**]
5. Left anterior tibial angioplasty [**9-6**]
5. R (critical)>L RAS
6. [**5-3**] contrast nephropathy
7. CVA X 2: L-residual weakness
8. multiple skin grafts to thigh and buttocks for calciphlaxysis
9. seizures
10. DM1 since 4 years of age: neuropathy, retinopathy,
nephropathy
11. reactive airway disease
12. COPD
13. RLL PNA [**7-3**]
14. cellulitis
Social History:
She is a tobacco user times 30 years and has occasional drinks
alcohol. Otherwise, unremarkable.
Family History:
Negative for heart disease or diabetes.
Physical Exam:
99.1 81 112/42 16 93% on 4.5L NC
Gen: Lethargic, Non-toxic, NAD
Heent: EOMI, PERRL, scattered hard exudates and cotton [**Last Name (un) **]
spots, no neovascularization, MM dry.
Neck: No JVD, thyroidectomy scar. No bruits audible.
Heart: RRR, nl S1 and S2. No murmurs. +S4.
Lungs: Diffuse rhonchi and wheezing. Decreased breath sounds
bibasilarly. No
Abd: Soft, nt/nd. +BS
Ext: No edema. 1+DP/PT on left. Very faint DP/PT on R. No
femoral bruits.
Pertinent Results:
[**2167-1-8**] 09:35AM WBC-6.1 RBC-3.16* HGB-10.3* HCT-34.1*
MCV-108* MCH-32.6* MCHC-30.2* RDW-17.0* PLT COUNT-168
[**2167-1-8**] 09:35AM NEUTS-85.4* LYMPHS-10.1* MONOS-4.2 EOS-0
BASOS-0.2
[**2167-1-8**] 09:35AM GLUCOSE-374* UREA N-34* CREAT-5.4*#
SODIUM-134 POTASSIUM-3.8 CHLORIDE-92* TOTAL CO2-29 ANION GAP-17
ALBUMIN-3.7 CALCIUM-8.3* PHOSPHATE-4.3# MAGNESIUM-2.1
[**2167-1-8**] 09:35AM CK(CPK)-1223* CK-MB-14* MB INDX-1.1
cTropnT-3.01*
[**2167-1-8**] 04:25PM CK(CPK)-1244* CK-MB-8 cTropnT-2.82*
[**2167-1-8**] 10:29PM CK(CPK)-1218* CK-MB-9 cTropnT-2.58*
[**2167-1-8**] 10:29PM TSH-0.83
[**2167-1-8**] 10:15AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2167-1-8**] CXR-Patchy new opacity within the superior segment of the
left lower lobe concerning for pneumonia.
[**2167-1-8**] ECG-Sinus rhythm, Long QTc interval, Probable
anteroseptal infarct, age indeterminate, Low QRS voltages in
limb leads
Since previous tracing, no significant change
[**2167-1-9**] CT Head- No intracranial hemorrhage or mass effect.
[**2167-1-9**] ECHO- 1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. There is mild
global left
ventricular hypokinesis. Overall left ventricular systolic
function is mildly depressed. EF 50%
3. The right ventricular cavity is dilated. Right ventricular
systolic
function appears depressed.
4. The aortic valve leaflets (3) are mildly thickened.
5. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6. Compared with the findings of the prior study (tape reviewed)
of [**2165-10-3**], LV function has decreased.
[**2167-1-11**] CT Chest- 1. Extensive multifocal ground glass opacities
bilaterally. The rapid course of development compared to the
recent chest-xrays favours pulmonary edema. However, lack of
siginficant pleural effuions and upper lobe involvement argues
against pulmonary edema. Other considerations include atypical
infection and hypersensitivity pneumonitis.
2. Mediastinal lymph nodes.
3. Left lower lobe and right lower lobe areas of consolidation
could represent pneumonia or aspiration.
[**2167-1-12**] CTA Chest- No evidence of pulmonary embolus. No interval
change in bilateral diffuse ground-glass opacities, bibasilar
patchy consolidation, small left pleural effusion, and
mediastinal lymphadenopathy
[**2167-1-17**] MRI Head- Diffusion images demonstrate no evidence of
slowed diffusion to indicate acute infarct. No evidence of mass
effect or midline shift are seen. Subtle right frontal
hyperintensities are unchanged from the previous study of
[**2165-7-14**] and [**2165-10-5**], and could be due to a chronic right
frontal cortical infarct or changes of small vessel disease.
There is no evidence of new infarct identified. The suprasellar
and craniocervical regions are normal in the sagittal images.
Brief Hospital Course:
# SOB/Respiratory Failure-Pt initially presented with SOB and
mental status changes. She was empirically started on
Lecofloxacin for possible PNA. DFA's were negative. However
there was also concern that her resp status could be effected by
HF, PE, and/or COPD flare. She had no improvement and give her
recent hosp stays was added gent and vanco for broad coverage.
Despite this she continued to worsen. She continued to have
periods of hypoxia with fever. blood and urine cultures were
negaitve. She worsened with interstitial pattern on CXR and
increased wheezing. Pt then had episode of sever hypoxia and
required NIMV and was sent to [**Hospital Unit Name 153**] for BiPAP. There viral
culture demonstarted parainfluenza. They also checked CTA which
ruled out any evidence of PE. Because it was felt the virus was
also causing a COPD flare she was on steroids and responded well
and were tapered slowly. She then returned to the florr and did
well until she had second decompensation after dialysis with
hypoxia. She once again required short admission to the MICU
for observation. Once again a CTA was negaitve for PE. She was
continued on steroids and completed a 14 day course of
levo/gent/vanco for presumed super infection. After second ICU
stay returned to the floor and was afebrile, no leukocytosis.
Slowly was weaned off of O2, Started on MDI for COPD. On
discharge she was ambulating without supplemental O2 and
maintaining sats. Sent home on steroid taper with MDI's.
# Visual Changes- Complained of right eye visual problems. [**Name (NI) **]
by ophtho. Got MRI head which did not show any stroke or signs
of optic neuritis. Visual problems felt to be [**2-4**] vasculopathy
(retinal artery ischemia) associated with HTN, diabetes.
Recommmended optimizing regimens for these chronic illnesses.
# DM- Insulin pump was stopped intially and she was started on
lantus and RISS. She was followed by [**Last Name (un) **] throughout here
stay. Insulin regimen was adjusted accordingly. She remained
on this regimen until discharge when her pump was restarted.
# CAD-Pt presented with SOB . Trop elavated to 3.00 when
baseline had been 0.04, without any significant ECG changes.
She was seen by cardilogy who felt she had NSTEMI likely [**2-4**]
demand ischemia/[**Month/Day (2) **] failure and recommended optimizing medical
management. Concern for some myositis [**2-4**] statin so this was
held. She remained CP free during stay and troponin trended
down. CShe was continued on BB, aspirin, plavix, imdur, ACEI
# CHF- ECHO done in house showed EF of 50% with mild global
hypokinesis.
# Hypothyroid- Cont on levothyroxine
# Mental Status Changes- Initial CT head showed no evidence of
ischemia, bleed. Later MRI confirmed this result. MS changes
felt to be secondary to hypoxia, infection, medications, and
[**Month/Day (2) **] failure. Her psychiatric meds were adjusted but
ultimately was able to restart them all. As she imprved from a
respiratory and ID standpoint here mental status gradually
improved and returned to baseline.
# Psych- On multiple pysch meds. Some were initially held due
to sedating effects. As her MS improved these were gradually
restarted per psych recs.
# ESRD - SHe remained on schedule of HD on MWFSa. Followed by
[**Month/Day (2) **] throughout hospital stay.
# h/o seizures- She was continued on phenytoin. Levels were
checked and doasge adjusted as needed. No seizures during her
hospital stay.
Medications on Admission:
asprin 81 qd, calcitriol 0.5mcg qd, plavix 75 mg qd, indur 30mg
qd, folate, prevacid 30mg qd, wellbutrin SR 300 [**Hospital1 **], levoxyl
250mcg qd, renagel 800 with meals, albuterol prn, flovent [**Hospital1 **],
serevent [**Hospital1 **], dilantin 300mg qd, celexa 10mg qd, reglan 10mg
with dinner, tums 500 between meals, sennakot, dulcolax,
methadone prn, dilaudid prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lansoprazole 30 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:*2*
7. Levothyroxine Sodium 125 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
Disp:*QS Disk with Device(s)* Refills:*2*
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
14. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*QS * Refills:*2*
15. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
16. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*15 Patch 24HR(s)* Refills:*0*
17. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO once a day.
Disp:*90 Capsule(s)* Refills:*2*
18. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
Disp:*QS * Refills:*2*
20. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
21. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
22. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
Disp:*120 Tablet Sustained Release(s)* Refills:*2*
23. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
24. Prednisone 10 mg Tablet Sig: 2-4 Tablets PO once a day for 2
weeks: please take 4 tabs for 4 days, then 3 tabs for another 5
days then 2 tabs for another 6 days, then taper it per your
doctor's evaluation.
Disp:*45 Tablet(s)* Refills:*0*
25. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: One (1)
puff Inhalation twice a day.
Disp:*1 bottle* Refills:*2*
26. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
27. Mirtazapine 45 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Parainfluenza infection
Diabetes
NSTEMI
Hyperlipidemia
Hypothyroid
Anemia secondary to [**Hospital1 **] failure
ESRD on hemodialysis
Discharge Condition:
stable, ambulating on room air, chest pain free
Discharge Instructions:
Please take your medicine as directed, you are on prednisone
taper and need to be seen by your doctor for re evaluation
within 2 wks for tapering dosage.
Please make follow up appt as directed.
Please have your liver function tests AST, ALT done within 1
month.
Please go to ED or call 911 if have worsening shortness of
breath, chest pain, unremitting fever or other concerning
symptoms.
Followup Instructions:
Call [**Last Name (un) **] Psych at [**Telephone/Fax (1) 60675**] for follow up in [**1-4**] wks.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2167-2-26**] 1:00
Please call Dr. [**Last Name (STitle) 174**] at [**Telephone/Fax (1) 9979**] for follow up in [**1-4**] wk.
You will need to discuss with Dr. [**Last Name (STitle) 174**] about referral to
pulmonology to follow your lung disease.
You will need to follow up with your ophthamologist (eye doctor)
Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 28100**].
|
[
"493.92",
"285.21",
"403.91",
"362.84",
"V53.91",
"250.41",
"410.71",
"487.0",
"599.0",
"V49.72",
"518.81",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12943, 12949
|
5558, 9047
|
336, 343
|
13136, 13185
|
2630, 5535
|
13623, 14281
|
2105, 2146
|
9470, 12920
|
12970, 13115
|
9073, 9447
|
13209, 13600
|
2161, 2611
|
275, 298
|
371, 1278
|
1300, 1975
|
1991, 2089
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,438
| 192,738
|
44252
|
Discharge summary
|
report
|
Admission Date: [**2173-8-6**] Discharge Date: [**2173-8-12**]
Service: MEDICINE
Allergies:
Digoxin
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
I fell and hurt my arm
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 y/o M w/ h/o CKD (cr 1.9-2.0), HTN, CHF (most recent ECHO w/
EF 60%), who presented s/p fall, found to have right humerus
fracture.
.
Fell while trying to pull off a safety strap while repairing his
boat. The strap suddenly came loose and he fell 6 feet off a
platform onto his right side. Denies associated lightheadedness,
dizziness, chest pain or palpitations.
.
In the ER, he was found to have right humerus fracture. CT head
and C-spine negative for fracture. Evaluated for surgical
repair, however patient refuses surgical intervention. Plan for
sling with follow-up in 2 weeks. However, overnight developed
decreased urine output (110 cc out over 8 hour period). Given 1L
NS bolus and placed on 80cc/hr LR. However, still w/ low uop
(~10cc/hr), bladder scan showed empty bladder. Given additional
1L NS without response. Subsequently tried 5mg IV lasix to see
if component of CHF, without effect. Creatinine noted to be
elevated from 2.1 to 3.2.
Past Medical History:
HTN
CRI (baseline cr 1.5-1.8)
Gout
Polycystic kidney disease
Social History:
Pt is semi-retired heavy epuipment engineer. Married. No
smoking, EtOH, or drugs.
Family History:
No CAD, HTN, or DM
Physical Exam:
vitals- T 99.1, BP 100/60, HR 84, RR 16, 92% RA (99% on 2l O2)
gen- sitting up in chair, no labored breathing, NAD
heent- EOMI. MM dry
neck- jvp non-distended
pulm- CTA b/l. good air movement. slight decreased at bases
cv- RRR. no m/r/g
abd- soft, NT/Nd
ext- no edema, distal pulses 2+ ; R arm in sling; grip strength
full b/l
neuro- alert and oriented, follows commands. language fluent
Pertinent Results:
[**2173-8-6**] 10:59AM BLOOD WBC-4.4 RBC-3.87* Hgb-12.8* Hct-37.2*
MCV-96 MCH-33.1* MCHC-34.4 RDW-13.8 Plt Ct-205
[**2173-8-6**] 10:59AM BLOOD PT-13.1 PTT-32.3 INR(PT)-1.1
[**2173-8-6**] 10:59AM BLOOD Plt Ct-205
.
.
[**2173-8-7**]
BLOOD WBC-7.2# RBC-3.18* Hgb-10.2* Hct-31.5* MCV-99* MCH-32.0
MCHC-32.3 RDW-13.8 Plt Ct-197
WBC-7.8 RBC-3.05* Hgb-9.9* Hct-31.6* MCV-104* MCH-32.6*
MCHC-31.4 RDW-13.6 Plt Ct-180
PT-13.2* PTT-30.9 INR(PT)-1.2*
Plt Ct-197
Glucose-112* UreaN-34* Creat-3.2*# Na-142 K-5.3* Cl-110* HCO3-24
AnGap-13
Glucose-110* UreaN-38* Creat-3.7* Na-140 K-5.1 Cl-109* HCO3-21*
AnGap-15
ALT-22 AST-36 LD(LDH)-272* CK(CPK)-2423* AlkPhos-60 TotBili-0.4
CK(CPK)-[**2151**]*
Calcium-7.8* Phos-5.8* Mg-2.2 Iron-12*
Calcium-8.3* Phos-5.8*# Mg-2.2
calTIBC-191* VitB12-685 Folate-10.0 Hapto-127 Ferritn-160
TRF-147*
TSH-1.5
T4-5.5 Free T4-0.95
.
.
([**2173-8-12**])
WBC-5.1 RBC-2.74* Hgb-9.0* Hct-26.6* MCV-97 MCH-32.7* MCHC-33.7
RDW-13.9 Plt Ct-251
Glucose-88 UreaN-35* Creat-2.4* Na-142 K-4.3 Cl-109* HCO3-25
AnGap-12
Calcium-8.6 Phos-2.8 Mg-2.2
.
.
RADIOLOGY:
([**2173-8-6**])
KNEE:
Four radiographs of the right knee demonstrate no effusion.
There is mild narrowing of the medial and lateral compartment
joint space heights on non-weightbearing views. No fracture.
Small marginal osteophytes involve all three joint compartments.
There is evidence of old Osgood-Schlatter's disease. Regional
soft tissues are unremarkable.
IMPRESSION: Mild tricompartmental osteoarthritis
.
.
SHOULDER
Three radiographs of the right shoulder demonstrate a
comminuted, displaced, fracture involving the surgical neck and
head of the right humerus. There is avulsion of the greater
tuberosity. There is impaction of the distal fracture fragments.
Acromioclavicular joint demonstrates mild degenerative change.
Visualized lung and ribs are unremarkable. Regional soft tissues
unremarkable.
IMPRESSION:
Comminuted and impacted fracture through the surgical neck and
head of the right humerus with avulsion of the greater
tuberosity.
.
.
CONTRAST CT ABD/CHEST:
FINDINGS: There is a large multinodular goiter with a dominant
nodule in the left lobe of the thyroid, displacing the airway to
the right. There is no evidence of mediastinal hematoma or
traumatic aortic injury. Pulmonary artery main right and left
branches are enlarged up to 3.3 cm, consistent with pulmonary
hypertension. There is dense calcification of the coronary
arteries, predominantly affecting the LAD. The heart,
pericardium, and great vessels are otherwise unremarkable. No
significant pericardial effusion is detected to account for the
FAST findings. The lungs demonstrate mild basilar atelectasis
and mild emphysematous change in the upper lobe but no
pneumothorax, contusion, or suspicious nodules or masses. No
pathologically enlarged axillary, mediastinal, or hilar
lymphadenopathy.
CT ABDOMEN WITH IV CONTRAST: A large portion of the upper
abdomen is obscured by beam hardening artifact from the
patient's overlying arm which cannot be repositioned.
Specifically, evaluation of the anterior hepatic dome is very
limited, and a laceration could easily be missed in this
location. There is a small geographic hypodense focus in segment
II of the liver and an area obscured by artifact, which appears
atypical for laceration but this is not excluded. No evidence of
active extravasation. There is bilateral polycystic kidney
disease, with a dominant cyst on the right measuring 16.5 x 15.1
x 17.4 cm (transverse, AP, SI). Several of the cysts demonstrate
hyperdense components consistent with hemorrhage or
proteinaceous debris, there appears to be no free fluid or
stranding to suggest traumatic cyst rupture. No evidence of
hematoma or free fluid within the abdomen or mesentery. Given
beam hardening artifact, no definite traumatic injury to the
remainder of the abdominal viscera. No free air.
CT PELVIS WITH IV CONTRAST: Foley catheter in a nondistended
bladder. There is no prominent mesenteric stranding or pelvic
hematoma. Large right scrotal hernia is present. No
pathologically enlarged lymph nodes. No evidence of active
extravasation.
BONE WINDOWS: There is a comminuted fracture of the right
proximal humerus involving the head and surgical neck with
avulsion of the greater tuberosity. Partially imaged, as the
right arm and hand could not be moved to the study, there is the
suggestion of a perilunate dislocation involving the right
wrist, though this may be artifactual due to positioning and
correlation with dedicated wrist x-rays is recommended. There is
extensive thoracic and lumbar spinal spondylosis without
evidence of acute fracture. Patchy ground-glass opacity in the
right ilium may relate either to fibrous dysplasia or Paget's
disease but appears chronic. No acute pelvic fractures or hip
fractures are appreciated. The femoral heads are normally
located in the SI joints and pubic symphysis are congruent.
MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images
confirm the above findings.
IMPRESSION:
1) Comminuted and impacted fracture of the surgical neck and
head of the proximal right humerus with avulsion of the greater
tuberosity.
2) Question of right wrist perilunate dislocation, partially
imaged on this study; while this could be artifactual due to
positioning; if there is clinical concern, this could be
assessed with a dedicated wrist radiograph.
3) Extensive beam hardening artifact from the patient's
overlying arm obscures portions of the right upper abdomen,
specifically the dome of the liver. There is a small ill-defined
hypoechoic focus in segment II of the liver, which appears
atypical for a laceration but this cannot be excluded on this
study. If this is clinical concern, an ultraound may be helpful.
No other definite evidence of traumatic injury throughout the
abdomen and pelvis.
4) Large multinodular goiter.
5) No evidence of pericardial effusion as suggested on FAST.
6) Coronary artery calcification and evidence of pulmonary
hypertension.
7) Polycystic kidney disease with the dominant right cyst,
exerting mass effect on the adjacent organs.
8) Large right scrotal hernia.
9) Question fibrous dysplasia vs Paget's disease in the right
ilium.
.
.
CT SPINE
FINDINGS: There are extensive multilevel degenerative changes,
worse at C2, 3, 4, 5, and 6 respectively. There is
retrolisthesis of C3 in relation to C4 of approximately 3 mm.
There is retrolisthesis of C4 in relation to C5 of approximately
4 mm. There is very mild retrolisthesis of C5 in relation to C6.
There is significant narrowing of the intervertebral disc spaces
at the following levels: C2-3, C3-4, C4-5, C5-6, C6-7, C7-T1.
The vertebral body heights are decreased uniformly at C2, C3,
C4, C5, and C6. There are extensive subchondral cysts and
Schmorl's nodes throughout the cervical spine. No acute fracture
or malalignment is detected. There is mild narrowing of the
neural foramina at the C4-5 level, C5-6, and C6-7 levels
respectively. Non-contrast soft tissue windows demonstrate a
heterogeneous predominantly hypodense mass in the left lobe of
the thyroid which displaces the trachea to the right and has a
significant substernal component. The right lobe of the thyroid
contains an irregular area of hypodensity measuring 1.1 x 0.6
cm. A few areas of calcification are noted throughout the
enlarged left lobe of the thyroid. The visualized portion of the
lung apices is unremarkable.
IMPRESSION:
1. Severe degenerative disease of the cervical spine as noted
above. No acute fracture or malalignment present.
2. Enlarged, asymmetric-appearing thyroid gland. Ultrasound
examination is recommended if clinically warranted
.
.
ECG: (06/
Sinus rhythm with baseline artifact. Borderline prolonged P-R
interval. Left
anterior fascicular block. Probable prior anteroseptal
myocardial infarction.
Anterolateral ST-T wave changes - cannot exclude ischemia.
Clinical correlation
is required. Compared to the previous tracing of [**2173-2-9**]
premature ventricular
beats are no longer present. QTc interval is shorter and
anterolateral
ST-T wave changes are less prominent.
CT HEAD:
FINDINGS: Images are slightly limited secondary to patient
motion. There is no evidence of acute intracranial hemorrhage,
shift of normally midline structures, hydrocephalus or major
vascular territorial infarction. Incidental note is made of
calcification of the dentate nuclei within the cerebellum
bilaterally. There are prominent periventricular white matter
changes consistent with small vessel ischemia. No acute
fractures are identified. There is evidence of bilateral
cataract surgery. The soft tissues, osseous structures,
visualized portions of the paranasal sinuses and mastoid air
cells are unremarkable.
IMPRESSION: No evidence of acute hemorrhage or fracture.
.
.
CHEST X-RAY
Large superior mediastinal mass deviating the trachea towards
the right with associated coronal narrowing of the trachea
appears worse compared to [**2172-2-16**]. Heart remains enlarged
with left ventricular configuration, and aorta is markedly
tortuous. Bibasilar opacities are present with associated volume
loss, involving the lower lobes and right middle lobe, with a
predominantly linear orientation. No pleural effusions are
identified. As compared to the recent radiograph, the right base
is minimally improved and the left base is slightly worse.
IMPRESSION:
1. Bibasilar opacities suggestive of atelectasis.
2. Large left superior mediastinal mass consistent with enlarged
left lobe of thyroid gland on recent CT torso, [**2173-8-6**].
.
.
THYROID ULTRASOUND: Comparison with [**2173-3-10**]. Several
thyroid nodules are seen in both lobes. The largest, in the left
lobe, measures 2.1 x 5.4 x 6.5 cm, and is not appreciably
changed. In the right lobe, dominant nodule with cystic,
measures 1.2 x 1.0 x 1.5 cm, in the inferior lobe. In the
superior lobe, a hypoechoic nodule measuring 5 x 3 x 4 mm is
seen.
IMPRESSION: Bilateral thyroid nodules, without significant
change
.
.
ECG: ([**2173-8-8**])
Sinus rhythm with baseline artifact. Borderline prolonged P-R
interval. Left anterior fascicular block. Probable prior
anteroseptal myocardial infarction. Anterolateral ST-T wave
changes - cannot exclude ischemia. Clinical correlation is
required. Compared to the previous tracing of [**2173-2-9**] premature
ventricular beats are no longer present. QTc interval is shorter
and anterolateral ST-T wave changes are less prominent.
.
.
ECHO ([**2173-8-9**])
Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall and basal half of the
inferior wall. The remaining segments contract well. Right
ventricular chamber size and free wall motion are normal. There
is focal hypokinesis of the apical free wall of the right
ventricle. The aortic root is moderately dilated at the sinus
level. The ascending aorta is moderately dilated. The aortic
arch is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-16**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2172-7-6**],
regional left ventricular systolic dysfunction is more apparent
and mild pulmonary artery systolic hypertension is now
identified. The ascending aortic dilation is similar at the
sinus level (on review).
.
.
Brief Hospital Course:
82 y/o male with fractured humerus, acute renal failure
superimpossed on chronic secondary to ADPCKD and congestive
heart failure.
1. Humeral Fracture: Comminuted and impacted fracture of right
humerus affecting surgical neck and head of the right humerus
with avulsion of the greater tuberosity. Patient remained
neurovascularly intact, evaluated by orthopaedic service and
offered surgery which he refused. Trauma CT series performed,
with CTA of arm for vascular assessment. Mr [**Known lastname 94915**] renal
function was severely affected by contrast and he developed ARF.
Aggressive IVF were started to minimize contrast nephropathy,
but due to CHF he became fluid overloaded and symptomatic. He
was transfered to the MICU for closer monitoring and did not
require invasive ventilation to maintain oxygenation. After a
short course in MICU, he was transferred back to the wards where
his UOP gradually continued improving and creatinine returned to
baseline. Renal service was actively involved in patient
management. He was discharged home with outpatient physical
therapy and occupational therapy.
.
2. Acute Renal Failure on CRI: As above, Patient with underlying
polycystic kidney disease and HTN. Creatinine is trended back
towards baseline, down to 2.4 at discharge from 2.6 ([**8-11**]) 3.2
([**8-10**]) and 4.2 ([**8-9**]) with UOP greater than 500ml in 8hrs.
.
3. CHF: History of congestive heart failure, with last
documented EFs before admission of 30% ([**2172-3-20**]) and 60%
([**2172-7-6**]) from medical management. Because of fluid overload,
his clinical condition worsened and a new ECHO was obtained,
which showed a 40% EF ([**8-9**]) with mild pulmonary hypertension.
He was maintained on coreg and had clinical improvement in JVD
and edema with good diuresis and no pulmonary compromise.
.
4. HTN: Longstanding history of hypertension probably secondary
to PCKD. As CHF resolved, hypertension again became an issue to
address. Because of ARF, ACE-I was stopped and BP began to
increase. Felodipine was increased to 10mg and as reneal
function improved, lisinopril was added as per renal rec's.
Patient was discharged with BP ranging from 120's to 140's.
.
5. Anemia: During hospitalization, hematocrit was noted to be
decreased. An iron panel demonstrated normal B12, normal
ferritin, decreased TIBC and Iron level of 12.
Anemia pattern remained normocytic and was initially worse
likely secondary to dilution from fluid overload. Hct stabilized
around 9, and GUIAC by DRE was heme negative. Dr [**First Name (STitle) 216**] is aware
and will follow up on an oupatient basis.
.
6. Multi-nodular Goiter: An incidental fiding of a multinodular
goiter was made during trauma scout film evaluation. Reviewing
patients history, thyroid u/s from [**2-21**] showed increase in size
of a previously existing dominant nodule measuring 10 cm.
Thyroid function tests were obtained and showed no anomalies.
Repeat thyroid ultrasound ([**8-11**]) showed no interval change. F/U
scheduled with Dr [**Last Name (STitle) **], ([**Telephone/Fax (1) 30788**], as requested by PCP.
.
7. FEN: With sporadic nausea but tolerating PO intake in the
last 12hrs without any furhter nausea. Continue senal, cardiac,
low Na diet.
.
8. ACCESS: Only peripheral access was needed during this
hospitalization
.
9. PPx. Heparin SQ, PPI, bowel regimen
.
10. COMMUNICATION: Patient, wife
.
11. CODE STATUS: Patient remained full code througout admission
.
Medications on Admission:
Coreg 25 mg twice daily
lisinopril 40 mg daily
allopurinol 300 mg daily
meclizine 12.5 mg daily
aspirin 325 mg daily
Discharge Medications:
1. Outpatient Physical Therapy
Requires gait and endurance training and right arm
rehabilitation. Follow up for right arm pendulum excercises and
ADL's
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for nausea for 10 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. Humerus fracture
2. Acute renal failure on Chronic renal failure
3. Hypertension
4. Congestive heart failure
5. Anemia
SECONDARY:
1. Scrotal hernia
2. Gout
Discharge Condition:
Stable, strong palpable pulses on right upper extremity,
neurologically intact. Urinating without difficulty and with
resolving kidney function.
Discharge Instructions:
You were admitted to the hospital because you fractured your
right arm when you fell off your boat. In order to evaluate the
facture and if it affected the nerves and arteries of the arm, a
CT scan was ordered. It showed no compromise to the blood
vessels, and you chose not to have an operation to fix this
broken bone. While you were admitted, you began having worsening
kidney function. The medical team felt this was most likely due
to the contrast used for the CT scan. In order to prevent any
permanent damage to the kidneys, a large amount of fluid was
give through your veins. We were concerned about your breathing
and your heart because of the all the fluid we gave you, so you
were closely monitored in the intensive care unit. You did not
develop any problems and were able to be transfered to the
regular floor, where you continued to improve.
Physical therapy and occupational therapy have been working with
you to improve your strength and teach you how to use your arm.
We have set you up with outpatient physical therapy as well.
.
Please do not take your ALLOPURINOL until your primary care
doctor evaluates you. Also, please arrange for a Nephrologist
(Kidney doctor) to follow you up.
.
If you develop new arm pain, notice excessive swelling, numbness
or tingling in the finger of the right hand, feel chest pain,
shortness or breath, nausea, vomiting or diarrhea, blood in your
stool or black stools or stop making urine, please call your
primary care doctor or come into the Emergency Department.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2173-10-20**] 11:30
DR [**Last Name (STitle) 844**] (THYROID) ([**Telephone/Fax (1) 30788**] [**8-23**], 9:15AMProvider:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2173-8-16**] 12:15. At
this time you should have your kidney function and blood counts
checked and discuss setting an appointment with the kidney
doctors to monitor your condition and adjust your LISINOPRIL.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
|
[
"753.13",
"E947.8",
"E834.3",
"428.0",
"274.9",
"276.7",
"424.0",
"425.4",
"584.9",
"285.21",
"403.90",
"550.90",
"241.1",
"585.9",
"812.01",
"812.09"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
18700, 18706
|
13689, 17142
|
236, 242
|
18918, 19065
|
1873, 9945
|
20633, 21297
|
1429, 1449
|
17310, 18677
|
18727, 18897
|
17168, 17287
|
19089, 20610
|
1464, 1854
|
174, 198
|
271, 1229
|
9954, 13666
|
1251, 1313
|
1329, 1413
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,121
| 108,353
|
48852
|
Discharge summary
|
report
|
Admission Date: [**2180-3-28**] Discharge Date: [**2180-3-31**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male retired physician with [**Name Initial (PRE) **] history of critical aortic
stenosis, hypertension, hypercholesterolemia who presents
today with chest pain. The patient usually only has minimal
baseline exertion, also gets nonexertional chest pain, about
10 times in the past one to two months lasting 5 to 15
minutes at a time. He denies other symptoms. On day of
admission, he presented to the Emergency Room with acute
chest pain with radiation to his left arm which occurred at
rest 7 out of 10 in intensity. No shortness of breath,
diaphoresis, nausea, vomiting or palpitations.
REVIEW OF SYSTEMS: The patient denies orthopnea, dyspnea on
exertion, lower extremity edema, no change in bowel
movements, occasionally has bloody urine secondary to his
bladder cancer. Good energy, denies cough, fevers, chills.
No syncope or claudication. The patient is hard of hearing.
The patient refused surgery for his aortic stenosis when
offered one to two years ago. In the Emergency Department,
the patient's electrocardiogram showed ST elevations in the
anterior leads. He was taken directly to cardiac
catheterization. Vital signs in the Emergency Department:
pulse 90, blood pressure 170/80, respirations 18, saturating
95% on room air. The patient's chest pain resolved about 30
minutes into his Emergency Department visit. Cardiac
catheterization showed a right dominant system with three
vessel disease, left main 80% distally, LAD 80% at ostium, as
well as diffuse disease. Distal LAD with ulcerated 90%
stenosis, however with TIMI-3 beyond lesion. Left circumflex
with focal 70% stenosis at origin of OM. RCA had focal 70%
stenosis at mid segments. Hemodynamics revealed elevated
right and left sided filling pressures. Mean RA pressure 11.
PA systolic pressure 54. RVEDP at 12. Mean wedge 28. LVEDP
30. Cardiac output 3.3, cardiac index 1.7. Systemic and
pulmonary vascular resistance is elevated at 2150 and 250.
Aortic valve area 0.43 with a gradient of 51. Left V-gram
revealed fair anterolateral hypokinesis with apical and
inferior hypokinesis and an ejection fraction of 38%. No
mitral regurgitation was seen.
PAST MEDICAL HISTORY:
1. Colon cancer, status post right hemicolectomy greater
than 10 years ago
2. Bladder cancer status post left ureteral stent
3. Prostate cancer, status post prostatectomy greater than
10 years ago
4. Polycythemia [**Doctor First Name **] for the past 10 to 15 years, oncologist
Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**]
5. Hypertension, LDL cholesterol was 115 in [**8-29**].
6. Critical aortic stenosis
MEDICATIONS:
1. Metoprolol 50 mg po bid
2. Allopurinol 300 mg po q day
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a retired general physician,
[**Name10 (NameIs) **] alcohol. Quit smoking 50 years ago. He uses a cane to
walk. Lives alone with family assistance.
FAMILY HISTORY: Negative for coronary artery disease.
PHYSICAL EXAM:
VITAL SIGNS: Temperature 95.6??????, pulse 67, blood pressure
174/78, respirations 21, saturating 98% on 4 liters by nasal
cannula
GENERAL: The patient is in no acute distress with a groin
sheath in place.
HEAD, EARS, EYES, NOSE AND THROAT: Moist mucous membranes.
Jugular venous distention to jaw while lying in bed.
Extraocular movements full.
NECK: Carotids 2+ without bruits.
LUNGS: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm, grade [**2-2**] high
pitched systolic ejection murmur at the left upper sternal
border.
ABDOMEN: Soft, nontender, nondistended with normoactive
bowel sounds.
EXTREMITIES: No edema. DPs 1+ bilaterally.
GENITOURINARY: Foley bag with grossly bloody urine.
LABS AND RADIOGRAPHIC STUDIES: Initial CK 69, troponin 2.4.
Arterial blood gases 7.25, 42, 106. Chem-7: Sodium 140,
potassium 4.5, chloride 101, bicarbonate 27, BUN 38,
creatinine 1.6, glucose 126. Initial electrocardiogram
showed sinus rhythm of 93 with normal axis, 3 to [**Street Address(2) 37683**]
elevations in leads V2 through V4 with good R-wave
progression. No Q wave. T-wave inversions in 1 and L and
biphasic in V6. Subsequent electrocardiogram showed sinus
rhythm of 64 with normal axis, Q in V2, [**Street Address(2) 1766**] elevations in
V2 through V3, T-wave inversions in lead 2 through V6, 1 and
L. Diffuse T-wave changes.
HOSPITAL COURSE: The patient refused any surgical therapy
for his coronary artery disease. He refused coronary artery
bypass graft as well as percutaneous transluminal coronary
angioplasty. The patient was medically managed by starting
aspirin, Plavix and Lipitor. The patient received 48 hours
intravenous heparin. The patient remained symptom free on
heparin. The patient's beta blocker was also increased to
metoprolol 100 mg po bid. Nitrates were avoided secondary to
patient's critical aortic stenosis to avoid preload
reduction. The patient was evaluated by physical therapy and
was deemed unsafe to go home and short rehabilitation was
recommended.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Discharge patient to rehabilitation.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg po q day
2. Metoprolol 100 mg po bid
3. Plavix 75 mg po q day
4. Lipitor 10 mg po q day
5. Allopurinol 200 mg po q day
6. Protonix 40 mg po q day
7. Colace 100 mg po bid
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post anterior myocardial
infarction
2. Critical aortic stenosis
3. Hypertension
4. Hypercholesterolemia
5. Polycythemia [**Doctor First Name **]
6. Prostate cancer
7. Bladder cancer
8. Colon cancer
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Doctor Last Name 10735**]
MEDQUIST36
D: [**2180-3-31**] 08:22
T: [**2180-3-31**] 08:34
JOB#: [**Job Number 13654**]
|
[
"424.1",
"410.11",
"V10.05",
"V10.51",
"238.4",
"401.9",
"414.01",
"V10.46",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
5210, 5275
|
3093, 3132
|
5530, 6044
|
5298, 5509
|
4541, 5188
|
3147, 4523
|
777, 2313
|
118, 757
|
2335, 2892
|
2909, 3076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,974
| 150,946
|
43447+58625
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-12-3**] Discharge Date: [**2107-12-13**]
Date of Birth: [**2062-12-20**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
--Intubation/mechanical ventilation
--Tunneled catheter placement by IR
History of Present Illness:
This is a 44-year-old woman with a pmhx. significant for DM 2,
hypertension, HCV, depression, and ESRD on peritoneal dialysis
(with history of peritonitis) who is admitted from the ED with
hypoxia in the setting of missing peritoneal dialysis for the
past 3 days.
Ms. [**Known lastname 93492**] states that she has had worsening, crampy abdominal
pain for the past 2 days, and as such, has not used peritoneal
dialysis since the night of [**12-1**]. She denies fevers, chills, or
dysuria. Does endorse a recent cough that is productive of
mucous. Of note, patient had similar abdominal symptoms in
[**10-30**] when she developed a coag negative staph infection in her
peritoneal cavity. She was treated with a 14-day course of
intra-peritoneal vancomycin. Patient was also instructed to
follow-up with her nephrologist and transplant surgeons in
anticipation of starting hemodialysis.
.
Patient states that she was having trouble breathing the night
prior to admission, and felt acutely dyspneic on the morning of
admission. In the ED, initial vitals were: 130 164/89 and 53%
on RA. An ABG was significant for: 7.43 pCO2 28 pO2 37. White
count was 19.5 with a leftward shift and lactate was 4.4. A CXR
was consistent with volume overload. Ms. [**Known lastname 93492**] was given 120mg
of IV lasix (she put out 600cc of urine) and nitro. She was
started on a BIPAP mask with improvement in her sats to 99% with
[**3-24**] and FIO2 of 100. Renal was consulted and recommended
admission to ICU with initiation of hemodialysis. On transfer,
vitals were: 115, 169/100, 99% on CPAP.
Past Medical History:
Diabetes mellitus type 2,
Hypertension,
Hepatitis C
-- genotype 1.
-- never previously been treated.
-- history of intravenous drug use.
Depression,
End-stage renal disease
----18mo ago on peritoneal dialysis x 1 year
----peritonitis in [**2107-7-21**] w/ culture + for mycobacterium
fortuitum
----h/o HD line infections as well as failed fistula
Social History:
The patient lives with her mother and daughter. She was
employed as a medical [**Doctor Last Name **], positive tobacco use [**11-23**] pack per
day for 20 years. No alcohol use, prior history of heroin use.
Family History:
Mother hypertension and diabetes mellitus and aunt has
hypertension
Physical Exam:
VS: 98.2, 115, 143/95, 95% on CPAP
GENERAL: Slightly labored breathing, NAD
CHEST: Crackles bilaterally
NECK: JVP up
CARDIAC: RRR, 3/6 systolic murmur
ABDOMEN: Peritoneal catheter in place, area looks clean and
non-erythematous
EXTREMITIES: 1+ edema bilaterally, warm, dry
On discharge, VS were all stable.
Lung exam was CTAB, no wheezes/rhonchi/rales
No peripheral edema
Pertinent Results:
====================
LABORATORY RESULTS
====================
On Admission:
WBC-19.5*# RBC-3.31* Hgb-8.7* Hct-27.2* MCV-82 RDW-14.8 Plt
Ct-267
--Neuts-90.7* Lymphs-6.4* Monos-2.5 Eos-0.4 Baso-0.1
PT-15.6* PTT-26.2 INR(PT)-1.5*
Glucose-96 UreaN-72* Creat-11.3*# Na-133 K-7.8* Cl-99 HCO3-18*
ALT-12 AST-21 LD(LDH)-377* CK(CPK)-78 AlkPhos-102 TotBili-0.4
Albumin-2.3* Calcium-8.0* Phos-7.4*# Mg-1.8
On Discharge:
WBC-13.2* RBC-3.53* Hgb-9.7* Hct-29.8* MCV-84 RDW-15.4 Plt
Ct-163
Glucose-158* UreaN-16 Creat-4.4*# Na-135 K-3.7 Cl-96 HCO3-29
Calcium-8.8 Phos-3.6# Mg-1.9
Other Important Labs:
Lipase-365*
[**2107-12-3**] 04:56PM BLOOD CK-MB-3 cTropnT-0.22*
[**2107-12-4**] 04:16AM BLOOD CK-MB-3
[**2107-12-4**] 05:59AM BLOOD cTropnT-0.24*
[**2107-12-5**] 07:30AM BLOOD cTropnT-0.18*
[**2107-12-3**] 10:42PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2107-12-7**] 01:57AM BLOOD ANCA-NEGATIVE B
[**2107-12-7**] 01:57AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2107-12-5**] 07:30AM BLOOD HIV Ab-NEGATIVE
================
OTHER STUDIES
===============
ECHO [**2107-12-8**]: The left atrium is normal in size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.
CXR [**2107-12-3**]: A single AP radiograph was obtained. There is
diffuse airspace opacity within the lungs, radiating from the
hila, most consistent with severe pulmonary edema. The heart
size is difficult to assess. The mediastinal contours are
normal. No definite pleural effusions. There is no pneumothorax.
IMPRESSION: Diffuse pulmonary airspace opacity which may reflect
severe pulmonary edema.
Brief Hospital Course:
ThiS is a 44-year-old woman with a pmhx. significant for HTN,
DM2, HCV, and ESRD on peritoneal dialysis who presents with
acute shortness of breath, likely from volume overload.
Active issues:
# Acute diastolic heart failure: On admission, pt presented
with exam findings and radiographic evidence of volume overload,
likely [**12-22**] missing PD. In the ED, Ms. [**Known lastname 93492**] was started on
BIPAP and her respiratory status improved. She was given 120mg
of IV lasix and put out about 700cc. She was then transferred
to the MICU where she was given 120mg of IV lasix and 500mg of
chlorothiazide with little urine output. Patient continued to
be short of breath, and an urgent HD line was placed.
Ultra-filtration was started that night. However, respiratory
status continued to decline and on second hospital day, patient
was intubated and started on ARDS net protocol. She continued
to receive UF and was ultimately extubated on [**2107-12-8**]. An ECHO
showed a normal EF. On discharge, her lungs were clear to
auscultation and she had no peripheral edema. She will
transition to outpatient HD after discharge.
# ESRD: Patient with ESRD likely from diabetes and hypertension.
Nephrology service was consulted and felt that she was not a
good candidate to continue PD and felt she should be
transitioned to HD. She had a tunneled LIJ placed for access
and AVF mapping prior to discharge. She will continue to
follow-up with the outpatient nephrology team. She is also
scheduled to follow up with the transplant surgery service for
removal of her PD catheter.
# Delirium/Encephalopathy: Pt had waxing/[**Doctor Last Name 688**] mental status
following extubation and transfer to the floor, with occasional
agitation that responded well to low doses of IV haldol. This
was thought most likely due to sedating medications used during
her intubation and MICU course. Her AMS resolved by discharge
without intervention.
# Hypotension: Pt was hypotensive after HD with BP 80s/50s. She
remained asx and her BP improved to low-normal without
intervention. Her amlodipine was decreased to 5mg daily and her
clonidine patch was decreased to 0.1mg/24H to prevent post-HD
hypotension, and she should follow up with her PCP and HD
nephrologist regarding her antihypertensive regimen.
# Leukocytosis: On admission pt had elevated WBC at 15. This
was initially concerning for infection and she was started on
broad spectrum antibiotics in the MICU. However she had no
focal s/sx of infection and culture data was negative.
Antibiotics were discontinued and her leukocytosis resolved.
# Abdominal pain: Patient had abdominal pain on presentation
that prevented her from adhering to PD. Her lipase was
elevated, but she had no radiographic signs of pancreatitis (on
CT without contrast). Patient's abdominal pain eventually
resolved and she was able to eat without difficulty.
Chronic issues:
# HTN: Her amlodipine and clonidine doses were decreased due to
post-HD hypotension as above.
# DM: Patient was briefly hypoglycemic in the MICU but this
improved once her AMS cleared and she was taking normal diet.
However she had a low insulin requirement without her basal
insulin, and her home lantus dose was decreased to 10units qAM.
# METHADONE MAINTENANCE: Methadone was initially held due to
AMS. She was restarted on her home methadone dose (70mg daily)
after her delirium resolved.
# CHRONIC PAIN: Gabapentin and oxycodone were initially held
due to AMS and then resumed on discharge.
# ANXIETY/DEPRESSION: Stable on home venlaflaxine and
hydroxyzine.
Transitional issues:
- Medication changes: decreased amlodipine to 5mg daily and
clonidine patch to 0.1mg/24hr patch due to hypotension after HD,
decreased gabapentin to 300mg QHD for HD dosing, and decreased
lantus to 10u every morning due to low insulin requirement
during hospitalization.
- She is scheduled to follow-up with her PCP and transplant
surgeon after discharge.
- She will continue HD as an outpatient with [**Location (un) **] [**Location (un) **]
Dialysis Center.
Medications on Admission:
1. venlafaxine 75 mg Tablet Sig: as directed Tablet PO once a
day: Take one half ([**11-21**]) tablet daily for 7 days, then increase
to one (1) tablet daily.
Disp:*30 Tablet(s)* Refills:*0*
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever: Do not take more than 2 grams
per day.
Disp:*30 Tablet(s)* Refills:*0*
4. insulin glargine 100 unit/mL Solution Sig: Twenty Three (23)
units Subcutaneous once a day: in the morning.
5. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
7. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. methadone 10 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily).
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: take with meals per previous sliding scale.
13. lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO
every six (6) hours as needed for constipation.
14. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
15. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three
times a day.
Discharge Medications:
1. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Do not exceed 2g in 24 hours.
4. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
qAM.
5. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. methadone 10 mg Tablet Sig: Seven (7) Tablet PO once a day.
9. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain.
11. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: As directed by sliding scale.
12. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every
six (6) hours as needed for Constipation.
13. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*10 Patch 24 hr(s)* Refills:*0*
14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis): Take after hemodialysis.
15. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) patch
Transdermal once a week: Start on Wednesdays.
Disp:*4 patches* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute diastolic heart failure
End stage renal failure
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 93492**],
You were admitted to [**Hospital1 18**] because you were having difficulty
breathing. This likely happened because you missed your
peritoneal dialysis and fluid accumulated in your lungs. You
were admitted to the intensive care unit and were intubated.
You had fluid removed by dialysis and your breathing improved,
and your breathing tube was removed. You had a tunneled line
placed so you can continue to receive dialysis as an outpatient
after you leave the hospital.
We made the following changes to your medications while you were
in the hospital:
-STOP hydroxyzine, loratidine for now as they may cause sedation
and confusion - please talk to your outpatient providers about
when it is safe to restart these medications
-DECREASE amlodipine to 5mg daily
-DECREASE gabapentin to 300mg with hemodialysis
-DECREASE insulin glargine (lantus) to 10 units every morning
-CHANGE your clonidine patch to 0.1mg/24hours patch once a week
(you will need to get new patches)
We made no other changes to your medications while you were in
the hospital. Please continue taking the rest of your
medications as prescribed by your outpatient providers.
Please call your primary care physician to schedule an
appointment within 1 week of leaving the hospital. Please see
below for your currently scheduled appointments at [**Hospital1 18**].
It has been a pleasure taking care of you at [**Hospital1 18**] and we wish
you a speedy recovery.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
WHEN: THURSDAY [**2107-12-15**] AT 9:45 AM
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Phone: [**Telephone/Fax (1) 3581**] 1255
You will be followed by your nephrologist, Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
during your upcoming dialysis appointment:
Chronic Unit-[**Location (un) **] T# [**Telephone/Fax (1) 5972**] F# [**Telephone/Fax (1) 10374**]
Nephrologist-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Schedule-T/T/S
You have the following appointments currently scheduled at
[**Hospital1 18**]:
Department: INFECTIOUS DISEASE
When: FRIDAY [**2107-12-16**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: MONDAY [**2108-1-2**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Known lastname 14758**],[**Known firstname 14759**] Unit No: [**Numeric Identifier 14760**]
Admission Date: [**2107-12-3**] Discharge Date: [**2107-12-13**]
Date of Birth: [**2062-12-20**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins
Attending:[**Doctor First Name 3492**]
Addendum:
Respiratory Failure / Acute Diastolic Heart Failure: The patient
presented with hypoxemic heart failure and considerable A-a
gradient (as evidenced by PO2 of 37 in ED and need for BiPAP).
Pt has no clear history of CHF and echo reflected a structurally
normal heart but given massive volume overload from dialysis
non-compliance heart was unable match output and pulmonary edema
developed. Her respiratory status was transiently stabilized
with BiPAP and supplementary O2 through the first two days of
her hospitalization but due to persistent tachypnea and
respiratory effort she was intubated on [**12-5**]. She was
ventilated with low tidal volume ventilation given concern for
ARDS/[**Doctor Last Name **] (due to significant Aa gradient and slow response to
volume removal) but ultimately she improved significantly over
the ensuing days with further volume removal and was extubated
on [**12-8**] with further resolution of her O2 requirement so that at
discharge she required no supplementary O2 and had clear lung
exam. Ultimate etiology of respiratory failure somewhat unclear
but given ultimate response to volume removal, clear etiology of
volume overload, improvement with NIPPV, and relatively quick
improvement felt most likely to be acute diastolic heart failure
causing pulmonary edema. This was due to massive volume
overload that even her structurally normal heart was unable to
pump forward adequately. [**Doctor Last Name **]/ARDS felt much less likely.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Name6 (MD) **] [**Name8 (MD) 3493**] MD [**MD Number(2) 3494**]
Completed by:[**2108-1-12**]
|
[
"349.82",
"304.00",
"428.31",
"V58.67",
"571.5",
"311",
"584.9",
"799.02",
"V49.87",
"518.81",
"V45.12",
"338.29",
"250.40",
"300.00",
"070.54",
"585.6",
"428.0",
"403.91",
"V70.7",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"39.95",
"38.95",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
17328, 17511
|
5133, 5312
|
305, 378
|
12471, 12471
|
3097, 3158
|
14122, 17305
|
2613, 2683
|
10851, 12279
|
12381, 12450
|
9237, 10828
|
12622, 14099
|
2698, 3078
|
3507, 5110
|
8750, 8752
|
8772, 9211
|
246, 267
|
5327, 8039
|
406, 1999
|
3172, 3493
|
12486, 12598
|
8055, 8729
|
2021, 2370
|
2386, 2597
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,466
| 101,514
|
54538
|
Discharge summary
|
report
|
Admission Date: [**2149-10-8**] Discharge Date: [**2149-10-15**]
Date of Birth: [**2098-5-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Prosthetic aortic valve fungal endocarditis
Major Surgical or Invasive Procedure:
[**2149-10-8**] - Redo Sternotomy, Replace Ascending Aorta and
hemiarch, Reimplant anomalous right coronary artery, Aortic
annulus repair with pericardial patch.
History of Present Illness:
Mr. [**Known lastname **] is a 51-year-old gentleman who underwent aortic valve
replacement with replacement of his ascending aorta in [**2148-11-23**]. He did quite well until [**2149-7-25**] when he started to
develop myalgias and fevers. A workup revealed fungal
endocarditis of this prosthetic aortic valve. Since that time,
he has been on intravenous antimicrobial therapy, and he
presents today for reoperative intervention.
His most recent echocardiogram was from today, which showed a
moderate-sized vegetation on his aortic valve that was trace AI,
trivial MR, and trivial TR. His ejection fraction was 55%. MRI
of his head showed no significant change of the laminar necrosis
and subacute infarct, and his abdominal CT scan showed a wedge-
shaped splenic infarction in the superior spleen.
Past Medical History:
Past medical history is significant for bicuspid aortic valve
and ascending aorta for which he underwent aortic valve
replacement with replacement of his ascending aorta on [**2148-11-23**]. His past medical history is also significant for
hyperlipidemia, varicose veins, and bilateral hernia repair as a
child. He has had embolic cerebral infracts and a splenic
infarct related to his fungal endocarditis.
Social History:
Patient is a cullinary arts professor [**First Name (Titles) **] [**Last Name (Titles) **] [**Location (un) **] of
[**Location (un) 3844**], and lives at home with his wife. [**Name (NI) **] denies
tobacco and IVDU. Denies EtOH use since [**Month (only) 116**]. Per prior notes,
patient has ingested unpasteurized milk, and has had contact
with horses.
Family History:
Significant for one aunt and one uncle with CVAs, and an aunt
with SLE.
Physical Exam:
Physical examination in my office today was pulse of 82,
respirations of 12, and a blood pressure of 90/48. In general,
he was a well-developed and well-nourished male in no acute
distress. He did appear mildly pale in color. His skin was
warm and dry. There was no cyanosis or clubbing. Venous stasis
changes were noted in both lower extremities. His oropharynx
was benign. His teeth were in good repair. His sclerae were
anicteric. His neck was supple with full range of motion.
There was no JVD. Both lungs were clear to auscultation
bilaterally.
Pertinent Results:
[**2149-10-7**] TEE
The left atrium and right atrium are normal in cavity size. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). A bioprosthetic aortic valve
prosthesis is present. There is a moderate-sized vegetation on
the aortic side of the right cusp of the prosthetic aortic valve
measuring 0.9 x 0.7cm. Trace aortic regurgitation is seen. [Due
to acoustic shadowing, the severity of aortic regurgitation may
be significantly UNDERestimated.] The mitral valve appears
structurally normal with trivial mitral regurgitation. No mass
or vegetation is seen on the mitral valve. No masses or
vegetations are seen on the pulmonic valve, but cannot be fully
excluded due to suboptimal image quality. There is no
pericardial effusion.
IMPRESSION: Moderate-sized vegetation on the right cusp of the
prosthetic aortic valve. Normal left ventricular function. Trace
aortic regurgitation.
Compared with the prior study (images reviewed) of [**2149-9-4**],
the vegetation on the right cusp fo the aortic valve appears
larger. The 1cm mass on the ascending aortic graft lumen is not
well-visualized on the current study.
[**2149-10-8**] TEE
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal.
3. The descending thoracic aorta is mildly dilated.
4. A bioprosthetic aortic valve prosthesis is present. There is
a moderate-sized vegetation on the aortic valve. Vegetation is
attached to the right and left coronary cusps.
5. An abscess pocket was noted near the sino-tubular junction
between the right and left coronary cusp just proximal to the
ascending aortic graft. Color flow was noted into this pocket
from the aortic root. Pocket measures 1 x 1.6 cm.
4. The mitral valve leaflets are structurally normal. No mass or
vegetation is seen on the mitral valve.
5. No masses or vegetations are seen on the tricuspid valve, but
cannot be fully excluded due to suboptimal image quality.
6. There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified of results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including Phenylephrine and
briefly on epinephrine. Pt is in a sinus rhythm.
1. A well-seated bioprosthetic valve is seen in the Aortic
position with normal leaflet motion and gradients (Peak gradient
= 20 mmHg). A mild central eccentric AI jet is seen directed
towards the Interventricular septum.
2. An ascending aortic graft is seen.
3. Biventricular function is preserved.
4. Other findings are unchanged.
[**2149-10-15**] 06:13AM BLOOD WBC-8.3 RBC-4.24* Hgb-11.6* Hct-34.8*
MCV-82 MCH-27.3 MCHC-33.2 RDW-16.4* Plt Ct-437
[**2149-10-8**] 02:48PM BLOOD WBC-13.7*# RBC-2.70*# Hgb-7.1*#
Hct-21.9*# MCV-81* MCH-26.3* MCHC-32.4 RDW-16.2* Plt Ct-164#
[**2149-10-14**] 06:55AM BLOOD PT-14.5* INR(PT)-1.3*
[**2149-10-15**] 06:13AM BLOOD UreaN-15 Creat-0.8 K-4.3
[**2149-10-13**] 05:30AM BLOOD Glucose-93 UreaN-16 Creat-0.8 Na-136
K-3.7 Cl-104 HCO3-26 AnGap-10
[**2149-10-9**] 02:22AM BLOOD Glucose-80 UreaN-10 Creat-0.7 Na-136
K-4.1 Cl-108 HCO3-25 AnGap-7*
[**2149-10-11**] 02:42PM BLOOD ALT-26 AST-39 LD(LDH)-307* AlkPhos-108
Amylase-94 TotBili-0.4
[**2149-10-15**] 06:13AM BLOOD ALT-30 AST-36 LD(LDH)-256* AlkPhos-156*
Amylase-106* TotBili-0.2
[**2149-10-11**] 02:42PM BLOOD Lipase-51
[**2149-10-15**] 06:13AM BLOOD Albumin-3.4 Mg-1.9
[**2149-10-9**] 11:09AM BLOOD Albumin-2.9* Calcium-8.1* Mg-2.1
[**2149-10-9**] 05:12PM BLOOD Phenyto-15.7
[**2149-10-15**] 06:13AM BLOOD Phenyto-7.1*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2149-10-8**] for surgical
management of his fungal endocarditis. He was taken directly to
the operating room where he underwent a redo sternotomy with
replacement of his ascending aorta and hemiarch, replacement of
his aortic valve with a pericardial valve, remimplantation of
his anomalous right coronary artery and repair of his aortic
annulus with a pericardial patch. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. His antifungals (voriconazole + Caspofungin) and
antibiotic (Ceftriaxone) were continued. On postoperative night,
Mr. [**Last Name (Titles) **] awoke and was found to have left sided upper
extremity weakness,left sided visual neglect, right upper
extremity myoclonus, and was not able to consistently follow
commands. He remained intubated over night.Dr.[**Last Name (STitle) 914**] was
notified. POD#1 Mr.[**Known lastname **] [**Last Name (Titles) 66413**] appeared to be improving and
he was extubated. Neurology was reconsulted and during the
consultation, Mr [**Known lastname **] appeared to have tonic clonic seizure
activity; with new right sided weakness. He was reintubated to
protect his airway and a head CT scan was done. EEG performed
showed encephalopathy, no seizure activity. Phenytoin was
started. Also that morning his heart rhythm went into rapid
atrial fibrillation and he was treated with IV lopressor and
loaded with Amiodarone and placed on a drip. POD#2 Brain MRI
showed acute right frontal/parietal cortical infarct, in
addition to the previously noted old infarct. No anticoagulation
for AFib per Dr.[**Last Name (STitle) 914**]. Neurology and Infectious Disease
followed Mr.[**Known lastname **] throughout his postoperative course. POD#2 he
was extubated and continued to show neurologic improvement with
deficit resolution. He continued to progress and on POD#4 was
transferred to step down unit for further monitoring and
recovery.His rhythm converted back to sinus with a 1'AVB, LBBB,
unchanged from postoperative EKG. Amio and beta-blocker
adjusted as HR and BP tolerated. [**10-8**] Tissue/Fungal Cxs growing
Scopulariopsis Brevicaulis (same as preop CXs), and ID sent Cx
to [**State **] for drug sensitivities. ABX continued per
ID recommendations with Voriconazole and Caspofungin. Discussed
with Infectious disease Dr.[**Last Name (STitle) 438**] regarding Mr.[**Known lastname **] follow-up
and ABX course. He had a PICC inserted for IV Caspofungin for a
minimum 6 week course or per ID changes when sensitivities come
in. Voriconazole was changed to po dosing for discharge.
Mr.[**Known lastname **] is to follow-up with Dr.[**Last Name (STitle) 438**] 3-4 weeks following
discharge and surveillance labs:LFTs, CBC, ESR,CRP,and
BUN/Creatnine are to be monitored weekly.As per neurolgy
recommendations,Mr.[**Known lastname **] is to follow-up with Dr.[**Last Name (STitle) 78537**] in 2
months as an outpt. and to continue Dilantin until otherwise
advised.POD# 6 Mr.[**Known lastname **] was started on Keflex x 5 days for a
left forearm phlebitis. Mr.[**Known lastname **] continued to progress in his
recovery and on POD# 7 he was discharged to home with VNA/IV
ABX. All follow-up visits were advised.
Medications on Admission:
Voriconazole 300 mg IV twice daily
Caspofungin 50 mg IV once daily
Ceftriaxone 2 g daily
Multivitamin.
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Continue as long as you take narcotics for pain.
Disp:*60 Capsule(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
6. Voriconazole 50 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO QID (4
times a day): Please take for total of 5 days ([**10-14**] was day 1).
Disp:*20 Capsule(s)* Refills:*0*
10. Caspofungin 70 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
Disp:*30 Recon Soln(s)* Refills:*2*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
community health and hospice
Discharge Diagnosis:
Fungal Endocarditis
h/o bicuspid AV s/p AVR(tissue)/Ascending Aorta Replacement
Hyperlipidemia
Varicose veins
Past phlebitis
Bilateral hernia repair
Embolic fungal CVA
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 6 months or unless otherwise cleared by
Neurology
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr.[**Last Name (STitle) 28768**] in 2 weeks
Please follow-up with Dr. [**Last Name (STitle) 111575**] in [**1-27**] weeks. [**Telephone/Fax (1) 111588**]
Please follow-up with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**]: Infectious Disease
Clinic ([**Telephone/Fax (1) 6732**] in [**2-25**] weeks
Please follow-up with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 78537**], Neurology:([**Telephone/Fax (1) 8951**] in 2months
Completed by:[**2149-10-15**]
|
[
"434.91",
"441.2",
"997.02",
"996.62",
"996.61",
"V42.2",
"348.39",
"451.82",
"E878.1",
"780.39",
"117.9",
"427.31",
"746.85",
"421.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.59",
"38.93",
"38.45",
"39.61",
"35.21",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
11625, 11684
|
6686, 9985
|
365, 529
|
11896, 11905
|
2856, 6663
|
12688, 13384
|
2187, 2260
|
10138, 11602
|
11705, 11875
|
10011, 10115
|
11929, 12665
|
2275, 2837
|
282, 327
|
557, 1365
|
1387, 1797
|
1813, 2171
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,514
| 108,728
|
2004
|
Discharge summary
|
report
|
Admission Date: [**2108-12-1**] Discharge Date: [**2108-12-7**]
Date of Birth: [**2047-9-9**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Codeine / Atenolol
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
hypotension/somnolence
Major Surgical or Invasive Procedure:
Placement of central venous line
History of Present Illness:
Mr. [**Known lastname 10983**] is a 61 year old male with past medical history
munchhausens syndrome, anti-social behaviour, possible PTSD who
frequently presents here to ED with hypotension and somnolence.
In the past pt was discovered to have been hording his blood
pressure medication (mainly clonidine) and taking it all at
once. Pt also admitted in the past with eating his clonidine
patch. In the past this had led to multiple ICU admissions, with
ARF and most recently MI as a consequence. This time patient
brought in to the hospital by EMS after being found poorly
responsive.
In the ED his initial vital signs were T 98, BP 120/60, HR 66,
RR 8, O2sat 99%4L. 100 mg hydrocortisone, started on levophed
for subsequent hypotension, kayexilate/insulin/glucose for
hyperkalemia, renal consult for ARF, Vanc/zosyn for possible
sepsis. Bedside FAST u/s was negative for bleeding. Narcane
produced agitation and agressive bahaviour, pt started on
empiric heparin drip for possible PE given history.
ROS not obtained as pt barely arousable.
Past Medical History:
- anti social behaviour leading to discharge from shelters,
- munchhausens syndrome
- s/p STEMI w/ BMS in LAD in [**10-1**], due to GI bleed stopped
plavix cont only aspiring
- Malignant Hypertension: thought to be secondary to medication
non-compliance, but had hypotension during recent admission in
[**10-31**] and BP meds were cut back. (most likely due to Clonidine
effect: overdose/ withdrawal)
- Pulmonary Embolus: Recurrent [**Month/Year (2) 11011**] s/p IVC filter , not on
coumadine due to non compliance
- Heroin abuse: methadone maintenance clinic [**Street Address(2) 11016**]
daily at 7AM (most recent daily dose on [**Month (only) 462**] 135 mg daily.
- Hepatitis B previous infection, now sAg negative
- Hepatitis C, undetectable HCV RNA [**3-29**]
- Chronic obstructive pulmonary disease
- Gastroesophageal reflux disease
- PTSD ([**Country 3992**] veteran)
- Anxiety / Depression
- Antisocial personality disorder
- Microcytic anemia
- Vitamin B12 deficiency
- Chronic kidney disease baseline Cr 1.5
Social History:
[**Country 3992**] veteran. Past heroin abuse, now on methadone. On
disability. Currently living at [**Doctor Last Name **] House.
Family History:
Father died of myocardial infarction at unknown age. Mother died
of pancreatic cancer.
Physical Exam:
VS: T 97.7, BP 112/77, HR 60, RR 18, O2sat 100% RA
GENERAL: caucasian male somnolent, withdraws to pain, resists
eye exam
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP flat
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. bradycardic with RR, and soft heart sounds. No mumur
appreciated though.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, with crackles at
the bilateral bases
ABDOMEN: +BS Soft, NT,ND. No HSM or tenderness.
EXTREMITIES: trace pitting edema bilateral LE.
SKIN: Several excoriations over his extremities and ecchymoses.
Pertinent Results:
Admission labs:
[**2108-12-1**] 01:00PM BLOOD WBC-4.5 RBC-3.04* Hgb-8.6* Hct-25.5*
MCV-84 MCH-28.3 MCHC-33.7 RDW-14.9 Plt Ct-190
[**2108-12-1**] 01:00PM BLOOD Neuts-62.9 Lymphs-24.5 Monos-3.8 Eos-8.1*
Baso-0.8
[**2108-12-1**] 01:00PM BLOOD PT-16.6* PTT-35.6* INR(PT)-1.5*
[**2108-12-1**] 01:00PM BLOOD Glucose-82 UreaN-53* Creat-3.7*# Na-133
K-6.2* Cl-97 HCO3-26 AnGap-16
[**2108-12-1**] 01:00PM BLOOD ALT-12 AST-20 CK(CPK)-468* AlkPhos-71
TotBili-0.4
[**2108-12-1**] 01:00PM BLOOD Lipase-18
[**2108-12-1**] 01:00PM BLOOD cTropnT-0.06*
[**2108-12-1**] 01:00PM BLOOD Calcium-8.5 Phos-6.2*# Mg-2.8*
[**2108-12-2**] 03:59AM BLOOD calTIBC-220* Ferritn-195 TRF-169*
[**2108-12-2**] 02:13PM BLOOD PTH-143*
[**2108-12-1**] CT Head: IMPRESSION: No evidence of acute intracranial
process seen including acute intracranial hemorrhage. Exam is
unchanged from multiple recent prior studies except to note
small locules of gas along the muscles of mastication on the
right, which are of uncertain clinical significance. If acute
infarction remains a concern, MRI would be recommeneded for more
sensitive evaluation.
[**2108-12-1**] CXR:
IMPRESSION: Mild cardiomegaly, with bibasilar atelectasis and
pulmonary
vascular prominance, likely accentuated due to low lung volumes.
No overt
heart failure.
[**2108-12-1**] Bilat Lower extremity ultrasound: IMPRESSION:
1. No evidence of DVT seen in either lower extremity.
2. Interval resolution of thrombosis involving the right common
femoral vein through the right upper calf veins, as seen on most
recent prior ultrasound of [**2108-10-28**].
3. Diffusely decreased respiratory variation in venous waveforms
again
suggestive of more proximal thrombosis.
[**2108-12-1**] Renal US: IMPRESSION: No evidence of hydronephrosis.
Allowing for patient motion, no definite stone or renal mass
seen. Diffusely increased renal echotexture again consistent
with medical renal disease.
[**2108-12-1**] CT abd/pelvis: IMPRESSION:
1. Bibasilar patchy pulmonary opacities, could be consistent
with aspiration, pneumonia, or atelectasis.
2. Cardiac enlargement, with small pericardial effusion.
3. No evidence of abdominal or pelvic hematoma.
4. Expansion and thickening of the IVC (inferior to the IVC
filter), common iliac veins, right external iliac vein, and
right common femoral vein are again consistent with chronic
thrombosis, with many collateral vessels noted along the
anterior abdominal wall.
5. Moderate-to-large amount of stool.
6. Small hyperdense lesions in the right kidney are unchanged,
possibly
representing hyperdense cysts. No evidence of hydronephrosis or
stone noted in the kidneys.
[**2108-12-3**] TTE: The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the distal segments and probable dyskinesis
of the apex. A left ventricular mass/thrombus cannot be
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets appear structurally normal
with good leaflet excursion. The number of aortic valve leaflets
cannot be determined. 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 tricuspid regurgitation jet is
eccentric and may be underestimated. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2108-11-21**],
global LV systolic function is slightly better. The distal
segments remain hypokinetic. The degree of mitral regurgitation
has decreased. The LV thrombus seen on the echo of 10//[**3-31**] is
not seen on the current study.
Brief Hospital Course:
This is a homeless 61 year old male with a past medical history
of medication overdose with clonidine, repeat acute renal
failure and recent STEMI status post bare metal stent to LAD,
hypertension/hyotension, post-tramatic stress disorder, and
depression who presents with hypotension somnolence.
# Hypotension/somnolence: Symptoms consistent with and likely
due to Clonidine overdose (bradycardia, hypotension and
lethargy, miosis). This has occurred before in setting of
patient's Munchausen syndrome. Patient was monitered in the
intensive care unit, with supportive therapy and improvement of
his symptoms, and was stable enough to come to the regular floor
where his outpatient medications were re-started.
.
# Acute on chronic renal failure: Acute on chronic renal
failure, most likely due to hypotension in the setting of
medication overdose. Resolved with IV fluids and supportive
management. Renal was involved.
.
# Anemia: Guiac negative, remained stable.
.
# Chronic systolic congestive heart failure: Remained stable,
maintained outpatient medications.
.
# History of DVT/Recurrent Pulmonary Emboli, status post IVC
filter: Stable.
.
# Chronic Obstructive Airway Disease: Continued outpatient
therapy.
.
# Psychiatric disorder/Post-traumatic stress
disorder/Munchausen's: Social work was involved during hospital
course. Patient should seek outpatient follow up with
psychiatry.
.
# Gastroesophageal reflux disease: Continued outpatient prilosec
20 mg [**Hospital1 **].
Medications on Admission:
Tamsulosin 0.4 mg
Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device
Quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS
Omeprazole 20 mg Capsule, [**Hospital1 **]
Gabapentin 300 mg [**Hospital1 **]
Lisinopril 5 mg
Metoprolol Succinate 25 mg Tablet Sustained Release
Methadone 135 mg PO daily ([**Street Address(1) 11017**] clinic)
Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler \
Duloxetine 60 mg Capsule, Delayed Release once a day.
Clonazepam 2 mg Tablet Sig: One Tablet PO three times a day.
Aspirin 81 mg Tablet
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Methadone 10 mg Tablet Sig: One [**Age over 90 10973**]y Five (135) mg
PO DAILY (Daily).
11. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Toxic ingestion
Secondary:
Muchausen's Syndrome
Coronary artery disease
[**Last Name (un) 11020**] systolic congestive heart failure
Discharge Condition:
Good. Patient with stable vital signs.
Discharge Instructions:
You were admitted with toxic ingestion of your outpatient
medications. You were monitered and managed supportively with
improvement in your symptoms.
Please take medications AS DIRECTED.
Please follow up with [**Last Name (un) 4314**] as directed.
Please contact physician if develop chest pain/pressure,
shortness of breath, fevers/chills, any other questions or
concerns.
Followup Instructions:
Please follow up with these previously scheduled [**Last Name (un) 4314**]:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2108-12-18**] 2:00
Provider: [**Name10 (NameIs) 11021**] [**Name11 (NameIs) 11022**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-12-27**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-12-27**] 3:00
|
[
"304.01",
"428.0",
"414.01",
"584.9",
"V45.82",
"276.7",
"301.51",
"780.09",
"428.22",
"403.90",
"E858.3",
"496",
"410.92",
"301.7",
"309.81",
"972.6",
"285.21",
"V60.0",
"530.81",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10756, 10829
|
7201, 8693
|
313, 348
|
11016, 11058
|
3384, 3384
|
11484, 12028
|
2632, 2722
|
9325, 10733
|
10850, 10995
|
8719, 9302
|
11082, 11461
|
2737, 3365
|
251, 275
|
376, 1423
|
4110, 7178
|
3400, 4101
|
1445, 2467
|
2483, 2616
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,281
| 122,888
|
23258
|
Discharge summary
|
report
|
Admission Date: [**2185-9-16**] Discharge Date: [**2185-9-28**]
Date of Birth: [**2117-5-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Acute, severe abdominal pain
Major Surgical or Invasive Procedure:
ERCP - [**2185-9-17**]
Exploratory laparotomy, lysis of adhesions, partial small bowel
resection, Roux-en-Y cholecystoenterostomy - [**2185-9-20**]
History of Present Illness:
68 yo male with a histoy of gallstone pancreatitis and
pancreatic abscess drainage [**12-16**], presented with severe
abdominal pain on [**2185-9-16**] since 7 PM the night before. He
described it as constant, radiating to his chest and RUQ, with
some mild radiation to his back between his shoulder blades. He
denied any fever, chills, nausea, vomiting, constipation, or
diarrhea. He also denied any shortness of breath or diaphoresis.
He had been tolerating a regualr diet at home.
Past Medical History:
DVT and PE
gallstone pancreatitis
diverticulosis
liver cysts s/p partial hepatectomy
BPH
dyslipidemia
Social History:
Lives with his wife. Denies tobacco. Occasional EtOH.
Family History:
non-contributory
Physical Exam:
On admission:
99.0F 65 114/75 20 94%RA
A&O X 3, NAD
NC/AT, PERRL, EOMI, sclera anicteric
Heart irregular, some missed beats, no murmur appreciated
Lungs CTAB, no w/r/r
Abd soft, mild tenderness to palpation in epigastric region and
RUQ. - [**Doctor Last Name 515**],
no masses felt, no hernias, +BS x 4, no guarding or rebound
tenderness. Old scar inferior to R. costal margin.
Ext. no c/c/e, distal pulses 2+ b/l
Rectal- normal tone, heme negative
Pertinent Results:
POTASSIUM-4.0 LIPASE-148*
GLUCOSE-108* UREA N-19 CREAT-0.9 SODIUM-140 POTASSIUM-5.4*
CHLORIDE-107 TOTAL CO2-22 ANION GAP-16
ALT(SGPT)-95* AST(SGOT)-187* CK(CPK)-122 ALK PHOS-183*
AMYLASE-324* TOT BILI-1.4
LIPASE-951* cTropnT-<0.01 CK-MB-2
ALBUMIN-4.1 CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-2.0
WBC-10.2# RBC-4.69# HGB-14.3# HCT-42.0# MCV-90# MCH-30.5
MCHC-34.0 RDW-13.4
PLT SMR-LOW PLT COUNT-126* PT-19.7* PTT-29.5 INR(PT)-2.6
WBC-11.8* RBC-4.27* Hgb-13.1* Hct-37.9* MCV-89 MCH-30.5
MCHC-34.4 RDW-13.1 Plt Ct-158
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
RUQ US ([**9-16**]): Cholelithiasis, without evidence of cholecystitis.
Six mm, nonobstructing stone within the mid pole of the right
kidney.
ERCP ([**9-17**]): The common duct, left hepatic duct, and cystic duct
appeared normal. 3 stones are noted in the gallbladder, one of
which was located in the gallbladder neck. By report,
sphincterotomy was performed.
Bilateral LE US ([**9-22**]): No evidence of deep venous thrombosis
Brief Hospital Course:
On [**2185-9-16**], Mr. [**Known lastname 59755**] was admitted to the Gold Surgery
service with acute gallstone pancreatitis under the care of Dr.
[**Last Name (STitle) **]. He was made NPO, hydrated, and started on IV
antibiotics. On HD 1, he was noted to have PVC's while on
telemetry. His EKG showed an irregular rhythm with a rate of 70
BPM, unchanged from previous EKGs. He complained of some mild
chest pain and RUQ pain that he has had since admission, and his
cardiac enzymes were all normal. This irregular rhythm was
noticed on admission and was monitored.
Overnight on HD 1, Mr. [**Known lastname 59755**] received 6 Units of FFP and
vitamin K for an INR of 2.6, in preparation for an ERCP the
following day. On HD 2 he underwent an ERCP by Dr. [**Last Name (STitle) 59756**] that
showed 3 stones in the gallbladder and a possible filling defect
in the CBD. A sphincterotomy was performed. For the next 2 days,
the patient remained stable on the floor. He was transfused 4
more units of FFP and 1 unit of platelets. He was scheduled for
the OR for an exploratory laparotomy and probable open
cholecystectomy on [**2185-9-20**].
On [**2185-9-20**] Mr. [**Known lastname 59755**] went to the OR. Because of his history
of severe pancreatitis, there were tenuous adhesions of the
bowel in the whole abdomen.
The gallbladder was firm and showed evidence of chronic
cholecystitis with a rubbery thick wall. It was plastered to the
edge of the liver and was almost indistinguishable from that
capsule. The duodenum was plastered to the porta hepatis and to
the cystic duct area. The ductal orifice was socked in
inflammation. Multiple stones were felt in the gallbladder and
at that point it was obvious that an open cholecystectomy would
be impossible. It was then decided to perform an internal
drainage procedure and removal of the gallstones. In order to do
this, the lower abdomen had to be completely unadhesed. There
were multiple onerous adhesions to the
anterior abdominal wall and small bowel that was a set up for a
torsion or obstruction in the future. A primary resection of 1
foot of small bowel was performed and re-anastomosed. The
gallbladder was finally drained with a Roux limb side-to-side
cholecystoenterostomy.
POD 1, Mr. [**Known lastname 59755**] spent in the ICU because of the extent of
surgery and the fact that he experienced a SBP drop in the OR to
approximately 70. He did very well and was extubated on POD 1.
He was transferred to the floor. A vascular consult was obtained
because of his history of DVT/PE. LE US was performed that
showed no evidence clot progression. His pain was well
controlled with PCA morphine. He did have a postoperative fever
of 100.7. All cultures were negative Sips of clear liquids were
started on POD 5. He did very well and his diet was advanced
slowly over the next 2 days. Pain control was switched to po
Percocet and he did very well. He had been OOB and ambulating
with PT. He was discharged home on POD 8 with home PT and
follow-up with Dr. [**Last Name (STitle) **] in [**3-17**] weeks.
Medications on Admission:
Coumadin 5mg alternating with 7.5mg QD
Flomax
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. 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*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Gallstone pancreatitis
Discharge Condition:
Good
Discharge Instructions:
Please resume all pre-hospital medications EXCEPT Coumadin. You
do not need to take this anymore. Please call your doctor or go
to the ER if you experience any high fever >101.5F, severe pain,
worsening nausea and vomiting, or foul smelling/pus from wound.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**3-17**] weeks. Call
[**Telephone/Fax (1) 1231**] for an appointment.
|
[
"577.1",
"458.29",
"568.0",
"999.8",
"574.81",
"600.00",
"575.3",
"998.2",
"593.2",
"577.0",
"V12.51",
"553.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.91",
"53.51",
"00.17",
"51.32",
"45.51",
"54.59",
"99.07",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
6418, 6481
|
2804, 5868
|
342, 492
|
6548, 6554
|
1731, 2781
|
6859, 6989
|
1220, 1238
|
5964, 6395
|
6502, 6527
|
5894, 5941
|
6578, 6836
|
1253, 1253
|
274, 304
|
520, 1005
|
1268, 1712
|
1027, 1130
|
1146, 1204
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,009
| 181,341
|
30774
|
Discharge summary
|
report
|
Admission Date: [**2132-11-19**] Discharge Date: [**2132-11-25**]
Date of Birth: [**2058-2-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ativan / Demerol
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheobronchomalacia.
Major Surgical or Invasive Procedure:
[**2132-11-19**]: Right thoracotomy and thoracic tracheoplasty with
mesh, left mainstem bronchoplasty with mesh, right mainstem
bronchus and bronchus intermedius bronchoplasty with mesh,
flexible bronchoscopy with aspiration.
[**2132-11-21**]: Flexible bronchoscopy with therapeutic
aspiration.
History of Present Illness:
Mr. [**Known lastname 72853**] is a 74-year-old gentleman who has had a history of
severe dyspnea. He underwent stent trial after it was discovered
that he had
severe diffuse tracheobronchomalacia. This stent trial was
positive in the sense that he had marked improvement in his
overall symptoms. He had less dyspnea, less choking sensations
and less orthopnea as well. Prior to the airway
surgery, we did correct his reflux which was severe via
laparoscopic fundoplication. He now presents for correction of
his tracheobronchomalacia.
Past Medical History:
Trachael Bronchiomalasia
Myocardial infarction [**2130**] s/p cath (? stent)
Hypertension
Hypercholesterolemia,
BPH
PSH: multiple bronchoscopies [**2130**], s/p Y stent placement and
removal, Cholecystectomy (35 yrs), appy, ventral hernia repair
(20 yrs), back surgery [**2107**] and [**2114**], RLE varicose veins (40
yrs)
Social History:
The patient lives alone, used to work in a steel shop, smoked
for
a 60-pack-year history, quit 30 years ago. Questionable history
of extensive alcohol use
Family History:
non-contributory
Physical Exam:
VS: T; 96.0 HR: 66 SR BP: 140/70 Sats: 98% 2L
General: 74 year-old male no apparent distress
HEENT: normocephalic
Neck: supple, no lymphadenopathy
Card; RRR
Resp: scattered rhonchi right lower lobe otherwise clear
GI:benign
Extr: warm no edema
Incision: Right thoracotomy site w/staple clean, dry intact
Neuro: non-focal
Pertinent Results:
[**2132-11-24**] WBC-8.8 RBC-4.24* Hgb-11.4* Hct-34.2* Plt Ct-420
[**2132-11-23**] WBC-8.9 RBC-4.13* Hgb-11.0* Hct-33.5* Plt Ct-380
[**2132-11-19**] WBC-13.8* RBC-4.47* Hgb-11.6* Hct-35.2* Plt Ct-293
[**2132-11-19**] Neuts-88.8* Lymphs-4.8* Monos-6.3 Eos-0.1 Baso-0.1
[**2132-11-24**] Glucose-116* UreaN-15 Creat-0.9 Na-142 K-4.3 Cl-107
HCO3-28
[**2132-11-23**] Glucose-85 UreaN-20 Creat-0.9 Na-140 K-4.1 Cl-104
HCO3-28
[**2132-11-19**] Glucose-142* UreaN-15 Creat-1.0 Na-136 K-4.3 Cl-104
HCO3-25
[**2132-11-20**] CK(CPK)-1398* [**2132-11-20**] CK(CPK)-1238*
[**2132-11-24**] Calcium-8.5 Phos-2.9 Mg-2.1
[**2132-11-19**] MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2132-11-22**]): No MRSA isolated.
CXR:
[**2132-11-23**]: FINDINGS: As compared to the previous radiograph,
there is no relevant change. Unchanged clips in the right chest
wall. The lung volumes are slightly increased, the pleural
effusions have slightly decreased. No newly occurred focal
parenchymal opacities suggestive of pneumonia. Unchanged size of
the cardiac silhouette.
[**2132-11-23**]: There are small bilateral effusions, left greater than
right. Skin staples are again seen on the right. There is no
pneumothorax.
[**2132-11-21**]: In comparison with the study of [**11-20**], the right chest
tube has
been removed. No evidence of pneumothorax.
[**2132-11-19**]: From the right, both pleural drain and the chest tube
are
inserted into the right hemithorax. There is moderate soft
tissue air
collection extending to the cervical soft tissues. The
evaluation of the lung itself is impaired by moderate motion
artifact. There is no visualization of pneumothorax. The left
costophrenic sinus is blunted by a small pleural effusion. No
effusion is seen on the right. Relatively low lung volumes with
moderate cardiomegaly, but without overt signs of overhydration.
Moderate retrocardiac atelectasis
Brief Hospital Course:
Mr. [**Known lastname 72853**] was admitted on [**2132-11-19**] for Right thoracotomy and
thoracic tracheoplasty with mesh, left mainstem bronchoplasty
with mesh, right mainstem bronchus and bronchus intermedius
bronchoplasty with mesh, flexible bronchoscopy with aspiration.
He was extubated in the operating and transferred to the SICU
for further postoperative management. The chest-tube was to
suction followed by serial chest films a foley, and NGT. He had
an Epidural Bupivacaine 0.25% + Dilaudid 0.2mg managed by the
acute pain service. On POD1 his pain was not well controlled
and the bupivacaine was increased to 1%. He was seen by Speech
and Swallow but they deferred evaluation secondary to large
amount of secretions. On POD2 he a Flexible bronchoscopy with
therapeutic aspiration. He was again seen by Speech and Swallow
and he had nos/SX of oropharyngeal dysphagia or aspiration. He
was started on a clear liquid diet and advanced as tolerated.
The epidural was split with a Dilaudid PCA. The chest tube was
removed and follow-up chest film revealed no pneumothorax. On
POD3 the epidural was removed. His PCA was converted to PO pain
medication with good results. He transferred to the floor. His
home medications were restarted. On POD4-5 the foley was
removed. He failed to void and the foley was re-inserted. His
flomax was restarted. He required aggressive pulmonary toilet
and nebulizers. He was seen by physical therapy who recommended
rehab. His lytes were repeated as needed. He was in sinus
rhythm throughout his hospital course.
Medications on Admission:
Plavix 75mg daily, atorvastatin 20mg daily, fish oil 1000mg
daily lisinopril 2.5mg daily,l lopressor 25mg [**Hospital1 **], ranitidine
150mg [**Hospital1 **], flomax 0.4mg daily, Irbesartan 75mg daily, mucomyst
nebs"
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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 BID (2 times a day).
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ML Inhalation Q6H (every 6 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: Three (3) ML
Inhalation Q6H (every 6 hours).
8. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO daily ().
13. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q6H (every 6 hours).
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Tracheobronchomalacia.
Myocardial infarction [**2130**]
Hypertension/Hyperlipidemia
GERD/Barrett's Esophagus
BPH
PSH: Y stent placement and removal [**2130**]
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage. Staples removal in office
You may shower. No tub bathing or swimming for 6 weeks
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2348**] Date/Time:[**2132-12-9**]
11:00am on the [**Hospital Ward Name 121**] Building, [**Hospital1 **] I Chest Disease Center.
Report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology
Department for a Chest X-Ray 45 minutes before your appointment.
Follow-up with Dr. [**Last Name (STitle) 11623**] PCP [**Telephone/Fax (1) 72854**]
Completed by:[**2132-11-26**]
|
[
"412",
"V45.82",
"786.09",
"338.18",
"272.0",
"414.01",
"600.00",
"401.9",
"V12.51",
"530.85",
"519.19",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"38.91",
"31.79",
"96.05",
"33.48"
] |
icd9pcs
|
[
[
[]
]
] |
7021, 7107
|
4018, 5585
|
309, 608
|
7310, 7326
|
2095, 3995
|
7642, 8108
|
1712, 1730
|
5856, 6998
|
7128, 7289
|
5611, 5833
|
7350, 7619
|
1745, 2076
|
246, 271
|
636, 1174
|
1196, 1523
|
1539, 1696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,624
| 152,128
|
43868
|
Discharge summary
|
report
|
Admission Date: [**2114-5-19**] Discharge Date: [**2114-5-23**]
Date of Birth: [**2070-8-1**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
dark stools
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy with Varceal Banding
History of Present Illness:
43 y/o m with h/o HCV, Cirrhosis, EtOH abuse, Esophageal Varices
grade III s/p banding in apst year, IVDA p/w dark stools, nausea
and vomiting since morning of admission. Vomitied coffee ground
appearing material, was unable to tolerate po intake. Then
developed foul smelling diarrhea with black stool and clots
present. He reports increased EtOH consumption in past 2-3 days.
Denies fever/chills/abd pain. Last drink was evening of [**5-18**].
Denies lightheadedness but reports feeling weak. No
falls/LOC/headache. No recent NSAID use.
He called his hepatologist who told him to go the ED. Presented
to OSH with HR 124, BP 157/81 and hematocrit down to 19%.
Started on IV protonix, octreotide gtt, IVF, trasfused 1UPRBCs
and transferred to [**Hospital1 18**].
In [**Hospital1 18**] ED HR 110-125 BP 164/100 given 4-5 L IVF and admitted
to MICU for emergent EGD.
Past Medical History:
1. HCV Infection: last VL 52,800 [**11-7**]; genotype
2. Grade 3 esophageal varices with multiple admissions for GIB
3. Ethanol abuse with history of DTs.
4. Nephrolithiasis.
5. MVA [**2113-5-4**] with two fractured lumbar vertebrae, torn
rotator cuff, and humeral head fracture.
Social History:
+tobacco 30 pack years; no IVDA now but +cocaine/heroin use in
past; +etoh abuse past and present; sexually active monogamously
with female partner; works as carpenter and fisherman; hx of
incarceration in the past.
Family History:
noncontributory
Physical Exam:
T afeb HR 110-125 BP 164/80 R 17 sat 100% RA
gen: anxious, diaphoretic, A+OX3
HEENT: anicteric, dry mm
CV: tachycardic, regular, no m/r/g
pulm: decreased BS at bases bilat, otherwise CTA
abd: s/nt/ slightly distended, no HSM +BS
ext no edema, 2+ pulses
skin: spider angiomas
neuro: CN 2-12 intact, no asterixis, sensation intact, strength
[**5-9**] bilat
Pertinent Results:
[**2114-5-19**] 10:10PM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2114-5-19**] 10:10PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2114-5-19**] 10:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2114-5-19**] 08:50PM GLUCOSE-123* UREA N-20 CREAT-0.6 SODIUM-141
POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
[**2114-5-19**] 08:50PM ALT(SGPT)-37 AST(SGOT)-82* ALK PHOS-84 TOT
BILI-1.5
[**2114-5-19**] 08:50PM WBC-6.7 RBC-2.66*# HGB-6.6*# HCT-21.8*#
MCV-82# MCH-24.8*# MCHC-30.3* RDW-18.2*
[**2114-5-19**] 08:50PM NEUTS-71.0* LYMPHS-23.2 MONOS-5.4 EOS-0.1
BASOS-0.2
[**2114-5-19**] 08:50PM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MICROCYT-2+
[**2114-5-19**] 08:50PM PLT COUNT-85*
[**2114-5-19**] 08:50PM PT-15.6* PTT-32.4 INR(PT)-1.6
EGD: ([**2114-5-20**])
Varices at lower third of the esophagus, grade II-III, with
stigmata of recent bleeding including cherry red spots, 3
variceal bands were placed successfully. Gastric Antral Vascular
Ectasia noted.
Brief Hospital Course:
1. variceal bleed: presented with melena, significant
tachycardia, and hct 19%. Emergent EGD revealed grade [**2-6**]
varices with stigmata of recent bleeding, 3 bands were placed
successfully. Treated with IV protonix, and octreotide gtt for 5
days, and nadalol. Was also treated with cipro to prophylax
against transient bacteremia. Recieved a total of 6U PRBCs, hct
remained stable for 48 hours prior to discharge. He will follow
up with Dr. [**First Name (STitle) **] on [**6-12**] for follow up EGD.
2. EtOH abuse: was started on valium per CIWA scale which was
tapered as an inpatient, advised to abstain from EtOH as this
will not only worsen his liver failure it may precipitate a life
threatening variceal bleed again. Seen by [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**] and
given numbers of detox programs and shelters. Continued on B12,
folate, MVI.
3. thrombocytopenia: platelets stable at 79, chroniclly low
likely due to cirrhosis and hypersplenism
4. cirrhosis: continue nadalol 40 mg, f/u EGD [**6-12**] with Dr. [**First Name (STitle) **],
contuned on cipro for 2 more days after d/c for SBP ppx.
5. FEN: B12/folte/MVI
6. dispo: to home, f/u Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **]
Medications on Admission:
Carafate 1g qid
Spironolactone 25 mg daily
nadalol 120 mg daily
folate
MVI
thiamine
protonix 40 mg [**Hospital1 **]
Discharge Medications:
1. 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*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
4. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
Disp:*30 Cap(s)* Refills:*2*
5. Nadolol 40 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophageal Variceal Bleed
EtOH abuse with h/o withdrawl seizures
Hepatitis C Virus Infection
Cirrhosis
Discharge Condition:
stable
Discharge Instructions:
Please call or return if your symptoms worsen. Please take your
medications as listed below. Please make your follow up
appointments as listed below.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2114-5-31**] 1:30
2. Provider: [**Name10 (NameIs) 12161**] [**Name8 (MD) **], MD Where: [**Hospital Ward Name 121**] Building [**Location (un) **].
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2114-6-7**] at 12 pm for a follow up
EGD.
|
[
"291.81",
"070.51",
"303.91",
"724.5",
"287.5",
"285.1",
"571.2",
"289.4",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.05",
"96.71",
"42.33",
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
5394, 5400
|
3366, 4626
|
321, 371
|
5547, 5556
|
2235, 3343
|
5754, 6152
|
1822, 1840
|
4793, 5371
|
5421, 5526
|
4652, 4770
|
5580, 5731
|
1855, 2216
|
270, 283
|
399, 1268
|
1290, 1572
|
1588, 1806
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,050
| 118,833
|
13170
|
Discharge summary
|
report
|
Admission Date: [**2132-8-20**] Discharge Date: [**2132-8-27**]
Date of Birth: [**2050-2-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
sternotomy, aortic valve replacement with a [**Street Address(2) 11688**]. [**Hospital 923**]
Medical Bicor epic tissue heart valve.
History of Present Illness:
82 year old male s/p coronary artery bypass surgery with aortic
stenosis who has been followed by Dr. [**Last Name (STitle) 5017**] with serial
echocardiograms. Patient has noticed worsening symptoms of
dyspnea on exertion with some fullness in
his chest with exertion. His most recent echo showed severe
aortic stenosis. In preparation for surgery he underwent a
cardiac cath which showed native coronary disease and occluded
saphenous vein graft to obtuse marginal. He presents today after
randomizing to surgical arm of CORE valve study for redo
sternotomy/AVR/?CABG.
Past Medical History:
Atrial fibrillation
Hyperlipidemia
Diabetes Mellitus
Hypertension
BPH
Prostate Ca s/p TURP/XRT [**11-18**], receiving testosterone shots
Sleep apnea on CPAP
Coronary artery disease s/p coronary artery bypass graft x 4,
s/p 2 stents to SVG to RCA [**5-19**], s/p stent at anastomosis of SVG
to LAD and stent to proximal SVG to LAD [**11-20**], s/p LCx/?OM stent
and LM stenting [**2127-12-8**]
s/p coronary artery bypas graft x4
Cholecystectomy [**2117**]
Nephrolitiasis [**2128**]
Surgery: coronary artery bypas graft x 4
[**Hospital1 18**]- Dr [**First Name (STitle) 10102**] Date: [**2111**]
Social History:
-Denies toxic habits currently
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Pulse: 51 Resp: 18 O2 sat: 96% RA
B/P Right: 112/75 Left: 143/67
Height: 68" Weight: 82.8kg
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 [X] grade [**1-21**]
Abdomen: Soft [X] non-distended [X] non-tender [X] +BS [X]
Extremities: Warm [X], well-perfused [X] -open incision from
vein
harvest healed on RLE
Edema/Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: Right: - Left: -
Pertinent Results:
[**2132-8-21**] TEE
Pre-Bypass:
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (estimated LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. There are simple atheroma in the ascending aorta and
aortic arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are focal calcifications throughout the
aorta.
There are three aortic valve leaflets. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area calculated 0.7cm2). Trace aortic
regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
Post-Bypass
The patient is A-V paced on a phenylephrine infusion.
There is a well seated bioprosthetic valve in the aortic
position. Two paravalvular leaks persist after protamine
administration, one where the noncoronary cusp would have been,
and one at the former commissure between left and non-coronary
cusps. Peak and mean gradients through the valve are 17/7 with a
calculated cardiac output of 3.4L/min.
Left ventricular function is preserved with estimated EF > 55%.
There is no echocardiographic evidence of an aortic dissection
after de-cannulation.
The mitral regurgitation remains trace. The remainder of the
exam is unchanged.
[**2132-8-26**] 05:49AM BLOOD WBC-7.0 RBC-3.46* Hgb-10.4* Hct-30.6*
MCV-89 MCH-30.1 MCHC-34.0 RDW-15.7* Plt Ct-131*
[**2132-8-24**] 01:03AM BLOOD PT-12.7* PTT-33.6 INR(PT)-1.2*
[**2132-8-25**] 03:31AM BLOOD PT-14.9* PTT-41.1* INR(PT)-1.4*
[**2132-8-26**] 05:49AM BLOOD PT-38.0* INR(PT)-3.7*
[**2132-8-26**] 05:49AM BLOOD Glucose-85 UreaN-16 Creat-1.1 Na-138
K-3.6 Cl-101 HCO3-28 AnGap-13
[**2132-8-23**] 12:47AM BLOOD ALT-8 AST-36 AlkPhos-29* Amylase-24
TotBili-0.6
[**2132-8-26**] 05:49AM BLOOD Mg-2.1
Brief Hospital Course:
82 year old male s/p coronary artery bypass surgery now with
aortic stenosis. His most recent echo showed severe aortic
stenosis. In preparation for surgery he underwent a cardiac cath
which showed native coronary disease and occluded saphenous vein
graft to obtuse marginal. He was randomized to surgical arm of
CORE valve study for redo sternotomy AVR/ possible CABG.
On [**2132-8-21**] the patient went to the operating room where the he
underwent Redo sternotomy, aortic valve replacement with a [**Street Address(2) 40172**]. [**Hospital 923**] Medical Bicor epic tissue
heart valve. Please see operative note for further details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition. He arrived paced over slow junctional rhythm, on
pressors, hematocrit was low and he was transfused two units of
cells. He was hypoxic and confused and remained intubated until
POD#1. He extubated without difficulty. His confusion resolved
and narcotics were minimized. He remained weak after surgery but
neurologically intact. Chest tubes and pacing wires were
discontinued without difficulty. While in the unit he returned
to sinus rhythm with first degree atrial block and proceeded to
developed rapid afib that was difficult to control. He was
started on amiodarone and lopressor was increased. He remain
aystomatic and hemodynamically stable. He was also started on
coumadin and his INR was found to increase quickly even after
low doses of it. He was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD six the patient was ambulating with
assistance, the wound was healing and pain was controlled with
oral analgesics. The patient was discharged to [**Hospital1 **] Health
Center in good condition with appropriate follow up
instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Amoxicillin 500 mg PO PRN dental prophylaxis
2. fosinopril *NF* 40 mg Oral daily
3. ketotifen fumarate *NF* 0.025 % OU [**Hospital1 **]
2 gtts
4. Leuprolide Acetate 7.5 mg IM MONTHLY
5. Amlodipine 5 mg PO DAILY
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Sertraline 100 mg PO DAILY
10. GlipiZIDE XL 10 mg PO DAILY
11. Metoprolol Tartrate 50 mg PO BID
12. Nitroglycerin SL 0.3 mg SL PRN angina
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. GlipiZIDE 10 mg PO DAILY
3. Rosuvastatin Calcium 10 mg PO DAILY
4. Acetaminophen 650 mg PO Q4H:PRN pain/fever
5. Amiodarone 400 mg PO DAILY
taper to 200mg daily on [**2132-9-3**]
6. Bisacodyl 10 mg PR DAILY:PRN constipation
7. Cepacol (Menthol) 1 LOZ PO PRN sore throat
8. Diltiazem 60 mg PO QID
9. Docusate Sodium 100 mg PO BID
10. Furosemide 20 mg PO BID
11. Milk of Magnesia 30 ml PO HS:PRN constipation
12. Potassium Chloride 20 mEq PO Q12H
Hold for K+ > 4.5
13. Warfarin MD to order daily dose PO DAILY
goal INR 1.8-2.0
very sensitive to coumadin dosing
14. Amlodipine 2.5 mg PO DAILY
15. Pantoprazole 40 mg PO Q24H
16. ketotifen fumarate *NF* 0.025 % OU [**Hospital1 **]
2 gtts
17. Leuprolide Acetate 7.5 mg IM MONTHLY
18. Sertraline 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital 40173**] health center
Discharge Diagnosis:
Critical symptomatic aortic
stenosis, status post coronary artery bypass surgery.
Critical symptomatic aortic
stenosis, status post coronary artery bypass surgery.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, with assit of one
Sternal pain managed with oral analgesics
sternal incision: cleam and dry without drainage
Extremities: trace lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr.[**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2132-9-24**] 1:00pm in the [**Hospital Ward Name **] office building [**Hospital Unit Name **]
Cardiologist Dr. [**Last Name (STitle) 5017**] in [**12-17**] weeks: please call to schedule
a follow up appointment.
Dr.[**Name (NI) 32659**] office will contact you to schedule a follow up
appointment.
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Plaese call to schedule an appointment with Dr. [**First Name (STitle) 17859**]
[**Telephone/Fax (1) 40171**] in 2 weeks or upon discharge from rehab.
Completed by:[**2132-8-27**]
|
[
"E878.2",
"424.1",
"V13.01",
"V70.7",
"426.11",
"997.1",
"799.02",
"272.4",
"V15.3",
"V10.46",
"414.02",
"250.02",
"V45.82",
"285.9",
"293.0",
"327.23",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"38.93",
"33.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8109, 8170
|
4760, 6631
|
295, 430
|
8378, 8573
|
2525, 4737
|
9197, 9944
|
1716, 1734
|
7295, 8086
|
8191, 8357
|
6657, 7272
|
8597, 9174
|
1765, 2506
|
235, 257
|
458, 1031
|
1053, 1651
|
1667, 1700
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,901
| 189,210
|
29130
|
Discharge summary
|
report
|
Admission Date: [**2101-6-21**] Discharge Date: [**2101-7-13**]
Date of Birth: [**2028-11-15**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Esophageal Cancer/Barrett's Esophagus
Major Surgical or Invasive Procedure:
Transhiatal esophagectomy with feeding jejunostomy.
History of Present Illness:
Mrs. [**Known lastname **] is a 72-year-old woman, with scleroderma and an
immobile esophagus, who has been followed for Barrett's changes
in the distal esophagus. Recently, she was noted to have
high-grade dysplasia. She underwent an
attempt at ablative therapy; however, this was unsuccessful
with repeat biopsy continuing to show high-grade dysplasia. She
was referred for transhiatal esophagectomy.
Past Medical History:
CREST syndrome (GERD/Barrett's Esophagitis/Raynauds/Scleroderma)
Dilated Esophageal Stricture [**2076**]
Right Rotator Cuff Repair
Left shoulder Replacement
Hysterectomy
Social History:
Lives with spouse, retired.
Physical Exam:
General: 72 year-old thin well groomed female in no added
distress
HEENT: unremarkable
Resp: clear to auscultation bilaterally
Cardiac: regular rate & rhythm, normal S1, S2 no murmur/gallop
or rub
GI: bowel sounds present, abdomen soft,
non-tender/non-distended
Extremities: warm, dry no edema
Neuro: Awake, alert & oriented
Pertinent Results:
[**2101-6-30**]: UGI
IMPRESSION:
1. Status post total esophagectomy. Findings are concerning for
fistula from the anastomosis to the trachea with barium noted in
the left mainstem brochus.
2. Small amount of laryngeal penetration was noted in the barium
swallow study. No frank aspiration was identified. The barium in
the left mainstem bronchus is thus unlikely due to aspiration.
3. Partial small bowel obstruction with transition point in the
proximal jejunum.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 73 year-old female with Barrett's with dysplasia
who was taken to the operating room on [**2101-6-21**] for a
Transhiatal esophagectomy, pyloroplasty and feeding jejunostomy.
She was admitted to the surgical intensive care unit,
intubated, sedated, JP in place and hemodynamically stable.
During the night she was transfused with 2 units of packed red
blood cells for a Hct of 24 and post infusion HCT 31. Pain
service was consulted and her pain was well controlled on an
epidural and prn pain medication. On post-operative day 1 she
was extubed and started on a beta-blocker for a brief episode of
atrial fibrillation. On post-operative day 2 tube feeds were
started via J-tube and advanced as tolerated. Physical therapy
was consulted and the patient continued to make steady progress.
Post-operative x-rays showed left lower lobe collapse; the
patient remained stable on 3 L of oxygen by nasal canula, with
frequent chest PT and incentive spirometry.
On post-operative day 3, the patient was transferred to the
floors; she also underwent ultrasound guided thoracentesis, with
700 cc of bloody fluid removed from the left pleural
space.Another thoracentesis was performed on [**2101-7-1**] on the
right side, and 650 cc of serosanguineous fluid was removed.
Again, a left sided ultrasound guided thoracentesis weas
performed on [**2101-7-2**]; 550 cc of serosanguineous fluid was
removed. On post-operative day 6, the patient developed some
righ hand pain; plastic surgery (hand), and rheumatology were
consulted who recommended adequate pain control for symptoms
consistent with pseudogout. The patient also began having
episodes of post-tussive emesis, so tube feeds were temporarily
stopped, and a KUB was ordered. On the following day, the
patient developed atrial fibrillation with rapid ventricular
response, and received Mg, K, and an amiodarone drip was
started; cardiology was consulted.
On a follow up barium swallow on post-operative day 10, it
appeared as though the patient had developed a
tracheo-esophageal fistula. She was made NPO, in preparation
for the operating room, where the neck wound was explored and
opened. It was determined intraoperatively that there was no
anastamotic leak. Frequent (3-4 times per day) dressing changes
were performed with good result.
On [**2101-7-8**], the patient was taken for esophageal stenting with
good result.
Medications on Admission:
Lisinopril 2.5 mg once daily
Procardia 30 mg once daily
Nexium 40 mg once daily
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed.
Disp:*420 ML(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day: crush finely and mix in 30cc water and instill via j-tube
.
Disp:*60 Tablet(s)* Refills:*2*
3. tube feed
replete at 55 cc/hr continuous
4. Lactulose 10 g/15 mL Solution Sig: Thirty (30) mls PO daily
or 2x daily as needed for constipation: via feeding tube.
Disp:*600 ml* Refills:*1*
5. Colace 50 mg/5 mL Liquid Sig: Ten (10) mls PO three times a
day as needed for constipation: via feeding tube.
Disp:*300 ml* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
scleroderma, GERD, constipation, chronic abdominal pain
(?bacterial overgrowth [**2-4**] scleroderma), s/p back surgery
'[**86**]/'[**90**], shoulder surgery '[**88**]/'[**00**], hysterectomy, C-section, s/p
esophageal stricture that was dilated 25 years ago. EF 65%
([**1-9**])
Esophageal dysplasia/Barrett's Esophagus , anastomotic leak,
esophageal stent
Discharge Condition:
good-tube feed dependent
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office ([**Telephone/Fax (1) 170**]) if you
experience any of the following symptoms:
* Fever (>101 F) or chills
* new and continuing nausea or vomiting
* Abdominal or chest pain
* Shortness of breath
* Redness or drainage, swelling, warmth, or pus production
around wound site or any change in amount or character of
drainage
* Any other concerns
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative
such as Milk of Magnesia if you experience constipation.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**])
on [**2101-7-28**] at 4pm in the [**Hospital Ward Name 23**] clinical center [**Location (un) **].
Please arrive 45 minutes prior to your appointment and report to
[**Hospital Ward Name 23**] [**Location (un) **] radiology for a CXR.
Completed by:[**2101-7-13**]
|
[
"458.29",
"530.85",
"274.0",
"518.0",
"998.59",
"997.4",
"511.9",
"710.1",
"530.5",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"86.04",
"96.6",
"34.91",
"81.91",
"45.13",
"46.39",
"42.42",
"44.29",
"42.81"
] |
icd9pcs
|
[
[
[]
]
] |
5125, 5188
|
1937, 4349
|
360, 414
|
5589, 5616
|
1448, 1914
|
6268, 6631
|
4479, 5102
|
5209, 5568
|
4375, 4456
|
5640, 6245
|
1101, 1429
|
283, 322
|
442, 847
|
869, 1041
|
1057, 1086
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,338
| 106,528
|
5911
|
Discharge summary
|
report
|
Admission Date: [**2157-8-22**] Discharge Date: [**2157-9-1**]
Date of Birth: [**2103-9-28**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 53 year old
woman with metastatic renal cell cancer status post radical
nephrectomy, high dose chemotherapy and biliary obstruction,
who presents with nausea and poor p.o. intake. Her last
chemotherapy prior to admission was in [**2156-8-29**] with five
cycles of CC1-779. The patient had a neck mass resection in
[**3-29**] which was harvested for dendritic cell vaccine. The
patient received her first dose of dendritic cell vaccine in
[**4-29**]. She had disease progression in [**2157-6-29**] with
biliary obstruction status post failed ERCP with subsequent
PTC internalization of the stent. Since her last discharge
from [**Hospital1 18**], the patient continued to have fatigue, poor p.o.
intake and nausea. She denies fever, chills, vomiting,
diarrhea, melena, bright red blood per rectum. The patient
was admitted for hydration and further management of biliary
obstruction.
PAST MEDICAL HISTORY: Renal cell CA metastatic to cervical
and paracaval nodes, status post right nephrectomy in 5/98,
status post IL2 in 7/98, status post CC1-779 in 10/00, status
post dendritic cell vaccine in [**4-29**]. Hypertension. Biliary
obstruction status post failed ERCP, PTC with internalization
of stent.
MEDICATIONS ON ADMISSION: Atenolol 25 p.o. q.d., Reglan 10
q.i.d., Prilosec 20 q.d., Benadryl p.r.n., Compazine p.r.n.,
Dilaudid p.r.n.
ALLERGIES: Morphine and Demerol.
PHYSICAL EXAMINATION: On admission temperature was 98.9,
pulse 99, respirations 20, blood pressure 124/70, O2 sat 97%
in room air. In general, the patient was alert and oriented
times three, jaundiced. HEENT: pupils equally round and
reactive to light and accommodation, extraocular movements
intact, scleral icterus. Oropharynx clear, mucous membranes
dry. Supraclavicular lymphadenopathy on the right, no JVD.
Cardiovascular S1, S2, normal, no murmurs, rubs or gallops.
Lungs clear to auscultation bilaterally. Abdomen a bit
gastric and right upper quadrant tenderness. Extremities had
no clubbing, cyanosis or edema. On neuro exam cranial nerves
II-XII were intact, no sensory deficits.
LABORATORY DATA: On admission white count was 25, hematocrit
34.5, platelets 257, neutrophils 73, bands 16, lymphs 4,
monocytes 5. Sodium was 129, potassium 4.8, chloride 93,
bicarb 20, BUN 29, creatinine 1.0, glucose 166. Calcium 9.1,
phosphate 4.2, mag 1.9, ALT 31, AST 18, LDH 408, alka phos
634, total bili 208.
HOSPITAL COURSE:
1. Biliary obstruction. The patient underwent tube
injection that showed no biliary ductal dilatation, distal
flow, but slow flow likely secondary to extrinsic duodenal
compression from tumor. The patient was transferred to the
MICU because during an interventional radiology procedure the
patient developed stridor, shortness of breath. In the MICU
the patient was started on IV antibiotics. She was then
transferred out of the unit on the 26th. Interventional
radiology did not recommend changing the patient's internal
drainage tube, however, recommended letting it drain through
an external drain. The patient did have increased abdominal
distension and fluid. She had paracentesis on the 28th where
650 cc were drained. The patient was continued on Aldactone.
Her ascites slowly reaccumulated. The patient was treated
for SBP. She did grow out Pseudomonas and alpha and beta
strep from her intestinal fluid. She was on vanco, Cipro,
ceftriaxone and Flagyl. She was also on Aldactone for
ascites, but it was held secondary to hypotension. The
patient continued to have increased ascites and secondary to
the patient's hypotension, paracentesis was not able to be
performed. The patient was medicated via her PCA to keep her
discomfort at a minimum and to improve her shortness of
breath.
2. ID. The patient was admitted with leukocytosis.
Eventually her intestinal fluid grew out Pseudomonas and
alpha and beta hemolytic strep. The patient was on Cipro,
Flagyl, ceftriaxone and vancomycin.
3. Fluids, electrolytes and nutrition. The patient's fluid
status was very difficult to manage. All IV fluids that were
put in were being third spaced. However, the patient was
hypotensive and it was a precarious balance between volume
overload and hypotension. The patient was medicated on
Dilaudid PCA. She was continued on antibiotics.
On the 4th the patient was found to have stopped breathing.
She expired at 2:30 p.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], M.D. [**MD Number(1) 7782**]
Dictated By:[**Name8 (MD) 2069**]
MEDQUIST36
D: [**2157-11-24**] 12:53
T: [**2157-11-28**] 11:46
JOB#: [**Job Number 23337**]
|
[
"576.2",
"197.4",
"196.0",
"198.7",
"197.7",
"038.9",
"197.2",
"263.9",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
1412, 1558
|
2594, 4801
|
1581, 2577
|
155, 1063
|
1086, 1385
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,356
| 199,964
|
52087+52088
|
Discharge summary
|
report+report
|
Admission Date: [**2149-1-14**] Discharge Date: [**2149-1-17**]
Date of Birth: [**2090-1-12**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: A 59-year-old female with
multiple medical problems including end-stage renal disease
(on hemodialysis), type 2 diabetes, hypertension, hemolytic
anemia (with transfusions every month), status post recent
small-bowel obstruction with exploratory laparotomy and lysis
of adhesions complicated by postoperative atrial
fibrillation, myocardial infarction, Klebsiella pneumoniae
and wound infection, admitted with shortness of breath and
weakness today.
She was discharged to home three weeks ago, status post
exploratory laparotomy. She presented to the Emergency Room
today with shortness of breath and fever times one day. She
denies any chest pain. Also notable for a cough with scant
sputum production and fevers to 102.5. She vomited once this
morning with clear vomitus; no blood or bilious was noted.
She was also noted to have three-pillow orthopnea, but no
paroxysmal nocturnal dyspnea. She was taken to hemodialysis
and had 2.5 kg of fluid removed. She had a blood transfusion
initiated and received approximately 30 cc, but stopped
secondary to a temperature of 101.5. She later spiked to
102.5 and was sent back to the Emergency [**Hospital1 **]. She denies
headaches, neck stiffness, mouth sores, significant cough,
chest pain, abdominal pain. No nausea, but one episode of
vomitus. No diarrhea. No dysuria or hematuria.
In the Emergency Department she received Lopressor, Cardizem,
captopril and clonidine which was her outpatient regimen.
Additionally, she received her usual Lente insulin and
received one dose of vancomycin 500 mg times one and Tylenol
to control the fevers.
PAST MEDICAL HISTORY:
1. End-stage renal disease (on hemodialysis on Tuesday,
Thursday, and Saturday), and the patient was noted to be
oliguric.
2. Type 2 diabetes times 19 years.
3. Hypertension.
4. Hemolytic anemia with transfusions every month.
5. L5 disk rupture.
6. History of pancreatitis.
7. Status post appendectomy.
8. Status post total abdominal hysterectomy/bilateral
salpingo-oophorectomy.
9. Status post laparoscopic myomectomy.
10. Status post brain aneurysm clipping in [**2123**].
11. Status post small-bowel obstruction with exploratory
laparotomy and lysis of adhesions in [**2148-12-21**]
complicated by postoperative atrial fibrillation, myocardial
infarction, Klebsiella pneumoniae, and wound infection. Her
last echocardiogram in [**2148-12-21**] revealed an ejection
fraction of 60%, left atrial dilatation, left ventricular
hypertrophy, and moderate pulmonary hypertension.
MEDICATIONS ON ADMISSION: Lopressor 150 mg p.o. b.i.d.,
Cardizem 180 mg p.o. b.i.d., Tums, Coumadin 3 mg p.o. q.d.,
captopril 50 mg p.o. b.i.d., clonidine 0.1 mg p.o. b.i.d.,
Renagel, Lente insulin 10 units subcutaneous q.a.m. and
5 units subcutaneous q.p.m., Dilaudid p.r.n., and albuterol
p.r.n., ciprofloxacin (prescribed by her surgeon for
treatment of a postoperative wound infection).
ALLERGIES: AMPICILLIN, BETADINE, TYLENOL NO. 3.
FAMILY HISTORY: Family history of hypertension, diabetes.
SOCIAL HISTORY: Tobacco history notable for a 20-pack-year
history in the distant past. Occasional alcohol. Denies any
intravenous drug use. She lives with her daughter who is
supportive and a nurse.
PHYSICAL EXAMINATION ON PRESENTATION: In general, she was a
pleasant African-American female in no apparent distress,
breathing was nonlabored, and she was resting comfortably.
She was speaking in full sentences. Vital signs revealed
temperature maximum of 102.5, blood pressure of 222/74,
pulse 83, respiratory rate 29, satting 96% on 2 liters.
Head, ears, nose, eyes and throat revealed normocephalic and
atraumatic. Pupils were minimally reactive. Extraocular
movements were intact. Sclerae were anicteric. Mucous
membranes were moist. Neck was supple. No jugular venous
distention. Jugular venous distention to approximately 7 cm,
but no lymphadenopathy, and no bruits. Lungs revealed
bibasilar rales; otherwise, clear to auscultation. No
egophony noted. Cardiovascular revealed a regular rate and
rhythm with normal first heart sound and second heart sound.
No murmurs, gallops or rubs. The abdomen was obese, soft and
nondistended with a tender left lower quadrant. No rebound
or guarding, and a postoperative surgical scar noted with a
1-cm wound at the lower edge of the surgical wound which was
open with purulence expressed that was sent for culture.
Extremities revealed no edema, and 2+ dorsalis pedis pulses
bilaterally, symmetric. Neurologically, she was alert and
oriented times three. Cranial nerves III through XII were
intact and moved all four extremities well. No gross sensory
deficits were noted.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count 13.1, hematocrit 25.3 (with baseline being 26 to 30),
platelets 380. PT 14.6, PTT 30.9, INR 1.5. Sodium of 140,
potassium 4.2, chloride 97, bicarbonate 29, blood urea
nitrogen 22, creatinine 7, glucose 100. AST 16, ALT 6,
alkaline phosphatase 128, total bilirubin 0.8. Amylase and
lipase were within normal limits. She was noted to be Coombs
positive. Differential was normal. Urinalysis showed
greater than 300 protein; otherwise, was clean.
RADIOLOGY/IMAGING: Electrocardiogram revealed normal sinus
rhythm at 80 beats per minute, with normal intervals, normal
axis. No Q waves. No ST-T wave changes. Compared with
[**2149-1-16**] there were no changes except for rate and
rhythm when she was in atrial fibrillation at approximately
140 beats per minute.
Chest x-ray showed mild congestive heart failure with a small
left effusion, but no consolidation.
HOSPITAL COURSE: Ms. [**Known lastname 8260**] was admitted to the [**Hospital1 346**] on [**2149-2-14**], for ongoing
workup and treatment of fevers and shortness of breath.
The patient's shortness of breath was felt secondary to
volume overload and improved markedly after hemodialysis.
The subject of our investigation was turned to her fevers,
and it was felt most likely that this was secondary to an
ongoing pneumonia that was noted on prior hospital course.
However, based on the chest x-ray and the patient's physical
examination, it was felt that it was related to the purulent
drainage from the lower edge of her wound site. Based on
this, she was treated empirically with Levaquin and
vancomycin that was renally dosed.
During her hospital course her urine, blood, and wound
cultures results were followed, and they were completely
negative. This was felt most likely secondary to concurrent
treatment with ciprofloxacin as an outpatient which revealed
these cultures negative. She was treated symptomatically
with Tylenol for fever, and over the course of the next
several days her white blood cell count and temperature curve
diminished so that she was afebrile times 36 hours at the
time of hospital discharge.
In addition to this, she was continued on her outpatient
antihypertensive regimen with better control of her
hypertension. She received her normal dialysis on Saturday
and will continue receiving her dialysis on an outpatient
basis on Tuesday, Thursday, and Saturday schedule.
Hematologically, the patient was anemic and received a blood
transfusion on her every month schedule in dialysis on the
second of hospital admission.
By hospital day two, the patient had been afebrile times 36
hours and her white blood cell count had normalized. The
surgical team followed the patient while in the hospital and
recommended b.i.d. dressing changes to the wound on her
abdomen for the next three days and to follow up with her
surgeon, Dr. [**Last Name (STitle) 1305**], as an outpatient. The decision was made
to continue the antibiotics of Levaquin 250 mg p.o. q.4-8h.
for an extra six days for a total of an 8-day to 10-day
course. In addition, she will receive vancomycin to be dosed
at her hemodialysis; and this will be set up by the Renal
Service. She will be discharged with [**Hospital6 1587**] services for the wound dressing as well as her
daughter to take care of her who is also a nurse.
DISCHARGE STATUS: The patient was discharged to home.
CONDITION AT DISCHARGE: In good condition.
DISCHARGE FOLLOWUP: She was to follow up with her surgeon,
Dr. [**Last Name (STitle) 1305**], as an outpatient as well as with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]
for further issues regarding her dialysis. She was to
receive [**Hospital6 407**] services as well as
continue her antibiotics for a total of a 10-day course.
MEDICATIONS ON DISCHARGE:
1. Lopressor 150 mg p.o. b.i.d.
2. Cardizem 180 mg p.o. b.i.d.
3. Tums.
4. Coumadin 3 mg p.o. q.d.
5. Captopril 50 mg p.o. b.i.d.
6. Clonidine 0.1 mg p.o. b.i.d.
7. Renagel.
8. Lente insulin 10 units subcutaneous q.a.m. and 5 units
subcutaneous q.p.m.
9. Dilaudid p.r.n.
10. Albuterol p.r.n.
11. Levofloxacin 250 mg p.o. q.4-8h. times six days.
12. Vancomycin (to be dosed at hemodialysis).
DISCHARGE DIAGNOSES:
1. Fever secondary to postoperative wound infection.
2. End-stage renal disease (on hemodialysis).
3. Hypertension.
4. Anemia.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D. [**MD Number(1) 11866**]
Dictated By:[**Last Name (NamePattern1) 14434**]
MEDQUIST36
D: [**2149-2-17**] 13:37
T: [**2149-2-18**] 08:46
JOB#: [**Job Number **]
Admission Date: [**2149-1-14**] Discharge Date: [**2149-1-26**]
Date of Birth: [**2090-1-12**] Sex: F
Service: GEN SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 59 year old
woman with a history of nausea, vomiting, diffuse abdominal
pain, which she describes as crampy and colicky. The pain
started approximately 6:00 p.m. on the day prior to
admission. The patient notes she is passing gas. She had a
bowel movement yesterday which was normal. She denies any
fever or chills. She does note some mild distention.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis.
2. Diabetes mellitus.
3. Hypertension.
4. Hemolytic anemia.
5. L5 disc rupture.
6. History of pancreatitis.
PAST SURGICAL HISTORY:
1. Status post appendectomy.
2. Status post total abdominal hysterectomy, bilateral
salpingo-oophorectomy.
3. Laparoscopic myomectomy.
4. Status post clipping of brain aneurysm.
MEDICATIONS ON ADMISSION:
1. Lopressor 150 mg b.i.d.
2. Renagel 30 t.i.d.
3. TUMS.
4. Cardizem 180 mg b.i.d.
5. Coumadin 3 mg q.d.
6. Xalatan drops to her eyes.
7. Captopril 50 mg b.i.d.
ALLERGIES: The patient is allergic to Ampicillin and Tylenol
#3.
SOCIAL HISTORY: She is a smoker and denies alcohol abuse.
PHYSICAL EXAMINATION: On admission, the patient was in no
acute distress. The chest was clear. Cardiac was regular.
The abdomen was soft, tender especially in the left lower and
right lower quadrants. She did have percussion tenderness.
Rectal examination was guaiac negative with normal tone.
LABORATORY DATA: White count was 6.0. Liver function tests
were normal. Her amylase was 140 with a lipase of 41.
The patient had computed tomography which showed distal small
bowel obstruction with a transition point.
HOSPITAL COURSE: The patient was taken emergently to the
operating room where she underwent exploratory laparotomy
with lysis of adhesions. There was a small serosal injury
which was repaired. Postoperatively the patient went to the
Surgical Intensive Care Unit where she was stable. She
remained on the ventilator overnight. The renal team was
consulted for the patient's hemodialysis.
The patient remained intubated, actually began spiking fevers
and was noted to be somewhat tachycardic. On postoperative
day two, the patient went into atrial fibrillation and
enzymes were sent and she ruled in for myocardial infarction
by troponin.
The patient was spiking fevers. Sputum grew pseudomonas and
she was started on Ciprofloxacin for a pseudomonas pneumonia.
Her ventilatory status improved and the patient was weaned
from her ventilator. She was extubated postoperative day
six. She did well over the next several days with some
episodes of hypertension.
Her antihypertensive medications were adjusted and the
patient was transferred to the floor on [**2149-1-22**],
postoperative day eight. She remains on her Ciprofloxacin
and her blood pressure was usually well controlled on regimen
of Captopril, Clonidine, Cardizem and Lopressor.
The patient continued to do well. Her diet was advanced.
Inferior incision wound which was noted in the Surgical
Intensive Care Unit was being packed with dry dressings.
Postoperative day eleven, the day of discharge, the patient
was comfortable, afebrile with stable vital signs. She was
tolerating p.o. Her chest was clear to auscultation.
Cardiac examination was regular rate and rhythm. The abdomen
was soft, nondistended, nontender, and her incision wound was
clean being packed twice a day. Extremities were warm and
well perfused. Blood pressure at discharge was 174/78. The
patient was doing well and was discharged to home with the
visiting nurse assistance.
MEDICATIONS ON DISCHARGE:
1. Dilaudid 1 to 2 mg p.o. q4hours p.r.n.
2. Ciprofloxacin 500 mg p.o. b.i.d. times four days.
3. Captopril 50 mg p.o. b.i.d.
4. Clonidine 0.1 mg p.o. b.i.d.
5. Insulin per the patient's home sliding scale.
6. Lopressor 150 mg p.o. b.i.d.
7. Albuterol MDI one to two puffs p.o. q4hours p.r.n.
8. Atrovent MDI one to two puffs q6hours p.r.n.
9. Coumadin 3 mg p.o. q.d. to be followed up by the primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 55623**].
DISCHARGE INSTRUCTIONS: The patient was discharge home on
renal diet with no restrictions in her activities. She was
in stable condition. VNA was set up to change her dressing in
the inferior abdominal wound twice a day with loose dry
sterile dressing. The patient was to follow-up with Dr.
[**Last Name (STitle) 55623**] within one week and Dr. [**Last Name (STitle) 1305**] in two weeks. The
patient was discharged in stable condition.
DISCHARGE DIAGNOSIS: Small bowel obstruction, status post
exploratory laparotomy, lysis of adhesions, complicated by
postoperative myocardial infarction by troponin.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**]
Dictated By:[**Last Name (NamePattern1) 13197**]
MEDQUIST36
D: [**2149-1-26**] 13:16
T: [**2149-1-26**] 13:37
JOB#: [**Job Number 107810**]
|
[
"410.71",
"614.6",
"585",
"250.40",
"427.31",
"997.1",
"997.3",
"482.1",
"560.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.75",
"96.04",
"54.59",
"39.95",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
3150, 3193
|
9118, 9655
|
14202, 14629
|
13245, 13737
|
10472, 10708
|
11309, 13219
|
13762, 14180
|
10263, 10446
|
10791, 11290
|
8287, 8307
|
8328, 8658
|
9684, 10059
|
10081, 10240
|
10725, 10768
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,918
| 138,343
|
26054
|
Discharge summary
|
report
|
Admission Date: [**2108-11-8**] Discharge Date: [**2108-11-12**]
Date of Birth: [**2048-7-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p 3 cypher stents to left circumflex
artery
History of Present Illness:
60 y/o male with CHF, HTN, presented to [**Location (un) **] on [**11-6**] with
shortness of breath. Per patient, he rarely received medical
care prior to this admission and had no known heart disease. He
noted progressive worsening of DOE over the past 6 months. Over
the past few weeks, he noted a significant worsening of DOE, as
well as orthopnea and PND. Then a few days prior to presentation
he noted LE edema which prompted him seeking medical care. He
denied chest pain at any time. He did have some N/V over the
past few weeks which he attributes to poorly fitting dentures.
He has had a dry cough for some time. Denies fever. At [**Location (un) **],
he was treated with bronchodilators, antibiotics for ? PNA, and
nitro gtt, ACE, bblocker and diuretics for CHF. He had an
elevated BNP and TropI in the borderline zone. He was started on
ASA, plavix as well. He diuresed at least 1 liter with
significant improvement in symptoms and LE edema. On [**11-7**] he
had a pharmacologic stress that showed mostly fixed inferior and
lateral defects and an EF of 15%. On evening of [**11-7**], he became
symptomatically hypotensive (SBP 60s). He was given 250-500cc
IVFs, started on Dopamine drip and transferred to [**Hospital1 18**]. On
arrival to [**Hospital1 18**], patient's BP was 88/50 off dopamine and he
denied chest pain, shortness of breath, lightheadedness.
Past Medical History:
Hypertension
Hyperlipidemia
Tobacco use
Alcoholism
Social History:
Retired financial services
Currently 2 ciagarettes / day. Smoker X 35 years
+ ETOH, [**12-19**] glasses of wine / night
no IVDA
Married and lives with wife
Family History:
Non-contributory
Physical Exam:
Discharge Physical Exam
Temp 98.1
BP 98/57
Pulse 70s-80
Resp 18
O2 sat 98% RA
Gen - Awake, Alert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - no JVD noted, no cervical lymphadenopathy, no bruits
Chest - Clear to auscultation bilaterally No wheezing or
crackles
CV - Normal S1/S2, RRR, ii/vi SM at apex
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No edema. 1+ DP pulses bilaterally. Blanching erythema
of forearms b/l.
Pertinent Results:
[**2108-11-8**] 03:40AM BLOOD WBC-12.2* RBC-4.19* Hgb-13.9* Hct-42.3
MCV-101* MCH-33.1* MCHC-32.8 RDW-14.5 Plt Ct-285
[**2108-11-11**] 05:37AM BLOOD WBC-10.0 RBC-4.07* Hgb-13.8* Hct-39.9*
MCV-98 MCH-34.0* MCHC-34.7 RDW-14.4 Plt Ct-245
[**2108-11-8**] 03:40AM BLOOD PT-15.3* PTT-35.3* INR(PT)-1.6
[**2108-11-9**] 05:58AM BLOOD PT-14.7* PTT-29.8 INR(PT)-1.5
[**2108-11-11**] 05:37AM BLOOD PT-14.3* PTT-27.5 INR(PT)-1.4
[**2108-11-11**] 05:37AM BLOOD Plt Ct-245
[**2108-11-8**] 03:40AM BLOOD Glucose-139* UreaN-17 Creat-1.1 Na-135
K-3.6 Cl-99 HCO3-23 AnGap-17
[**2108-11-11**] 05:37AM BLOOD Glucose-113* UreaN-11 Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-29 AnGap-12
[**2108-11-8**] 03:40AM BLOOD ALT-101* AST-80* LD(LDH)-282* CK(CPK)-93
AlkPhos-118* TotBili-1.2
[**2108-11-11**] 05:37AM BLOOD ALT-73* AST-56* LD(LDH)-258* AlkPhos-116
TotBili-1.4
[**2108-11-8**] 03:40AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2108-11-8**] 03:40AM BLOOD Calcium-8.2* Phos-3.7 Mg-2.1
[**2108-11-11**] 05:37AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.3
[**2108-11-9**] 05:58AM BLOOD calTIBC-346 Ferritn-338 TRF-266
[**2108-11-8**] 08:36AM BLOOD %HbA1c-6.4* [Hgb]-DONE [A1c]-DONE
[**2108-11-10**] 05:25AM BLOOD Triglyc-94 HDL-35 CHOL/HD-3.3 LDLcalc-62
[**2108-11-9**] 05:58AM BLOOD TSH-2.3
.
[**2108-11-8**] CXR: cardiomegaly without evidence of pulmonary edema.
The patient is rotated rightward which makes it difficult to
evaluate right lung base and right hemidiaphragm. There is a
round lucency superimposed over the right side of the heart
which may represent hiatus hernia.
.
[**2108-11-9**] Cardiac catheterization: 1. Coronary angiography
revealed a left dominant system. The LMCA showed
no angiographically apparent flow-limiting stenosis. The LAD
showed mild
to moderate diffuse stenoses along its length, to a maximum of
40-50%
stenoses. The LCX gave rise to a small OM1 and very large OM2,
with a
long 70% stenosis from the proximal to mid-LCX and extending
into the
OM2 vessel. The distal LCX was a small caliber vessel giving
rise to a
small LPDA. The RCA showed a 100% proximal stenosis with right
to right
collaterals.
2. Hemodynamic studies demonstrated severely elevated right
sided
filling pressures (right atrial pressures 23 mmHg) with moderate
to
severe pulmonary hypertension (pulmonary artery pressure 60
mmHg), as
well as severely elevated pulmonary capillary wedge pressure (34
mmHg)
and severely reduced cardiac index (calculated by the Fick
method to be
1.7 L/min/m2). There was no evidence of pressure gradient across
the
mitral valve, or across the aortic valve upon pullback of the
catheter
from the left ventricle to the aorta.
3. Successful predilation using 2.0 X 30 Cross sail balloon and
stenting using two 3.0 X 23mm and one 3.0 X 13 Cypher stents of
the
proximal/mid CX and OM2 branch with lesion reduction from 70%
to 0%.
The final angiogram showed TIMI III flow with no dissection or
embolisation. (see PTCA comments)
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe diastolic dysfunction with severely elevated filling
pressures
suggestive of volume overload.
3. Moderate to severe pulmonary hypertension.
4. Successful stenting of the CX lesion.
[**2108-11-8**] EKG: Sinus rhythm. Rare ventricular premature beat.
Non-specific T wave inversions
in leads I and V2-V6. Broad Q waves in lead III, small Q waves
in II and aVF.
Non-specific T wave abnormalities. Possible transmural inferior
wall
myocardial infarction - old. Clinical correlation is required.
Rare ventricular
premature beat. Early transition. No previous tracing available
for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 142 98 444/479.71 17 23 172
Brief Hospital Course:
1) Hypotension: On admission his SBPs were in the low 90's
likelt secondary to diuresis and antihypertensives given at the
outside hospital. He was carefully monitored and all
antihypertensives were held. His blood pressure improved to the
low 100s/70s.
.
2) Cardiomyopathy/CHF: Patient was sent for cardiac
catheterization which revealed 70% stenosis of mid-LCX, 100%
stenosis RCA, and PCWP of 34. He tolerated the procedure well
with some persistent ooze at the groin site that resolved by the
day after the procedure with pressure dressings. He had only a
small 2x2 cm hematoma. It was felt that the degree if his
coronary disease did not corrlate with the severe depression of
his systolic function and that alcoholic cardiomyopthay was also
playing a role (CI 1.7). He was diuresed with a lasix drip in
order to avoid hypotension. By discharge he was diursed
approximately 4-5 liters and his blood pressure remained stable.
He was started on lisinopril, metoprolol, and PO lasix all of
which he tolerated well. On day prior to discharge, he was
started on 40 PO lasix, but was net positive by 800cc by the end
of the day. Hence on the day of discharge, his lasix was upped
to 80mg PO daily. The importance of avoiding alcohol and smoking
were stressed and he was provided with information about
maintaining a low salt diet, and fluid restriction. He will
follow up with Dr. [**Last Name (STitle) 11493**] 2 days after discharge and will have a
follow up echocardiogram in 1 month.
.
3) CAD: Carduac catheterization revelaed chronic occlusion of
RCA and mLCx 70% (with + FFR 0.45) so LCx was stented with 3
DES. He was started on ASA, plavix and metoprolol. His LFTS were
elevated but began to trend down during his hospitalization. He
was started on lipitor 10 mg po qd the day before discharge and
will follow up with Dr. [**Last Name (STitle) 11493**] to monitor his LFT and titrate his
statin dose.
.
4) Transaminitis: This was felt to be secondary to liver
congestion in the setting of CHF as well as alcohol. He was
monitored for alcohol withdrawal but did not require any valium
on CIWA scale. His LFTS continued to trend down and will be
follow as an outpatient.
.
4) Rash: Patient had a erythematous blanching rash on his
bilateral forearms. It was felt that this was a possible drug
allergy to Azithromycin or ceftriaxone given at [**Hospital **]. These were discontinued and the rash resolved by the
second hospital day.
.
Medications on Admission:
ASA 81mg Daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lasix 40 mg Tablet Sig: Two (2) Tablet PO once a day: Please
weigh yourself daily. If you gain more than 4 pounds, please
increase daily dosage to 120mg daily.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Congestive heart failure
2. CAD s/p Cypher stents x 3 to left circumflex/OM2 branch
3. Hyperlipidemia
4. Hypertension
Discharge Condition:
Hemodynamically stable, afebrile, satting well on room air.
Discharge Instructions:
If you have any chest pain, shortness of breath, dizziness, leg
swelling or any other concerning symptoms, call your doctor or
come to the emergency room.
Be sure to take all of your medications as directed. You MUST
take your Plavix everyday.
.
You should check your weight daily. If your weight increases by
3lbs or more or you notice increased swelling in you legs or
shortness of breath you should call your doctor.
.
You should continue to eat a low salt diet and restrict your
fluid intake to 2 liters per day.
.
The following changes/additions have been made to your
medications.
1. Lipitor 10 mg once daily
2. Toprol XL 25 mg once daily
3. Lisinopril 5 mg once daily
4. Aspirin 325 mg once daily
5. Plavix 75 mg once daily
6. Lasix ????
Followup Instructions:
You have a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] on
Wednesday, [**11-14**]. Please call ([**Telephone/Fax (1) 29810**] to find our
the time of your appointment. At that visit you should have your
blood work checked including your electrolytes and liver
enzymes.
You should also make an appointment with your primary [**First Name8 (NamePattern2) **]
[**Last Name (LF) 15144**],[**First Name3 (LF) **] P. [**Telephone/Fax (1) 15145**] in [**1-19**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2108-11-12**]
|
[
"790.4",
"272.4",
"401.9",
"305.01",
"425.4",
"782.1",
"416.8",
"458.9",
"428.0",
"427.1",
"412",
"305.1",
"414.01",
"573.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.47",
"00.40",
"88.56",
"37.23",
"99.20",
"00.66",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
9652, 9658
|
6304, 8745
|
327, 399
|
9823, 9885
|
2627, 5548
|
10679, 11362
|
2064, 2082
|
8811, 9629
|
9679, 9802
|
8771, 8788
|
5565, 6281
|
9909, 10656
|
2097, 2608
|
276, 289
|
427, 1799
|
1821, 1873
|
1889, 2048
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,977
| 142,294
|
54592
|
Discharge summary
|
report
|
Admission Date: [**2139-9-15**] Discharge Date: [**2139-9-24**]
Date of Birth: [**2098-10-13**] Sex: F
Service: INTERVENTIONAL RADIOLOGY
HISTORY OF PRESENT ILLNESS: Short gut syndrome, chronically
occluded superior vena cava, right brachiocephalic vein and
right jugular vein, occlusion of the inferior vena cava and
both common iliac veins, TPN dependent.
polyposis, she had resection of her colon at age 20 and now
has a high output ileostomy. She is dependent on TPN
although she can take small amounts of oral food. Over the
years, she has chronically occluded both internal jugular
veins, both subclavian veins and the upper segment of the
superior vena cava. She came in [**2138-7-26**], to our
attention when she had developed Staphylococcus aureus sepsis
At this time, we removed a tunneled femoral catheter which
had been tunneled from the right groin into the left upper
chest and placed temporary access. After clearing of the
infection, we were attempting to recanalize the occluded
central veins but were unsuccessful, even with a sharp
recanalization technique. On [**2138-12-9**], I then decided to
place a new tunneled right femoral 7French double lumen
Hickman catheter with tip at the level of L1 and the exit
site over the lateral thigh.
The patient came to see on [**2139-9-7**], in clinic with the chief
complaint of line dysfunction. She had noticed some
sluggishness of return during TPN infusions and then had
stopped TPN and only placed hydration. She brought a
venogram from [**2139-8-26**], which demonstrated that the tip of
the catheter had pulled back into the distal inferior vena
cava. There was some high grade narrowing in both common
iliac veins which were still patent at this time. The
inferior vena cava was not filled and there were paralumbar
collaterals.
On [**2139-9-11**], she was admitted to St. [**Hospital 107**] Medical Center
in [**Hospital1 189**], [**State 350**] for line sepsis, generalized
weakness, near syncope and low grade fever. She came to the
[**Hospital1 69**] on [**2139-9-15**]. She
presented in a severely debilitated status. Her blood
pressure was 96/54, with a pulse rate of 123, temperature
100, and oxygen saturation 99%. The catheter over the right
thigh had pulled back with the calf being outside of the
skin. There was some swelling and induration over the right
thigh extending to the level of the knee which was suggestive
of deep venous thrombosis but additional superinfection and
cellulitis could not be ruled out. The lungs were clear.
The abdomen was soft. There was an intact left lower
quadrant ileostomy. The heart rate was regular and
considering the rate, murmurs could not be elicited.
To assess her semi-obtunded status, blood was drawn which
revealed a severe hypomagnesemia with a level of 0.7 and a
hematocrit of 26.6. She received an infusion of Magnesium.
Because of an antibody to the blood, blood was ordered but
couldn't be transfused before the start of the procedure. To
reduce further risks of sepsis due to the line, we proceeded
with recanalization of the inferior vena cava. Because of
the patient's low pain threshold, all procedures had to be
performed under MAC anesthesia. I removed the tunneled right
femoral line and replaced it with a 7French bright tip
sheath. I also gained access through the left femoral vein.
It was possible to recanalize both iliac veins and the
chronically occluded inferior vena cava. Infusion catheters
were placed and TPA was infused for the remainder of the day
and of the night.
On [**2139-9-16**], the patient returned to the angiography suite in
the morning. Some interval lysis had occurred. The TPA
infusion was continued until the afternoon. In the meantime,
she had been transfused with two units of packed red blood
cells and her hematocrit had reached 30.0. In the afternoon,
I was able to dilate the occluded inferior vena cava and
place kissing stents in the chronic occlusion channels of the
inferior vena cava. Stents were also extended into both
common iliac veins and the adjacent segments of the external
iliac veins. The patient was heparinized overnight.
The next morning a follow-up was done which demonstrated that
the left sided system was still open. On the right side, a
separation between the caval and the iliac stent had occurred
and the inferior stent had moved slightly laterally. The
main goal for this day's procedure was to give the patient
also a superior vena cava access since it became clear that
she would be having recurrent infections in the long run.
The main treatment goal was to provide for the future three
access sites: one for a tunneled line, one for a temporary line
should the permanent one become infected and needs pulling, and
a 3rd for a new tunneled line, considering this patient is life-
long tpn.
She was controlled with Vancomycin. Her levels on the one
gram per day regimen was what she came from the outside
revealed a Vancomycin random level of 40. With input from
infectious diseases consult over the next days, appropriate
Vancomycin regimen was obtained. On [**2139-9-17**], I then
undertook sharp recanalization of the superior vena cava
through a right internal jugular approach by placing a snare
into the superior vena cava as a target. It was possible to
recanalize the internal jugular, brachiocephalic, and superior
vena cava with stents and place a temporary double lumen
catheter. In the same session, I also repaired the separated
caval stent by placing of an additional briding stent.
By the next morning, the patient remained heparinized. She
had some oozing around the right neck exit site. I had
removed the femoral access on the evening before to reduce
the overall risk of infection. We had obtained cultures from
the tip of the previously indwelling tunneled catheter and
blood cultures were obtained. There was no growth to date.
A regimen with one gram Vancomycin every eighteen hours was
then achieved with appropriate trough levels. Ultimately,
the right internal jugular line was exchanged for a tunneled
7French double lumen Angiodynamics catheter of 57
centimeter length. The tip was placed into the superior vena
cava.
In the following course, the patient had only low grade
temperature to 100, however, no spikes. She was transferred
to the [**Hospital1 **] from the Intensive Care Unit on [**2139-9-22**]. On
[**2139-9-22**], she still had some swelling of her neck and both
arms which may have been related to fluid therapy. An
ultrasound on [**2139-9-13**], demonstrated that the internal
jugular vein and superior vena cava were patent compatible
with a successful recanalization. On [**2139-9-23**], the swelling
had been much reduced so that now there also was a satisfying
clinic result, and on [**9-24**] facies and arms were normal.
We had attempted to Coumadinize her since she had been on
Coumadin on the outside. However, because of the unreliable
gastrointestinal absorption, we decided to add instead
greater amounts of Heparin to her TPN and her daily infusion
regimen.
Of note, her hematocrit drifted again down to 23.0% on
[**2139-9-22**]. This included a blood loss of about 250 cc for all
the surgical interventions. We therefore transfused her
again with two units of packed red blood cells.
From an infectious disease point, she never expressed open
sepsis. We will keep her on Vancomycin until [**2139-9-24**]. She
developed an oral herpes which was treated for five days with
Acyclovir.
The TPN is to be reinstituted with a nightly infusion. With
hematology consult we recommend to add folate and B12. B12 may
not be stable in TPN, so she may need addional injections. We
drew folate and B12 levels today. results are pending. adapted
the composition to address the recurrent. Heparin in the TPN
infusion bag should be increased to 8000 U per day. The daily 1
L infusion of D5-/2NS should be supplemented with 5000 U
heparin to be infused over the day. Additional fluid should not
contain heparin if need for hydration in presence of a high out
put ileostomy. We also obtained hematology consultation to
address the issue of recurrent bouts of anemia which the
patient also had at home. This resulted in the B12 and folate
additon recommendation. We also drew today Ferritin, folate, B12
and reticulocyte counts. Dr. [**Last Name (STitle) 3060**] will follow up with outpatient
consult. Recommend also bone density study because of prior
hysterectomy and heparin use as well as genetic cousneling
because of [**Doctor First Name **] familial inbcidence of cancer to assess for
Li-Frameni BRCA.
On discharge, the patient is stable. She has no signs of
acute infection.
DISCHARGE DIAGNOSES:
1. Short gut syndrome due to [**Location (un) **] syndrome.
2. Life long TPN dependent.
3. Occlusion of the inferior vena cava and both common iliac
veins treated by stent reconstruction.
4. Superior vena cava syndrome with occlusion of all central
veins treated by reconstruction of the right internal
jugular, brachiocephalic and superior vena cava.
5. High outout jejunostomy.
MEDICATIONS ON DISCHARGE:
1. TPN with Heparin at mixture of 8000 U for nightly
infusion . Add folate and B12. 800 units per hour. Hydration
with D5 one half normal saline with 1 L of this containing 5000
U Heparin, the remaining hydration fluid to be without heparin.
Keep PTT between 40 -80.
2. She treats pain with Dilaudid subcutaneous and wears a
Fentanyl patch.
FOLLOW-UP PLAN: The patient is to return for a clinic visit
with Dr. [**First Name (STitle) **] in one month. She is to follow up with Dr. [**Last Name (STitle) **]
in Hematology, obtain genetic counseling, get a bine
denistometry, consult pain clinic.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 29348**], M.D. [**MD Number(1) 29349**]
MEDQUIST36
D: [**2139-9-23**] 14:52
T: [**2139-9-23**] 19:58
JOB#: [**Job Number 96824**]
|
[
"996.74",
"038.9",
"054.9",
"579.3",
"280.0",
"453.8",
"996.62",
"459.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"99.15",
"99.10",
"39.90",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8719, 9104
|
9130, 9962
|
182, 8698
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,810
| 143,994
|
10120
|
Discharge summary
|
report
|
Admission Date: [**2183-1-9**] Discharge Date: [**2183-3-31**]
Date of Birth: [**2149-3-31**] Sex: F
Service: SURGERY
Allergies:
Vicodin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Exploratory Laparotomy, repair of duodenal perforation and
placement of g -tube into the gastric remnant.
Multiple washouts of abdominal wound with vac placements.
History of Present Illness:
33 yo female with history of gastric bypass in [**2174**] complicated
by leak and several surgies for bowel obstructions with
malabsorption and chronic pain with multiple hospital admiisions
and discussion of reversal of bypass, presents from
OSH complaining of acute onset severe abdominal pain that
started at 5pm last evening, more on the right side and in the
groin. She describes it as intractable, constant,
aching/stabbing pain. [**11-16**]. States very different from
baseline pain that is usually RUQ simliar to prior gallbladder
attacks, this is much more intense. loss of appetite and
diarrhea, no nausea/ vomiting. Last BM yesterday, no blood. OSH
imaging showed free air in retroperitoneum, concerning for
perforation. Received Zosyn at OSH and 1L NS and 1L LR.
Past Medical History:
PMHx:
- Community-acquired pneumonia
- Gastric bypass [**2174**], multiple hospitalizations for abdominal
pain, nausea, vomiting
- Recurrent small bowel obstructions secondary to adhesions s/p
multiple adhesiolysis
- Hypertension
- Migraine headaches
- Post traumatic stress disorder
- Obesity
- Chronic pain with narcotic use
- Chronic anemia
- B12 deficiency
- Electrolyte disturbance secondary to dehydration from diarrhea
- poor access, has venous access port in Right chest, states has
been on TPN in past
Social History:
Lives with husband. 4 children. Denies tobacco or alcohol use.
Family History:
Father with hypertension. Mother died of pancreatic cancer.
History of alcohol abuse in sister and brother.
Physical Exam:
PHYSICAL EXAM AT ADMISSION:
Gen: Ill-appearing women, in acute distress, diaphoretic, pale,
moaning in pain but conversing appropriately
HEENT: MM dry, no scleral icterus
Resp: Decreased breath sounds bases, distant
CV: Tachycardic
Abd: Obese, non-distended, diffusely tender with rebound and
guarding, peritoneal, guiaic negative, no stool in vault
Ext: no C/C/E
Pertinent Results:
LABS AT ADMISSION:
(OSH) WBC 14.3, Hg 12.5, Hct 39.6, Plt 476
([**Hospital1 18**])
K:3.8
Lactate:1.7
Hgb:13.8
CalcHCT:41
137| 109| 12 <138
3.9| 15| 0.7
ALT: 14 AP: 103 Tbili: 0.4
AST: 12 Lip: 70
(WBC 14)-> 4.6 >39.7< 456
N:80 Band:10 L:7 M:3 E:0 Bas:0 Hypochr: 1+ Anisocy: 1+ Plt-Est:
High
PT: 12.1 PTT: 20.8 INR: 1.0
IMAGING:
1) CT Abdomen: Significant for patchy infiltrate with left lung
base. There is moderate perihepatic and perisplenic free fluid.
There is a large duodenal diverticulum on measuring 4.6 x 4.9 cm
(image 33, series 2).
2) CT Pelvis: Significant for diffuse small bowel dilatation
with
transition point in left lower quadrant. There are two closely
apposed decompressed loops of small bowel suggesting a
closed-loop obstruction. Distal loops of ileum are decompressed
compatible with high-grade obstruction. Bowel loops within left
lower quadrant demonstrate mild wall thickening with a moderate
amount of free fluid in the pelvis. Colon is decompressed.
Numerous colon diverticula.
Brief Hospital Course:
This is a 33 year old woman who is status post open Roux-en-Y
gastric bypass in [**2174**] with complicated postoperative course
including anastomotic leak as well as some element of
malnutrition. She was evidently recently under evaluation at
[**Hospital **] [**Hospital3 33807**] for possible revision of her
gastric bypass due to malnutrition.
She presented to an outside hospital with new onset abdominal
pain of approximately 5-hour duration. She was ultimately
transferred to [**Hospital1 18**] with 10 to 12 hour history of pain. Upon
presentation to [**Hospital1 18**] she had an acute abdomen with peritoneal
signs, acidemia and tachycardia. The CT scan at the outside
hospital ([**Hospital 23925**] [**Hospital **] Hospital)demonstrated
retroperitoneal fluid consistent with abscess as well as free
air in the region of the duodenum, most likely consistent with a
perforated duodenal ulcer. She was resuscitated with intravenous
fluids, administered intravenous antibiotics and urgently taken
to the OR for an exploratory laparotomy.
Her intra-operative course ([**2183-1-8**] morning) was significant for
a perforated duodenal ulcer, which was repaired, closure of
internal hernia jejunojejunostomy, gastrostomy tube placement in
the gastric remnant, as well as drainage and wash out of the
retroperitoneal abcess. JP drains x2. Please refer to the
operative note for further details. Post-operatively, she was
taken to the ICU without pressor support.
On the evening of [**2183-1-8**], she was taken back to the OR for an
exploratory laporatomy because of continued tachycardia with
rising lactate. Ex lap was negative.
On the morning of [**1-10**], pt was showing improvement after
washout. LA returned to [**Location 213**]. Bladder pressure in teens
instead of 20's. PIP was 30's pre take back, with abd open and
with abd closed. Now PIP in 20s this AM. Still tachy HR 110-120
(but is it pt's baseline? on beta blockade) SBP 90's. Pt fluid
avid. 12L fluid positive.
Infectious Disease evaluated patient and in the setting of
intraabdominal peritoneal soiling [**3-11**] perforation emperic
treatment with Zosyn x 5-7 days was adequate. Pt was febrile
101.4 ([**1-10**]), likely sirs. Cxs from [**1-9**] were followed.
[**1-11**]: Minimized lasix gtt since auto-diuresing (~2L neg). Cont
w/ albumin. Fever to 101. Hct 22. Given 1u pRBC. LENI negative.
Morphine for pain control
[**1-12**] Confused started on zyprexa. Febrile blood and urine
cultures sent (neg)
[**Date range (1) 33808**]: Given 1 unit PRBC. Continued fevers to 102, new
onset right sided abdominal wall erythema/tenderness consisent
with cellulitis. CT showing intra-abdominal fluid collection
with necrotic tissue s/p retro exposure and I&D. Confusion
resolved, patient lucid and oriented.
[**2183-1-19**] Given 1 unit PRBC. Due to CT scan showing fasciitis,
patient was brought to the Operating room for Right flank
incision, drainage and debridement of right retroperitoneum with
pulse lavage. The wound was packed with kerlex. The outer
dressing had to be changed frequently over the next several days
due to continued leakage of bilious material.
[**2183-1-20**] Given 1 unit PRBC
[**2183-1-21**] Patient brought to Operating room for exploration and
washout of retroperitoneal abscess. Her wound was repacked.
PICC line and TPN restarted.
[**2183-1-24**] Patient brought back to operating room for exploration
and washout of retroperitoneal abscess. Kerlex noted to be
saturated with bilious material. A wound vac was applied.
Patient given 1 unit PRBC. Wound vac output was nearly 1 liter
per day following this.
[**2183-1-27**]: Patient brought back to OR for exploration and washout
with vac change. Still no visible fistula.
[**2183-2-2**]: patient brought back to OR for exploration and washout
with vac change
[**2183-2-5**]: abdominal CT with contrast showing markedly enlarged
intrabdominal abcess and fistula track from 2nd/3rd portion of
duodenum to flank. 1 JP drain was pulled (this drain had put
out only 5-10cc/day for weeks)
[**2183-2-6**]: went to IR for percutaneous drainage of intrabdominal
fluid collection with return of a large amount of pus. Pig tail
catheter left in. Taken to OR for I+D and vac change.
[**2183-2-10**]: patient brought back to OR for exploration and washout
with vac change. LENIs of both lower extremities were negative
for clot formation.
[**2183-2-12**]: patient underwent CT of abdomen that showed fluid
collection in lower abdominal wall and incidental finding of
thrombus of left renal vein. Spoke with vascular team, and she
was started on heparin IV weight based dosing to reach
therapeutic levels of PTT.
[**2183-2-13**]: patient underwent IR guided aspiration of fluid
collection in pelvis/lower abdomen and placement of pigtail
catheter. She was continued on heparin IV.
[**2183-2-14**]: patient brought back to OR for exploration and washout
with vac change. Her heparin was stopped prior to leaving the
floor for the OR, and was restarted upon arriving back to the
floor.
[**2183-3-6**]: patient went to IR for drainage of pelvic abscess.
Antibiotics adjusted per Infectious disease.
[**3-10**] and [**3-16**] Patient went to operating room for washout of R
flank abscess and placement of wound vac. device.
[**3-19**] Dermatology consulted for spreading red, raw rash on
buttocks. Started on fluconazole and fungal cream applied.
[**2183-3-20**] - Patient taken to the operating room for washout of R
flank abscess and placement of wound vac. device.
[**2183-3-26**] - Patient taken to the operating room for washout of R
flank abscess and removal of wound vac. Wet to dry dressings
applied.
[**2183-3-27**] - Wound care consult obtained. AMD dressings applied as
wound care suggest to R flank wound [**Hospital1 **].
[**2183-3-28**] - Infectious disease consulted regarding po antibiotics.
Problems at Discharge:
1. R flank wound abscess - continued dressing changes at home
with VNA to monitor. Oral Antibiotics per ID. Follow up with ID
to evaluate continued need for antibiotics.
2. LLL PE and thrombus of L renal vein - on Lovenox sq [**Hospital1 **] for
total 3 months. Follow up with Dr. [**Last Name (STitle) 1391**] made for one month
to assess continued need for lovenox.
3. Nutrition - On regular diet currently and tolerating well.
Has needed intravenous TPN and electrolytes in past. Will keep
existing port in at this time.
Recommended Follow up with Dr. [**Last Name (STitle) **] in 2 weeks, infectious
disease, vascular and primary care provider.
Medications on Admission:
- Atenolol 25 mg [**Hospital1 **]
- Percocet 1 tab tid
- Metoclopramide 10 mg 4x/day
- Fioricet 1-2 tabs prn
- Miralax and Dulcolax
Discharge Medications:
1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Enoxaparin 120 mg/0.8 mL Syringe Sig: One Hundred-Ten (110)
mg Subcutaneous Q12H (every 12 hours).
Disp:*6600 mg* Refills:*2*
4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for pain with dressing changes.
Disp:*30 Tablet(s)* Refills:*0*
7. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*1*
8. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*1*
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*1*
10. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
Disp:*120 Tablet(s)* Refills:*1*
11. Medication and follow up
Please continue all antibiotics until you see Infectious disease
on [**4-23**]. Please eat yogurt daily. Please review all
medications with your primary care physician and please get any
new refills for narcotics from your primary care physician.
12. Multivitamin Tablet Sig: One (1) Tablet PO twice a day.
13. 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*
14. commode
Please provide Commode for home use
15. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: Please
flush portacath per policy.
Disp:*30 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 33809**] Healthcare of [**Location (un) 33810**]
Discharge Diagnosis:
Primary Diagnosis: Duodenal Perforation
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**11-21**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **] on [**4-18**] at 1:00 pm.
[**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building [**Location (un) 470**]. Contact number
[**Telephone/Fax (1) 3201**] or [**Telephone/Fax (1) 305**].
2. Please follow up with Infectious Disease on Wednesday [**4-23**] at 11:30, Dr. [**First Name (STitle) **], [**Last Name (NamePattern1) 33811**]. Office number is [**Telephone/Fax (1) 457**].
3. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] (to follow up on
your L renal vein thrombosis and L pulmonary embolism) office
number = [**Telephone/Fax (1) 1393**], [**4-30**] Wednesday, 10:45. [**Doctor First Name **], suite 5C.
4. Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) 3646**],
[**Telephone/Fax (1) 33812**] in one to two weeks to draw labs, review your
current medications and current health status. Labwork needs to
be done weekly and faxed to Infectious Disease at [**Telephone/Fax (1) 6147**]
(Labwork CBC w/diff, bun, cre, lft's.)
Completed by:[**2183-3-31**]
|
[
"567.38",
"569.69",
"780.09",
"266.2",
"415.11",
"E878.8",
"112.3",
"280.0",
"569.81",
"729.39",
"263.9",
"300.4",
"041.4",
"285.1",
"338.29",
"452",
"567.9",
"682.2",
"579.3",
"401.9",
"309.81",
"562.00",
"V09.80",
"560.1",
"276.6",
"041.04",
"276.2",
"278.00",
"995.90",
"V45.86",
"346.90",
"533.11",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"44.42",
"53.59",
"43.19",
"97.29",
"88.01",
"54.0",
"86.28",
"83.21",
"93.57"
] |
icd9pcs
|
[
[
[]
]
] |
12124, 12215
|
3446, 9332
|
281, 448
|
12299, 12299
|
2397, 3423
|
13668, 14804
|
1886, 1997
|
10180, 12101
|
12236, 12236
|
10024, 10157
|
12444, 13645
|
2012, 2378
|
9346, 9998
|
227, 243
|
476, 1255
|
12255, 12278
|
12313, 12420
|
1277, 1789
|
1805, 1870
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,690
| 191,976
|
50782
|
Discharge summary
|
report
|
Admission Date: [**2174-5-11**] Discharge Date: [**2174-5-19**]
Date of Birth: [**2094-1-29**] Sex: F
Service: MEDICINE
Allergies:
spironolactone
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
abdominal pain, hematuria
Major Surgical or Invasive Procedure:
continuous bladder irrigation
History of Present Illness:
Ms. [**Known lastname **] is an 80 year-old woman with sCHF (EF 45%), CKI
(baseline 1.6-2.3), pAfib and DM presently residing at rehab for
osteoarthritis presents for evaluation of bleeding, which rehab
feels was from vagina notable for recent UTI diagnosed 2 days
ago. The patient was started on levofloxacin 250mg daily 2 days
ago for proteus UTI. Of note, the patient's daughter had called
cardiology RN because patietn was experiencing LE swelling, N/V
and abdominal pain on [**5-10**]. The patient was complaining of
abdominal pain today that was worse in suprapubic area and was
sent to the ED for further evaluation.
Initial vitals in the ED were 97.6 98 124/70 24 99%. Labs in
the ED were notable for WBC 15.7 94.1%N, HCT 37.9, PLTS 332, INR
2.1, Na 135, K 5.4, HCO3 19, BUN 92, Cr 4.3, Gluc 222 and
lactate 1.8. UA >182 WBC, >182 RBC and pH 8.5. Blood cultures x2
and urine cultures were obatined. Foley placed in the ED drained
2L of blood tinged urine. Patient's blood pressure transiently
fell to SBP of 80s and responded well to 2L NS bolus with SBPs
100s-120s. The patient received Vancomycin 1g IV and Cefepime 2g
IV and was admitted to the MICU for further evaluation. Vitals
on transfer were 98.1 89 101/66 22 99% 4L NC.
On arrival to the MICU, patient appears comfortable and is
without additional complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies sinus tenderness. Denies shortness of breath, cough,
dyspnea or wheezing. Denies constipation, diarrhea, dark or
bloody stools. Denies rashes or skin changes.
Past Medical History:
Past Medical History:
# HTN
# HL
# DM: uncontrolled at 9.4% [**3-/2174**]
# AF, CHADS 2: 4 (on Coumadin/amiodarone) dx. [**8-11**].
# CHF: EF 45%
# Valvular heart disease (?rheumatic): 2+ MR, 3+ TR
# Non-ischemic global CM, EF 45%. RV dilation/dysfunction.
[**3-/2173**]
# Chronic dyspnea (? of OSA)
# GERD
# CKD with most recent baseline 1.5-2
# Anxiety s/p survival of hurricane in [**State 108**] in [**2170**]
# Cervical spondylotic myelopathy with severe cervical stenosis
s/p cervical decompression and fusion in [**2171**]
# Thyroid nodules (TSH 1.2, benign as per FNA)
# Breast lumps
# Orthostasis
# Hypercalcemia: nl calcium, PTH, vitamin D levels
.
Past surgical history:
# s/p hysterectomy
# s/p multiple breast biopsies with negative results
Social History:
Pt lives alone in [**Location (un) **] with support from daughter nearby.
Performs all ADL's but does not drive. She lives on the [**Location (un) 17879**] and is able to up one flight of 18 stairs. She
has a 40+ year pack year smoking, although she quit in [**2158**]. She
denies alcohol and IV drug use. She is currently divorced. Uses
a cane at baseline.
Family History:
Hypertension in daughter; breast cancer in maternal uncle and
maternal aunt; diabetes and thyroid problems in daughter. Mother
had lung disease. Also significant for diabetes, heart disease,
and kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL - well-appearing obese female in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, MMM, OP Clear
NECK - supple, no thyromegaly, no JVD appreciated, no carotid
bruits
LUNGS - Bibasilar crackles, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, holosystolic murmur best heard
at LLSB, nl S1-S2
ABDOMEN - +BS, obese, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox2, CNs II-XII grossly intact, muscle strength
[**5-7**] throughout, sensation grossly intact throughout.
.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1 98.3 113/71 [106-125/53-77] 95-100 18-20 100% RA
I/O: 600/945 (straight cathed, occas voids ~100cc independently)
GENERAL - well-appearing obese female in NAD, comfortable,
appropriate, AAOx3
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear
NECK - supple, no thyromegaly, no JVD appreciated, no carotid
bruits
LUNGS ?????? Bibasilar crackles, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, holosystolic murmur best heard
at LLSB, nl S1-S2
ABDOMEN - +BS, obese, soft, mild suprapubic and LLQ tenderness,
no CVAT, no rebound/guarding, no HSM or masses
EXTREMITIES - WWP, no c/c/e, 1+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-7**] throughout, sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS:
WBC-15.7*# RBC-4.09* Hgb-12.2 Hct-37.9 MCV-93 MCH-29.9 MCHC-32.3
RDW-14.0 Plt Ct-332
Neuts-94.1* Lymphs-4.1* Monos-1.4* Eos-0.4 Baso-0
PT-22.3* PTT-29.1 INR(PT)-2.1*
Glucose-222* UreaN-92* Creat-4.3*# Na-135 K-5.4* Cl-99 HCO3-19*
AnGap-22*
Lactate-1.8 K-5.6*
Hgb-12.6 calcHCT-38
.
DISCHARGE LABS:
WBC-7.4 RBC-3.40* Hgb-10.1* Hct-32.5* MCV-96 MCH-29.6 MCHC-31.0
RDW-14.4 Plt Ct-294
PT-31.0* INR(PT)-3.0*
Glucose-156* UreaN-56* Creat-2.4* Na-135 K-4.7 Cl-102 HCO3-20*
AnGap-18
Calcium-8.5 Phos-4.2 Mg-2.1
.
URINE STUDIES:
[**2174-5-11**]: Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.020 Blood-LG
Nitrite-NEG Protein->600 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-8.5* Leuks-LG RBC->182* WBC->182* Bacteri-NONE
Yeast-NONE Epi-0 WBC Clm-FEW
[**2174-5-18**]: Color-AMBER Appear-Hazy Sp [**Last Name (un) **]-1.015 Blood-LG
Nitrite-NEG Protein-100 Glucose-TR Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-LG
RBC-80* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 URINE CastHy-9*
URINE Mucous-RARE
[**2174-5-18**]: URINE LYTES (random): Creat-106 Na-69 K-24 Cl-48 HCO3-
<5
-Uosm 445
-Posm 288
[**2174-5-16**]: URINE CYTOLOGY - PENDING
.
OTHER LABS:
-[**2174-5-17**] 06:50AM BLOOD Cortsol-16.1
-[**2174-5-13**] 06:35AM BLOOD TSH-0.30
.
MICROBIOLOGY:
-Blood cultures ([**2174-5-11**]): NEGATIVE
-Urine cultures ([**2174-5-11**]): fecal contamination
.
PA/LATERAL CHEST X-RAY ([**2174-5-11**]): The cardiomediastinal and hilar
contours
are stable, with the heart in the upper limits of normal. The
lungs are well expanded and clear, without consolidation,
pulmonary edema, pleural effusion or pneumothorax. Minimal
right basilar atelectasis is noted.
IMPRESSION: No acute cardiopulmonary pathology.
.
PORTABLE [**Last Name (un) **] X-RAY ([**2174-5-12**]): Supine abdominal radiographs are
limited by motion artifact. No radiopaque renal calculus is
visualized. The bowel gas pattern is nonobstructive. There is no
evidence of pneumoperitoneum. Osseous structures are
unremarkable. IMPRESSION: No radiopaque renal calculus
visualized.
.
CT [**Last Name (un) **]/PELVIS WITHOUT CONTRAST ([**2174-5-12**]):
1. No renal, ureteric or bladder stones identified. No
hydronephrosis.
2. Hypodense lesions in the left kidney, likely represent renal
cysts. No renal neoplasm is identified in this non-contrast
study.
3. Cholelithiasis.
Brief Hospital Course:
80F with sCHF (EF 45%), CKI (baseline 1.6-2.3), pAfib and DM
presently residing at rehab for osteoarthritis now admitted for
urosepsis.
# Urosepsis - The patient presented in the setting of N/V and
abdominal pain of several days duration with identification of
proteus UTI at rehab 2 days prior to admission for which
levofloxacin was initiated. On presentation to the ED, the
patient met SIRS criteria given tachycardia to 98, tachypnea to
RR of 28 and a WBC count of 15.7K, which given suspected
urologic infection confers the diagnosis of sepsis. The patient
was transiently hypotensive in the ED with SBP to the 80s that
rapidly corrected to the 100s-120s. Patient remained afebrile.
Blood and urine cultures were obtained in the the ED and given
treatment failure with levofloxacin, the patient was broadended
to vancomycin and cefepime. It is also likely that underlying
urinary retention (possibly from blood clots in the setting of
hematuria) complicated treatment of underlying infection. Give
hematuria and identification of proteus species in urine, there
was also concern for possible renal calculus or struvite stone,
which would further complicate her mangement. A KUB was done
which did not show evidence of stone. A follow up CTU also did
not show any evidence of stones or hydronephrosis. No gross
neoplasm was identified. She was admitted to the MICU for
further management and antibiotics were narrowed to cefepime
only. She was given fluid recussitation and was started on
continuous bladder irrigation. Urology was notified and a urine
cytology study was sent. Patient clinically improved and
remained hemodynamically stable. She was then transferred to the
general medical service where she remained afebrile and
hemodynamically stable. On the floor, urine culture
sensitivities returned sensitive to [**Last Name (LF) **], [**First Name3 (LF) **] patient was
transitioned to PO [**First Name3 (LF) **] to complete total of 14 days of
antibiotics (last day [**2174-5-24**]).
.
# URINARY RETENTION: After DC'ing CBI and Foley on [**2174-5-16**],
patient continued to retain large volumes of urine requiring
re-insertion of Foley. Spoke with urology who did not feel that
inpatient consult was merited, as history suggests bladder
stress s/p cystitis which will resolve with rest and
intermittent straight cath. Once her urine was clear without
gross hematuria, her Foley was DC'd and she was straight cathed
as needed. On day of discharge, she was seen by Nephrology for
her hyperkalemia (see below), who felt that she had near
complete bladder atonia at this point. They recommended straight
cath FOUR TIMES daily at her nursing home, plus checking
post-void residuals and straight cathing for >150cc on bladder
scan. She will follow up with Urology within 1 week for voiding
trial and possible urodynamic studies, and also with Nephrology
within 2 months.
.
# ACUTE ON CKD: Baseline Cr 1.6-2.3, elevated to 4.3 on
admission. Improved to baseline with IV fluids, CBI (tapered to
intermittent cath per above), and holding Lisinopril and Lasix.
Likely multifactorial etiology: pre-renal due to urosepsis,
intrinsic renal due to slightly worsening diabetic nephropathy,
and post-renal from bladder dysmotility and blood clots causing
bladder obstruction. Patient's Lasix was restarted on the floor
at 20mg daily ([**1-3**] home dose) as she appeared mildly clinically
volume overloaded and also had developed mild hyperkalemia (see
below). Per renal recs, full home Lasix 40mg daily dose was
reinstated on discharge. Lisinopril continued to be held on
discharge and will be restarted at discretion of PCP.
.
# HYPERKALEMIA: On transfer to the floor, patient was noted to
be intermittently hyperkalemic to 5.7-5.9 despite progressive
improvement in her renal function. Initially considered
hyperglycemia or hypocortisolism but sugars not particularly
elevated and AM cortisol was WNL. On HD #7 her bicarb was also
noted to be low, which raised question of Type 4 RTA caused by
hypoaldosteronism and/or her known diabetic nephropathy (EGFR
20-22, stage IV-V CKD). Her TTKG was inappropriately low which
supported this diagnosis. Nephrology was consulted and advised
that her hyperkalemia was likely mainly secondary to bladder
obstruction, which can cause hyperkalemia even in the setting of
an apparently improving GFR. They felt that hyporenin-hypoaldo
state could be contributing, but less likely explanation than
bladder obstruction. Regardless, they advised increasing Lasix
to home dose (40mg daily) to increase solute delivery to distal
collecting duct, and low potassium diet (<2g/day), to prevent
her hyperkalemia from worsening. Potassium normalized to 4.8 on
day of discharge. She will follow up with Dr. [**Last Name (STitle) 4883**] of
nephrology as an outpatient.
.
# GROSS HEMATURIA: Per rehab, patient appeared to have vaginal
bleeding on the day she was sent to ED. CBI revealed large gross
blood in bladder, so source of bleeding was most likely urologic
in nature, potentially secondary to the UTI itself. However,
large volume of blood and presence of clots suggest there could
be some additional process present. CT [**Last Name (un) 103**]/pelvis shows no
renal stones. Urine cytology was checked to assess for urologic
malignancy: she is at risk for bladder cancer given 30 pack-year
smoking history. Cytology results pending on discharge. She has
no documented h/o abnormal [**Last Name (un) **] smear, but GYN malignancy such
as cervical cancer could also present with gross vaginal
bleeding. She will follow up with Urology as outpatient for
further work-up.
.
# Severe OA: Patient has chronic severe OA, with worse BL knee
pain during hospitalization most likely due to immobilization.
No joint warmth, erythema etc suggestive of infection or
crystalline arthropathy. Her pain improved after starting
Lidocaine patch daily, Tramadol 50mg PO BID, and uptitrating
Tylenol to 1000mg PO TID standing. She will follow up as an
outpatient with her orthopedist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
consideration of corticosteroid injections, which have been
helpful in the past.
.
#.AFIB: CHADS 2 of 4 (age, HTN, CHF, DM), on amiodarone,
metoprolol, diltiazem and warfarin as an outpatient. Metoprolol
was held, then restarted at reduced dose (100mg daily vs.
original 300mg daily) on discharge. Diltiazem was stopped, to be
restarted by PCP if needed. Amiodarone was continued. Warfarin
dose was decreased progressively during hospitalization due to
treatment with [**Last Name (NamePattern1) **] which caused INR prolongation, with
subsequent recurrence of gross hematuria. Discharge Warfarin
dose is 0.5mg daily, to be followed and uptitrated PRN by
[**Hospital3 537**].
.
# CHF - last known EF 45%. Reported worsening SOB while in rehab
but subjectively better now, satting high 90's RA. CXR without
pulm edema, no pedal edema/JVD. Lasix initially held, then
restarted at home dose per above.
.
# NIDDM: Held home glipizide during hospitalization. Mildly
hyperglycemic to ~200s on home Lantus 16 units daily. Restarted
glipizide on discharge.
.
# HTN: Initially held Lasix, Dilt, Metoprolol; remained
normotensive throughout hospitalization.
.
# Depression - continued home mirtazapine.
.
============================
TRANSITION OF CARE:
-Studies pending on discharge: urine cytology
-Meds held on discharge: diltiazem + lisinopril. Restart as
tolerated.
-Please straight cath patient 4 times daily. Also please check
post-void residuals and straight cath PRN for >150cc's on
bladder scan.
-Please check Chem 10 and INR on [**5-21**] to monitor ongoing
improvement in serum potassium and titrate warfarin dosing as
needed.
-Please continue low potassium diet (<2 grams/day).
Medications on Admission:
- Amiodarone 200 mg daily
- Diltiazem HCl 240 mg daily
- Furosemide 40 mg daily
- Glipizide 10 mg daily
- Lisinopril 40 mg daily
- Metoprolol succinate 300 mg daily
- Mirtazapine 15 mg QHS
- Pravastatin 80 mg QHS
- Aspirin 81 mg daily
- Calcium Citrate + D 630-400 [**Hospital1 **]
- Warfarin 2mg Mondays and Thursdays and 1.5mg 5 other days
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO twice a day.
6. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for eye dryness, irritation.
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. warfarin 1 mg Tablet Sig: [**1-3**] Tablet PO Once Daily at 4 PM.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO twice a day.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Lantus 100 unit/mL Solution Sig: Sixteen (16) units
Subcutaneous at bedtime.
17. [**Month/Day (2) **] 500 mg Tablet Sig: One (1) Tablet PO every
twenty-four(24) hours for 5 days: First day = [**2174-5-11**]
Last day = [**2174-5-24**].
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
ACUTE PROBLEMS:
1. Urosepsis
2. Hematuria and blood clots in bladder treated with CBI
3. Acute on chronic renal failure
CHRONIC PROBLEMS:
1. Atrial fibrillation
2. Congestive heart failure
3. Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital for a urinary tract infection.
Due to low blood pressure when you arrived, you were initially
cared for in the ICU. You were started on IV antibiotics and
your symptoms improved. You also had blood in your urine and
blood clots in your bladder, which were treated with bladder
irrigation. This will need more investigation as an outpatient.
.
Please attend the outpatient appointments listed below with
Urology and Orthopedics to follow up on your urine retention and
osteoarthritis. Also please attend your other
previously-scheduled outpatient follow up appointments listed
below.
.
We made the following changes to your medications:
1. STARTED Tramadol (Ultram) 50mg by mouth twice daily (for
osteoarthritis pain)
2. STARTED Lidocaine patch once daily
3. INCREASED Tylenol to 1000mg by mouth every 8 hours (for
osteoarthritis pain)
4. DECREASED Warfarin to 0.5mg by mouth daily (to be adjusted by
[**Hospital3 537**] as needed)
5. DECREASED Metoprolol succinate to 100mg by mouth daily
6. STOPPED Lisinopril and Diltiazem (your primary care doctor
will decide whether to restart these in the future)
Followup Instructions:
***You will be called by the Nephrology (kidney) Department to
schedule a follow-up appointment with Dr. [**Last Name (STitle) 4883**] within 2
months. If you do not hear from them within 1 week, please call
[**Telephone/Fax (1) 721**] to schedule the appointment.***
Department: ORTHOPEDICS
When: FRIDAY [**2174-5-27**] at 9:50 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: MONDAY [**2174-6-6**] at 1:30 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2174-6-8**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2174-6-8**] at 1 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2174-9-6**] at 11:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"276.2",
"424.0",
"599.0",
"038.49",
"428.0",
"425.4",
"300.4",
"585.4",
"599.71",
"588.89",
"424.2",
"403.90",
"427.31",
"788.20",
"530.81",
"715.36",
"428.23",
"276.7",
"995.91",
"596.54",
"599.60",
"584.9",
"V15.82",
"250.42"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17021, 17111
|
7297, 14632
|
301, 332
|
17371, 17371
|
4923, 4923
|
18740, 20473
|
3123, 3336
|
15445, 16998
|
17132, 17350
|
15079, 15422
|
17546, 18220
|
5236, 6081
|
2658, 2731
|
3376, 4040
|
14686, 15053
|
18249, 18717
|
1713, 1953
|
236, 263
|
361, 1694
|
4939, 5220
|
17386, 17522
|
1997, 2635
|
2747, 3107
|
6093, 7274
|
4065, 4904
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,081
| 144,926
|
12476
|
Discharge summary
|
report
|
Admission Date: [**2110-4-3**] Discharge Date: [**2110-4-8**]
Date of Birth: [**2035-4-19**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 74-year-old white male
who was last seen in his usual state of health. At
approximately 7 a.m. on the morning of admission, after which
time, he was found at 2:30 p.m. by his grandson to be on the
floor confused and acting inappropriately. The patient was
taken to [**Hospital3 3583**] where he had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma scale of
15 initially, but decreased to 14, and he was then intubated
and sedated with need to protect the airway. Soon after
this, he developed a seizure and wasgiven vecuronium before
transfer to the [**Hospital1 **] Hospital. He also
received Vitamin K and two units of fresh frozen plasma at
the outside hospital.
PAST MEDICAL HISTORY: Multiple cerebral vascular accidents.
He is status post myocardial infarction. He has a positive
history of chronic obstructive pulmonary disease and a
positive history of alcohol use and two pack a day tobacco
abuse.
ALLERGIES: He has an allergy history reaction to penicillin
and Benadryl and his current medications include Coumadin,
aspirin, metoprolol and Combivent.
At the time of admission and examination, he was intubated,
sedated and paralyzed and the examiner was therefore unable
to elicit a full neurological exam.
CT scan from the outside hospital showed a large cerebellar
hemorrhage with hydrocephalus.
LABORATORIES: His hematocrit was 40.6, white blood cell
count 8.4, platelet count 164,000. His PT was 16, PTT 39,
INR was 1.8 and this was after four units of fresh frozen
plasma. The INR had come down from an INR of 4.9 initially
at the outside hospital. His sodium was 133, potassium 4.7,
chloride 95, co2 26, BUN 8, creatinine 0.8 and blood glucose
130.
HOSPITAL COURSE: Due to the clinical findings, the patient
was admitted urgently to the Neurosurgical Intensive Care
Unit. A ventricular drain was placed and the patient was
placed supine with head of bed slightly elevated and the
ventricular drain allowing from drainage of cerebrospinal
fluid. Patient was subsequently stabilized and was initially
extubated and doing well, however, later on the [**6-4**],
he was reintubated for emesis and question of aspiration. On
the [**6-5**], he was noted to be awake and moving all
extremities but not clearly following commands. The
ventricular drain was patent at approximately 10 cm above the
tragus and he was otherwise considered stable.
On the 10th, he remained arousable, moving all four
extremities and obeying commands, and on the 11th, he
remained intubated and when propofol was turned off for
neurological exam, the patient attempted to open his eyes to
sternal rub. His legs bilaterally withdrew briskly to painful
stimuli. His left arm localized and he could stick out his
tongue and wiggle his toes partially to command but was
requiring careful blood pressure monitoring and control, as
well as continued sedation and continued intubation. On the
12th, it was noted that the patient remained intubated,
sedated, but was no longer responding to call or command. CT
scan was obtained and following this, a number of lengthy
discussions were entered with the family and with a social
worker present and decisions were made by the family to
withdraw care with consideration that they felt the family
member would not care to have his life sustained with all of
the necessary medical interventions that were being taken and
with the poor prognosis. For that reason, and with the
family's consent and request, the patient was subsequently
extubated and converted to comfort measures only and care was
essentially withdrawn other than for comfort measures and the
patient subsequently died late on the [**2110-4-8**] with
the patient's family present and comfortable with this event.
CONDITION ON DISCHARGE: Deceased.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Name8 (MD) 5474**]
MEDQUIST36
D: [**2110-6-21**] 18:43
T: [**2110-6-21**] 18:43
JOB#: [**Job Number 38725**]
|
[
"518.81",
"431",
"305.1",
"286.9",
"E888.9",
"V11.3",
"331.4",
"401.9",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"02.2",
"96.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
1887, 3916
|
154, 859
|
882, 1869
|
3941, 4198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,569
| 132,070
|
11695
|
Discharge summary
|
report
|
Admission Date: [**2139-7-14**] Discharge Date: [**2139-7-27**]
Date of Birth: [**2070-7-11**] Sex: F
Service: MEDICINE
Allergies:
Benadryl / Winrho Sdf / Heparin Agents
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
The patient is a 69 year-old lady with a h/o severe
valvulopathies s/p AVR/MVR/TVR with prolonged post-op course,
respiratory failure s/p trach, severe secondary pulmonary
hypertension, CHF, cirrhosis, renal failure, and ITP, presenting
from [**Hospital **] rehab with hypotension (SBPs in 70s) and
desaturations to the 80s (trached, on vent). ABG at 4am:
7.35/42/58. She received a dose of Levoquin prior to transfer.
.
Of note, she was recently discharged from [**Hospital1 18**] on [**2139-7-3**] after
her tri-valve replacement and long complicated post-op course.
She developed paroxysmal atrial fibrillation that was controlled
with diltiazem but was not anticoagulated, and she developed
renal failure requiring hemodialysis. She was found to have a
Klebsiella UTI and C.diff colitis, gram positive bacteremia, and
Serratia marcesans pna, so she completed full-course treatment
with Cipro, Flagyl, Vanc, and Cefepime.
.
In the ED, she was found to be hypotensive with SBPs in the 70s
(baseline SBP 90s), anuric, and without desaturations. She also
had 1 episode of clear diarrhea. It was noted that she had a
left subclavian line and right subclavian dialysis tunneled
line, both from her prior admission. Lung exam showed crackles
and rhonchi on the right, clear on the left, and CXR showed
possible right-sided pna. She received 3L of fluid, Vanc and
Flagyl, and was admitted to the MICU.
.
Past Medical History:
1. Severe valvulopathies, including aortic stenosis, mitral
regurgitation, and tricuspid regurgitation, now s/p AVR/MVR/TVR
on [**2139-5-21**].
2. Renal failure, dialysis dependent, developed after recent
surgery. Pt now on HD qMWF.
3. Severe secondary pulmonary hypertension, on home oxygen
therapy at home 2.5 liters per minute. Her last pulmonary
pressures were 53/25/37 on catheterization in [**2138-9-21**].
Portopulmonary hypertension is felt to be a contributor.
4. Congestive heart failure, post-op echo with preserved
systolic
function (LVEF>55%) on [**2139-6-9**].
5. Longstanding diabetes type 2, last hemoglobin A1c 5.9 on
[**2139-5-20**].
6. Liver cirrhosis, followed by Dr. [**Last Name (STitle) 34448**], presumed
secondary to NASH with contribution from cardiac cirrhosis,
complicated by ascites, splenomegaly, and varices on EGD
[**2139-1-22**] (grade 2 and one grade [**12-23**] in the distal 3-4 cm of the
esophagus). Childs class B cirrhosis.
7. ITP, compounded by severe liver disease and splenomegaly,
followed by Dr. [**Last Name (STitle) 6944**]. No response to IVIG, low and high dose
Prednisone therapy, and life-threatening intravascular hemolysis
following WinRho. On no therapy at present.
8. Osteoporosis, on Fosamax.
9. Basal Cell Carcinoma.
.
Social History:
She lives alone at home, with extensive VNA services
(telemonitoring). Her daughter is very involved in her care. She
used to work in consumer services, has been unable to work in
recent months.
Family History:
Non-contributory
Physical Exam:
VS - HR 120s, BP 90s/60s, R29, sat 99% AC-400x16/0.50/5.0
Gen - laying in bed, alert, answering questions, ill-appearing
HEENT - NCAT, PERRL, dry mucous membranes
Neck - supple, no JVD
Chest - +crackles/rhonchi bilaterally, R>L; decreased BS at
right base
CVS - RRR, Grade II/VI SEM
Abd - decreased BS; soft/NT/markedly distended (ascites); +fluid
wave; +HSM; no rebound/guarding
Extrem - 2+ BLE edema to knees
Skin - numerous ecchymoses throughout with few areas of skin
breakdown, +decubitus ulcer
Neuro - A&Ox3, follows simple commands, responds to
verbal/tactile stimuli
Pertinent Results:
[**2139-7-14**] 10:34PM CORTISOL-143.8*
[**2139-7-14**] 10:06PM CORTISOL-125.8*
[**2139-7-14**] 09:30PM CORTISOL-112.9*
[**2139-7-14**] 09:30PM PLT COUNT-33*
[**2139-7-14**] 08:44PM TYPE-MIX
[**2139-7-14**] 08:43PM LACTATE-2.0
[**2139-7-14**] 07:37PM ASCITES TOT PROT-0.9 TOT BILI-0.7 ALBUMIN-<1.0
[**2139-7-14**] 07:37PM ASCITES WBC-55* RBC-[**Numeric Identifier 37020**]* POLYS-90* LYMPHS-3*
MONOS-4* EOS-1* MACROPHAG-2*
[**2139-7-14**] 05:45PM GLUCOSE-146* UREA N-80* CREAT-2.7* SODIUM-143
POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-21* ANION GAP-20
[**2139-7-14**] 05:45PM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-2.4
[**2139-7-14**] 05:45PM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-1+ POLYCHROM-1+ SCHISTOCY-1+ STIPPLED-1+
TEARDROP-1+
[**2139-7-14**] 05:45PM PLT SMR-VERY LOW PLT COUNT-26*
[**2139-7-14**] 11:40AM ALBUMIN-2.9* CALCIUM-9.1 PHOSPHATE-4.2
MAGNESIUM-2.6
[**2139-7-14**] 11:40AM WBC-13.6*# RBC-3.00* HGB-9.6* HCT-30.7*
MCV-103* MCH-32.0 MCHC-31.3 RDW-23.6*
[**2139-7-14**] 11:40AM CK-MB-NotDone cTropnT-0.36*
[**2139-7-14**] 11:40AM NEUTS-94 BANDS-0 LYMPHS-3 MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2139-7-14**] 11:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2139-7-14**] 11:40AM PT-23.6* PTT-41.7* INR(PT)-2.4*
Brief Hospital Course:
ICU course: 69-yo woman with h/o severe valvulopathies s/p
AVR/MVR/TVR with prolonged post-op course, severe secondary
pulmonary hypertension, CHF, cirrhosis, and ITP, presented with
hypotension (SBPs in 70s) and probable sepsis in the setting of
multiple possible etiologies.
.
## Hypotension: of unknown etiology, DDx includes infectious
(including UTI, pna, colitis, line infxn, SBP) vs. cardiogenic
- fluid boluses for SBP<90, goal MAP>60, CVP 12
- if refractory to fluids, start Levophed, consider vasopressin
for synergy
- hold anti-hypertensives (nadolol, furosemide, spironolactone)
for SBP<90
- place arterial line
- check ECG, serial cardiac enzymes
- check Blood Cx, UA/Urine Cx, Stool Cx/C.diff, Sputum Cx
- diagnostic paracentesis for possible SBP: send cell count with
diff, fluid cx, total protein, albumin, total bili
- TTE to rule-out endocarditis
- check mixed venous O2, lactate, [**Last Name (un) 104**] stim
- continue Abx: Vanc, Zosyn, Flagyl
- consider discontinue left SC, right HD tunneled line
- consider placing left IJ / PICC
.
## Respiratory failure: consider pna given pt's history of
desaturations and hypotension as well as exam and CXR findings,
although pt is afebrile; also consider cardiogenic failure given
complex hx and recent cardiac surgery
- continue broad-spectrum abx for possible pna
- check sputum cx, blood cx
- check ECG, serial cardiac enzymes
- pt already with trach
- Mech Vent on AC: 400x16/0.50/5.0
- wean as tolerated
.
## Renal failure: no acute need for HD/CVVH
- renal following, consider d/c HD tunneled line
- renal-dose meds
- avoid renal toxins
- consider UTI given pt's history of Klebsiella UTI on prior
admission
- check UA/Urine Cx, blood cx
- continue broad-spectrum abx
.
## Coagulopathy: pt with h/o ITP with cirrhosis and splenomegaly
- give ddAVP, 1U platelets, 2U FFP for procedures
- continue to monitor, correct as necessary
- contact pt's hematologist Dr. [**Last Name (STitle) 6944**]
.
## Cirrhosis: presumed [**1-23**] NASH with cardiac congestion
- check LFTs
- continue rifaximin
- discuss with Liver team/contact pt's hepatologist Dr. [**Last Name (STitle) **]
- 69 y.o. female with NASH cirrhosis, ITP, s/p multivalve repair
admitted with hypotension and leukocytosis concerning for
sepsis. Currently in the ICU with massive amount of ascites,
negative for SBP.
-Plan for therapeutic tap once no longer on pressors and
hemodynamically stable.
.
## DM2:
- RISS
- consider insulin drip if BS>200
.
## CHF:
- check serial cardiac enzymes
- daily ECGs
- TTE tomorrow to rule-out endocarditis, assess LVEF
.
## FEN/GI: NPO except meds, replete lytes PRN, folic acid, iron
## Prophylaxis: PPI/H2-blocker, pneumoboots, bowel regimen
## Access: left SC, right dialysis tunneled line, right arterial
line
## Communication and Code Status: Communicating with the patient
and her daughter [**Name (NI) **]. Notably on the morning of [**2139-7-27**] the
patient expressed to her daughter that she no longer wanted to
undergo aggressive medical therapy. In consultation with the
ICU team, the patient, and her daughter, the patient was made
comfort measures only and expired on [**2139-7-27**].
Medications on Admission:
Medications: (transfer medications not available, medications
listed are those listed on discharge summary from [**2139-7-3**])
1. Folic Acid 1mg PO DAILY
2. Nadolol 20mg PO DAILY at 5pm
3. Insulin Glargine 75U SC QHS
4. Insulin Lispro sliding scale
5. Docusate Sodium 100mg PO BID
6. Ferrous Sulfate 325mg PO DAILY
7. Trazodone 25mg PO QHS PRN
8. Ropinirole 0.25mg PO QPM PRN
9. Fosamax 70mg PO QWeek
10. Spironolactone 50mg PO DAILY
11. Ampicillin-Sulbactam 3g Q8H x6days
12. Furosemide 40mg PO DAILY
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"428.0",
"571.5",
"996.73",
"V42.2",
"733.00",
"518.83",
"250.00",
"V66.7",
"V10.83",
"285.9",
"593.9",
"995.92",
"038.49",
"482.83",
"416.8",
"584.9",
"117.9",
"V46.11",
"276.2",
"789.5",
"785.52",
"287.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"99.07",
"54.91",
"96.72",
"38.95",
"39.95",
"99.04",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
9047, 9056
|
5294, 8462
|
309, 323
|
9107, 9116
|
3919, 5271
|
9172, 9182
|
3290, 3308
|
9015, 9024
|
9077, 9086
|
8488, 8992
|
9140, 9149
|
3323, 3900
|
258, 271
|
351, 1759
|
1781, 3061
|
3077, 3274
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,365
| 107,421
|
50277
|
Discharge summary
|
report
|
Admission Date: [**2124-3-15**] Discharge Date: [**2124-3-21**]
Date of Birth: [**2055-1-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / lisinopril / Wellbutrin / Seroquel
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Palpitations during hemodialysis
Major Surgical or Invasive Procedure:
Radioablation (via right femoral access)
Hemodialysis
History of Present Illness:
69F with history of SVT/AT s/p ablation [**3-2**], CAD s/p two BMS in
LAD ([**9-26**]), depressed EF 35% ([**9-/2123**]), ESRD (HD M/W/F), who was
admited after developing palpitations during hemodialysis this
morning. She was able to complete the dialysis. She denies chest
pain, SOB, or lightheadedness during the episode. No
syncope/presyncope. She has a long history of becoming
tachycardic during HD; admitted at [**Hospital1 18**] last [**Month (only) **]. She
continues to breakthrough despite pharmacologic therapy with
metoprolol, and failed amiodarone. She undewent ablation by Dr.
[**First Name (STitle) **] on [**2124-3-2**].
.
She had been discharged yesterday from [**Hospital 882**] hospital after
admission for SOB and was found to have pulmonary edema. She
uses 2 pillows/day and wakes up SOB [**2-18**]/week. She has not
noticed any changes in her functional status recently. She lives
with her husband and is able to perform ADL.
.
In the ED, VS were T-98.2, P-130, BP-98/65, RR-16, 96% on RA;
triggerred for tachycardia. Received 500cc NS bolus. Labs
remarkable for troponin of 0.18 in the setting of ARF.
Past Medical History:
-Paroxysmal SVT/AT
-CAD; NSTEMI ([**9-26**]) BMS to LAD, RCA 100% occluded
-chronic systolic HF, LVEF 35%
-DM2
-Hypertension
-Hyperlipidemia
-CVA (residual R weakness and intermittent R facial droop)
-PAD
-ESRD on HD 3x/week: anuric, on HD for >5y
-Sleep apnea (not using CPAP)
-Seizure disorder since [**3-/2123**] on Keppra: one seizure per pt
-depression with psychosis
-GERD with gastric ulcer causing UGI [**3-/2123**]
-Cervical Disk disease
-Syncope and collapse
-diabetic retinopathy
-gout
-anemia
-carotid artery stenosis
-thyroid cancer (vastly fluctuating TSH)
.
PSHx:
-bariatric surgery
-cholecystectomy
-C section x3
-LUE braciocephalic AV fistula last angioplasty [**11-25**]
Social History:
Married, lives with husband. 2 sons, [**Name (NI) **] and [**Name (NI) 74998**] (HCP).
Able to perform ADL.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother died in her 70's of cancer. Father
was killed.
Physical Exam:
ADMISSION EXAM:
VS: T-98.3 P-128 BP-107/70 97% Sat on RA
GENERAL: Thin, pleasant elderly woman in NAD. Lethargic. Alert
and Oriented x3. Mood-appropriate. Affect-flat.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mucous membrane
moist.
NECK: Supple with JVP of 8cm. Carotid bruits L>R. +Hepatojugular
reflex
CARDIAC: PMI nondisplaced, tachy, normal S1, S2. Difficult to
appreciate murmurs due to heart-rate. No rubs or thrills.
LUNGS: Unlabored, no accessory muscle use. Crackles in mid-lower
lung fields b/l. No wheezes or rhonchi. Scoliosis.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. [**Name (NI) 104848**] bruit over L brachiocephalic
fistula.
SKIN: Xerosis. No stasis dermatitis or ulcers.
PULSES: 1+ carotid, 1+ brachial, 1+ DP and PT.
NEURO: CN 2-12 grossly intact, motor strength and sensation
grossly intact bilaterally. 3/5 strength symmetric. No facial
droop or dysarthria.
.
DISCHARGE EXAM:
VS. 98.3 BP 109/58 (95-125/50-60) HR 87 18 100/RA fasting FS 111
Wt 55.4 kg
GENERAL: well-appearing elderly female sitting up in chair,
pleasant, alert and conversational, NAD.
NECK: supple, JVP 7 cm. Carotid bruits L>R.
CARDIAC: normal S1, S2. high-pitched holosystolic [**Name (NI) 9413**] best
@LUSB
LUNGS: prominent sternum/clavicle. respirations unlabored, no
accessory muscle use. bibasilar crackles, no wheezes or rhonchi.
Scoliosis.
ABDOMEN: Soft, NTND.
Pulse: palpable R femoral bruit (decreased from yesterday's
exam). warm, well-perfused RLE and LLE, warm feet, palpable
distal pulses, no edema
NEURO: AOX3, face symmetric, speech fluent but slow, moves all
extremities spontaneously
Pertinent Results:
ADMISSION LABS:
[**2124-3-15**] Glucose-109* UreaN-22* Creat-4.1*# Na-140 K-5.4* Cl-96
HCO3-32 AnGap-17 Calcium-9.3 Phos-3.4 Mg-2.0
[**2124-3-15**] WBC-4.6 RBC-3.16* Hgb-10.8* Hct-33.3* MCV-105*#
MCH-34.0* MCHC-32.3 RDW-13.7 Plt Ct-182 Neuts-74.5* Lymphs-15.2*
Monos-5.0 Eos-2.0 Baso-3.3*
.
DISCHARGE LABS
03/06/12Glucose-103* UreaN-48* Creat-6.7*# Na-139 K-3.9 Cl-96
HCO3-26 AnGap-21* Calcium-8.9 Phos-3.4 Mg-1.9
[**2124-3-21**] WBC-5.0 RBC-2.91* Hgb-9.8* Hct-29.9* MCV-103*
MCH-33.8* MCHC-33.0 RDW-14.9 Plt Ct-146*
.
OTHER PERTINENT LABS
[**2124-3-16**] TSH-2.5
.
IMAGING
CXR ([**2124-3-15**]):
FINDINGS: Single frontal view of the chest was obtained. There
are low lung
volumes, accentuate the bronchovascular markings. Fullness of
the hila and
mild perihilar opacities may relate to mild fluid overload
and/or crowding of vessels. No definite focal consolidation is
seen. No large pleural effusion or pneumothorax. Cardiac and
mediastinal silhouettes are grossly stable.
IMPRESSION: Low lung volumes with possible mild fluid overload.
Consider
repeat with better inspiration when patient able.
.
EKG
[**2124-3-15**]: HR 120, atrial tachycardia, Nl axis, normal interval,
nl R wave progression, no ST-changes.
[**2124-3-19**]: NSR 84
.
Microbiology:
[**2-/2041**] Blood culture (FINAL): NO growth
MRSA screen: NO MRSA isolated
.
[**3-17**] TTE
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 20 %) secondary to extensive apical akinesis
and severe hypokinesis of the rest of the left ventricle with
the exception of the basal posterior and lateral walls, which
are relatively preserved. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] A left ventricular apical mass/thrombus cannot
be excluded with certainty. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular free wall thickness is normal. The right
ventricular cavity is dilated with depressed free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] 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. There is severe
mitral annular calcification. Severe (4+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
Severe [4+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2123-10-7**], there has been marked further
deterioration of left ventricular contractile function as well
as marked increased in mitral and tricuspid regurgitation.
.
[**3-19**] R FEMORAL ULTRASOUND
FINDINGS: Focused vascular ultrasound of the right groin, the
common femoral artery and vein was performed with [**Doctor Last Name 352**]-scale,
color Doppler, and spectral analysis. Findings are concerning
for an AV fistula between the right common femoral artery and
vein, just proximal to the greater saphenous vein takeoff, where
there is turbulent, mixed broad waveform and suggestion of
connection between the two vessels. No evidence of
pseudoaneurysm is seen. No evidence of hematoma is seen in the
right groin.
IMPRESSION: Findings concerning for AV fistula between the right
common
femoral artery and vein. No evidence of pseudoaneurysm.
Brief Hospital Course:
69F with HX SVT, ESRD, CAD, PAD, and sCHF p/w symptomatic atrial
tachycardia to the 130s during outpatient dialysis; admitted for
management of this chronic problem, previously refractory to
pharmacologic therapy and a 1st ablation attempt on [**2124-3-2**];
during this admission she underwent a 2nd ablation attempt which
was not wholly successful (some intermittent Atach episodes
thereafter), and which was c/b a post-procedure R femoral AVF.
.
# ATRIAL TACHYCARDIA
Admitted from HD w/atrial tachycardia, a chronic intermittent
issues. Usually asymptomatic; now symptomatic w/lightheadedness
at HD. Admission EKG here documented atrial tachycardia to the
130s, no ischemic changes. Hemodynamically stable and
asymptomatic despite HR intermittently to the 130s. Underwent
successful ablation here on [**2124-3-16**], after which she was in NSR
for >24h. However, she did flip into atrial tachycardia
intermittently thereafter, with HR max 120s - episodes
self-resolved, occurred primarily during HD, and were
asymptomatic. Attempts to increase beta-blockade beyond Toprol
75mg PO QD were limited by BP. Patient will see Dr. [**First Name (STitle) **]
(electrophysiologist) in outpatient follow-up in ~1 week to
discuss any possible future intervenion. In the interim, at home
and at HD, her inpatient cardiologist felt comfortable
tolerating asymptomatic atrial tachycardia to the 120s-130s.
We note that on [**3-16**], post-procedure recovery was initially
complicated by anaesthesia-induced hypotension (requiring
overnight ICU obs) and later by the slow development of a R
femoral AVF (documented by ultrasound, see results). For the R
femoral AVF, vascular surgery consult service evaluated her
daily and recommended conservative management vascular surgery
f/u in 4 weeks. Expect spontaneous resolution.
.
# CHRONIC SYSTOLIC HEART FAILURE, LVEF 20%
TTE during this admission demonstrated LVEF 20%, MR 4+ TR 4+,
all worse than prior. MR [**First Name (Titles) 9413**] [**Last Name (Titles) **] on exam. Ischemic vs.
tachycardia-induced cardiomyopathy suspected as underlying
cause. She was euvolemic during admission; volume/BP control
primarily via BB and dialysis. Imdur was stopped due to relative
hypotension (SBP 90s-110s). Metoprolol dose increased to Toprol
75 mg QD. We note hx lisinopril allergy; considered started [**First Name8 (NamePattern2) **]
[**Last Name (un) **] but deferred this for outpatient f/u in setting of
borderline BPs.
.
# ORTHOSTATIC HYPOTENSION
Patient's BP fell to 75/palp when working w/PT on [**3-20**]. Family
confirmed that she suffers from lightheadedness when she first
rises to stand, especially after watching television (she like
Westerns). Imdur had already been stopped prior to this PT eval;
BB was subsequently lowered from Toprol 100 QD to 75 QD (further
decrease thought inappropriate given need to control atrial
tachycardia). She worked with PT twice more and was instructed
on techniques to decrease orthostatic symptoms and prevent
falls. Outpatient PT arranged at discharge.
.
# DM2
Patient has known DM2, not on either oral hypoglycemics or
insulin. Insulin needs here ranged from 8-12U/day. Discussed
initiating insulin w/pt, but she refused. [**Month (only) 116**] require ongoing BS
evaluation/discussion of therapeutic options as an outpatient.
.
INACTIVE ISSUES
.
# CAD
Patient w/ significant 2V CAD (LAD stented w/BMS x2, RCA
occluded 100% on [**9-/2123**] cath). EKGs negative for evidence of
restenosis or ischemic changes. No chest pain or dyspnea.
Continued Plavix and ASA 81mg.
.
# CHRONIC ANEMIA
Chronic; family confirms that she receives Epo at outpatient HD.
Denies h/o melena or GI bleeding. Hct remained stable ~30.
.
# ESRD:
Longstanding, on qMWF schedule. No difficulty w/LUE AV fistula
access. Atrial tachycardia episodes occurred primarily during HD
sessions, were asymptomatic and self-resolved within minutes.
See above for cardiology plan re: any future asymptomatic ATach
during HD.
.
# Hx Hypothyroidism s/p thyroidectomy
TSH wnl at admission. Continued home dose of synthroid.
.
# Hx HLD
Continued home statin.
.
# Hx Seizure disorder
One seizure in the past per patient. Continued home Keppra. No
seizure activity observed.
.
TRANSITIONAL ISSUES
1. EP to reassess for possible future repeat ablation attempt
2. DM2 - Pt refused discussion of insulin, had 8-12U/day insulin
requirement. [**Month (only) 116**] need further discussion/education about risks
of continuing with dietary control and without any medical
management.
3. Worsening sCHF (35%->20%). Suspected declining LVEF due to
tachycardia-induced crdiomyopathy [**2-17**] long-standing Atrial
Tachycardia. Suggest repeat TTE in [**4-21**] mos to reassess LVEF, MR
and TR once rate better controlled.
4. Follow-up HR, BP, orthostatic VS. Toprol dose increased to
75mg po DAILY, imdur stopped.
5. Follow-up logistics of outpatient PT, recommended by
inpatient PT consult
6. Monitor exam for changes in R femoral AVF (vascular surgery
f/u arranged)
6.
Medications on Admission:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. aripiprazole 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO ONCE
(Once) for 1 doses.
9. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. senna 8.6 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily).
15. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
16. metoprolol succinate 50mg po qday
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aripiprazole 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
15. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: Three (3)
Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Atrial tachycardia
2. Coronary artery disease
3. Depressed ejection fraction
4. End-stage renal disease
5. Hypothyroidism
6. Type 2 Diabetes
7. Hypertension
8. Sleep Apnea
9. Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
.
It was a pleasure taking care of you when you were admitted for
rapid heart rate during dialysis similar to the episodes you
have experienced in the past.
.
During this hospital stay, you underwent an ablation procedure.
The procedure was successful - you developed occasional rapid
rates but eventually returned to [**Location 213**] sinus rhythm. Dr. [**First Name (STitle) **]
will see you in follow-up to discuss whether you might need
another ablation procedure if you develop rapid heartrate again.
We noticed that you were lightheaded and had slightly low blood
pressures when you first stand up, especially on dialysis days.
You worked with a physical therapist here who gave
recommendation about standing up slowly to avoid lightheadedness
and falls. We also adjusted your medications to minimize
symptoms.
You had elevated blood sugars here, to >300 on more than 1
occassion. On average, you received 12 units of insulin/day to
control your blood sugar. You did not want to start diabetes
medications. You should discuss this further with your PCP, [**Name10 (NameIs) 3**]
you should be taking medication to control high blood sugar at
home.
The following changes were made to your medications:
CHANGED METOPROLOL FORMULATION:
START TAKING TOPROL XL 75 MG PER DAY (EXTENDED RELEASE). DON'T
TAKE YOUR OLD METOPROLOL/LOPRESSOR PILLS.
STOP TAKING IMDUR
Review your medication list with your PCP and cardiologist at
your next appointment. Please keep your follow-up appointments
as scheduled below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Tuesday [**2124-3-28**] 11:00am
Name: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Appointment: Friday [**2124-3-31**] 1:10pm
Department: VASCULAR SURGERY
When: WEDNESDAY [**2124-4-19**] at 2:45 PM [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: WEDNESDAY [**2124-4-19**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Street Address(2) 34126**] [**Location 1268**], [**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 38275**]
Appointment: Thursday [**2124-4-27**] 2:10pm
*You did have an appointment scheduled for tomorrow which has
been cancelled. If you have any questions or concerns please
call the office.
|
[
"425.4",
"585.6",
"440.20",
"427.89",
"412",
"362.01",
"250.50",
"458.29",
"244.0",
"V45.86",
"403.91",
"447.0",
"327.23",
"424.0",
"414.01",
"250.40",
"V45.11",
"V58.67",
"345.90",
"E938.4",
"V10.87",
"458.0",
"V45.82",
"428.22",
"272.4",
"428.0",
"V12.54",
"397.0",
"285.21",
"V12.71",
"530.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"39.95",
"99.62",
"37.26",
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
15827, 15884
|
8177, 13175
|
353, 409
|
16123, 16123
|
4279, 4279
|
17956, 19465
|
2481, 2624
|
14521, 15804
|
15905, 16102
|
13201, 14498
|
16299, 17933
|
2639, 3548
|
3564, 4260
|
281, 315
|
437, 1565
|
4295, 8154
|
16138, 16275
|
1587, 2277
|
2293, 2465
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,570
| 143,628
|
36261
|
Discharge summary
|
report
|
Admission Date: [**2137-5-5**] Discharge Date: [**2137-5-21**]
Service: SURGERY
Allergies:
Metoprolol
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Infected ax-fem bypass graft, UTI, chronic renal insufficiency
Major Surgical or Invasive Procedure:
[**2137-5-8**]:Ligation and excision of infected right axillofemoral
bypass graft.
[**2137-5-10**]:Evacuation of right chest wall hematoma.
History of Present Illness:
88 M ,DNR, w/ extensive vascular history transferred from
[**Location (un) **], NH with an infected right ax-[**Hospital1 **] fem graft. Pt was
transferred from his nursing home to OSH w/ chest pain [**2137-4-30**].
He r/o'd for MI and PE, but was found to have an infected graft
and staph aureus bacteremia. He was noted to have had 2
episodes
of bilious vomiting at the nursing home. He was transferred to
[**Hospital1 18**] for further care.
He denies pain at this time, though the right chest is sore over
the graft.
Past Medical History:
1. PVD s/p right fem-[**Doctor Last Name **] ([**2108**]), left fem-[**Doctor Last Name **] ([**2110**]), aortobifem
([**2119**]), right ax-[**Hospital1 **] fem, right AKA
2. CAD
3. Afib s/p pacemaker
4. Hyperlipidemia
5. HTN
6. Renal atrophy
7. GERD
8. Anemia
9. Hiatal hernia
10. Depression, h/o suicide attempts
11. Anxiety
12. Dementia
13. BPH
Social History:
SH: Legal Guardian- [**Name (NI) 3608**] [**Name (NI) 4334**] (w) [**Telephone/Fax (1) 5350**], (c)
[**Telephone/Fax (1) 74331**]. DNR- paperwork in chart. Lives at [**Hospital Ward Name **]-[**Doctor Last Name **] NH.
h/o EtOH abuse. Quit tobacco many years ago.
Family History:
no h/o early CAD
Physical Exam:
96.1 F 70 VP 146/74 16 95% RA Ht: 6' Wt: 88 Kg
Gen: NAD, alert
Cor: RRR. Right Ax-bifem graft erythematous along most of
tract, 2 areas of presumed fluid collections (one below nipple,
the other mid abdomen), no drainage, palpable pulse. No
carotid/abdominal bruits
Pulm: CTAB
Abd: well healed midline incision, moderately distended,
nontender
LE: warm, s/p R AKA, Left good, well healed incision, cap refill
normal, no edema
Pulses: Ax-Fem Fem [**Doctor Last Name **] graft DP PT
[**Name (NI) 167**] 1 1
Left 1 - 1 1 1
Pertinent Results:
[**2137-5-5**] 08:10AM VANCO-11.5
[**2137-5-5**] 07:00AM POTASSIUM-3.5
[**2137-5-5**] 07:00AM MAGNESIUM-1.9
[**2137-5-5**] 04:34AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2137-5-5**] 04:34AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2137-5-5**] 04:34AM URINE RBC-0-2 WBC-[**4-4**] BACTERIA-NONE YEAST-NONE
EPI-<1
[**2137-5-5**] 02:53AM GLUCOSE-151* UREA N-62* CREAT-2.5* SODIUM-138
POTASSIUM-5.5* CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
[**2137-5-5**] 02:53AM estGFR-Using this
[**2137-5-5**] 02:53AM WBC-18.3* RBC-3.74* HGB-10.8* HCT-33.2*
MCV-89 MCH-28.9 MCHC-32.6 RDW-14.4
[**2137-5-5**] 02:53AM PT-15.9* PTT-30.4 INR(PT)-1.4*
Brief Hospital Course:
Pt was admitted from [**Hospital6 19155**] for infected
ax-fem graft and staph aureus bactremia. He was started on IV
Vanc, Zosyn as well as IVF for his renal insufficiency. He was
DNR/DNI on admission.
ID/SURGICAL: Pt was started on IV Vanc/Zosyn for his infected
ax-fem bypass graft on admission. A CTA showed Multiple small
fluid pockets along the course of the right ax-[**Hospital1 **]-fem graft.
After consulting with the legal guardian and the patient, the
decision was made to remove the graft. His DNR/DNI status was
revoked for the OR. Before removal, and ultrasound showed patent
right ex-fem bypass graft with no evidence of stenosis. He went
to the OR on [**2137-5-8**] for removal of the graft. He tolerated the
procedure well, but due to the patient's ongoing need for
resuscitation, we elected to not to extubate the patient in the
operating room, and instead, sent him to the CV ICU for
continuing intensive monitoring. He was continued on Vanc and
Zosyn post-op. He developed an anterior chestwall hematoma which
needed to go to the OR emergently for evacuation. He was sent
back to the CV-ICU for continued intensive monitoring. His
cultures grew MRSA, sensitive to vancomycin, so the zosyn was
discontinued. His WBC count remained high post-operatively, and
a new infectious w/u showed a UTI. He was started on
Ciprofloxacin. Once the decision was made to make the patient
[**Date Range 3225**], anti-biotics were discontinued.
CV: Pt has a paced rhythm. Pre-operatively, an ECHO was obtained
per anesthesia, which showed LVEF>55%, and probable normal left
ventricle function, though a focal wall motion abnormality
cannot be fully excluded, and showed Mild mitral regurgitation.
Mild pulmonary artery systolic hypertension. Post-operatively,
he coded in the ICU for asystole, which responded to chest
compressions. Following his second trip to the OR, he coded once
again for asystole, which he quickly bounced back (evidenced by
palpable femoral pulses) after chest compressions. A stat
cardiology consult was obtained for an ECHO which RV is more
clearly visualized and appears dilated and hypokinetic compared
to the previous study. He had a troponin leak during this time,
but it was likely due to repeated chest compressions, and after
evaluation by cardiology a cardiac cath was not indicated.
RESP: He had some pleural effusions on his admission CTA (not
picked up on CXR), though he was not symptomatic from this so it
was watched. His respiratory status was stable pre-operatively.
Pt was intubated intra-operatively and weaned slowly off the
vent after his second surgery once his RISB scores were low and
felt safe to do so. He tolerated extubation without difficulty.
GI: There was a question of ileus on admission, an AXR showed
small dilated loops without air-fluid levels, and he was
monitored clinically. This resolved over the first 2 days of
admission. Post-operatively, he was started on tube feeds
briefly while intubated through an NGT, though this was
discontinued on extubation. He was taking poor POs at this
point, and a nutrition consult recommended placement of a
Dobhoff tube and resuming tube feeds. this was discontinued when
patient was made [**Date Range 3225**], and he was allowed to eat ad lib (soft
diet).
RENAL: Acute on chronic renal insufficiency/anuria. Pt was
admitted with chronic renal insufficiency coming in at a creat
of 2.5. He was not on diaylsis. Which worsened pre-operatively,
and did not respond to fluids. Post-operatively, he became
anuiric, and a renal consult was obtained. He was started on
CVVH through a right IJ line. During CVVH, up 10L of fluid were
taken off. He was switched to HD and more fluid was taken off.
He went for multiple treatments on a T TH Sa schedule, though
after discussing with the legal guardian and the patient
himself, Mr. [**Known lastname **] decided he did not want further diaylsis
and wanted his right IJ removed. He was aware of his kidney
failure. The was confirmed with the legal guardian.
HEME/ONC: pt did have elevated WBC, which was worked up
extensively for infectious etiology, which was positive. (see ID
section). He did require multiple transfusions of pRBCs, FFP,
and platelets post-operatively for low hct, platelets.
NEURO: He has baseline confusion and dementia, though is altered
and somewhat oriented. His pain was controlled throughout his
course, he required IV fentanyl while in the ICU, though is now
controlled on PO dilaudid 2-4mg Q3:PRN.
DISPO: After the discussion was made and the DNR/DNI status was
re-instated, the patient decided he would prefer not to have
further interventions performed. He was evaluated by the
palliative care team, and the the decsion was made in
corraboration with his legal guardian to make the patient
comfort measures only. His preference was to return to the
nursing home, which has been arranged. He will be discharged
stable to the nursing home [**Known lastname 3225**].
Medications on Admission:
Plavix 75 Daily
Aspirin 81 Daily
Pravachol 40 Daily
Nifedipine 90 Daily
Protonix 40 [**Hospital1 **]
Spiriva prn
CaCO3 [**Hospital1 **]
Celexa 20 Daily
Clonidine 0.2 PO BID
FeSO4 325 [**Hospital1 **]
Lisinopril 5 Daily
Mirtazapine 7.5 HS
MTV
Vicodin q4 prn
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H:PRN as
needed for pain.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
4. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 57894**] Home - [**Location (un) **]
Discharge Diagnosis:
Infected ax fem bypass s/p removal
Post-op chest wall hematoma s/p evacuation
Anuiria, kidney failure s/p CVVH, HD
Asystole, recovered after code/chest compressions
Discharge Condition:
stable to hospice ([**Location (un) 3225**])
Discharge Instructions:
Pt is [**Name (NI) 3225**], he is DNR/DNI. He has declined further intervention
for his renal failure (diaylsis, etc). His line has been
removed.
His sutures should remain in for 10 more days, at that point
they may be removed if applicable.
Please control patient's pain if he has any.
Followup Instructions:
comfort measures only
Completed by:[**2137-5-21**]
|
[
"414.01",
"599.0",
"518.5",
"996.62",
"998.12",
"585.9",
"427.31",
"427.5",
"V45.01",
"553.3",
"530.81",
"995.92",
"584.9",
"285.1",
"403.90",
"038.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"38.95",
"39.95",
"96.6",
"34.01"
] |
icd9pcs
|
[
[
[]
]
] |
8876, 8952
|
3057, 8010
|
279, 421
|
9161, 9208
|
2292, 3034
|
9544, 9597
|
1651, 1669
|
8318, 8853
|
8973, 9140
|
8036, 8295
|
9232, 9521
|
1684, 2273
|
177, 241
|
450, 977
|
999, 1349
|
1365, 1634
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,496
| 146,355
|
14888
|
Discharge summary
|
report
|
Admission Date: [**2150-5-20**] Discharge Date: [**2150-5-30**]
Date of Birth: [**2092-1-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Intubation
EGD with banding
History of Present Illness:
58 year old female with a PMH of hepatitis C cirrhosis,
hepatocellular carcinoma who presents with hematemsis. Of note
she was recently admitted to the OMED service (Dr. [**Last Name (STitle) **]
attending) for monitoring after chemo-embolization of a vascular
hepatic dome mass on [**2150-5-7**]. She had an EGD on [**2150-5-14**]
demonstrating 4 cords of grade III varices. She had an episode
of hematemesis this morning and her family called EMS. Noted to
have SBP 60/palp enroute and witnessed hematemesis by EMS.
In ED, she was felt to have hemorrhagic shock and thought to be
in acute distress though not actively vomiting. L femoral TLC
placed. 2 18 G PIV placed. She received 2 L NS with improvement
of SBP from 80-100. HCT at 23, down from baseline at 31-33. The
patient was intubated for airway protection and anticipation of
EGD (of note, required a Bougie during intubation). The patient
was started on octreotide gtt. Received 2 u pRBCs. Received 1 gm
ceftriaxone. Had 1 melanotic stool (75-100 cc) post intubation.
No pressors started. Accompanied by son who speaks English; pt.
speaks Arabic. VSS on transfer to MICU: 97.3 108/56 12 100% HR
104. Note - ETT pulled back 1.5 cm in ED after CXR indicating R
main stem intubation.
In the MICU she was intubated, sedated, and hx limited.
Past Medical History:
- Hepatocellular ca (3.8x3.0x3.0 cm lesion in dome of the liver)
- Hepatitis C - diagnosed in [**2141**], underwent tx c pegylated
interferon and ribavirin in [**2144**] with sustained virologic
response. Had a stable 1 cm hepatic dome nodule until [**3-/2150**]
when nodule noted to be 3.8 cm on MRI with associated probable
tumor thrombus of side branch L portal vein. AFP [**2142**]. Underwent
selective chemo-embolization from the R hepatic artery.
- Cirrhosis - liver bx showed mild portal
predominantly mononuclear cell infiltrate with minimal
periportal
extension (Grade 1). No steatosis or necrotic hepatocytes.
Moderate to focally marked portal fibrosis on trichrome stain,
with focal bridging and bile duct proliferation (Stage 2-3).
Complicated by portal HTN and extensive esophageal varices
Social History:
No tobacco, alcohol, or illicit drug use.
Family History:
N/C
Physical Exam:
On admission:
VS - 97.5, 102/60, 69, RR 19, 100% on A/C 40%, PEEP 5, VT 400,
RR 18
HEENT- anicteric sclerae, OP c ETT in place
LUNGS- coarse rhonchi diffusely, no obvious wheeze
HEART- +tachycardic, no murmurs
ABDOM- soft, nontender though exam limited by sedation. blood at
anus
EXTRE- wwp, no edema
NEURO- sedated. moving extremeties to painful stimuli
On discharge:
VS - 96.8, 122/72, 91, RR 14, 95%RA
HEENT- anicteric sclerae, conjunctiva pale, OP clear, MMM
LUNGS- CTAB
HEART- RRR,nls1s2, 1/6 SEM at LUSB
ABDOM- soft, ND, mild TTP, worse in RUQ, no organomegaly noted,
no fluid wave appreciated, no caput
EXTRE- wwp, no edema, no spiders
NEURO- AA&Ox3, moves all ext., nl sensation, no asterixis.
Pertinent Results:
EGD [**5-20**]:
Esophagus: Protruding Lesions 4 cords of grade III varices were
seen starting at 20 cm from the incisors in the lower third of
the esophagus. The varices were oozing. 5 bands were
successfully placed.
Stomach: Protruding Lesions Non [**Month/Year (2) **] varices were seen in
the fundus and cardia.
Duodenum: Mucosa: Normal mucosa was noted.
Impression:
- Varices at the lower third of the esophagus (ligation)
- Varices at the fundus and cardia
- Normal mucosa in the duodenum
CT Head:
FINDINGS: There is no evidence of hemorrhage, edema, mass, or
mass effect. The ventricles and sulci are unremarkable. There is
no evidence of hydrocephalus. There is normal [**Doctor Last Name 352**]-white matter
differentiation. No fractures are identified. The visualized
paranasal sinuses are clear.
CXR:
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: Following extubation,
lung volumes have decreased slightly. A left retrocardiac
opacity represents atelectasis. There is no significant pleural
effusion. Radiodense material projecting over the right upper
quadrant represents chemoembolization material. The bony thorax
is normal.
Liver US:
FINDINGS: The liver is diffusely heterogeneous, with a nodular
contour, compatible with cirrhosis. The patient has known
hepatocellular carcinoma seen in the right hepatic lobe,
measuring 7.5 x 5.1 x 5.9 cm.
The main portal vein is thrombosed extending from the portal
confluence to the hilum, with the exception of a trickle of
flow, which is hepatopetal in direction. The left and right
portal veins were not imaged. The inferior vena cava and splenic
veins are patent. The main hepatic artery and hepatic veins are
also patent.
The gallbladder is unremarkable. The spleen is enlarged,
measuring 15.9 cm. There is a moderate amount of ascites.
[**2150-5-30**] 09:24AM BLOOD WBC-3.1* RBC-3.41* Hgb-10.2* Hct-28.8*
MCV-84 MCH-30.1 MCHC-35.6* RDW-16.7* Plt Ct-104*
[**2150-5-20**] 02:50PM BLOOD WBC-5.3 RBC-2.80*# Hgb-8.0*# Hct-23.1*#
MCV-83 MCH-28.5 MCHC-34.5 RDW-18.5* Plt Ct-222#
[**2150-5-30**] 09:24AM BLOOD PT-16.5* PTT-29.5 INR(PT)-1.5*
[**2150-5-22**] 03:37AM BLOOD Gran Ct-1260*
[**2150-5-30**] 09:24AM BLOOD Glucose-186* UreaN-12 Creat-0.8 Na-134
K-4.2 Cl-106 HCO3-19* AnGap-13
[**2150-5-30**] 09:24AM BLOOD ALT-16 AST-38 AlkPhos-95 TotBili-0.6
[**2150-5-30**] 09:24AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.1
Brief Hospital Course:
58 year old female with HCC, HCV cirrhosis who presented with a
large volume GIB and ten point hematocrit drop from her
baseline. She was initially admitted to the intensive care unit
and intubated for airway protection. An EGD was done which
revealed Grade IV esophageal varices. The varices were [**Month/Day/Year 43652**]
and the patient was successfully extubated the morning after
admission.
The patient was initiated on an octreotide gtt, which was
continued until she was transferred to the floor. She was also
treated with a five day course of ceftriaxone, which she
completed while in house. She was started on Nadolol and the
dose was reduced from 20 mg to 10 mg prior to discharge as the
patient had some dizziness. She was also started on both Lasix
and spironolactone, which were discontinued as her blood
pressure did not tolerate all of the above agents. Her
hematocrit remained stable after an initial transfusion of four
units of packed red blood cells. She will follow up for repeat
banding with GI.
While in the intensive care unit, an ultrasound demonstrated
cirrhotic liver with re-demonstration of a known hepatocellular
carcinoma in the right hepatic lobe as well as near complete
occlusion of the main portal vein, which had progressed since
the ultrasound of [**2150-4-9**]. Unfortunately, the progression of
disease and the associated thrombus made the patient ineligible
for listing as a transplant candidate. This was discussed with
the patient and with her family on several occasions.
On the floor, the patient had nausea and vomiting. She was
treated with IV anti-emetics, which resolved her discomfort. At
discharge, she was tolerating PO intake without difficulty and
had no further episodes of vomiting. She was discharged with
medications for nausea.
The patient does not wish to know her diagnosis and thus knows
she is no longer a transplant candidate but does not know she
has hepatocellular cancer. Her family is aware of the diagnosis
and prognosis. The patient was discharged to home in the care
of her family, with VNA services and plan for repeat banding as
an outpatient.
Medications on Admission:
Nadolol 20 mg qdaily
Compazine 10 mg q6h PRN nausea
Oxycodone 5 mg q4h PRN pain
Docusate
Senna
Bisacodyl
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
Disp:*1 tube* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
5. Lorazepam 0.5 mg Tablet Sig: one half Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*1*
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*2*
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Portal vein occlusion
Secondary diagnosis:
Hepatocellular carcinoma
Liver cirrhosis secondary to HCV
Discharge Condition:
VSS, no nausea or vomiting, ambulating/eating/drinking at
baseline.
Discharge Instructions:
You were admitted to the hospital with a GI bleed. While you
were in the hospital, you received several blood transfusions.
The GI doctors [**Name5 (PTitle) 43652**] the [**Name5 (PTitle) **] vessels in your esophagus.
You will need to return to the hospital next week to have more
bands placed. Your blood counts have been stable since your
transfer from the intensive care unit.
You were also started on new medications. Please take these
medications as prescribed.
You should have your pulse checked 1-2 times a day. If it is
less than 60, you should not take the nadolol that day.
Please call your primary care physician or come to the emergency
room if you experience increasing abdominal pain, vomiting,
fever, or other concerning symptoms. If you experience
recurrent [**Name5 (PTitle) **], call an ambulance to come to the ER right
away.
Followup Instructions:
Please follow up as scheduled below:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2150-6-4**] 3:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2150-6-4**]
3:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-6-10**] 11:30
|
[
"785.59",
"155.0",
"518.81",
"571.5",
"453.8",
"456.20",
"311",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"42.33",
"96.04",
"99.07",
"99.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9285, 9343
|
5721, 7857
|
325, 354
|
9508, 9578
|
3333, 3829
|
10480, 10852
|
2589, 2594
|
8013, 9262
|
9364, 9364
|
7883, 7990
|
9602, 10457
|
2609, 2609
|
2979, 3314
|
274, 287
|
382, 1684
|
3838, 5698
|
9427, 9487
|
9383, 9406
|
2623, 2965
|
1706, 2512
|
2528, 2573
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,994
| 181,353
|
11932+56305
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-2-8**] Discharge Date: [**2132-2-28**]
Date of Birth: [**2087-11-5**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 9035**] is a 44-year-old woman
with alcoholism who was transferred from an outside hospital with
a chief complaint of hypotension, acute respiratory distress
syndrome, in the setting of necrotizing pancreatitis. At the
outside hospital the patient admitted to an alcohol intake of
three glasses of wine every other day, but on further questioning
her boyfriend reports that she drinks approximately 1 liter of
wine per day for at least the several days prior to admission.
On [**2-1**], the patient experienced the onset of epigastric
pain, nausea, vomiting. On [**2-3**] she vomited five to six
times and was unable to keep down p.o. fluids. The patient
presented to the Emergency Room at [**Hospital3 417**] Hospital. Her
review of systems at that point was positive for chest pain and
shortness of breath. On the morning of presentation she also
noted dyspepsia. She denied bright red blood per rectum or
urinary complaints. Her last menstrual period had been 10 days
prior. She had no sexual activity in the past five months. Her
examination at the outside hospital was notable for present bowel
sounds and periumbilical tenderness. Her laboratories there
were notable for a white blood cell count of 11.4 with 86%
polymorphonuclear leukocytes, and a sodium of 130, and potassium
of 2.7, and an anion gap of 17. Her AST was 101, and her amylase
was 195. Her alcohol screen was negative.
She was admitted to [**Hospital3 417**] Hospital for conservative
management of pancreatitis. She received intravenous fluids,
potassium repletion, Demerol, and Vistaril for pain management.
Chest x-ray on admission was clear. A CT scan of her abdomen
showed a fatty liver, diffuse enlargement of the pancreas with
areas of decreased enhancement, presenting the question of
necrosis, moderate fat surrounding, and no fluid collection. The
patient was started on imipenem on [**2-4**]. She did
relatively well through [**2-6**].
On the morning of [**2-7**], the patient complained of
shortness of breath. Her temperature at that point was 100
degrees Fahrenheit. Her pulse was 161. Her blood pressure was
144/87, and her respiratory rate was 38. She was saturating 63%
on 2 liters. A chest x-ray showed bilateral alveolar
infiltrates. She was given Ativan and morphine and intravenous
Lasix. An arterial blood gas revealed a pH of 7.33, PCO2 of 37,
and PO2 of 39. She was intubated and taken to the [**Hospital3 417**]
Hospital Intensive Care Unit. The patient was given diltiazem for
sinus tachycardia, phenylephrine drip for hypotension. Also
started on a propofol drip, calcium, and magnesium. A central
venous catheter was placed in the right internal jugular vein,
and a femoral arterial line was placed. She had a right atrial
pressure of 19, pulmonary artery pressure of 98/31, and a
pulmonary capillary wedge pressure of 25. She was given an
additional 100 mg of Lasix intravenously and transferred to
[**Hospital1 69**] for further management.
On arrival, the patient was intubated and not responsive to
voice. She was admitted to the MICU.
PAST MEDICAL HISTORY:
1. Gravida 4, para 2; two cesarean sections; spontaneous
abortion times one; therapeutic abortion times one.
2. Herniated L5-S1 disk.
3. Depression.
4. Chronic vertigo.
5. Alcoholism.
MEDICATIONS ON ADMISSION: Medications as a outpatient
include Ambien 10 mg p.o. q.d. p.r.n., Motrin 600 mg p.o.
p.r.n., Celexa 10 mg p.o. q.d., Antivert p.r.n.
MEDICATIONS ON TRANSFER: Propofol drip, phenylephrine drip,
Ativan, morphine, Versed, Lasix, Demerol, Celexa, imipenem,
levofloxacin, vitamin B1, diltiazem drip.
ALLERGIES: BACTRIM.
SOCIAL HISTORY: Divorced, lives with two children ages 15
and 10. Has a boyfriend. Positive history of alcoholism;
one bottle of wine per day per boyfriend. Positive tobacco
history; one pack per week. No drugs.
FAMILY HISTORY: Mother with diabetes. Father with history
of coronary artery disease.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature of 101.2
rectally, pulse 106, respiratory rate 22, blood pressure
138/84, oxygen saturation 95% on FIO2 of 100%. Pulmonary
artery pressure of 36/21, pulmonary capillary wedge pressure
of 13, central venous pressure of 13, cardiac output of 4.96.
Systemic vascular resistance of 1258. Ventilator setting
assist control ventilation 450 X 18, positive end-expiratory
pressure 15, FIO2 1. The patient was intubated and sedated.
She purposefully opened eyes. Occasional myoclonus. No
meaningful response to verbal or tactile stimuli. Her
conjunctivae were pink. Her pupils were equal, round, and
reactive to light. She had no doll's eye reflex. Her neck
was supple. No jugular venous distention was appreciated.
Her heart had a regular rate and rhythm with a 2/6 systolic
murmur at the apex radiating to the axilla. She had
decreased breath sounds at the bases and in the apices
without rales or wheezes. Her bowel sounds were absent. Her
belly was softly distended. The patient became agitated with
epigastric pressure. There was no peripheral edema. The
lower extremity pulses were dopplerable. There was no
stigmata of chronic liver disease.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count of 13.4, hematocrit 32, platelets 286. Sodium 133,
potassium 3.4, chloride 98, bicarbonate 20, blood urea
nitrogen 11, creatinine 0.8, glucose of 251. Calcium 5.3,
magnesium 0.9, phosphorous 1. Creatine kinase was 272, with
a MB fraction of 1.2, troponin was negative. Arterial blood
gas on admission revealed pH of 7.33, PCO2 of 37, PO2 of 39
on FIO2 of 1.
RADIOLOGY/IMAGING: Electrocardiogram revealed sinus
tachycardia at 163 beats per minute with T wave flattening in
leads V3 through V6, III, and F.
Chest x-ray on admission revealed bilateral upper lobe
alveolar opacities consistent with pulmonary edema.
Endotracheal tube in good position, and a pulmonary artery
catheter in the right lower lobe pulmonary artery.
CT of the abdomen revealed fatty infiltration of the liver;
normal spleen, adrenals, and kidneys. Small bilateral
effusions and bibasilar atelectasis. Diffuse enlargement of
the pancreas, moderate fatty stranding, some areas of
decreased enhancement. No abscess or fluid collections.
Right upper quadrant ultrasound revealed ascites, no
gallstones.
HOSPITAL COURSE: This is a 44-year-old female with
alcoholism who presented to the [**Hospital1 188**] from an outside hospital with physiology consistent
with acute respiratory distress syndrome and hypovolemic
shock secondary to third spacing from necrotizing pancreatitis.
Her Medical Intensive Care Unit course was notable for the
following:
1. PULMONARY: Upon arrival the patient was intubated, and
ventilated, and paralyzed. Paralysis was discontinued on
[**2-10**]. By [**2-15**], the ventilator was decreased to
minimal pressure support, but the patient failed a spontaneous
breathing trial. A chest x-ray on [**2-17**] revealed a right
upper lobe infiltrate and sputum Gram stain showed gram-negative
rods. The patient was thus started on vancomycin and gentamicin
for presumed ventilator-associated pneumonia. The patient
remained stable but was not extubated due to inability to
decrease sedation and improve mental status. The patient would
become increasingly agitated with withdrawal of her sedation. The
patient self-extubated on [**2-24**], and oxygen saturations
remained stable thereafter. The patient continued to be treated
for presumed ventilator-acquired pneumonia with vancomycin and
gentamicin after she was transferred to the hospital floor. Her
antibiotic therapy will be discontinued on [**3-8**].
2. CARDIOVASCULAR: The patient was transferred to [**Hospital1 346**] on pressor agents. These were
discontinued soon after her arrival. The patient was
intermittently tachycardic, worse with temperature spikes and
sedative withdrawal. She also had transient episodes of
hypotension which were responsive to fluid boluses. After
extubation, she remained hemodynamically stable and was
transferred to the floor in stable condition.
3. GASTROINTESTINAL: Surgery was consulted for management
of the necrotizing pancreatitis. Repeat CT scans showed
extensive necrosis. CT-guided pancreatic aspiration was
performed on [**2-15**] which grew no organisms in culture. A
repeat CT scan on [**2-22**] showed stable pancreatic necrosis
with developing surround pseudocyst without signs of
superinfection.
On transfer to the floor, the patient was tolerating tube
feeds via a postpyloric nasogastric tube. She was without
abdominal pain. Her diet was slowly advanced.
4. RENAL: Urine output, blood urea nitrogen, and creatinine
have been stable throughout the admission.
5. INFECTIOUS DISEASE: The patient continued to spike fevers
throughout her hospital course. On the morning of [**2-27**],
the patient spiked a temperature to 102. Blood cultures, fungal
isolators, urine cultures, sputum, and Clostridium difficile
assays were sent. At the time of this dictation, all of these
tests were negative.
The patient was switched from imipenem to vancomycin and
gentamicin on [**2-17**] because she developed a drug rash to
imipenem. Dermatology was consulted regarding this rash which
was erythematous and bullous. A biopsy revealed perivascular
lymphocytic and eosinophilic infiltrates consistent with drug
reaction.
6. NEUROLOGY: The patient required high doses of sedation and
was difficult to wean from sedative drips. She was started on
Haldol to decrease agitation during the weaning of sedation. She
was started on a 50-mcg per 72-hour Fentanyl patch on [**2-26**]
and weaned off her Fentanyl drip. She was changed to oral Ativan
on [**2-27**].
On the hospital floor, the Ativan was slowly weaned. She was
started on Seroquel 25 mg p.o. three times per day for agitation
and delirium as the Ativan was being weaned off. She was followed
by Psychiatry throughout this admission for recommendations on
managing her sedative medications.
7. HEMATOLOGY: The patient received 1 unit of packed red
blood cells during her admission, but her hematocrit has remained
relatively stable throughout the admission at 25 to 26. Iron,
B12, and folate studies were all within normal limits. The
patient also developed a reactive thrombocytosis. This was
followed closely, and at the time of this dictation had begun to
trend downward.
8. ENDOCRINE: The patient had mild hypoglycemia presumed
secondary to pancreatitis. Her fingerstick blood glucoses
were monitored, and she was maintained on a regular insulin
sliding-scale for new diabetes.
9. FLUIDS/ELECTROLYTES/NUTRITION: At the time of this
dictation, the patient was diuresing large amounts of fluid
on her own. Her fluid status was approximately even. Her
electrolytes were stable. She was receiving tube feeds
through a postpyloric feeding tube for nutrition. She was to
be transferred to a clear liquid. The plan was to hold off
on starting Pancrease pending clinical need (ie diarrhea).
10. ADDICTION: The patient is being followed closely by Social
Work and Psychiatry. At the time of this dictation, she had very
little insight into the problems that caused this
hospitalization. At this point it is unclear the extent to which
she was drinking prior to this hospitalization; however, it was
clear that a major trigger for this pancreatitis was alcohol and
that the patient will need to abstain from alcohol in the future
to avoid further recurrences of pancreatitis. She would benefit
from addiction treatment in the future.
Note: This completes the hospital course from admission on
[**2132-2-8**] until [**2132-2-28**]. The remainder of
the patient's hospitalization will be dictated in an Addendum
to this Discharge Summary on the day of discharge.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2132-2-28**] 17:56
T: [**2132-2-28**] 19:28
JOB#: [**Job Number 37574**]
Name: [**Known lastname 4359**], [**Known firstname 540**] A Unit No: [**Numeric Identifier 6775**]
Admission Date: [**2132-2-8**] Discharge Date: [**2132-3-5**]
Date of Birth: [**2087-11-5**] Sex: F
Service: Medicine
ADDENDUM: This is an addendum to the Discharge Summary dictated
[**2132-2-28**]. This addendum describes the [**Hospital 1325**] hospital
course from [**2132-2-28**] to discharge on [**2132-3-5**].
HOSPITAL COURSE BY SYSTEM:
1. PULMONARY: The patient's oxygen requirements decreased
as she auto-diuresed on the floor. At the time of discharge,
she was doing well on room air. Her lung examination was clear.
Her antibiotics were discontinued on [**2132-3-2**] after a 14-
day course plus seven days of imipenem at the outside hospital.
2. CARDIOVASCULAR: She remained hemodynamically stable.
3. GASTROINTESTINAL: The patient's diet was advanced slowly.
Her postpyloric tube was removed when she was tolerating a full
liquid diet. Her pancreatic enzymes normalized. At discharge,
she was tolerating a full/low-fat diet. She has had minimal
diarrhea. She may require pancreatic enzyme supplements in the
future.
4. RENAL: No new issues.
5. INFECTIOUS DISEASE: As above; she has remained afebrile
off antibiotics.
6. NEUROLOGY: The patient was weaned slowly from Ativan and
Fentanyl following transfer from the Medical Intensive Care Unit
to the floor. Psychiatry has been following her for assistance
with this. At their recommendation she was started on Seroquel
25 mg p.o. t.i.d. for agitation during the wean. At discharge,
she was off all opiates and benzodiazepines and continues on
Seroquel. She has had difficulty sleeping lately and will
require improved sleep hygiene as she is sleeping during the day
and was sleepless at night.
7. HEMATOLOGY: No new issues.
8. ENDOCRINE: The patient has been having fingersticks q.i.d.
She has required only small amounts of sliding scale regular
insulin in the morning. Her blood sugars have been between 150
and 200.
9. FLUIDS/ELECTROLYTES/NUTRITION: The patient was taking a
low-fat diet. She was keeping up with her fluid requirements.
10. ADDICTION: The patient has limited insight into her
drinking and the connection between her alcohol consumption and
her pancreatitis. She will need treatment as an inpatient or
outpatient for addiction, as she places herself at great risk if
she continues to drink alcohol.
11. PSYCHIATRY: By history, the patient expressed signs of
depression. Psychiatry felt that it would be best to defer
starting an SSRI until her agitation and anxiety stabilize
somewhat. Therefore, she was continued only on the Seroquel. She
will require further followup for this as an outpatient.
DISCHARGE DISPOSITION: The patient was discharged to [**Hospital6 6776**]. She will require [**Hospital 6777**]
rehabilitation to assist with strength-conditioning, and balance.
CONDITION AT DISCHARGE: In good condition.
DISCHARGE FOLLOWUP: She was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
at [**Hospital1 **] [**Hospital6 534**] in one to two
weeks.
DISCHARGE DIAGNOSES:
1. Necrotizing pancreatitis.
2. Pancreatic pseudocyst.
3. Acute respiratory distress syndrome.
4. Alcoholism.
MEDICATIONS ON DISCHARGE:
1. Regular insulin sliding-scale.
2. Colace 100 mg p.o. b.i.d.
3. Miconazole powder 2% topical as needed.
4. Seroquel 25 mg p.o. t.i.d.
5. Seroquel 25 mg p.o. b.i.d. p.r.n.
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Last Name (NamePattern1) 4499**]
MEDQUIST36
D: [**2132-3-5**] 16:05
T: [**2132-3-6**] 07:09
JOB#: [**Job Number 6778**]
|
[
"305.00",
"577.2",
"486",
"599.0",
"518.82",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15038, 15205
|
4059, 6490
|
15441, 15556
|
15582, 16007
|
3503, 3638
|
6508, 12696
|
12724, 15014
|
15220, 15240
|
15262, 15420
|
167, 3264
|
3664, 3824
|
3286, 3476
|
3841, 4042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,831
| 128,947
|
8450+55947
|
Discharge summary
|
report+addendum
|
Admission Date: [**2130-8-2**] Discharge Date: [**2130-8-11**]
Date of Birth: [**2047-4-25**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Morphine / Codeine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Obstructive jaundice, abdominal pain.
Major Surgical or Invasive Procedure:
[**2130-8-2**]:
1. Exploratory laparotomy.
2. Liver wedge biopsy.
3. Open cholecystectomy.
4. Biliary bypass consisting of Roux-en-Y
choledochojejunostomy.
5. Gastroenterostomy.
History of Present Illness:
This 83-year-old woman presented initially with obstructive
jaundice. She was found to have a stricture which was a very
short segment in her distal bile duct originally. ERCP was
performed for this, and she received a stent. However, she also
had a very significant post-ERCP pancreatitis event. This is
close to 3 months ago. This set her back significantly for a
number of weeks. After all this settled out she met with Dr.
[**Last Name (STitle) **] and discussed the finding of her biliary stricture. He
was convinced that this was amalignant stricture given the fact
that there was a double-duct sign including the pancreatic duct.
She initially required more medical reconditioning prior to
being able to embark on a significant cancer resection
operation.
Unfortunately, in the interim she became floridly septic from a
stent migration process. This was recovered and a new stent was
placed. On a second occasion after this, she also presented with
evidence of cholangitis once again. The stents were not managing
her stricture and jaundice problem and she required yet another
stent placement. Since this event was more self-limiting and
less threatening, plans were made for a Whipple procedure to
follow within 7-10 days of the last event.
Past Medical History:
PMHx: AF (not on coumadin), CAD, HTN, Hypothyroidism, Type II
DM,
Hypercholesterolemia, Anemia, h/o Myasthenia [**Last Name (un) **], GERD,
Dysphagia, h/o Bronchitis, chronic pancreatitis, periampullary
cancer.
.
PSHx: TAH, Sinus surgery, ORIF UE fx w/ bone grafting
Social History:
Retired from work in accounting office and as florist. No
tobacco, alcohol, drugs. Patient will be discharged to a skilled
nursing facility, where her husband resides.
Family History:
Non-contributory
Physical Exam:
On Admission:
Temp 98 HR 88 sl irreg BP 140/80 RR 18
HEENT: NCAT, conjunctiva pale, sclera sl injected PERRLA
Neck: supple, no JVD, No thyromegly
Chest: clear
COR: sl irreg, II/VI sem
Abd: soft, minimally tender
Ext: Tr edema, calves soft
.
At Discharge:
VS: 97.2 PO, 76, 140/74, 20, 96% RA
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **].
LUNGS: CTA(B).
COR: Irregular, II/VI SEM loudest @ LSB.
ABD: Subcostal chevron incision with steri-strips c/d/i with
minimal marginal erythema. (R)LQ prior JP sire c/i with DSD
cover and min. serous drainage (just d/c'd today). BSx4.
Soft/NT/ND. (+) flatus and BM.
EXTREM: Trace edema. WWP.
NEURO: Markedly deconditioned. A+Ox3. Mental status at baseline.
Pertinent Results:
[**2130-8-2**] 11:25AM HGB-10.0* calcHCT-30
[**2130-8-2**] 11:25AM GLUCOSE-141* LACTATE-1.4 NA+-133* K+-2.9*
CL--98*
[**2130-8-2**] 09:28PM GLUCOSE-153* UREA N-15 CREAT-1.8* SODIUM-137
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-23 ANION GAP-12
[**2130-8-2**] 09:28PM CK(CPK)-158*
[**2130-8-2**] 09:28PM CK-MB-4 cTropnT-<0.01
[**2130-8-2**] 09:28PM CALCIUM-7.6* PHOSPHATE-4.5 MAGNESIUM-2.2
[**2130-8-2**] 09:27PM URINE HOURS-RANDOM CREAT-92 SODIUM-51
[**2130-8-2**] 02:55PM GLUCOSE-137* UREA N-16 CREAT-2.1*# SODIUM-139
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2130-8-2**] 02:55PM CK(CPK)-57
[**2130-8-2**] 02:55PM CK-MB-NotDone cTropnT-0.01
[**2130-8-2**] 02:55PM WBC-8.9# RBC-3.07* HGB-10.0* HCT-31.1*
MCV-101* MCH-32.7* MCHC-32.3 RDW-16.4*
[**2130-8-2**] 02:55PM PLT COUNT-373
[**2130-8-2**] 02:55PM PT-12.5 PTT-25.7 INR(PT)-1.1
[**2130-8-2**] 01:52PM freeCa-1.17
.
[**2130-8-2**] OR Pathology : 1. Liver lesion (A):
Metastatic moderately differentiated adenocarcinoma best seen on
level 2.
2. Gallbladder (B-C): Chronic cholecystitis.
3. Portion of jejunum (D): Small intestinal mucosa, no
diagnostic abnormalities recognized.
Note: Given the histology and the history of a pancreatic mass,
the findings are consistent with metastatic pancreatic
adenocarcinoma.
.
[**2130-8-2**] ECG:
Sinus rhythm. Compared to the previous tracing of [**2130-7-11**] T wave
inversions in the precordial leads are slightly more prominent.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
76 202 98 440/468 70 -15 172
.
[**2130-8-4**] Brain MRI :
Gadolinium-enhanced images not obtained secondary to low EGFR
limiting evaluation for metastasis. Foci of hyperintensity in
the left temporo-occipital and left cerebellar regions could be
due to subacute infarcts given the configuration but metastatic
disease cannot be excluded in
absence of gadolinium-enhanced images. Moderate brain atrophy
and small vessel disease are identified. If clinically indicated
further evaluation can be obtained with gadolinium enhanced
images following informed consent and consultation with renal
service. No acute infarcts or mass effect seen.
.
[**2130-8-9**] Bilateral LOWER EXT VEINS:
1. No evidence of acute deep venous thrombosis. The peroneal
vein on the
left was not visualized.
2. Prominent bilateral subcutaneous edema.
.
[**2130-8-10**] Echocardiogram:
*LEFT ATRIUM: Mild LA enlargement.
*RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
*LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Mild regional LV systolic dysfunction. No LV mass/thrombus. 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: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Calcified tips of papillary
muscles. Moderate (2+) MR.
*TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
*PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
*PERICARDIUM: No pericardial effusion.
.
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with
inferior/inferoseptal hypokinesis (most c/w CAD). The remaining
segments contract normally (LVEF = 45%). No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w. Moderate mitral regurgitation. No left ventricular thrombus
seen.
Brief Hospital Course:
Mrs. [**Known lastname 4312**] was admitted to the hospital and taken to the
Operating Room where she underwent the aforementioned procedure.
A palliative procedure was done due to positive liver
metastasis. See Operative note for specific details. She
tolerated the procedure well and returned to the PACU in stable
condition. Her pain was controlled with a Dilaudid PCA.
Following full recovery from anesthesia she was transferred to
the Surgical floor for further management.
.
Over the first few post operative days, she was very weak and
was unable to do much for herself as she had no stamina. She
was unable to stand with assistance, required a [**Doctor Last Name 2598**] lift to
get out of bed, and had generalized muscle weakness. Her
Mestinon was resumed post-operatively at the baseline dose. She
was followed by Physical Therapy Services. She was discharged to
a rehabilitation facility for continued post-operative
conditioning.
.
The neurology service followed her closely post-operatively, and
a brain MRI was done to rule out metastatic disease. After
reviewing the study with the neurology radiologists, it was felt
the picture was most indicative of a subacute stroke. This
prompted lower extremity venous studies and trans-thoracic
echocardiogram to rule out a source of a thrombus, which were
unremarkable. Pre-operative aspirin was restarted as soon as
possible. NIFs and vital capacities were monitored daily for [**1-25**]
days post-operatively. The patient remained hemodynamically
stable. In consultation with Dr. [**Last Name (STitle) 29790**], the patient's outpatient
neurologist, Imuran was discontinued.
.
Once the NG tube was discontinued, her diet was gradually
advanced after she had return of bowel function, although her
appetite initially was only fair, but improved by discharge, at
which time she was tolerating a diabetic regular. Pain was
initially well controlled with a Dialudid PCA, which was
transitioned to Dilaudid PO plus Acetaminophen PRN for pain
control with good effect. Home medications were restarted at
this time as well. A urine performed on [**Last Name (STitle) **]#2 was consistent
with a UTI, for which she received a three day course of
Ciprofloxacin with symptomatic resolution. Urine culture was
pending at the time of discharge. The foley catheter was
discontinued on [**Last Name (STitle) **]#3; she subsequently voided without problem.
On [**Name2 (NI) **]#8, the JP was discontinued and staples removed.
Steri-strips were placed.
.
At the time of discharge on [**2130-8-10**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
diabetic regular diet, voiding with assistance due to
immobility, and pain was well controlled. She required maximum
assistance using a [**Doctor Last Name 2598**] lift to get out of bed to a chair.
Physcial Therapy documented discharge recommendations. The
patient was discharged back to a rehabilitation facility for
further conditioning 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. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**2-27**]
hours as needed for fever or pain.
8. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for Anxiety.
13. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
14. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO once
a day.
15. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QAM.
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
5. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**2-27**]
hours as needed for fever or pain.
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for Anxiety.
14. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
15. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO once
a day.
16. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QAM.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 29789**] Country Manor - [**Location (un) 29789**]
Discharge Diagnosis:
Primary:
1. Pancreatic cancer - metastatic to the liver.
.
Secondary:
1. Myasthenia [**Last Name (un) **]
2. Type 2 DM
3. Hypothyroidism
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 is 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 [**4-2**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
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:
Please call ([**Telephone/Fax (1) 7761**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (Oncology) in [**12-27**] weeks.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2130-9-8**] 9:45. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Please call ([**Telephone/Fax (1) 29791**] to arrange a follow-up appointment
with [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29790**], MD, [**Hospital1 **] Neurology in [**1-25**]
weeks.
Completed by:[**2130-8-10**] Name: [**Known lastname 5209**],[**Known firstname 5210**] Unit No: [**Numeric Identifier 5211**]
Admission Date: [**2130-8-2**] Discharge Date: [**2130-8-11**]
Date of Birth: [**2047-4-25**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Morphine / Codeine
Attending:[**First Name3 (LF) 2083**]
Addendum:
Discharged planned for [**2130-8-10**] delayed until [**2130-8-11**] due to a
change in bed status at the [**Location (un) 5212**] Manor (Rehabilitation
facility). On the evening of [**8-10**], a small incisional wound
opened along (L) aspect of the incision measuring approximately
2.5cm x 1cm x 2cm. Staples had been removed earlier with
steri-strips placed. Moist-to-dry dressing at site started [**Hospital1 **],
and will continue at Rehabilitation facility. A suture was
placed at prior JP site to approximate opening due to serous
drainage; suture will need to be removed in 2 weeks. The patient
remained hemodynamically stable. No other relevant changes to
the Discharge Summary.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5212**] Country Manor - [**Location (un) 5212**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2130-8-11**]
|
[
"427.31",
"599.0",
"576.2",
"401.9",
"244.9",
"157.0",
"414.01",
"424.0",
"250.00",
"576.1",
"434.91",
"997.02",
"272.0",
"276.52",
"197.7",
"593.9",
"575.11",
"998.32",
"358.00",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"50.12",
"51.36",
"44.39",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
16857, 17106
|
7255, 10396
|
328, 512
|
13123, 13132
|
3077, 7232
|
15138, 16834
|
2296, 2314
|
11544, 12825
|
12963, 13102
|
10422, 11521
|
13156, 14610
|
14626, 15115
|
2329, 2329
|
2585, 3058
|
251, 290
|
540, 1803
|
2343, 2571
|
1825, 2094
|
2110, 2280
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,964
| 175,607
|
31348
|
Discharge summary
|
report
|
Admission Date: [**2108-1-2**] Discharge Date: [**2108-1-9**]
Date of Birth: [**2032-11-19**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
hypotension, nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 y.o. Hispanic F with h/o colon Ca s/p resection, CHF (EF 25%)
who presents with severe weakness and vomiting x 24 hours.
Patient reports poor appetite x 5 days. She reports decreased
intake, while taking her medications including her lasix and her
zestril. Patient notes onset of lightheadedness, and nausea
since AM of [**1-1**]. Patient had 2 episodes of vomiting, small
amount of emesis, nonbloody. She also reports decreased urine
output, but no change in color. No dysuria/hematuria. Patient
denied any f/c, no neck stiffness, no sore throat, no dysphagia,
but reports metalic taste in her mouth. No chest pain, no sob,
no cough, no orthopnea, no PND, no LE swelling. No abdominal
pain. She denies any change in her osteomy output or
consistency. No recent antibiotics. No myalgias /arthralgias.
.
ED VS: were 96.4 HR 66 BP 64/p RR 12 Sating 100%% on RA - 2L; BP
improved to 500 cc NS to 93/p; UO was 60 cc in ED; She received
a total of 2800 cc. Patient was found to be in ARF with K of 8.0
(slightly hemolyzed), no peaked T waves, she was given 1 mp Ca
Gluconate, 10 units of IV insulin/1 amp D50 with repeat K of
6.8. She was also started on Heparin gtt and received ASA 325
for presumed NSTEMI.
Past Medical History:
- subtotal colectomy and ileostomy on [**2107-7-2**] for pneumotosis, R
sided colono dilation with ileocecal valve incompetence, and
adenocarcinoma in the sigmoid, perforation in the ileum, also
with ileal attachment to the invasive adenoCa, LN were negative.
- baseline Blood pressure 90/60, even as low as SBP of 80
- severe ischemic CHF - EF 20-25% with global HK - NYHA Class 2
---- full mile in warm weather, a block in cold weather
- CAD
- baseline Cr 0.8 -> 1.3 in [**12-2**]
Social History:
No tobacco/EtOH/DOA, lives w/ family at home.
Family History:
+ for Ca, no h/o CHF, HTN, MI or SCD
Physical Exam:
T: 96.6 BP: 113/40 P: 100 RR: 17 O2 sats: 100 2L UO: 225
Gen: NAD, speaking in full word sentences
HEENT: NCAT, PERRL, EOMI, anicteric
Neck: flat JVP
CV: RRR 2/6 SEM @ apex; no pericardial rub appreciated, nl S1,
S2
Resp: CTAB/l, no w/r/r, no crackles
Abd: decreased BS, RLQ ostomy, no surrounding erythema,
nontender, soft, no guarding, no rebound
Back: no CVA tenderness
Ext: no edema, no cyanosis, + 1 DP b/l
Neuro: no focal deficits
Pertinent Results:
CXR: clear
.
EKG: NSR @ 73; negative axis; incomplete LBBB, STD of 0.5 mm in
II, III, aVF with inverted TWaves and in V4-V6; there was
mentioning of T wave flatening on [**2107-8-3**] cardiology note -
although not present when compared to prior EKG of [**7-2**]
.
Echo [**12-2**]: EF 20-25; + 1 MR; mild pHTN.
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. Left ventricular wall thicknesses are normal. The
left ventricular cavity is mildly dilated with severe global
left ventricular hypokinesis (LVEF = 20-25 %). Systolic function
of apical segments is relatively preserved. No left ventricular
thrombus is seen. Tissue Doppler suggests and incresaed LVEDP
(>18mmHg). Right ventricular chamber size is normal with mild
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
Compared with the prior study (images reviewed) of [**2107-7-1**],
left ventricular cavity size is smaller and the severity of
mitral regurgitation is reduced. The heart rate is also much
lower.
.
MIBI [**8-2**]:
.
IMPRESSION:
1. Partially reversible, large, severe perfusion defect
involving the LAD territory.
2. Fixed, medium sized, severe perfusion defect involving the
PDA territory.
3. Increased left ventricular cavity size. Severe systolic
dysfunction with severe hypokinesis of the mid anteroseptal,
distal anterior, distal septal, distal inferior and apical walls
as well as the mid and basal inferior and inferolateral walls.
.
HCT stable in mid 20's during hospitalization. On discharge CBC
was WBC 5.4, HCT 26.1, Hgb 8.7, Plt 308
.
Cr was 9 on admission with baseline of 0.8. This trended down to
1.1 on the day of discharge.
On discharge sodium 141, K 4.8, Cl 111, HCO3 26, BUN 10, Cr 1.1
Glucose 74
.
Other lab values of interest during hospitalization:
[**2108-1-3**] 06:16AM BLOOD LD(LDH)-138 Amylase-155*
[**2108-1-3**] 06:16AM BLOOD Lipase-168*
[**2108-1-1**] 10:45PM BLOOD Lipase-422*
[**2108-1-2**] 02:42AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2108-1-1**] 10:45PM BLOOD cTropnT-0.06*
[**2108-1-8**] 06:05AM BLOOD Mg-1.7
[**2108-1-5**] 07:10AM BLOOD Mg-1.4*
[**2108-1-3**] 06:16AM BLOOD Calcium-8.3* Phos-5.3* Mg-1.2* Iron-101
[**2108-1-1**] 10:45PM BLOOD Albumin-4.1 Calcium-9.7 Phos-12.3*#
Mg-2.1
[**2108-1-3**] 06:16AM BLOOD calTIBC-306 Hapto-241* Ferritn-226*
TRF-235
[**2108-1-2**] 02:42AM BLOOD Triglyc-54 HDL-59 CHOL/HD-2.7 LDLcalc-89
[**2108-1-3**] 11:48AM BLOOD TSH-1.0
Brief Hospital Course:
75 year old female with CAD, CHF EF 25%, subtotal colectomy who
presented with ARF
.
# ARF:
Likely prerenal, creatinine was up to 9 on admission and patient
required MICU admission for hypotension and hyperkalemia. She
was stabilized quickly with IV fluids. Creatinue trended down
gradually with IV fluids over the course of several days and was
1.1 at discharge. Renal US was unremarkable for structural renal
disease. Her ACEI was held given the renal failure and
hypotension. Her lasix was also held given the dehydration.
.
# Diarrhea:
The diarrhea is likely the cause of the patient's presenting
hypovolemia. She did have watery, profuse output from her stoma.
The cause is unclear though viral gastroenteritis is likely.
Stool studies for c diff and bacterial diarrhea were negative.
She did require IV fluid repletion to balance her stool output.
At discharge her stoma output was more formed.
.
# elevated troponin:
There was a mild troponin elevation to 0.06 with negative CK and
MB in setting of hypotension and ARF. There were lateral ECG
changes. She had a positive stress in [**8-2**] for which
intervention has been considered though not yet pursued. She was
continued on aspirin, BB, statin.
.
# Pancreatitis
This was likely secondary to acute illness. The pancreatic
enzymes trended down. She has no abdominal pain.
.
# systolic CHF with EF 25%:
She remained hypovolemic during the admission. Lasix was held
and she was given IV fluids. Beta-blocker was continued but the
dose was lowered given her hypotension. Her lisinopril was held
given the ARF and hypotension.
.
# Access - 2 PIV
.
# PPx - Heparin SC; H2Blocker
.
# FEN - cardiac diet
.
# Code - FULL
.
# Communication - Discussed with son [**Name (NI) **] [**Telephone/Fax (1) 73900**]; Also
spoke to PCP office, Dr. [**Last Name (STitle) 31**] and faxed this report to
[**Telephone/Fax (1) 73901**].
.
.
TO DO FOR PCP:
[**Name10 (NameIs) 357**] check blood pressure, weight and creatinine, BUN and
potassium.
If patient blood pressure above systolic of 100, please increase
carvedilol to 3.125mg [**Hospital1 **].
If patient weight increases by more than 2 pounds or she is
clinically fluid overloaded, please restart lasix for fluid
overload. (weight was 45.3 kg (99.7 pounds).
If the patient blood pressure is above systolic of 120, please
restart lisinopril (but please check Cr and Potassium as well-
Cr was 1.1 on discharge with baseline at 0.8).
Medications on Admission:
Carvedilol 25 mg [**Hospital1 **]
Lisinopril 5 mg Daily
Lasix 40 mg daily
ASA 325 Daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
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:*2*
4. Carvedilol 3.125 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
acute renal failure
diarrhea- viral gastroenteritis
hypotension
hypovolemic shock
Secondary Diagnosis:
chronic systolic CHF with EF 25%
CAD
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital with low blood pressure and kidney
failure. You were found to have diarrhea. This was monitored in
the hospital until it resolved. Your kidney function is almost
back to baseline.
Please note the following medication changes (and please see the
medication sheet for details):
1. Your carvedilol dose has been lowered. Please discuss with
your doctor when to increase it.
2. Your lisinopril and lasix (furosemide) was stopped. You
should discuss restarting this when you see your primary care
physician for repeat labs
3. Prilosec is a new medication that was started to protect your
stomach since you are taking aspirin
You should take your weight daily. If you gain more than 3
pounds, please call your doctor. Please monitor your fluid
intake and limit it to 1.5L/day (unless you are having extensive
diarrhea. If you have extensive diarrhea, please call your
doctor.). Please limit your salt intake to 2g per day.
If you have further diarrhea, fevers, chills, dizziness,
light-headedness, or any other concerning symptoms, please call
your doctor or go to the emergency room.
Followup Instructions:
Dr. [**Last Name (STitle) 31**], PCP, [**Name10 (NameIs) **] up appointment on Thursday [**2108-1-12**] at 2pm. Please call to reschedule at [**Telephone/Fax (1) 2115**].
Please call Dr.[**Name (NI) 3536**] office to make sure that you have
appropriate follow-up. I called and left a message with the
office that you would need follow up in the next week or two.
You are currently scheduled for an appointment in [**Month (only) **].
Provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2108-6-18**]
9:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2108-1-9**]
|
[
"V10.05",
"285.29",
"410.71",
"276.7",
"276.52",
"428.22",
"577.0",
"008.8",
"584.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8422, 8428
|
5398, 7826
|
294, 300
|
8632, 8641
|
2636, 5375
|
9796, 10550
|
2125, 2163
|
7965, 8399
|
8449, 8449
|
7852, 7942
|
8665, 9773
|
2178, 2617
|
235, 256
|
328, 1537
|
8572, 8611
|
8468, 8551
|
1559, 2046
|
2062, 2109
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,373
| 108,070
|
8661
|
Discharge summary
|
report
|
Admission Date: [**2201-12-11**] Discharge Date: [**2202-2-9**]
Date of Birth: [**2148-10-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
continuous bleeding after tooth extraction 1 day PTA
Major Surgical or Invasive Procedure:
bone marrow biopsy [**2201-12-17**]
splenectomy
picc line
exchange of abdominal drain
History of Present Illness:
53 yo M w/ hep C cirrhosis s/p OLT in [**4-/2198**], chronic
thrombocytopenia and recent pan-cytopenia, CRF who presents with
continuous bleeding (oozing) after a dental extraction. In the
[**Name (NI) **] pt. was noted to have a plt count of 11 and was transfused 1
bag of platelets with some improvement in oozing. He was then
admitted for further observation and w/u of his pancytopenia.
This AM he has no specific complaints and his gum bleeding has
further improved. He does report starting on neurontin on
[**2201-11-10**] (by pain clinic) and taking prophylactic abx. (unclear
which one) starting on Wednesday prior to his dental procedure.
.
ROS: no recent f/c, weight loss, SOB. Reports rectal pain and
some blood in stool which is his baseline. Also, c/o of some
urinary discomfort.
Past Medical History:
# ESLD [**1-23**] HCV cirrhosis, s/p OLT on [**2198-5-20**]
- c/b biliary strictures w/ Roux en-Y hepaticogjejunostomy
[**2198-12-24**]
# h/o polysubstance abuse
# h/o L ureteral obstruction s/p stent placement [**2201-6-16**]
- new stent placed [**2201-11-20**] for L hydronephrosis
# anal fissures/fistulae s/p repair [**2198-12-4**], [**2199-4-29**], [**2201-9-30**]
# hypertension
# SVT
# esophagitis
# cognitive disorder
# adjustment disorder
.
PSH: (per initial H&P)
# OLT [**2198-5-20**] c/b biliary strictures w/ Roux en-Y
hepaticojejunostomy
# incision hernia repair [**2196-12-6**]
# s/p hemorrhoid repair
# anal fistulectomy in [**2198-12-4**] + [**2199-4-29**], seton placement
[**2201-9-30**]
# appendectomy
# cholecystectomy
Social History:
Lives with elderly aunt and uncle. Denies tobacco, alcohol or
drug use. Has a sister, a nurse, who is very aware of his health
issues.
Family History:
Non-contributory.
Physical Exam:
Vitals: T:98.7 BP:118/70 HR:60 RR:20 O2Sat:99% on RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: + blood clots over tooth extraction sites, still with
small amounts of oozing, dry mucous membranes, EOMI, PERRL,
sclera anicteric, no epistaxis
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, II/VI early systolic murmur at LUSB and LLSB
non-radiating, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, palpable spleen tip, scar from liver
[**Month/Day/Year **], no rebound or guarding.
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II - XII
grossly intact. No asterixis. moves all 4 extremities. Strength
[**4-26**] in upper and lower extremities. Patellar DTR +1. Plantar
reflex downgoing. No gait disturbance. No cerebellar
dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2201-12-11**] 04:01PM WBC-1.2* RBC-3.11* HGB-9.0* HCT-28.8* MCV-93
MCH-28.9 MCHC-31.2 RDW-17.3*
[**2201-12-11**] 04:01PM PLT COUNT-11*
[**2201-12-11**] 04:01PM GRAN CT-900*
[**2201-12-11**] 04:01PM PT-14.3* PTT-28.8 INR(PT)-1.2*
[**2201-12-11**] 04:01PM GLUCOSE-84 UREA N-46* CREAT-1.4* SODIUM-139
POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-29 ANION GAP-15
[**2201-12-11**] 04:55PM POTASSIUM-4.5
.
[**2202-1-5**] 5:47 pm BLOOD CULTURE Source: Line-R PICC.
**FINAL REPORT [**2202-1-8**]**
Blood Culture, Routine (Final [**2202-1-8**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle [**Month/Day/Year **] Stain (Final [**2202-1-6**]):
[**Month/Day/Year **] NEGATIVE ROD(S).
.
MRI PELVIS W/O & W/CONTRAST [**2202-1-10**] 9:15 PM
MRI PELVIS W/O & W/CONTRAST
Reason: assess for perirectal abscess.
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
53 year old man s/p liver [**Hospital **], rectal fissure surgery,
fever.
REASON FOR THIS EXAMINATION:
assess for perirectal abscess.
CONTRAINDICATIONS for IV CONTRAST: None.
EXAMINATION: MR pelvis.
INDICATION: Status post liver [**Hospital **]. Rectal fissure
surgery, fever. Evaluate for perirectal abscess.
COMPARISON: Comparison is made with the previous MR [**First Name (Titles) 767**] [**2199-4-27**].
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired
on a 1.5 Tesla magnet, including dynamic high-resolution 3D
imaging, obtained prior to, during and after the uneventful
intravenous administration of 0.1 mmol/kg of gadolinium-DTPA. 2D
and 3D reformations and subtraction images were performed on an
independent workstation.
MR [**First Name (Titles) 30339**] [**Last Name (Titles) **]: In the [**2-25**] o'clock position (when viewed
lithotomy position, left-to-left/posterior) of the
intersphincteric space situated approximately 2 cm proximal to
the anus, an area of crescentic high signal intensity is
identified on the T2-weighted imaging (series 6, image 26) that
measures 1.5 cm AP x 7 mm TV x 1.5 cm SI, with a peripherally
enhancing rim, consistent with a tiny abscess too small to
drain. This is at approximately the level of the levator ani
(series 105a, image 14), and might communicate inferiorly with
the rectal canal at the 6:00 location (series 100, image 68),
approximately 4.5 cm superior from the anal verge.
A thin slip of high signal on T2W images (series 6, image 29),
with thin curvilinear enhancement extends from this tiny
collection inferiorly along the intersphincteric space and along
the expected location of the internal sphincter from the
3:00-6:00 location until reaching the anal verge, where there is
thickening of the external sphincter on the left side (series
104a, image 27). It is unclear if this represents a tract, or
may be secondary to previous surgery or granulation tissue. This
lays along the course of the fistula described in [**2199-4-21**]. No
definite fluid is seen along this slip. Susceptibility is seen
along the inferior aspect, similar to images from [**2198**]. The
internal sphincter is hypoenhancing on post- gadolinium images,
and indistinct but slightly hyperintense on T2W images, again
possibly due to prior surgery.
There is nonspecific edema and vascular engorgement within the
perirectal fat.
There are bilateral hydroceles with an inguinal hernia on the
left containing some peritoneal fat and fluid. Left ureteral
catheter is seen with pigtail curling within the bladder.
Bladder is nondistended.
No evidence of any significant lymphadenopathy. The remainder of
the bowel where visualized is unremarkable. The osseous
structures where visualized are normal.
2D and 3D reformations provided multiple perspectives for the
dynamic series.
IMPRESSION:
1. Small intersphincteric abscess from the 3 to 6 o'clock
location (from lithotomoy position) on the left at the level of
the levator ani. This may communicate with rectal lumen
inferiorly, crossing the internal sphincter at the 6 o'clock
position as described above, but is too small to drain.
2. No drainable abscess.
3. Mild hyperintensity on T2W images, mild enhancement, and
thickening of left external sphincter along course of previously
([**2198**] MRI) described intersphincteric tract, which may represent
residual tract, or postoperative or granulation
tissue--correlate with surgical history.
4. Bilateral hydroceles with left inguinal hernia containing fat
and peritoneum.
5. Nonspecific edema and engorgement of vessels in perirectal
fat. This may be due to hepatic disease and collateral portal
blood flow.
6. Left ureteral stent with pigtail in the bladder.
Brief Hospital Course:
This was a 53 yo M s/p liver [**Year (4 digits) **] in [**2197**], pan-cytopenia,
splenomegaly who presented with continuous oozing after tooth
extraction. Hospital course by problem below:
Thrombocytopenia - platelet count of 69 on [**11-25**]. Platelet count
on [**12-10**] was 14. Neurontin (started on [**2201-11-10**]) and
prophylactic antibiotics [**12-10**]. Neurontin was held. DIC labs
were negative for chronic DIC. HIT Ab negative. Parvovirus B19
Ab negative. Bone marrow biopsy showed ITP. Prednisone and
rituxan were not options for therapy given his history of Hep C.
The patient underwent two doses of IVIG at 35g, two days apart.
He experienced only minimal improvement in his platelet counts
each time, from [**10-5**]. He was also transfused platelets on two
occasions, when his platelets decreased below 10. he
experienced only minimal improvement in platelet counts after
transfusion, from [**6-3**]. It was decided that splenectomy would
be the next best option for him. An abd CT was done on [**12-26**] to
evaluate for splenic vein thrombosis. [**Month/Day (1) **] were significant
for non-occlusive thrombus adherent to the wall of the main
portal, splenic, and the tributaries forming the SMV near the
portosplenic confluence.
On [**1-15**] splenectomy and distal pancreatectomy were performed.
Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please see operative note for
further details. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed. Postop, he was sent
to the SICU. Pain management was an issue requiring Acute Pain
service management. He was trasferred out of the SICU to the
med-[**Doctor First Name **] unit where he continued to have high outputs via the JP
(~ 3 liters) for which he received IV fluid replacements and
albumin. Given that he had a distal pancreatectomy, the JP fluid
was sent for amylase. This was initially 191 on [**1-22**], but
increased to 4170 on [**1-25**]. A repeat JP amylase on [**1-27**] was 2769.
JP drainage trended down to 40 by [**2-4**]
Bacteremia: Patient developed fever and leukocytosis on [**1-5**].
He was treated empirically for a neutropenic fever with
cefepime. The following day his fever had resolved. Blood
cultures grew pan sensitive e.coli. His abx were switched to
cipro, and his PICC line was removed. A source of his bacteremia
was thought to be from a perirectal abscess identified on MRI.
He remained afebrile while on cipro. A general surgery consult
was obtained with recommendations for an MRI. A MRI was done
noting small intersphincteric abscess from the 3 to 6 o'clock
location (from lithotomoy position) on the left at the level of
the levator ani. This was non-drainable. Cipro and flagyl were
recommended for 2 weeks. On [**1-24**] CVL was d/c'd for low grade
temps.
On [**1-25**] he was febrile to 101.2. Blood and urine cultures were
negative. JP fluid was negative for growth. An abd CT was done
revealing partially walled-off fluid in the left upper abdomen
with air locules, interval progression of nonocclusive thrombus
in the portal system, to a greater degree in the splenic vein
and left portal vein, moderate left pleural effusion, and left
nephroureteral stent in stable position, with moderate
dilatation of the left renal pelvis, which has progressed from
the prior study. A heparin drip was started. Coumadin was then
started with goal inr achieved and discontinuation of heparin.
He was sent home on a coumadin dose of 0.5mg qd with inr to be
drawn on [**2-10**].
On [**1-30**] he spiked a temp to 101.8. Blood and urine cultures were
again sent with the urine negative and blood cultures negative
to date. Vanco and Zosyn were started on [**1-31**]. A CXR
demonstrated L lung base atelectasis and a small left pleural
effusion. A CT guided exchange of the drain was done for failure
of the JP to drain. Upsizing of left abdominal drain as
described above without immediate complications. Pull back study
through track failed to demonstrate track communucation with the
left thorax or left pleural effusion. The drain was upsized.
Vanco and Zosyn were started on [**1-31**]. After 3 doses, the zosyn
was switched to Levaquin. Flagyl was added on [**2-3**]. He was
discharged home on Vanco, flagyl and Levaquin with indefinate
duration pending resolution of fluid collection. He did complain
of some loose stool which was sent for c.diff x 2. These were
negative.
.
#) Hypertension -diltiazem and atenolol were continued at 25mg
daily. He received his home doses of lasix (40 qam and 20mg
qpm). Lower leg edema persisted.
.
#) Diabetes - Glargine was discontinued due to persistent low
glucoses. Humalog sliding scale continued. [**Last Name (un) **] followed.
Kcals were ordered for poor po intake and supplements were
ordered.
.
#) Liver [**Last Name (un) **] - His tacrolimus, lamivudine (tx. liver from
hep B+ patient), and prednisone were continued. His tacrolimus
levels were monitored and dose adjusted based on levels.
VNA services were arranged for home as he was discharged with
the JP in place. A picc line was also present in his Left arm
for iv vancomycin.
He was ambulatory with stable vital signs tolerating a regular
diet at time of discharge. Labs were to be drawn on [**2-10**] with
results fax'd to the [**Month/Year (2) 1326**] office. Blood cultures from [**2-5**]
finalization were pending (negative to date).
Medications on Admission:
atenolol 50mg PO Q day
calcium carbonate + vit D2 600mg/400u 1 tab PO Q day
diltiazem HCL 180mg PO QD
colace 100mg PO BID
glargine 12u SC QHS
HISS
lamivudine 100mg PO Q day
lidocaine 4% cream TP TID prn
methadone 65mg PO Q day
omeprazole 40mg PO Q day
prednisone 3mg PO Q day
risedronate 35mg PO Q week
sertraline 50mg PO Q day
tacrolimus 1.5mg PO BID
testosterone 100mg TP Q day
white petrolatum TP [**Hospital1 **] prn
Trazodone 150mg qHS
neurontin 100 TID
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Risedronate 35 mg Tablet Sig: One (1) Tablet PO qSunday ().
8. Testosterone 1 %(50 mg/5 [**Hospital1 **]) Gel in Packet Sig: One (1)
Transdermal [**Hospital1 **] ().
9. Methadone 10 mg Tablet Sig: Seven (7) Tablet PO DAILY
(Daily): total of 75mg qd. took [**2-9**].
10. Methadone 5 mg Tablet Sig: One (1) Tablet PO once a day:
total of 75mg qd. took [**2202-2-9**].
11. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
12. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): both eyes.
13. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
14. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
17. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale Subcutaneous qid per sliding scale.
Disp:*1 bottle* Refills:*0*
18. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*60 Tablet(s)* Refills:*0*
19. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*42 Tablet(s)* Refills:*0*
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*14 Tablet(s)* Refills:*0*
21. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Warfarin 1 mg Tablet Sig: half Tablet PO qd (Once).
25. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
26. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection DAILY (Daily) as needed: and after antibiotic.
Disp:*60 ML(s)* Refills:*0*
27. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: following saline
after antibiotic infusion.
Disp:*60 ML(s)* Refills:*0*
28. Vancomycin in Dextrose 1 [**Month/Day/Year **]/200 mL Piggyback Sig: One (1)
[**Month/Day/Year **] Intravenous once a day.
Disp:*14 doses* Refills:*0*
29. Outpatient Lab Work
Labs Wednesday for cbc, chem 10, ast, alt, alk phos, t.[**Month/Day/Year **],
albumin, trough prograf, PT/INR
Then labs every Monday and Thursday for cbc, chem 10, lfts,
PT/INR, trough prograf and trough vanco level
fax to [**Telephone/Fax (1) 697**]
30. Glucometer
Free Syle Lite
31. Lancets
1 box
Refill: 1
32. Test Strips
Free Style Lite
1 box
Refill: 1
33. Insulin
syringes-lo dose for qid sliding scale insulin
1 box
refill: 1
34. Alcohol
pads
1 box
refill: 1
35. Methadone
Received 75mg on [**2202-2-9**] at 6am
36. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
37. LUQ abdominal drain Flushes
Normal saline 0.9% prefilled 10cc syringes for LUQ abdominal
drain tid
Supply: 60
Refill:
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
thrombocytopenia
portal vein thrombus
s/p liver [**Hospital **]
splenomegaly
h/o substance abuse on methadone
HTN
DM
Portal vein thrombus
Discharge Condition:
stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if you have fevers, chills, nausea, vomiting,
abdominal distension, incision redness/bleeding, drainage,
bleeding, easy bruising, chest pain, shortness of breath, bloody
stools, dizziness, or any other concerns.
.
Please take all medications as directed.
No heavy lifting
No driving while taking pain medication.
.
You received methadone 75 mg on the day of discharge.
Followup Instructions:
You should follow-up with Dr. [**Last Name (STitle) 497**] [**Telephone/Fax (1) 673**] in 2 weeks.
Call Dr.[**Name (NI) 10946**] office ([**Telephone/Fax (1) 9011**] to schedule a
follow up appointment in [**12-23**] weeks
Please call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] to schedule follow
up visit in 1 week.
Call [**Hospital **] clinic to schedule follow up appointment within the
next few weeks
Completed by:[**2202-2-9**]
|
[
"E879.8",
"070.54",
"287.31",
"998.11",
"733.00",
"790.7",
"427.89",
"572.3",
"530.10",
"E849.8",
"550.90",
"566",
"304.01",
"250.82",
"603.8",
"309.9",
"585.6",
"V42.7",
"289.59",
"041.4",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5",
"41.31",
"52.52",
"99.04",
"38.93",
"99.05",
"50.11",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
17958, 18016
|
8529, 13962
|
367, 455
|
18198, 18207
|
3213, 4745
|
18657, 19107
|
2210, 2229
|
14471, 17935
|
4782, 4856
|
18037, 18177
|
13988, 14448
|
18231, 18634
|
2244, 3194
|
275, 329
|
4885, 8506
|
483, 1279
|
1301, 2041
|
2057, 2194
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,783
| 139,043
|
54574
|
Discharge summary
|
report
|
Admission Date: [**2182-7-2**] Discharge Date: [**2182-7-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Generalized Weakness/FTT
Major Surgical or Invasive Procedure:
a-line
History of Present Illness:
Pt is a [**Age over 90 **] yo male with a history of HTN, Afib(not on
anticoagulation), interstitial lung disease secondary to
asbestosis exposure who presented with worsening SOB, nausea,
and daytime somnolence. Family says that there was no inciting
event but they felt that he needed to come in for futher wk up.
He denied chest pain, palpitations, abdominal pain,
fevers/chills or diarrhea. He does report chronic LE edema which
he states is unchanged and some intermittent nausea with lying
flat. He was admitted to the medical floor for further work-up.
Past Medical History:
1. Hypertension
2. BPH
3. h/o Hiatal Hernia
4. Paroxysmal Atrial Fibrillation
5. h/o herpes opthalamicus
6. Interstitial lung disease secondary to asbestos exposure. Has
extensive pleural calcifications on CXR.
7. H/o of right knee septic bursitis
Social History:
Worked as a welder in battleships in the [**Hospital1 392**] shipyard during
World War II where he was intensely exposed to asbestos dust. He
also is a long time cigarette smoker, although he quit 40 years
ago. Lives with wife.
Family History:
NC
Physical Exam:
T: 96.2 BP: 158/83 P: 88 irreg RR: 20 O2 sats: 92% 2LNC, 88-90%
on RA
Gen: Elderly male, who appears mildly dyspneic
HEENT: PERRL, EOMI, crusting of the left eye but not injected,
dry mm, anicteric
Neck: No LAD, difficult to assess JVD
CV: Irregular, no m/r/g
Resp: Diffuse crackles, worse in the bases, decrease breath
sounds in the upper lung fields, scant wheezes
Abd: Soft, small umbilical hernia, NT, ND + BS
Ext: [**1-15**]+ ptting edema in LE, 1+ DP's, feet cool
Neuro: A&O times x 3
Pertinent Results:
[**2182-7-1**] 11:00PM PT-14.3* PTT-28.8 INR(PT)-1.3*
[**2182-7-1**] 11:00PM PLT COUNT-136*
[**2182-7-1**] 11:00PM NEUTS-77.5* LYMPHS-15.4* MONOS-5.1 EOS-1.8
BASOS-0.1
[**2182-7-1**] 11:00PM WBC-7.8 RBC-3.45* HGB-11.5* HCT-33.8* MCV-98
MCH-33.4* MCHC-34.1 RDW-15.6*
[**2182-7-1**] 11:00PM CK-MB-NotDone
[**2182-7-1**] 11:00PM cTropnT-0.04*
[**2182-7-1**] 11:00PM CK(CPK)-73
[**2182-7-1**] 11:00PM estGFR-Using this
[**2182-7-1**] 11:00PM GLUCOSE-138* UREA N-32* CREAT-1.1 SODIUM-148*
POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-28 ANION GAP-13
[**2182-7-1**] 11:30PM LACTATE-1.2
[**2182-7-2**] 05:30AM calTIBC-321 VIT B12-371 FOLATE-13.8
FERRITIN-49 TRF-247
[**2182-7-2**] 05:30AM ALBUMIN-3.5 CALCIUM-8.5 PHOSPHATE-4.3
MAGNESIUM-2.3 IRON-24*
[**2182-7-2**] 05:30AM CK-MB-NotDone
[**2182-7-2**] 05:30AM cTropnT-0.04* proBNP-3691*
[**2182-7-2**] 05:30AM LIPASE-8
[**2182-7-2**] 05:30AM CK(CPK)-51
[**2182-7-2**] 05:30AM ALT(SGPT)-33 AST(SGOT)-35 LD(LDH)-208 ALK
PHOS-83 AMYLASE-28 TOT BILI-0.5
[**2182-7-2**] 05:30AM GLUCOSE-140* UREA N-28* CREAT-0.9 SODIUM-146*
POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-32 ANION GAP-8
[**2182-7-2**] 08:27AM O2 SAT-91
[**2182-7-2**] 08:27AM TYPE-ART PO2-73* PCO2-76* PH-7.25* TOTAL
CO2-35* BASE XS-2
[**2182-7-2**] 11:34AM LACTATE-0.7
[**2182-7-2**] 11:34AM TYPE-ART PO2-62* PCO2-62* PH-7.33* TOTAL
CO2-34* BASE XS-3
[**2182-7-2**] 03:18PM URINE RBC-5* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2182-7-2**] 03:18PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2182-7-2**] 03:18PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2182-7-2**] 03:30PM TYPE-ART PO2-55* PCO2-52* PH-7.38 TOTAL
CO2-32* BASE XS-3
[**2182-7-2**] 10:07PM TYPE-ART TEMP-36.7 PO2-82* PCO2-66* PH-7.28*
TOTAL CO2-32* BASE XS-1
.
CXR ([**7-3**]): There has been no significant change since the prior
chest x-ray. Patchy opacities are again noted. Extensive pleural
calcifications are seen suggesting asbestos exposure. The heart
is enlarged but unchanged in size. I doubt the presence of
failure as the lung appearances are stable going back to [**2177**].
IMPRESSION: Stable cardiomegaly. Extensive pleural fibrosis and
calcification.
Brief Hospital Course:
A/P: [**Age over 90 **] yo male with a history of HTN, Afib(not on
anticoagulation), interstitial lung disease secondary to
asbestosis exposure who presented with sob, and nausea. The
following issues were investigated during this hospitalization:
.
# DOE: Thought to be due to worsening underlying interstitial
lung disease secondary to asbestosis. After being admitted to
the floor, patient was transferred to the MICU for somnolence
and an ABG showing hypercapnea. In the ICU, he was treated with
noninvasive ventilation, which he did not tolerate well and
later refused. Discussions were held with the patient and his
family who agreed that no additional measures, namely
intubation, given the patient's DNR/DNI status, should be
persued. As a result, the patient was maintained on supplemental
oxygen with a goal O2 sat of 88-90% given severe COPD and
transferred to the floor for further evaluation by pulmonary.
However, shortly after being transferred to the floor, the
patient expired without further intervention.
Medications on Admission:
Atenolol 25 mg Qday
Terazosin 5 mg QHS
Pantoprazole 40 mg Qday
Valsartan 160 mg Qday
Quinapril 40 mg Qday
Valtrex 1 g QHS
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Chronic Interstitial Lung Disease
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"427.31",
"280.9",
"518.83",
"053.29",
"276.51",
"515",
"287.5",
"276.0",
"501",
"530.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5461, 5470
|
4234, 5259
|
285, 293
|
5548, 5559
|
1947, 4211
|
5611, 5618
|
1416, 1421
|
5433, 5438
|
5491, 5527
|
5285, 5410
|
5583, 5588
|
1436, 1928
|
221, 247
|
321, 882
|
904, 1153
|
1169, 1400
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,236
| 101,246
|
51360
|
Discharge summary
|
report
|
Admission Date: [**2199-7-5**] Discharge Date: [**2199-7-13**]
Date of Birth: [**2123-4-14**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Descending colostomy [**2199-7-6**]
History of Present Illness:
76 yo female with Paget's disease of the anus who presents with
a large bowel ostruction. She was taken to the operating room on
[**2199-7-6**] for descending colostomy.
Past Medical History:
Colon cancer s/p lap resection '[**93**]
HTN
Paget's disease s/p resection [**12-2**]
Family History:
Noncontributory
Physical Exam:
Vitals: T 98.8 HR 104 BP 110/54 RR 16 96% RA
Gen: A&Ox3
CV: regular rate and rhythm
Pulm: Clear to auscultation bilaterally
Abdomen: Soft, tender at LLQ, distended with tympany; no rebound
tenderness
Rectal: tight anal stricture
Pertinent Results:
[**2199-7-5**] 02:19PM GLUCOSE-131* UREA N-48* CREAT-2.0* SODIUM-137
POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-31 ANION GAP-17
[**2199-7-5**] 02:19PM ALT(SGPT)-21 AST(SGOT)-19 ALK PHOS-97
AMYLASE-48 TOT BILI-0.4
[**2199-7-5**] 02:19PM LIPASE-42
[**2199-7-5**] 02:19PM ALBUMIN-4.3
[**2199-7-5**] 02:19PM WBC-15.1*# RBC-3.40* HGB-10.6* HCT-30.5*
MCV-90 MCH-31.1 MCHC-34.7 RDW-12.9
[**2199-7-5**] 02:19PM PLT COUNT-471*#
CT ABDOMEN W/O CONTRAST [**2199-7-5**] 5:23 PM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: eval colitis, eval obstruction. - oral contrast only.
Field of view: 36
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with hx of Paget's dz of rectum, chronic
incontinence now with no stool output past 3days.
REASON FOR THIS EXAMINATION:
eval colitis, eval obstruction. - oral contrast only.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 76-year-old female with history of Paget's disease
of the rectum and chronic incontinence.
COMPARISONS: None.
TECHNIQUE: MDCT axial images were obtained from the thoracic
inlet through the pubic symphysis without intravenous contrast.
Multiplanar reconstructions were performed.
CT ABDOMEN WITHOUT IV CONTRAST: No pulmonary nodules, opacities
or pleural effusions are present at the lung bases. There are
extensive coronary artery calcifications. Evaluation of the
visceral organs is limited secondary to lack of intravenous
contrast. Allowing for this factor, the liver, pancreas, spleen
and adrenal glands appear grossly normal. There is moderate
right hydronephrosis with hydroureter extending from the renal
pelvis to the level of the pelvic inlet. No definite obstructing
calculi or mass is identified. Extensive gas and stool is seen
within mildly dilated loops of large bowel. There is no evidence
of bowel wall thickening, pneumatosis or intraperitoneal air.
There is extensive atherosclerosis involving the abdominal aorta
and its branches. No intraperitoneal fluid is present. A normal
appendix is seen in the right lower quadrant. No mesenteric or
retroperitoneal lymph nodes are pathologically enlarged.
CT PELVIS WITH IV CONTRAST: A large amount of stool and air is
seen within the sigmoid colon with mild wall thickening.
Extensive soft tissue density is seen in the region of the
rectum without evidence of rectal stool or air. Several suture
lines are seen within the lower pelvis. A Foley catheter is seen
within a partially distended bladder. Air within the bladder is
likely iatrogenic. There is no free pelvic fluid. There are
several borderline enlarged left inguinal lymph nodes.
BONE WINDOWS: No suspicious osteolytic or sclerotic lesions are
identified. There are significant degenerative changes within
the lower lumbar spine.
IMPRESSION:
1. Coronary artery calcifications.
2. Right hydronephrosis and hydroureter without evidence of
obstructing calculi or mass.
3. Air and stool seen within dilated loops of large bowel.
Moderate soft tissue density is seen involving the rectum. Air
is not definitely seen in the rectum and obstruction at this
level cannot be excluded. Correlation with colonoscopy/flex
sigmoidoscopy is recommended.
Cardiology Report C.CATH Study Date of [**2199-7-7**]
*** Not Signed Out ***
BRIEF HISTORY:
76 yo female with history of rectal cancer and hypertension who
presented to the hospital with rectal obstruction. She underwent
diverting colostomy and in the PACU developed mild hypotension
and
and was noted to have new STE V1-V3 on ECG. She was taken
emergently to
the cath lab.
INDICATIONS FOR CATHETERIZATION:
STE on ECG
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
right femoral vein, using a 6 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 6 French left [**Last Name (un) 2699**] catheter,
advanced
to the ascending aorta through a 6 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 6
French JL4 and a 6 French JR4 catheter, with manual contrast
injections.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 1.74 m2
HEMOGLOBIN: 10.4 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 11/7/5
RIGHT VENTRICLE {s/ed} 37/9
PULMONARY WEDGE {a/v/m} 17/12/9
AORTA {s/d/m} 99/56/72
**CARDIAC OUTPUT
HEART RATE {beats/min} 84
RHYTHM SR
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 45
CARD. OP/IND FICK {l/mn/m2} 4.8/2.8
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 1117
**% SATURATION DATA (NL)
PA MAIN 67
AO 99
**ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N 21
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DIFFUSELY DISEASED
2) MID RCA DISCRETE 100
2A) ACUTE MARGINAL DIFFUSELY DISEASED
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN DISCRETE 20
6) PROXIMAL LAD DIFFUSELY DISEASED
6A) SEPTAL-1 DIFFUSELY DISEASED
7) MID-LAD DIFFUSELY DISEASED
8) DISTAL LAD DIFFUSELY DISEASED
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX DISCRETE 60
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
15) OBTUSE MARGINAL-2 NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 21 minutes.
Arterial time = 20 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 55 ml
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 0 units IV
Other medication:
Fentanyl 25 mcg
Midazolam 0.5 mg
Cardiac Cath Supplies Used:
200CC MALLINCRODT, OPTIRAY 200CC
- ALLEGIANCE, CUSTOM STERILE PACK
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel coronary artery disease. The LMCA had a 20% ostial
stenosis.
The LAD had moderate diffuse disease throughout. The LCX had a
50-60%
stenosis in the mid vessel and the RCA was totally occluded in
after the
marginal branch and filled via left to right collaterals.
2. Resting hemodynamics revealed normal filling pressures and a
preserved cardiac index.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Normal filling pressures and cardiac index.
CHEST (PORTABLE AP) [**2199-7-7**] 2:35 AM
CHEST (PORTABLE AP)
Reason: r/o Pulmonary edema, EKG changes
[**Hospital 93**] MEDICAL CONDITION:
76 year old woman POD 1 with EKG changes
REASON FOR THIS EXAMINATION:
r/o Pulmonary edema, EKG changes
PORTABLE CHEST [**2199-7-7**] AT 02:44
INDICATION: EKG changes postop.
COMPARISON: [**2199-7-5**].
FINDINGS: Again seen is an elevated right hemidiaphragm. Since
the prior study, there is subsegmental left basilar atelectasis
but otherwise no evidence for new infiltrate and no evidence for
interval development of CHF. There has been placement of an NG
tube with the tip overlying the left upper quadrant of the
abdomen.
IMPRESSION:
Left basilar atelectasis. No significant interval change versus
prior.
Brief Hospital Course:
Ms. [**Known lastname 17832**] was admitted to the hospital on [**2199-7-6**]. That
same day, she underwent a diverting colostomy for anal stricture
due to Paget's disease of the anus. In the PACU, post-op, she
had low urine output, for which she received a total of 2 L of
bolused fluids. Her urine output remained marginal, and then
dropped off again. She then had an EKG, and Drs. [**Last Name (STitle) **] and
[**Name5 (PTitle) **] were informed. The on-call cardiologist was contact[**Name (NI) **] and
became involved. Ms. [**Known lastname 17832**] was then taken to the
catheterization suite, where she was diagnosed with a complete
right coronary artery occlusion with collateralization and a
mid- to high-grade occlusion of the left circumflex artery. She
was not anticoagulated, as both lesions appeared chronic in
nature.
She was followed in the ICU until HD3, observed to be stable,
and then transferred to the floor.
The ostomy nurse began teaching Ms. [**Known lastname 17832**] to change and
care for her stoma.
On hospital day 7, she experienced one bout of nausea with
vomiting. She vomited 200 cc, but had flatus and bowel sounds.
On hospital day 8, she was tolerating a regular diet, she had
passed much of the residual stool in her colon, and her incision
appeared clean, dry and intact. She was discharged to her home
in good condition with strong family support.
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(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. Milk of Magnesia 800 mg/5 mL Suspension Sig: [**12-31**] PO twice a
day as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Bowel obstruction
Discharge Condition:
Good
Discharge Instructions:
Return to the emergency room if you develop fevers, chills,
nausea, vomiting, abdominal pain, diarrhea and/or any othr
syptoms that are concerning to you.
Follow up with Dr. [**Last Name (STitle) **] next week in clinic.
Follow up with your primary doctor [**First Name (Titles) 4120**] [**Last Name (Titles) 51794**] a stress
test.
Followup Instructions:
Please follow up with your Primary Care Doctor to receive a
cardiac stress test. Please call and schedule an appointment.
Call [**Telephone/Fax (1) 6439**] for an appointment with Dr. [**Last Name (STitle) **] in Surgery
CLinic next week.
|
[
"569.2",
"V10.06",
"787.6",
"401.9",
"560.89",
"530.81",
"154.3",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.56",
"37.23",
"46.11"
] |
icd9pcs
|
[
[
[]
]
] |
10309, 10367
|
8223, 9623
|
328, 366
|
10429, 10436
|
975, 1580
|
10819, 11063
|
690, 707
|
9646, 10286
|
7582, 7623
|
10388, 10408
|
7349, 7545
|
10460, 10796
|
722, 956
|
6418, 7332
|
4547, 6399
|
274, 290
|
7652, 8200
|
394, 565
|
587, 674
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,530
| 159,574
|
48622
|
Discharge summary
|
report
|
Admission Date: [**2173-11-3**] Discharge Date: [**2173-11-5**]
Date of Birth: [**2112-8-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 year old gentleman with COPD, NSCLC stage IV mucinous
adenocarcinoma and recent PE who presents with worsening cough.
Mr. [**Last Name (Titles) 102283**] lung cancer was first diagnosed this summer and has
been progressive despite two cycles of carboplatin paclitaxel.
Recent treatment has included placement of a pleurex catheter
for management of RLL collapse and initiation of second line
therapy with premetrexed (day 21) and discussion regarding home
hospice care.
Mr. [**Known lastname 102284**] initial oncologic course has been complicated by
shortness of breath and recurrent thoracentesis. He was
hospitalized in late [**Month (only) 359**] for elective placement of pleurex
catheter for management of RLL collapse. He was subsequently
seen in the ED for worsening dyspnea from baseline on [**10-26**] for which he was prescribed levofloxacin for 7 days. A CTA
demonstrated no evidence of pulmonary embolism, interval
worsening of bilateral effusions and concern for a LUL
pneumonia. Since disharge he has noted progressive shortness of
cough, with acute worsening last night with symptoms of self
described air hunger. His pleurex catheter has been draining
100cc of tea colored fluid per day without change.
In the ED, initial vitals were: A chest xray demonstrated
evidence of a probably left lower lobe pneumonia. He was started
on vancomycin and cefepime for HCAP. He desaturated to the low
80s and was started on BiPAP 7/4 with saturations in the
90s-100s and RR in the 30s. Due to discomfort he was
transitioned to a non-rebreather at 12L with oxygen saturation
100% and RR 30 with intermittant transitions back to BiPAP. His
code status was confirmed as DNR/DNI. He was given 125mg IV
solumedrol and albuterol and ipatropium nebs for his COPD. He
was given 2mg of ativan twice for anxiety, morphine 5mg for pain
and zofran 4mg for nausea. Given his oxygen requirement, he was
transferred to the MICU for further care. Interventional
pulmonology and oncology were made of aware of his admission.
On arrival to the MICU, initial vitals were 96 136 143/93 31 88.
The patient's brathing was visibly labored and he was unable to
speak full words. His physical exam was significant for mottled
skin, rhoncherous breath sounds throughout his lung fields and
diaphoresis, closed eyes. Discussion regarding goals of care was
initiated with the patient and long-time partner at the bedside.
When asked what the patient would like regarding his care, he
replied morphine. Goals of care was discussed with his partner
who indicated the goal was comfort and explained outpatient
initiation of hospice. The legal health care proxy, his sister
[**Name (NI) 5969**] [**Name (NI) **] was contact[**Name (NI) **] by phone who discussed that her
brother would at this time wish to be made comfortable. It was
explained with the partner, health care proxy and the patient
that goals of care would be focused towards comfort measures
including morphine. The patient at this time was unable to
participate in this conversation. A morphine drip was started.
The patients primary oncologist, and oncology nursing staff were
notified of his admission. Chaplain and social work services
were offered.
Review of systems: Unable to obtain.
Past Medical History:
- NSCLC stage IV EGFR, ALK, and KRAS w/t
- Osseous mets, fourth and ninth ribs
- PE in [**7-/2173**]
- Carotid stenosis s/p CEA [**2173-7-31**]
- Hypertension
- Ocular migraine
- Alcohol abuse
- Hyperlipidemia
Social History:
- Tobacco: Smoked 2 PPD age 20 to 61
- Alcohol: Former heavy drinker, drinks [**11-29**] bottle of wine per
night
- Illicits: Denies
- Occupation: ECG engineer
- Exposures: Denies
Family History:
Mother- colon cancer at 83 s/p resection, still alive at 88,
hypertension
Father- died of multiple myeloma at age 80, high cholesterol
Sister 1- died of malignant brain tumor at age 24
Sister 2- hypertension
No FH of stroke, diabetes
Physical Exam:
Admission exam:
Vitals: 96 136 143/93 31 88
General: Somnolent, diaphoretic, labored breathing
HEENT: mm dry,
Lungs: Audible rhoncherous breath sounds, use of all accessory
muscles, labored breathing w/ rhonchi throughout all lung
fields, decreased BS on right.
CV: Tachycardic, 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: Pale, mottled skin throughout, cool hands and feet w/
palpable DPs
Discharge exam:
VS 98.3; 117; 92/55; 18; 94% 4LNC
General: AAOx3
Lungs: Bibasilar crackles with decreased BS on right side
CV: tachycardic, 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: no foley
Pertinent Results:
Admission labs:
[**2173-11-3**] 08:56AM BLOOD WBC-10.7 RBC-2.75* Hgb-8.3* Hct-26.5*
MCV-97 MCH-30.3 MCHC-31.4 RDW-19.0* Plt Ct-700*#
[**2173-11-3**] 08:56AM BLOOD Neuts-85* Bands-0 Lymphs-5* Monos-8 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-11-3**] 08:56AM BLOOD Glucose-229* UreaN-8 Creat-0.6 Na-122*
K-4.9 Cl-91* HCO3-22 AnGap-14
[**2173-11-3**] 08:56AM BLOOD Calcium-8.6 Phos-5.1* Mg-1.7
[**2173-11-3**] 09:05AM BLOOD Lactate-3.5*
CXR [**2173-11-3**]:
IMPRESSION:
1. New left lung base consolidation most likely represents
pneumonia, less
likely new pulmonary mass given short term interval development.
2. Slightly increased opacification of the right apex consistent
with known lung carcinoma. Unchanged opacification of the right
hemithorax and volume loss.
3. New soft tissue calcifications in the region of the right
scapula. Given interval development, query whether this is
external to the patient or palpable on exam.
CXR [**2173-11-4**]:
IMPRESSION: Regression of previously identified left lower lobe
infiltrates suspected to be of inflammatory origin in this
patient with history of advanced right-sided pulmonary
carcinoma. A left-sided pleural effusion stable blunts the
lateral pleural sinus.
DISCHARGE LABS:
[**2173-11-5**] 05:28AM BLOOD WBC-11.3* RBC-2.56* Hgb-7.8* Hct-25.5*
MCV-100* MCH-30.6 MCHC-30.6* RDW-18.7* Plt Ct-410
[**2173-11-5**] 05:28AM BLOOD Plt Ct-410
[**2173-11-5**] 05:28AM BLOOD Glucose-104* UreaN-14 Creat-0.4* Na-131*
K-4.3 Cl-94* HCO3-29 AnGap-12
[**2173-11-5**] 05:28AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.5*
Brief Hospital Course:
61 year old gentleman with COPD, NSCLC stage IV mucinous
adenocarcinoma complicated by recent PE, placement of R pleurex
catheter for RLL collapse and progression of disease on first
line therapy who presents with respiratory distress.
# Respiratory distress- History of NSCLC stage IV EGFR, ALK, and
KRAS with osseous mets. Initial DDx PNA, atelectasis, mucous
plugging. CXR showed now LLL consolidation. Received one dose
Vanc/Cefepime in the ED, which did not continue. Patient
presented to the MICU with respiratory distress, initially
requesting morphine. Per discussion with [**Last Name (LF) 16883**], [**First Name3 (LF) **]-term
partner, and sister [**Name (NI) 382**], initiated morphine drip for [**Name (NI) 3225**].
Patient improved markedly overnight, so morphine drip was
stopped. Acute respiratory decompensation attributed to mucus
plug, aspiration, perhaps with contributing atalectasis.
Continued albuterol/ipratropium nebulizers. Continued home dose
Lovenox [**Hospital1 **] for recent PE. Repeat CXR showed improvement of LLL
consolidation, so antibiotics not restarted.
# NSCLC: Was undergoing palliative second line therapy on day 21
of premetrexed prior to admission. Chemotherapy discussed with
Dr. [**Last Name (STitle) **] (outpatient oncologist), who will re-address
chemotherapy with patient in the outpatient setting. Oncology
nurse will contact him at home for scheduling.
# Hyponatremia: Chronic hyponatremia in setting of pulmonary
disease. Likely underlying SIADH.
# Goals of care: Patient presented with acute decompensation.
Family agreed to focus on pain control, symptomatic control,
family support, and morphine drip started. Patients respiratory
and mental status markedly improved overnight in the ICU, so
morphine drip was stopped and patient back to DNR/DNI from [**Last Name (STitle) 3225**].
# Hypertension- Held hydralazine and metoprolol for low BP.
Restarted on discharge, patient aware of holding paramete of
BP<90/60 and will monitor BP at home.
# Anemia: Chronic in setting of chemotherapy for NSCLC.
# Transitional issues-
- Oncology nurse will contact him at home for scheduling.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 1 puff IH up to
every 4 hours as needed for shortness of breath
BENZONATATE - 100 mg Capsule - [**11-29**] Capsule(s) by mouth 3 times a
day prn
DEXAMETHASONE - 2 mg Tablet - [**11-29**] Tablet(s) by mouth 2 pills
twice daily for 2 days around chemo. Then 1 pill every other day
ENOXAPARIN - 80 mg/0.8 mL Syringe - 80 Syringe(s) twice a day
FAMOTIDINE - 20 mg Tablet - 1 Tablet(s) by mouth twice a day
FLUTICASONE-SALMETEROL [ADVAIR HFA] - 45 mcg-21 mcg/Actuation
HFA
Aerosol Inhaler - 1 puff inhaled twice a day
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily
HYDRALAZINE - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth three times a day
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth HS
MEGESTROL - 20 mg Tablet - 1 Tablet(s) by mouth daily ICD9 162.9
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth twice a day
MORPHINE - 15 mg Tablet Extended Release - 1 Tablet(s) by mouth
hs take with colace
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth three times
a day for three days after chemo
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth four times a day
as needed for pain
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
three times a day for three days after chemo and as needed for
nausea
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 cap IH daily with inhaler
BISACODYL - 10 mg Suppository - 1 unit rectally daily until
having BM
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider) - Dosage uncertain
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day
MAGNESIUM CITRATE - Solution - [**11-29**] tablespoons by mouth up to
every 4 hours until stooling
MULTIVIT,CA,IRON-FA-LYCO-LUT [MULTIVITAL] - (Prescribed by
Other
Provider) - Dosage uncertain
NICOTINE - (Prescribed by Other Provider) - 7 mg/24 hour Patch
24 hr - Apply once patch daily as instructed. Daily Do not smoke
while wearing nicotine patch
Discharge Medications:
1. benzonatate 100 mg Capsule Sig: [**11-29**] Capsules PO TID (3 times
a day) as needed for cough.
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO BID (2 times a day):
Please do not take medication is BP <90/60. Tablet Extended
Release 24 hr(s)
3. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
12. dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO twice a
day: for 2 days around chemo, then 1 pill every other day.
13. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
14. hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times
a day: please hold if BP less than 90/60.
15. megestrol 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day: for three days after
chemotherapy.
17. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
three times a day as needed for nausea: for three days after
chemo.
18. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
19. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Respiratory distress
Non-small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization. You were admitted because you had trouble
breathing. We treated you with morphine and continued your home
medications. In discussion with your outpatient oncologist,
chemotherapy was deferred this week given your worsening
breathing. You will be contact[**Name (NI) **] by the chemotherapy nurse
regarding your appointment for next week
Please monitor your blood pressure closely, and do not restart
hydralazine or metoprolol if your blood pressure is less than
90/60
Followup Instructions:
YOU WILL BE CONTACT[**Name (NI) **] REGARDING THE DATE/TIME OF YOUR NEXT
CHEMOTHERAPY
Department: [**Hospital3 249**]
When: FRIDAY [**2173-11-26**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2173-11-5**]
|
[
"162.9",
"198.5",
"305.1",
"416.2",
"401.9",
"V58.61",
"V49.86",
"491.21",
"253.6",
"285.22",
"300.00",
"272.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13380, 13386
|
6778, 8930
|
324, 330
|
13497, 13497
|
5199, 5199
|
14239, 14780
|
4056, 4291
|
11268, 13357
|
13407, 13407
|
8956, 11245
|
13648, 14216
|
6433, 6755
|
4306, 4853
|
4869, 5180
|
3590, 3609
|
264, 286
|
358, 3570
|
5215, 6417
|
13426, 13476
|
13512, 13624
|
3631, 3842
|
3858, 4040
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,905
| 172,573
|
11965
|
Discharge summary
|
report
|
Admission Date: [**2141-6-17**] Discharge Date: [**2141-6-23**]
Date of Birth: [**2064-10-30**] Sex: M
Service: MEDICINE
Allergies:
Keflex / Zosyn / Imipenem/Cilastatin Sodium / Linezolid
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
fever, hypotension, maculopapular rash
Major Surgical or Invasive Procedure:
none
History of Present Illness:
76M with trachestomy/PEG, bronchopleural fistula, CHF, CVA,
Chest tube draining R sided empyema who was recently discharged
from [**Hospital1 18**] MICU now presents from [**Hospital1 **] with diffuse
maculopapular rash, SBPs in the 80s, temp to 102. At [**Hospital1 **],
750ccs fluids given with BP up to 108/52. Given
vanc/cipro/acyclovir. Due to the concern for viral exanthem, HSV
and vzv pcrs obtained and sent to lab.
.
Pt has recently had 2 hospitalizations at [**Hospital1 18**] MICU. First
hosp, beginnign of [**Month (only) 596**] was for resp failure and s/p asystolic
arrenst. Most recent hospitalization in the MICU for respiratory
failure (s/p yet another PEA arrest due to pulmonary infections.
.
In the ED, code sepsis was initiated, RIJ sepsis line was place,
pt was aggressivley fluid resuscitated and CVL was placed. The
patient was started on levophed and given that the patient is
full code he was brought up to the MICU for further monitoring.
Total of 3L IVF In the ED. Total UOP 215ccs somce 7 am [**2141-6-17**]
Past Medical History:
1) prior cardiac arrest with anoxic brain injury
2) Bronchopleural fistula with MRSA, chest tube in place
3) Chronic respiratory failure, with tracheostomy/PEG
4) Ischemic cardiomyopathy with EF 15%
5) Atrial fibrillation
6) GI bleed
7) Ischemic CVA--MCA territory
8) Seizure disorder
9) bilateral carotid strenosis
Social History:
From [**Hospital **] rehabilitation, former biochemist. Sister is HCP
Family History:
Non-contributory
Physical Exam:
Temp: 99.3; BP 121/39; HR 105; RR 14-19 VENT: AC 500x12, PEEP 5,
FIO2 0.4; PIPS 25-31
Gen; Elderly male, intubated, obvious facial fasciculations.
Pupils 3mm and miminally reactive.
RESP: trach in place. rhonchorous upper airway sounds. Decreased
breath sounds R base. crackles over L base
CV: tachy. reg S1 and S2. No MRG.
ABD: +BS. soft, nt, nd, no hsm. no guardng
ExT: 1+ edema
Skin: diffuse maculopapular/vesicular rash spacing mucous
membranes/lover leags. crossing several dermatomes
Neuro: obtunded. not currently posturing.
Pertinent Results:
Admission labs:
[**2141-6-17**] 11:43PM TYPE-[**Last Name (un) **] PO2-46* PCO2-51* PH-7.41 TOTAL
CO2-33* BASE XS-5
[**2141-6-17**] 11:43PM O2 SAT-78
[**2141-6-17**] 11:29PM GLUCOSE-166* UREA N-140* CREAT-2.9*
SODIUM-160* POTASSIUM-3.6 CHLORIDE-120* TOTAL CO2-32 ANION
GAP-12
[**2141-6-17**] 11:29PM ALT(SGPT)-82* AST(SGOT)-40 LD(LDH)-359* ALK
PHOS-114 AMYLASE-52 TOT BILI-0.2
[**2141-6-17**] 11:29PM LIPASE-17
[**2141-6-17**] 11:29PM ALBUMIN-2.0* CALCIUM-7.5* PHOSPHATE-2.2*
MAGNESIUM-2.7*
[**2141-6-17**] 11:29PM PHENYTOIN-<0.6*
[**2141-6-17**] 11:29PM WBC-21.4* RBC-2.28* HGB-6.8* HCT-21.4* MCV-94
MCH-29.9 MCHC-31.9 RDW-17.5*
[**2141-6-17**] 11:29PM PLT COUNT-319
[**2141-6-17**] 11:29PM PT-16.0* PTT-39.0* INR(PT)-1.5*
[**2141-6-17**] 09:32PM COMMENTS-GREEN TOP
[**2141-6-17**] 09:32PM LACTATE-2.0
[**2141-6-17**] 09:32PM O2 SAT-95
[**2141-6-17**] 07:54PM WBC-21.0* RBC-2.56* HGB-7.5* HCT-23.9* MCV-93
MCH-29.4 MCHC-31.5 RDW-17.6*
[**2141-6-17**] 07:54PM NEUTS-55 BANDS-12* LYMPHS-8* MONOS-2 EOS-23*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2141-6-17**] 07:54PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ TARGET-1+
SCHISTOCY-OCCASIONAL
[**2141-6-17**] 07:54PM PLT SMR-NORMAL PLT COUNT-292
[**2141-6-17**] 07:44PM LACTATE-2.7*
[**2141-6-17**] 07:44PM O2 SAT-96
[**2141-6-17**] 06:25PM PH-7.44 COMMENTS-GREEN TOP
[**2141-6-17**] 06:25PM GLUCOSE-121* LACTATE-2.5* NA+-160* K+-3.8
CL--114*
[**2141-6-17**] 06:25PM freeCa-1.09*
[**2141-6-17**] 06:05PM estGFR-Using this
[**2141-6-17**] 06:05PM CALCIUM-8.4 PHOSPHATE-2.4*# MAGNESIUM-3.0*
[**2141-6-17**] 06:05PM URINE HOURS-RANDOM
[**2141-6-17**] 06:05PM URINE GR HOLD-HOLD
[**2141-6-17**] 06:05PM WBC-18.7*# RBC-2.54* HGB-7.7* HCT-23.6*
MCV-93 MCH-30.3 MCHC-32.6 RDW-17.7*
[**2141-6-17**] 06:05PM NEUTS-55 BANDS-8* LYMPHS-7* MONOS-5 EOS-24*
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2141-6-17**] 06:05PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ TARGET-1+
SCHISTOCY-OCCASIONAL
[**2141-6-17**] 06:05PM PLT SMR-NORMAL PLT COUNT-276
[**2141-6-17**] 06:05PM PT-15.5* PTT-57.6* INR(PT)-1.4*
[**2141-6-17**] 06:05PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2141-6-17**] 06:05PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2141-6-17**] 06:05PM URINE RBC-[**10-31**]* WBC-21-50* BACTERIA-MOD
YEAST-MANY EPI-0-2
[**2141-6-17**] 06:05PM URINE AMORPH-MOD
[**2141-6-23**] 03:52AM BLOOD WBC-20.2* RBC-2.33* Hgb-7.2* Hct-20.8*
MCV-89 MCH-30.9 MCHC-34.6 RDW-18.0* Plt Ct-251
[**2141-6-23**] 03:52AM BLOOD Neuts-66 Bands-2 Lymphs-31 Monos-0 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-3*
[**2141-6-23**] 03:52AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-1+ Polychr-1+ Schisto-1+ Stipple-1+
Ellipto-1+
[**2141-6-23**] 03:52AM BLOOD Plt Smr-NORMAL Plt Ct-251
[**2141-6-23**] 03:52AM BLOOD Neuts-66 Bands-2 Lymphs-31 Monos-0 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-3*
[**2141-6-23**] 03:52AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-1+ Polychr-1+ Schisto-1+ Stipple-1+
Ellipto-1+
[**2141-6-23**] 03:52AM BLOOD Plt Smr-NORMAL Plt Ct-251
[**2141-6-23**] 03:52AM BLOOD PT-13.9* PTT-30.2 INR(PT)-1.2*
[**2141-6-23**] 03:52AM BLOOD Glucose-212* UreaN-120* Creat-4.5* Na-141
K-3.8 Cl-103 HCO3-21* AnGap-21*
[**2141-6-23**] 03:52AM BLOOD ALT-26
[**2141-6-22**] 05:01AM BLOOD ALT-26 AST-17 AlkPhos-96 TotBili-0.4
[**2141-6-23**] 03:52AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.2
[**2141-6-18**] 04:40AM BLOOD Cortsol-41.0*
[**2141-6-18**] 03:47AM BLOOD Cortsol-35.8*
[**2141-6-18**] 02:54AM BLOOD Cortsol-28.0*
[**2141-6-23**] 03:52AM BLOOD Phenyto-14.6
[**2141-6-21**] 02:27PM BLOOD Type-ART Temp-37.3 Tidal V-500 PEEP-5
FiO2-40 pO2-143* pCO2-35 pH-7.38 calTCO2-22 Base XS--3
-ASSIST/CON Intubat-INTUBATED
[**2141-6-21**] 03:28AM BLOOD Type-ART pO2-111* pCO2-38 pH-7.44
calTCO2-27 Base XS-1
[**2141-6-21**] 02:27PM BLOOD Lactate-2.5*
[**2141-6-21**] 03:28AM BLOOD Lactate-2.2*
[**2141-6-21**] 02:27PM BLOOD freeCa-1.08*
[**2141-6-21**] 03:28AM BLOOD freeCa-1.07*
[**2141-6-22**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
negative
[**2141-6-22**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {YEAST, GRAM NEGATIVE ROD(S)} INPATIENT
[**2141-6-22**] 11:41 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
GRAM STAIN (Final [**2141-6-22**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
YEAST. SPARSE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
FURTHER IDENTIFICATION TO FOLLOW.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
[**2141-6-20**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
negative
[**2141-6-20**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2141-6-20**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2141-6-19**] 11:59 am CATHETER TIP-IV Source: PICC line.
**FINAL REPORT [**2141-6-21**]**
WOUND CULTURE (Final [**2141-6-21**]): No significant growth.
[**2141-6-18**] 6:00 pm EAR RIGHT EAR, EXTERNAL AUDITORY CANAL.
GRAM STAIN (Final [**2141-6-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2141-6-20**]): NO GROWTH.
POTASSIUM HYDROXIDE PREPARATION (Final [**2141-6-18**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen for Fungal Smear (KOH).
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
[**2141-6-18**] 2:35 pm TISSUE Source: Skin biopsy.
GRAM STAIN (Final [**2141-6-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2141-6-21**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2141-6-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
[**2141-6-18**] Direct Antigen Test for Herpes Simplex Virus Types 1
& 2 Direct Antigen Test for Herpes Simplex Virus Types 1 &
2-FINAL; DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS-FINAL
negative
[**2141-6-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-negative
[**2141-6-18**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL
{GRAM NEGATIVE ROD(S), [**Female First Name (un) **] ALBICANS, STAPH AUREUS COAG +};
ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY {[**Female First Name (un) **]
ALBICANS}; VIRAL CULTURE-PENDING INPATIENT
[**2141-6-18**] 4:52 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2141-6-18**]):
[**10-5**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
YEAST. MODERATE GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
Daptomycin Susceptibility testing requested by DR. [**Last Name (STitle) **]
([**Numeric Identifier 37629**])
[**2141-6-22**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
DAPTOMYCIN------------ PND
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
FUNGAL CULTURE (Preliminary):
YEAST.
[**2141-6-18**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
URINE CULTURE (Final [**2141-6-19**]):
YEAST. >100,000 ORGANISMS/ML..
[**2141-6-18**] BLOOD CULTURE AEROBIC BOTTLE-PRELIMINARY
{ENTEROCOCCUS SP.}; ANAEROBIC BOTTLE-PENDING INPATIENT
[**2141-6-18**] 3:20 am BLOOD CULTURE Source: Line-LAC PICC.
AEROBIC BOTTLE (Preliminary):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] CC7D AT 22:15 ON [**2141-6-18**].
ENTEROCOCCUS SP.. RESEMBLING ENTEROCOCCUS FAECALIS.
FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
gentamicin. Screen predicts NO synergy with penicillins
or
vancomycin. Consult ID for treatment options.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
ISOLATE IS BEING SENT TO [**Hospital1 4534**] LABS FOR LINEZOLID
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LEVOFLOXACIN---------- R
LINEZOLID------------- PND
PENICILLIN------------ 2 S
VANCOMYCIN------------ =>32 R
ANAEROBIC BOTTLE (Pending):
[**2141-6-18**] BLOOD CULTURE BLOOD/AFB CULTURE-PENDING;
BLOOD/FUNGAL CULTURE-PENDING INPATIENT
[**2141-6-18**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) AEROBIC
BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT
[**2141-6-17**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL negative
[**2141-6-17**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL
negative
EEG [**6-/2141**]:
IMPRESSION: Very abnormal EEG due to marked voltage reduction,
moderate
background slowing diffusely, and frequent pseudoperiodic
generalized
bifrontally predominant and left side accentuated small spike
discharges.
Renal US [**2141-6-19**]:
IMPRESSION: No evidence for hydronephrosis. Slightly atrophic
kidneys,
unchanged from prior study.
EKG: [**2141-6-19**]:
Sinus tachycardia with premature atrial beats. Left
bundle-branch block.
Low QRS voltage in the limb leads. Compared to tracing on
[**2141-5-27**] sinus
tachycardia and premature atrial beats are new.
Brief Hospital Course:
76 y/o male with PMH significant for PEA arrest x2, anoxic brain
injury, MCA stroke, s/p trach/PEG, s/p chest tubes for recent
empyema, presented from rehab with fevers, hypotension and
diffuse maculopapular rash.
.
#Septic Shock: Initially, the pt presented with fevers,
hypotension, tachycardia, bandemia, lactic acidosis, multiorgan
failure. Was presumed to be a bacterial infection. Sepsis line
was placed in the ED under sterile conditions. Source most
likely lung. So far [**6-20**] sputum cx have grown MRSA (sensitivies
pending) and VRE has grown from the blood. The patient was
initially started on broad spectrum antibiotics
(Linezolid/Meropenem/acyclovir/fluconazole), Zosyn was later
added when the patient began to have persistent bandemia,
increasing white count and pressor requirements. ID was then
consulted and adjusted the anti-biotics (see below). The
patients was fluid resuscitated with numerous boluses of NS and
LR. The patient has continued to have pressor requiremnts but
pressors are currently being weaned. The patient is +20L LOS
positive, but has a lot of lossess due to current skin status.
Currently, the levophed is OFF, and the patient's MAPs have
stayed > 60 over the course of [**6-23**]. Levophed was dc'd this
morning ([**2141-6-23**]). As of [**6-23**], patient is not currently
exhibiting septic physiology, but is at risk for multiple
infections given skin breakdown and MRSA in blood and pleural
fluid. Micro Lab at [**Hospital1 18**] has sensitivities to datomycin
pending. Patient is currently on Daptomycin (to complete 14d
course, started on [**6-19**]) and Fluconazole (started [**6-19**], to
complete a 7 day course). For the past 3 days, CVPs ranged form
[**8-2**]. The patient should be supported with Levophed as
necessary. Currently, the patient is still maintained on a small
dose of levophed at 0.200. Pt is not currently acidotic. vs. VRE
(growing in blood). Not currently acidotic.
.
The patient was started on PO steroids to treat his AIN (see
below). He has gotten 2 doses of 60 PO prednisone. The
prednisone was dc'd [**6-23**] due to the possibility of infection
given skin breakdown and posible active infection.
.
#ID: h/o of pulmonary ESBL E. coli pneumonia, MRSA pneumonia,
h/o VRE in urine. Current infection likely VAP and pt has been
tx'd with multiple courses of abx (most recenly
linezolid/imipenem) over last several months and with AGEP
(Acute Generalized Exanthemous Pustulosis--rare drug reaction)
rash [**1-13**] unkown medication (see below). +Yeast UTI and in
pleural fluid. Pt is also growing out MRSA from pleural fluid.
Skin DFA negative for HSV/VZV; d/c'd acyclovir and droplet
precautions. Now the patient is growing out MRSA from sputum,
sensitivities to dapto are pending. however, given the patient's
state of the skin, pan cellulitis is also an emerging
possibility. Currently the patient is on dapto and fluconazole,
zosyn was stopped ([**6-21**]) to the fear that rash may be
exacerbated. On [**6-23**], the patient's WBC count has decreased from
27-->22. The patient has been consistently afebrile since [**6-20**].
He continues to be afebrile on Dapto and fluconazole. Cdiff has
been negative x 2. The patient has a indwelling chest tube
since [**2141-2-9**] for a h/o ESBL empyema and has been draining
pleural fluid that has been + for MRSA. Due to the multiple
suspected culprits for his drug eruption, the antibiotic choices
remain limited, but perhaps the patient can be re-challenged
with abx class if needed. For now, he is to remain on
Dapto/Fluconazole.
.
#Resp Failure: Trached and PEGd after hypoxic brain injury due
to prior PEA arrests in [**2140-12-12**]. Since than, the pt has
had multiple ventillatory associated pneumonias causing
respiratory failure over last 2 hospitalizations: E.Coli empyema
s/p R sided chest tube placement. Bronchopulm fistula continues.
The patient has stable, persistent basal R sided pneumothorax
due to his chest tube. there is no large sided pleural
effusions. The patient has failed pressure support trials due
to hypotension, tahchycardia and increasing pressor reqirements.
The patient has continued to have chest tube to water seal
draining about 30cc's of serosang. fluid per 24hrs. trial
yesterday due to hypotension. His current vent settings are AC
500x12, PEEP of 5, FIO2 0.4; PIPs ranged 23-28, Plateau
pressures 20-21. Oxygenation and ventillation have not been
problem[**Name (NI) 115**]. His latest ABG on these settings was 7.35/38/143.
.
#Neuro: Seizure/anoxic brain injury [**1-13**] PEA arrests and
subsequent multiple strokes. The patient has known anoxic brain
injury confirmed by neurology. There is currently no acute
intracranial process. During his [**2-/2141**] admission to [**Hospital1 18**] ICU
he was noted to have periodic facial twitching which may or may
not be seizure activity. At that point, the patient has had an
extensive neuro eval that concluded that the periodic facial
twitching were likely due to seizure actvity. EEG was done
which was negative for seizure activity. At his discharge form
[**Hospital1 18**] to [**Hospital1 **] vent facility, the patient was dc'd on IV
Phenytoin. For some reason, IV phenytoin was stopped on [**6-7**]/
Patient had been off IV phenytoin since [**6-7**] at rehab for
unclear reasons and presented subtherapeutic. MRI brain on [**5-10**]
showed a new right posterior temporal/superior
parietal/occipital regions, posterior to the chronic infarct,
which was the culprit for seizure/twitching. On admission, the
patient was exhibiting facial/eylid movements as well, neuro was
reconsulted. Since the patient has not been getting his dilantin
at rehab, he was reloaded with IV phenytoid and the movements
have stopped. During this admission, an EEG was done which was
markedly abnormal, but was negative for seizure activity. Neuro
set the patient's dilantin level to be 20-30 in order to be
therapeutic. Level was therapeutic upon dc from [**Hospital1 18**].
.
#Rash: on [**2141-6-17**], at rehab, the patient developed a generalized,
angry, pustular rash all over his head, trunk, extremities
(including the dorsum and and palm of the hands). Somehow, the
rash tended not to extend too much below the knee (where the
pnemoboots have been placed). The rash appeared disseminated
maculopapular rash across dermatomes with peripheral
eosinophilia (25% eos on admission) . Derm consulted (Dr. [**First Name4 (NamePattern1) 46**]
[**Last Name (NamePattern1) 9056**], [**Hospital1 112**]). AGEP (drug rash) per derm. Acute Generalized
Exanthematous Pustulosis diagnosed. Drug rash, [**Last Name (un) 5487**] offending
aagent. DFA negative for HSV/VZV. Less likely disseminated
fungal, bacterial infection. Unknown inciting [**Doctor Last Name 360**] but most
likely one of his recent antibiotics. Currently becoming much
more of an issue due to serious desquamation, bullae formation,
and loss of fluids. >70% of total body area is affected. Derm
following and recommends for xfer to burn unit. Estimated fluid
loss (by weighing soaked sheets and towels) was around 4L per
day. Per derm recs, xeroform dressings applied to all over the
body. Clobetasol cream applied all over the affected areas.
.
Official bx report: "Pustular and spongiotic dermatitis with
numerous eosinophils most consistent with a pustular drug
eruption.
Note: Sections reveal intraepidermal pustules with a mixture of
neutrophils and eosinophils. Within the dermis, there is a
superficial perivascular and interstitial dermatitis with
numerous eosinophils. In some sections there is marked
inflammation of pilosebaceous units. The superficial changes
are consistent with a pustular drug eruption. The finding of
numerous eosinophils histologically favors a pustular drug
eruption. Acute generalized exanthematous pustulosis is also
considered. It usually shows fewer eosinophils, however, there
may be overlap of these reaction patterns. The differential
diagnosis includes an id reaction, possibly to a bacterial or
viral infection elsewhere. The changes are not those of
pustular psoriasis.
.
There are some features such as the marked pilosebaceous
inflammation which raise consideration of herpesvirus infection
(possibly co-existent) or eczema herpeticum, however, no
definitive cytopathic changes are identified on initial and
level sections examined. Special stains (Gram, PAS, GMS, and
AFB) are negative for organisms. Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] has reviewed this
case and concurs with the diagnosis. This case was discussed
with Dr. [**Last Name (STitle) **] on [**2141-6-20**]."
.
Higher level burn unit care was recommended per derm to prevent
secondary overwhelming infections form skin breakdown. Allergy
was also curbsided during the hospital course and do not
recommend skin testing for the offending [**Doctor Last Name 360**].
.
#Renal: Patient presented in acute on chronic renal failure.
Thought likely due to to ATN in the setting of sepsis, however
may also be component of AIN given urine and peripheral
eosinophilia as well as rash. Patient's urine eos may be due to
initial overwhelming peripheral eisinophilia. Baseline 1.4-2.0;
now minimal urine output and extremely volume overloaded.
Patient basically anuric from [**Date range (3) 37630**] until renal
suggested a trial of diuretics, but response minimal (30ccs). No
plans for dialysis, renal not offering HD at this time. On
[**2141-6-22**], Renal recommended a trial of lasix gtt to "jump start"
the kidneys. Since then, the patient has been making on average
of 30cc's per hour of urine with total UOP since [**2141-6-22**] being
around 500ccs. Still, no plans for HD. Based on the patient's
fluid lossess form the skin (around 4l/day), his fluid status
should be monitored based on his CVP: [**7-21**] is the goal. Lasix
drip is currently at 8ccs/hr. The patient does have an anion
gap metabolic acidosis, presumably currently due to uremia.
Lactates have stayed flat throughout the admission. Acid/base
status needs to be monitored closely during the admission, and
patient needs to be basically needs to run even. In order to
keep flushing his kidneys, patient should be given 1/2 NS to
keep his UOP 30cc/hr and yet to keep him even (with the
insensible lossess). On [**2141-6-23**], the patient got xfused 2u
PRBCs.
.
#GIB: On admission, black stool out of rectal tube, guiaiac +.
Elevated BUN. Pt does not have h/o coagulopathy, but was
slightly coagulopathic (INR 1.4) on adission. (? nutritional vs
liver disease vs antibiosis). GI consult noted ulcerated lesions
on toungue and thinks that there may be similar lesions
throughout the GI tract causing GI bleeding resulting in slow
ooze. also platelets likely non-functional as pt very uremic
with high BUN/Cr. Patient was initially given Vit K. GI
currently not offering a scope, given the patients overall
status and thinks that treating the systemic infection. The
patient was trasnfused a total of 5 units of PRBCs since his
admission on [**2141-6-17**]. GI currently recommends continuing [**Hospital1 **] PPI
.
# CV: h/o CHF with EF 15%, was on BB and other agents as an
outpatient, now being held due to tenuous BP situaton. Extremely
volume overloaded due to acute renal failure. Renal following,
no plans for HD at this time. Also with h/o Afib but currently
sinus; not anticoagulated [**1-13**] h/o GIB.
.
#Endo: Pt came in hypotensive and code sespis was called.
currently mainitaining his BP with levophed and IVF.
-[**Last Name (un) 104**] stim during the admission normal, patient have stim'ed
appropriately, pt is NOT adrenally insufficient.
.
# F/E/N - TF
# PPx - p-boots, IV PPI [**Hospital1 **]>
# Access - R IJ, R a-line, L Picc line
# Code - FULL (discuss further with family at meeting
yesterday.)
# Communication - sister [**Name (NI) 382**], [**Name (NI) **]) [**First Name4 (NamePattern1) **] [**Name (NI) **] [**Telephone/Fax (1) 37628**]
# Dispo - ICU
Medications on Admission:
Meds at Rehab (per previous DC summ)
-Meropenem 500 mg Recon Soln [**Telephone/Fax (1) **]: One (1) 500mg soln
Intravenous every eight (8) hours for 5 weeks starting [**6-4**]
-Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: as directed
-phenytoin 100 mq q 8h
-Linezolid 600 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO every twelve
(12) hours for 5 weeks starting [**6-4**]
-Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
-Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Month/Year (2) **]: One (1)
neb Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
-Ascorbic Acid 500 mg/5 mL Syrup [**Month/Year (2) **]: One (1) 500mg/5mL PO
once a day.
-Zinc Sulfate 220 (50) mg Capsule [**Month/Year (2) **]: One (1) Capsule PO
DAILY (Daily).
-Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: Ten (10) mL PO BID (2
times a day).
-Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Month/Year (2) **]: One (1)
Appl Ophthalmic PRN (as needed).
-Albuterol 90 mcg/Actuation Aerosol [**Month/Year (2) **]: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
-Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Six (6)
Puff Inhalation Q6H (every 6 hours).
-Lorazepam 2 mg/mL Syringe [**Month/Year (2) **]: Two (2) injections Injection
Q4H (every 4 hours) as needed for seizures: Use only if
observered seizure activity and verbal order from MD .
-Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
-Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day).
-Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime).
-Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for signs of pain or
discomfort.
-Aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
-heparin SC 5000 TID
Discharge Medications:
Acetaminophen 650 mg PO/NG Q6H:PRN pain, fever
Albuterol [**12-13**] PUFF IH Q4H
Insulin SC sliding scale
Albumin 25% (12.5g / 50mL) 25 gm IV Q6H
Ipratropium Bromide MDI 2 PUFF IH QID
Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **] please apply
all areas of rash
Lorazepam 2 mg IV X1:PRN for status epilepticus if needed
Daptomycin 400 mg IV Q48H
Norepinephrine 0.3-0.5 mcg/kg/min IV DRIP TITRATE TO MAPs>60
Fentanyl Citrate 25-50 mcg IV Q2H:PRN give prior to dressing
changes
Pantoprazole 40 mg IV Q12H
Fluconazole 200 mg IV Q24H
Phenytoin (Suspension) 150 mg NG Q8H
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1708**]
Discharge Diagnosis:
Primary Diagnoses
Acute Generalized Exanthemous Pustulosis
Acute Tubular Necrosis
Anoxic Brain Injury
______________________________
Secondary Diagnoses:
Bronchopleural fistula with MRSA, chest tube in place
Chronic respiratory failure, with tracheostomy/PEG
Ischemic cardiomyopathy with EF 15%
Atrial fibrillation
chronic GI bleed
Seizure disorder
Bilateral carotid strenosis
Discharge Condition:
Unresponsive with decorticate posturing, vented, tolerating tube
feeds
Discharge Instructions:
-please continue care as outlined in the plan of care.
Followup Instructions:
-once treatment course is completed, the patient should be sent
back to [**Hospital **] rehab
Completed by:[**2141-6-23**]
|
[
"578.1",
"780.03",
"693.0",
"V09.80",
"433.30",
"428.0",
"584.5",
"585.9",
"403.90",
"510.0",
"427.31",
"E930.9",
"433.10",
"038.11",
"348.1",
"345.90",
"V44.1",
"414.8",
"518.83",
"785.52",
"995.92",
"V58.65",
"V09.0",
"038.0",
"V44.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.07",
"00.14",
"99.04",
"86.11",
"89.62"
] |
icd9pcs
|
[
[
[]
]
] |
28589, 28636
|
13773, 25781
|
355, 361
|
29057, 29129
|
2459, 2459
|
29232, 29356
|
1873, 1891
|
27979, 28566
|
28657, 28790
|
25807, 27956
|
29153, 29209
|
1906, 2440
|
28811, 29036
|
11328, 12754
|
10140, 11292
|
9206, 10099
|
277, 317
|
12783, 13750
|
389, 1429
|
2476, 6981
|
9010, 9025
|
1451, 1769
|
1785, 1857
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,675
| 145,965
|
38952
|
Discharge summary
|
report
|
Admission Date: [**2133-2-18**] Discharge Date: [**2133-2-23**]
Date of Birth: [**2088-5-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Cath
pulmonary stent
History of Present Illness:
44yo gentleman with h/o recently discovered pulmonary malignancy
presenting with dyspnea x 2 days.
The patient reports that he has had several weeks of air hunger.
Symptoms are worse with exertion and not particularly noticable
at rest. Two days ago, he woke up in the morning and was feeling
much more trouble breathing. Although he has reported chest
pressure to other interviewers, he is currently denying recent
chest pain or pressure. He has not had a cough or hemoptysis. He
denies orthopnea or PND. No weight gain, though he has had LE
edema that comes and goes. He denies fevers/chills. Of note, he
has had sweats and weight loss of 25 pounds over the last 6
weeks.
In the ED the patient had the following vital signs: 97.4 117/73
130 26 96%RA. Patient was found to have ST elevations and
borderline Q waves in V4-V6 and I and aVL. Pt also with subtle
ST elevations in V2-V3. The patient underwent CTA, which
preliminarily was negative for PE or aortic pathology. A bedside
echo was done, which preliminarily revealed mild regional left
ventricular systolic dysfunction (EF 40-45%) with hypokinesis of
the mid inferospetal and apical septal walls as well as moderate
global free wall hypokinesis. The patient was given ASA 325mg PO
ONCE, heparin gtt, nitro gtt, integrillin, and Plavix 600mg.
The patient was then rushed to the cath lab, where he was found
to have completely clean coronary arteries. The cath was also
notable for marked pulmonary hypertension with PA pressures of
60/27. Because of the marked pulmonary pressures and clean
coronaries, a pulmonary angiogram was done, which was also
negative for obvious pulmonary embolism, but subsegmental PE
could not be excluded. Because of the patient's anemia, he was
given 1 unit of PRBCs and transferred to the CCU for intensive
monitoring.
In the CCU, the patient feels mildly short of breath and appears
in mild respiratory distress. He is mainly complaining of back
pain, which is chronic and from metastatic disease per the
patient.
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.
Past Medical History:
Malignancy with mass in lung and spine--prelim diagnosis is
adenocarcinoma
CARDIAC RISK FACTORS: No diabetes, dyslipidemia, or HTN
CARDIAC HISTORY: none
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: See below
-PACING/ICD: None
OUTPATIENT CARDIOLOGIST: None
Oncologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23509**] [**Telephone/Fax (1) 72711**]; [**Telephone/Fax (1) 25517**]
([**Hospital **] Cancer Center)
PCP: [**First Name4 (NamePattern1) 892**] [**Last Name (NamePattern1) 19751**] [**Telephone/Fax (1) 19752**] (NEBH)
Social History:
-Occupation: works as a financial analyist
-Tobacco history: Never smoked tobacco, smoked marijuan a few
weeks ago for medicinal purposes but stopped after realized it
didn't help.
-ETOH: Occasional alcohol use, no heavy drinking
-Illicit drugs: None
Family History:
No family history of early MI, heart disease, blood clots.
Physical Exam:
VS: T=98.2 BP=119/84 HR=110 RR=22 O2 sat=95%5LNC
GENERAL: Obese, pale gentleman in mild distress. Alert, oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Pallor of sclera but anicteric.
NECK: Supple, obese, JVP not discernible
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 SEM. No r/g. No thrills, lifts. No
S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi anteriorly (had to lie flat for post-cath).
ABDOMEN: Obese, soft, NTND. No HSM or tenderness. Normoactive
BS.
EXTREMITIES: No c/c/e. Cool extremites, cap refill wnl
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2133-2-18**] 05:40PM BLOOD WBC-41.2* RBC-3.23* Hgb-10.4* Hct-28.3*
MCV-88 MCH-32.1* MCHC-36.7* RDW-18.9* Plt Ct-331
[**2133-2-23**] 07:46AM BLOOD WBC-16.8* RBC-1.98* Hgb-6.3* Hct-18.5*
MCV-94 MCH-32.0 MCHC-34.1 RDW-20.6* Plt Ct-39*
[**2133-2-23**] 07:40AM BLOOD PT-17.4* PTT-31.4 INR(PT)-1.6*
[**2133-2-18**] 05:40PM BLOOD PT-13.8* PTT-26.4 INR(PT)-1.2*
[**2133-2-23**] 09:21AM BLOOD FDP-80-160*
[**2133-2-23**] 04:28AM BLOOD Fibrino-412*
[**2133-2-22**] 01:49AM BLOOD Fibrino-403*
[**2133-2-21**] 07:35AM BLOOD Fibrino-409*#
[**2133-2-19**] 02:25AM BLOOD Fibrino-243
[**2133-2-22**] 01:49AM BLOOD Ret Man-7.6*
[**2133-2-23**] 05:16PM BLOOD Glucose-163* UreaN-38* Creat-0.7 Na-145
K-3.9 Cl-122* HCO3-15* AnGap-12
[**2133-2-18**] 05:40PM BLOOD Glucose-219* UreaN-24* Creat-0.6 Na-121*
K-4.3 Cl-89* HCO3-20* AnGap-16
[**2133-2-23**] 04:28AM BLOOD LD(LDH)-1783*
[**2133-2-22**] 01:49AM BLOOD ALT-27 AST-24 LD(LDH)-[**2095**]* AlkPhos-347*
TotBili-1.2
[**2133-2-21**] 07:35AM BLOOD ALT-27 AST-30 LD(LDH)-2560* AlkPhos-426*
Amylase-33 TotBili-1.3
[**2133-2-20**] 01:52AM BLOOD ALT-28 AST-44* LD(LDH)-3820* AlkPhos-581*
TotBili-1.9* DirBili-0.5* IndBili-1.4
[**2133-2-19**] 02:25AM BLOOD ALT-30 AST-56* LD(LDH)-3420* CK(CPK)-139
AlkPhos-643* TotBili-1.5
[**2133-2-19**] 02:25AM BLOOD CK-MB-9 cTropnT-0.18*
[**2133-2-18**] 05:40PM BLOOD cTropnT-0.23*
[**2133-2-18**] 05:40PM BLOOD CK-MB-17* MB Indx-7.9* proBNP-9576*
[**2133-2-23**] 05:16PM BLOOD Calcium-5.1*
[**2133-2-23**] 04:28AM BLOOD Calcium-7.9* Phos-4.7* Mg-2.7*
UricAcd-5.2
[**2133-2-18**] 05:40PM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2
[**2133-2-23**] 12:30PM BLOOD D-Dimer-[**Numeric Identifier 33162**]*
[**2133-2-19**] 11:23AM BLOOD calTIBC-218* Ferritn-GREATER TH TRF-168*
[**2133-2-22**] 01:49AM BLOOD Triglyc-129
[**2133-2-20**] 04:21PM BLOOD Osmolal-270*
[**2133-2-19**] 05:55AM BLOOD TSH-0.40
[**2133-2-19**] 11:23AM BLOOD Free T4-1.3
[**2133-2-21**] 08:17AM BLOOD freeCa-1.06*
[**2133-2-22**] 07:26PM BLOOD freeCa-1.11*
[**2133-2-23**] 12:46PM BLOOD freeCa-1.08*
[**2133-2-23**] 05:28PM BLOOD Type-ART Temp-37.2 PEEP-5 pO2-16*
pCO2-49* pH-7.19* calTCO2-20* Base XS--11 Intubat-INTUBATED
Vent-SPONTANEOU
[**2133-2-18**] 08:31PM BLOOD Type-ART pO2-163* pCO2-34* pH-7.51*
calTCO2-28 Base XS-4
[**2133-2-22**] Radiology CT ABDOMEN/PELVIS W/CONTRAST
1. L4 pathological fracture, with mild-to-moderate loss of
vertebral height
and 4 mm retropulsion into the central canal. If the patient
presents with
neurologic signs and symptoms, MRI lumbar spine can be performed
to further
assess.
2. Bilateral adrenal nodules, incompletely assessed in the
current study.
Ill-defined right hepatic hypodensity lesion, also incompletely
assessed.
Dedicated MR [**First Name (Titles) **] [**Last Name (Titles) 44394**] CT study could be performed for
further
characterization.
3. No intra-abdominal lymphadenopathy.
4. New small left pleural effusion. Interval subtotal LLL and
partial RLL
atelectasis. New RML ground-glass opacity concerning for
infectious process.
[**2133-2-21**] Radiology MR HEAD W & W/O CONTRAS
IMPRESSION:
No evidence of parenchymal metastases.
Predominantly right-sided pachymeningeal thickening of uncertain
etiology.
This could be seen in the setting of recent LP. Differential
diagnostic
considerations include neoplastic or inflammatory etiologies.
Multiple tiny presumed bilateral acute and subacute embolic
infarcts
predominantly supratentorially, although a few cerebellar
lesions are also
seen. None of these lesions has significant mass effect.
[**2133-2-19**] Cardiology ECHO
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed (LVEF= 35
%) secondary to extensive anteroapical akinesis. The basal
segments of the left ventricle are hyperdynamic. There is a mild
resting left ventricular outflow tract obstruction. Right
ventricular chamber size is normal. with focal hypokinesis of
the apical free wall. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2133-2-19**] Cytology MEDIASTINAL MASS
Most probably benign - consistent with a mixed micro- and
macrofollicular lesion of mediastinal thyroid with cystic
degeneration.
Cellular specimen with follicular cells in sheets,
macro-follicles and groups. Some macrophages are present. Some
colloid is present in variably-sized fragments.
[**2133-2-18**] Radiology CT HEAD W/O CONTRAST
IMPRESSION:
1. No evidence of acute intracranial hemorrhage given recent IV
contrast
administration for chest CTA.
2. Right periventricular hypodensity, likely represents chronic
small vessel ischemic change. Ill-defined low density in the
left basal ganglia may also represent chronic small vessel
ischemic change, although a small underlying lesion cannot be
entirely excluded given history of cancer. Findings can be
further characterized on brain MRI if there is no
contraindication.
[**2133-2-18**] Radiology CTA CHEST W&W/O C&RECON IMPRESSION:
1. No acute aortic pathology or pulmonary embolism. Pulmonary
hypertension.
2. Large pleural based mass extending into the left upper lobe,
found to
likely represent non-small carcinoma per outside hospital ([**Hospital1 86406**]) biopsy report. A smaller left posterior apical opacity
is concerning
for a second mass lesion.
3. Multifocal RUL ground-glass opacities, non-specific but could
represent
infection, inflammation, or neoplastic process.
4. Enlarged, thyroid containing large thyroid nodules extending
into the
anterior mediastinum, substernally. If these findings have not
previously
been further evaluated, further work-up is suggested.
5. 2.3 cm ill-defined hypodense segment VII hepatic lesion. 2.4
cm right
adrenal nodule. Recommend MRI for further characterization.
[**2133-2-18**] Cardiology C.CATH
1. Coronary arteries are normal.
2. Mild diastolic ventricular dysfunction.
3. Moderate primary pulmonary hypertension.
[**2133-2-18**] Cardiology ECHO
LV systolic function appears depressed (ejection fraction 30
percent) secondary to severe hypokinesis of the septum and
anterior free wall, and extensive apical akinesis. The basal
inferior and posterior walls are hyperdynamic. Right ventricular
chamber size is normal with focal hypokinesis of the apical free
wall. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
[**2133-2-18**] Cardiology ECG [**2133-2-20**] [**Doctor Last Name **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Sinus tachycardia. Anterolateral myocardial infarction with ST-T
wave
configuration consistent with acute process. Consider inferior
myocardial
infarction of indeterminate age although is non-diagnostic. No
previous
tracing available for comparison.
Brief Hospital Course:
44 year old gentleman with newly diagnosed lung mass admitted
with SOB likely secondary to compression of airway by lung mass.
Intially had ST changes on EKG, underwent cath and found to
have clean coronaries but notable for takosutbos cardiomyopathy.
He then underwent pulmonary stent and biopsy of mass by
interventional pulmonology. OSH biopsy came back with NSCLC.
He underwent two rounds of XRT. However, he had to be intubated
for respiratory distress and altered mental status. After which
he was noted to be in DIC which was thought to be secondary to
his tumor load. He was provides supportive care. He developed
bradycardia then lost his pulse and went into asystole. He
underwent cardiopulmonary resusitated for 20 mins, which was
unsuccessful.
Medications on Admission:
MEDICATIONS (confirmed with patient)
-Acetaminophen 1000mg PO Q8H PRN Pain
-Hydromorphone 4mg PO Q3H PRN Pain
-Ibuprofen 800mg PO Q6H PRN Pain
-Prilosec dosage unknown
-Patient no longer taking Dexamethasone 6mg PO Daily
Discharge Disposition:
Expired
Discharge Diagnosis:
PEA/Asystole
NSCLC
DIC
respiratory failure
anemia
takotsubo
leukocytosis
anemia
sinus tach
fever nos
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"519.19",
"733.13",
"285.22",
"416.8",
"414.8",
"162.8",
"287.5",
"253.6",
"212.5",
"429.83",
"246.2",
"338.3",
"427.89",
"198.5",
"724.2",
"518.81",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"92.29",
"33.23",
"88.56",
"99.60",
"38.93",
"31.99",
"33.24",
"34.25",
"96.04",
"96.71",
"88.43",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
13058, 13067
|
12022, 12787
|
342, 364
|
13211, 13220
|
4619, 11999
|
13276, 13422
|
3795, 3855
|
13088, 13190
|
12813, 13035
|
13244, 13253
|
3870, 4600
|
283, 304
|
392, 2932
|
2954, 3510
|
3526, 3779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,638
| 167,089
|
40446
|
Discharge summary
|
report
|
Admission Date: [**2154-11-15**] Discharge Date: [**2154-11-24**]
Date of Birth: [**2105-8-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Esophageal carcinoma s/p neoadjuvant chemoradiation
Major Surgical or Invasive Procedure:
[**2154-11-15**]: Minimally-invasive esophagectomy
History of Present Illness:
49M who presented with fatigue and anemia in [**5-/2154**] and was
found to have severe iron deficiency anemia. EGD demonstrated
ulcerated bleeding mass in the middle-third of the esophagus
rising from a long segment of Barrett's esophagus. Biopsy of
the mass demonstrated adenocarcinoma. EUS staging was T3
possibly N1 disease, however CT of the torso and PET scan ruled
out metastatic disease; he was stage IIA (T3N0M0). He started
neoadjuvant chemoradiation with cisplatin and 5-FU, and
completed one cycle. Followup PET/CT on [**10-9**] demonstrated
decreased uptake within known esophageal cancer following
neoadjuvant therapy. No new FDG-avid regions of concern were
detected. Given encouraging response of his tumor to
neoadjuvant treatment, without evidence of metastasis, the
patient was taken to the OR for minimally-invasive esophagectomy
to remove his primary tumor.
Past Medical History:
1. Bilateral inguinal hernia surgery about 10 years ago.
2. Longstanding gastroesophageal reflux disease.
3. History of major depression
4. History of alcohol abuse 10-years-ago
Social History:
The patient drinks several beers, two to three nights a week.
He does not smoke. He works for New Balance Corporation.
Family History:
Family history is notable for history of breast cancer in his
mother and an aunt.
Physical Exam:
Physical Examination on Admission:
On physical examination, he is a well-developed gentleman. Head,
eyes, ears, nose and throat are normal. The neck is supple,
without mass, nodes or thyromegaly. The chest is clear to
percussion and auscultation. Heart sounds are regular without
murmurs or gallops. The abdomen is soft without tenderness,
mass or organomegaly. There is a well-healed jejunostomy tube
site. The extremities are without cyanosis, clubbing or edema.
He is
neurologically intact.
Pertinent Results:
[**2154-11-23**] 06:15AM BLOOD WBC-5.8 RBC-2.92* Hgb-9.4* Hct-27.9*
MCV-95 MCH-32.1* MCHC-33.7 RDW-13.1 Plt Ct-350
[**2154-11-19**] 11:20AM BLOOD Glucose-106* UreaN-25* Creat-0.9 Na-137
K-3.8 Cl-102 HCO3-26 AnGap-13
[**2154-11-19**] 11:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.8
[**2154-11-20**]: Barium Swallow:
FINDINGS: Barium passed freely through the esophagogastric
anastomosis within
the chest without evidence of leak or stricture. Barium passed
from the
stomach into the small intestine.
IMPRESSION: No evidence of leak or stricture.
[**2154-11-22**]: Chest PA/Lateral
FINDINGS:
In the interval, a nasogastric tube and a left chest tube have
been removed. The Port-A-Cath ends in the distal SVC. There is
no pneumothorax. Small left and minimal right effusions, the
left effusion slightly increased compared to the prior exam.
Cardiomediastinal silhouette and hila are normal.
IMPRESSION: No pneumothorax.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
The patient was taken to the OR on [**2154-11-15**] for laparoscopic
esophagectomy for esophageal adenocarcinoma. The surgeons were
Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] and Dr. [**First Name (STitle) **] [**Name (STitle) 1526**].
Intra-operatively, the patient received an NG tube, JP drain for
the neck, and right chest tube. The patient tolerated the
procedure well. He was taken to the PACU, where he had no
events, so he was transferred to the surgical intensive care
unit for monitoring overnight. He was kept NPO with IV fluids
for hydration, and dilaudid PCA for pain control.
He had no acute events while in the surgical ICU, and he
progressed well, so he was transferred to the surgical floor on
[**2154-11-16**].
On [**2154-11-18**], the patient was having some throat discomfort
(mostly attributed to the NG tube) and difficulty mobilizing
[**Last Name (LF) 88625**], [**First Name3 (LF) **] the ENT service was consulted, and they found him to
have normal vocal folds without evidence of paralysis. The
patient was given humidified air, which was effective at helping
him mobilize [**First Name3 (LF) 88625**] to his satisfaction.
On [**2154-11-20**] the patient had a radiographic swallow study that
demonstrated no leak of or stricture at the anastamosis. He was
started on sips, which he tolerated well. He passed gas. Pain
control was transitioned to Roxicet via J tube.
On [**2154-11-21**], it was noted that the JP drain fluid was somewhat
darker and cloudier than previously, so the fluid was sent for
amylase, which was found to be normal at 15. The patient was
transitioned from sips to a clear liquid diet, which he
tolerated well without nausea or vomiting. He had a semi-loose
bowel movment, and he ambulated throughout the day without
difficulty.
On [**2154-11-22**], the JP drain fluid from the neck was sent for
gram stain and culture. Gram stain demonstrated 4+
gram-positive cocci, 4+ gram-negative rods, and 3+ gram-positive
rods. Levofloxacin was started for empiric coverage.
Preliminary culture on [**2154-11-23**] demonstrated pseudomonas
aeruginosa, determined on [**11-24**] to be sensitive to
ciprofloxacin. Therefore he was started on ciprofloxacin.
On [**2154-11-24**], he was felt to be stable for discharge to home
with VNA for J-tube and drain care. He will followup with Dr.
[**Last Name (STitle) **] in about two weeks. At discharge, he was tolerating
clears, tolerating jejunal tube feedings, ambulating without
assistance, with pain well-controlled. His drain JP drain will
stay in and he will remain on clear liquids until he follows up
with Dr. [**Last Name (STitle) **], and will remain on oral ciprofloxacin for 11
more days.
Medications on Admission:
Pantoprazole Extended Release 40 mg PO daily
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
3. Tube Feeding
Continue tube feeding per outpatient regimen. Use Nutren 1.5 at
80 ml/hr, cycled over 12 hours (at night).
4. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO every 4-6 hours as needed for pain: Note: this product
contains Tylenol. Do not exceed 4000 mg/day of Tylenol.
Disp:*150 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Esophageal adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the West 3 general surgery service for a
minimally invasive esophagectomy on [**2154-11-15**].
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed. Please eat slowly.
Complete an 11 day course (14 days total antibiotics) of
Ciprofloxacin as directed. The pills can be crushed if needed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications (Roxicet). You may also take acetaminophen
(Tylenol) as
directed, but do not exceed 4000 mg in one day. **IMPORTANT**
Note that Roxicet contains Tylenol (325 mg per dose). Note that
Roxicet can constipate you, therefore you may take Colace and
Senna (but do not take these medications if you are having loose
stools).
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash 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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Jejunal Feeding Tube Care:
*Flush tube with 10 cc of water before and after starting feeds
and at least 3 times a day
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
What to watch out for when you have a Jejunal Feeding Tube:
1. Blocked tube: If the tube won't flush, try using 15 mL
carbonated cola or warm water. If it still will not flush, call
your nurse or doctor. Always be sure to flush the tube with at
least 60 mL water after giving medicine or feedings.
2. Dehydration:
*Due to diarrhea, vomiting, fever, sweating. (Loss of water and
fluids.)
*Signs include: decreased or concentrated (dark) urine, crying
with no tears, dry skin, fatigue, irritability, dizziness, dry
mouth, weight loss, or headache.
*Give more water after each feeding to replace the water lost.
*Call your doctor.
3. Constipation:
*[**Month (only) 116**] be caused by too little fiber in diet, not enough water or
side effects of some medicines.
*Take extra fruit juice or water between feedings.
*If constipation becomes chronic, call the doctor.
4. Gas, bloating or cramping: Be sure there is no air in the
tubing before attaching the feeding tube.
Followup Instructions:
Followup Instructions:
Please call ([**Telephone/Fax (1) 1483**] upon discharge to schedule an
appointment in the office of Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] on [**12-2**], [**2153**]. Please feel free to call with any questions/concerns.
Clinic is located in the [**Hospital **] Medical Office Building, [**Location (un) **], [**Hospital1 18**].
Completed by:[**2154-11-24**]
|
[
"V15.3",
"041.7",
"E878.2",
"V87.41",
"150.4",
"280.9",
"V44.4",
"530.81",
"784.42",
"530.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.5",
"42.41",
"96.6",
"42.52"
] |
icd9pcs
|
[
[
[]
]
] |
6737, 6786
|
3306, 6041
|
357, 410
|
6856, 6856
|
2298, 3283
|
11375, 11771
|
1679, 1763
|
6136, 6714
|
6807, 6835
|
6067, 6113
|
7007, 7124
|
8290, 11329
|
1778, 1799
|
7156, 8275
|
266, 319
|
438, 1324
|
1813, 2279
|
6871, 6983
|
1346, 1526
|
1542, 1663
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,064
| 144,372
|
8943
|
Discharge summary
|
report
|
Admission Date: [**2117-6-2**] Discharge Date: [**2117-6-8**]
Date of Birth: [**2068-6-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 48 yr old male with hx of type A aortic dissection s/p
re-do repair in [**12/2116**], AVR who present with worsening SSCP x 5
days. Pt states that the pain is on-and-off, described as
"ripping" from his chest radiating into his back, assoc with
mild SOB, no n/v. Pain is not exertional and resolves on its
own. Pt presented to [**Location (un) 620**] where a CT was performed and showed
"new leakage and a large hematoma" so he was transferred to
[**Hospital1 18**]. Here, a CTA was performed and showed a type A dissection
with no leakage but a fluid collection around the ascending
aorta, likely [**12-30**] post-op changes. CT surgery evaluated the
patient and disagreed with radiology stating that he could not
have a type A dissection given that his ascending aorta has been
replaced. They diagnosed him with a chronic type B with a
residual hematoma. He was admitted to the MICU for rule out MI,
BP control and close observation. Pt is currently pain free.
.
Pt initially presented in [**2111**] with chest pain radiating to his
neck and a CT scan revealed a type I aortic dissection. At that
time, he had a tube graft replacement of the ascending aorta.
That hospital course was complicated by a left MCA CVA. In
[**12/2116**], pt again presented to the hospital with chest pain
radiating to his neck and CT scan showed Type 1 aortic
dissecting aneurysm involving thoracic and abdominal aorta,
extending to the proximal aspect of left iliac artery. He was
brought to the operating room where he underwent a Redo
Ascending Aortic replacement (and Bentall procedure) w/ a #28
Gel weave graft along with an AVR w/ a #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**].
Past Medical History:
PMH:
1. Type A Aortic dissection dx in [**2111**]
- [**2111**]: s/p repair with tube graft(thoracic/abd)
- [**12/2116**]: redo ascending aortic replacement with AVR
2. CVA of left MCA, residual right-sided hemiparesis, dysarthria
3. Hypertension
4. Hypercholesterolemia
5. GERD
6. Anemia
Social History:
Social Hx: Lives in [**Location 620**] with family. Currently not working.
Quit
smoking 5 yrs ago after 15 yr pk hx. no etoh
Family History:
Non-contributory
Physical Exam:
Exam: temp, BP 182/120-->99/65 on Nipride gtt, HR 75, R 14, O2
97% 2L
Gen: NAD, resting comfortably
HEENT: PERRL, EOMI, MMM
Neck: no JVD appreciated
CV: RRR, 3/6 systolic murmur heard best at RUSB, loud S2 click
Chest: clear
Abd: +BS, soft, NT
Ext: warm, no edema, 2+ DP
Neuro: CN 2-12 intact; left facial droop; +dysarthria; [**12-2**]
strength in RUE/RLE; [**4-1**] in LUE/LLE
PE on acceptance to floor:
Vitals: T97.0 / 56 / 18 / 120/62 / No O2 sat taken
Gen: A&Ox3, aphasic
HEENT: No JVD, no LAD, R facial drop, R face decreased
sensation, no erythema/edema/exudates in throat
Lungs: CTA B
Heart: 3/6 systolic murmur radiating to the carotids and USBs,
loud S1/S2, no r/g
Abdomen: Soft, mild RUQ tenderness, +BS, ND
Extr: R distal UE 0/5 motor (R hand paralysis), R leg [**4-1**] motor
(but much weaker than L leg), no c/c/e
Neuro: Aphasia, neuro findings noted above
Pertinent Results:
[**2117-6-1**] 07:00PM GLUCOSE-82 UREA N-16 CREAT-0.9 SODIUM-141
POTASSIUM-3.2* CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
[**2117-6-1**] 07:00PM CK-MB-3 cTropnT-<0.01
[**2117-6-1**] 07:00PM CALCIUM-9.2 MAGNESIUM-2.0
[**2117-6-1**] 07:00PM WBC-5.6# RBC-5.03# HGB-10.9*# HCT-36.7*#
MCV-73*# MCH-21.7*# MCHC-29.7* RDW-15.0
[**2117-6-1**] 07:00PM NEUTS-51.9 LYMPHS-41.8 MONOS-4.9 EOS-0.9
BASOS-0.5
[**2117-6-1**] 07:00PM HYPOCHROM-3+ MICROCYT-3+
[**2117-6-1**] 07:00PM PLT COUNT-246#
EKG: NSR at 67, LAD (new); LVH by voltage; no ST-T wave changes
.
CT of abd at [**Location (un) 620**], [**2118-6-1**]:
OLD DISSECTION OF UNCHANGED APPEARANCE EXTENDING WELL INTO THE
LUMBAR AORTA. ALSO EVIDENCE OF INTERVAL AORTIC VALVE REPAIR AND
CHANGES COMPATIBLE WITH A NEW LEAKAGE AROUND THE AORTIC ROOT
WHERE THERE IS A LARGE HEMATOMA EXTENDING CRANIALLY ENDING JUST
PRIOR TO THE TAKE OFF OF THE CRANIAL VESSELS. NO INVOLVEMENT OF
THE PERICARDIUM.
.
CTA at [**Hospital1 18**]:
1. Extensive type 1 aortic dissection extending superiorly into
the
brachiocephalic and left common carotid artery, and extending
inferiorly into the left iliac artery. All major aortic vascular
branches, with the exception of the left renal artery
originating off the true lumen. There is no evidence of major
organ infarction.
2. Small low-attenuation fluid collection around the ascending
aorta, at the area of the prior aneurysm graft repair. This is
likely postoperative in nature. There is no evidence to suggest
leak.
3. Small hiatal hernia.
4. Small low-attenuation lesion in the left lobe of the liver
likely
representing a small cyst versus hemangioma, but not
definitively
characterized on this study.
5. Bibasilar atelectasis.
.
Echo, [**3-2**]: The left atrium is moderately dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. A bileaflet aortic valve prosthesis is
present. The aortic prosthesis is well functioning. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
1. Chest Pain: Given the patient's initial presentation with
chest pain, the immediate concern was leakage or worsening
dissection. However, given the CTA performed at [**Hospital1 18**], it was
found that the changes that were initially so concerning at the
OSH were in fact more consistent with post-surgical changes than
with new dissection. There were no signs of leakage on the CTA.
CT surgery was consulted, and were in full agreement that there
did not appear to be any worsening of the patient's prior
surgical site, and that the patient's dissection was stable.
Cardiac enzymes were obtained that ruled the patient out for new
MI. EKG remained stable and convergent with previous EKGs on
file.
.
2. Chronic Type I Aortic Dissection: As noted above, the
initial workup revealed that the cause of the patient's chest
pain was not compatible with new aortic dissection or furthering
of the patient's previous dissection. It was immediately
obvious that the patient's BP was not being adequately
controlled, and so on arrival the patient was transferred to the
MICU for observation and management of hypertension. A Nipride
drip was started, then transitioned to captopril and metoprolol,
with a goal BP of 100-120 systolic. The patient had HR in the
50s for the majority of his hospitalization, but was reasonably
active with no subjective side effects of his bradycardia.
Because of initial concern at the OSH, the patient's warfarin
was held, and on arrival to [**Hospital1 18**], once it was clear that this
was not an evolution of his dissection, a heparin gtt was begun,
with eventual bridging to resumption of warfarin therapy. The
patient was eventually titrated to an adequate INR, with a goal
of 2.5-3.
.
3. Hypertension: As noted above, the patient was noted to be
hypertensive on arrival, and so he was initially given nipride
gtt, then onto metoprolol and captopril. This achieved the
target SBP with no adverse side effects other than an
asymptomatic bradycardia. He was instructed to continue this
regimen as an outpatient.
.
4. Hypercholesterolemia: The patient was continued on his
outpatient doses of pravachol and gemfibrozil. A FLP was
checked during his hospitalization that was found to be
satisfactory.
Medications on Admission:
coumadin 2mg qhs
protonix 40mg qd
pravachol 20mg qd
gemfibrozil 600mg [**Hospital1 **]
percocet
metoprolol 50mg [**Hospital1 **]
Discharge Medications:
1. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Pravastatin Sodium 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QMOWEFR
(Monday -Wednesday-Friday).
6. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QSAT
(every Saturday).
7. Warfarin Sodium 5 mg Tablet Sig: Two (2) Tablet PO QSUN
(every Sunday).
8. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO QTUES (every
Tuesday).
9. Warfarin Sodium 5 mg Tablet Sig: 1.5 Tablets PO QTHUR (every
Thursday).
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Type I aortic dissection
Aortic Valve Repair, St. [**Male First Name (un) 923**] Mechanical valve. INR goal 2.5-3
Hypertension, SBP goal of 100-120 SBP
Hypercholesterolemia
Discharge Condition:
Stable, ambulating well without assist.
Discharge Instructions:
If you experience chest pain, shortness of breath, fevers,
chills, nausea, vomiting, or any other concerning symptoms,
contact your physician or return to the emergency room.
Followup Instructions:
Please report for an INR check on THURSDAY of this week at your
regular location. Then, call your primary care physician for an
appointment on FRIDAY of this week. An INR was drawn before you
left on Tuesday and should be available to your primary doctor
during your appointment on friday.
Also, in the next week, please call Dr. [**Last Name (STitle) 31068**] (your
cardiologist) for an outpatient appointment. Please make this
appointment for sometime in the next 1-2 weeks.
Completed by:[**2117-6-15**]
|
[
"E878.8",
"V43.3",
"998.12",
"438.20",
"272.0",
"441.03",
"530.81",
"V58.61",
"427.89",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8975, 8981
|
5674, 7924
|
281, 287
|
9199, 9240
|
3417, 5651
|
9463, 9975
|
2484, 2502
|
8104, 8952
|
9002, 9178
|
7950, 8081
|
9264, 9440
|
2517, 3398
|
231, 243
|
315, 2012
|
2034, 2325
|
2341, 2468
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,059
| 181,621
|
2150
|
Discharge summary
|
report
|
Admission Date: [**2138-1-31**] Discharge Date: [**2138-2-4**]
Date of Birth: [**2072-2-1**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
woman recently admitted in [**2137-11-18**] after a fall at home
and found to have an acute left subdural hematoma with an
emergent evacuation. Her course was complicated by
Pseudomonas sepsis, as well as E. coli sepsis. She was
trach'd and pegged, and discharged to rehab on [**2137-12-27**].
She had a witnessed fall from a wheelchair in the nursing
home, hitting her forehead with a small amount of blood from
her trach site, hematoma on the forehead, was alert
throughout. She was sent to [**Hospital1 **] ER for a
head CT which showed an old left subdural hematoma in the
frontal region with small subdural more near the midline in
the frontal area which was new. The patient was admitted to
the ICU for observation.
PHYSICAL EXAM: Her temp was 97, BP 162/75, respiratory rate
24, heart rate 61, sats 94% on room air. In general, the
patient was lying in bed and in no acute distress. She had
trach and PEG in place.
HEENT: Pupils equal, round and reactive to light.
LUNGS: Clear to auscultation.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nontender, PEG tube in place.
EXTREMITIES: No clubbing, cyanosis or edema.
NEURO: Awake, alert, oriented to hospital, nods yes
appropriately with questions, no spontaneous speech, sticks
out tongue to command, has a right exotropia. EOMS are full.
Tongue midline. Face appears symmetric. She has no
pronator drift on the left. Her right upper extremity is
flaccid. She withdraws to pain briskly in her lower
extremities. Her right foot is externally rotated. Deep
tendon reflexes are 2+ throughout.
HOSPITAL COURSE: She was admitted for close observation. She
had a repeat head CT which showed no further bleeding or
extension of subdural hematoma, and she was transferred to
the regular floor on [**2138-2-1**]. She remains neurologically
stable with stable vital signs, neurologically nodding to
questions. Her gaze is conjugate. She has right
hemiparesis. Withdraws her lower extremities. She is stable
and ready for transfer back to rehab.
DISCHARGE MEDICATIONS:
1. Insulin per sliding scale and fixed dose.
2. Dilantin Infatab 50 mg po bid.
3. Lansoprazole 30 mg NG qd.
4. Hydralazine 50 mg po q 6 h--hold for SBP less than 100.
5. Metoprolol 75 mg po tid--hold for SBP less than 100.
6. Tylenol 650 po q 4 h prn.
CONDITION AT DISCHARGE: Stable.
FOLLOW-UP: She will follow-up with Dr. [**Last Name (STitle) 739**] in 1
month with a repeat head CT.
[**Doctor First Name 742**] [**Doctor Last Name **], 14.AAA
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2138-2-3**] 09:41
T: [**2138-2-3**] 09:58
JOB#: [**Job Number 11500**]
|
[
"401.9",
"250.00",
"E884.3",
"311",
"780.39",
"438.21",
"070.54",
"852.21",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23"
] |
icd9pcs
|
[
[
[]
]
] |
2242, 2505
|
1785, 2219
|
931, 1767
|
2520, 2867
|
158, 915
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,057
| 126,559
|
23048
|
Discharge summary
|
report
|
Admission Date: [**2186-1-13**] Discharge Date: [**2186-1-20**]
Date of Birth: [**2135-6-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
50 yr old male transferred from [**Hospital 1562**] hosp to [**Hospital1 18**] SICU for
resp distress requiring emergent intubation after elective
bronch at [**Hospital1 1562**] for right lung white out on CXR. Bronch
revealed 80% obstruction of right bronchus-intermedius.
Major Surgical or Invasive Procedure:
intubation, chest tubes, arterial line
History of Present Illness:
50 yo male w/ c/o SOB, chest pain. CXR showed right lung white
out. Elective bronch at [**Hospital 1562**] Hosp showed 80% occlusion of
right bronchus-intermedius. Pt had severe resp ditress post
beonch requiring emergent intubation. thoracentesis was also
performed for 2liters of fluid.
Tranferred to [**Hospital1 18**] SICU for furhter eval and management.
Past Medical History:
MS, Anxiety
Social History:
+ Tobacco
Family History:
brother- [**Name (NI) 59425**]
Physical Exam:
Intubated, Sedated
RRR S1, S2
Lungs: coarse on the left, inspir/expir wheezes right.
Abd: soft, NT, ND, +BS
Extrem: No clubbing or cyanosis, 2+ BLE edema
Pertinent Results:
[**2186-1-13**] 10:25PM TYPE-ART RATES-14/ TIDAL VOL-600 O2-40
PO2-79* PCO2-38 PH-7.44 TOTAL CO2-27 BASE XS-1 -ASSIST/CON
INTUBATED-INTUBATED
[**2186-1-13**] 10:10PM GLUCOSE-67* UREA N-21* CREAT-0.7 SODIUM-140
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-13
[**2186-1-13**] 10:10PM ALT(SGPT)-8 AST(SGOT)-10 ALK PHOS-153*
AMYLASE-144* TOT BILI-0.4
[**2186-1-13**] 10:10PM WBC-13.4* RBC-3.31* HGB-9.9* HCT-30.6* MCV-93
MCH-30.0 MCHC-32.4 RDW-13.5
Cytology:
[**2186-1-18**] 05-[**Numeric Identifier 59426**] LIVER:POSITIVE FOR MALIGNANT CELLS,
consistent with metastatic adenocarcinoma.
[**2186-1-17**] 05-[**Numeric Identifier 23441**] PLEURAL FLUID:POSITIVE FOR METASTATIC
ADENOCARCINOMA
Imaging:
MR HEAD W & W/O CONTRAST [**2186-1-16**] 10:05 AM: IMPRESSION:
1) Enhancing focus in the periphery of the right frontal lobe
worrisome for metastatic disease.
Brief Hospital Course:
%0 yo male transferred to [**Hospital1 18**] SICU from [**Hospital 1562**] hospital
following elective bronch for white-out right lung complicated
by severe resp distress requiring emergent intubation.
Pt remained intubated and sedated in the SICU during w/o of
right beonchus-intermedius tumor was done. Pt was found to have
adeno carcinoma of the lung w/ mets to brain and liver.
Radiation and Heme-onc consulted and felt paliative treatment
would not be beneficial.
After lengthy discussions with family pt was declared CMO. Pt
expired on [**2186-1-20**] at 19:45
Medications on Admission:
prozac, xanax, diclofenal, amantadine
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
metastaic adeno carcinoma of the lung
Discharge Condition:
expired
Discharge Instructions:
not applicable
Followup Instructions:
none
Completed by:[**2186-2-16**]
|
[
"263.9",
"340",
"198.3",
"162.2",
"197.7",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"96.72",
"96.04",
"50.11",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
2940, 2949
|
2245, 2813
|
603, 643
|
3030, 3039
|
1331, 2222
|
3102, 3137
|
1110, 1142
|
2901, 2917
|
2970, 3009
|
2839, 2878
|
3063, 3079
|
1157, 1312
|
290, 565
|
671, 1032
|
1054, 1067
|
1083, 1094
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,339
| 152,646
|
15010
|
Discharge summary
|
report
|
Admission Date: [**2116-2-12**] Discharge Date: [**2116-2-18**]
Date of Birth: [**2043-5-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
72 year old white male with new onset SOB.
Major Surgical or Invasive Procedure:
CABGx3(LIMA->LAD, SVG->PDA, OM)/MAZE [**2116-2-12**]
History of Present Illness:
This 72 year old white male presented to the ED on [**2116-1-24**] w/ SOB
which woke him from sleep. He was diagnosed with CHF and
pneumonia and had a toponin of .12. He was in AF/Flutter and
was treated with beta blockers and diuresis. He underwent
cardiac cath at [**Hospital1 18**] on [**2116-1-31**] which revealed: 60% [**Last Name (un) 2435**]. of
LMCA, 70% diag., 70% ostial LCX, 100% om1, subtotal, mid RCA,
35% LVEF, no MR. [**Name13 (STitle) **] is now admitted for elective CABG.
Past Medical History:
s/p NSTEMI [**2116-1-24**]
h/o pneumonia
h/o CHF
h/o HTN
h/p PAF/flutter since [**8-20**]
s/p urosepsis [**8-20**]
NIDDM
s/p bil. cataract surgery
s/p AAA [**2111**]
s/p resection and XRT for colon cancer [**2099**]
s/p SBO x7
h/o DJD
s/p bil. TKR
^chol.
Social History:
Lives alone
Cigs: 2ppd x 30 years, quit [**2098**]
ETOH: 1 glass wine/day
Family History:
Father died of prostate cancer, mother died at 89
Physical Exam:
Gen: Elderly, white male in NAD.
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign, adentulous.
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P.
CV: RRR without R/G/M
Abd: +BS, soft, nontender, without masses or hepatosplenomegaly,
well healed surgical scars.
Ext: without C/C/E, pulses 2+=bilat.
Neuro: nonfocal
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2116-2-17**] 06:00AM 12.2* 3.00* 9.5* 27.1* 90 31.8 35.2* 14.0
211#
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2116-2-18**] 05:20AM 19.9* 121.6* 2.5
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2116-2-18**] 05:20AM 97 24* 1.2 136 4.2 100 30* 10
Brief Hospital Course:
This 72 year old white male was admitted on [**2116-2-12**] and
underwent CABGx3 w/ LIMA->LAD, SVG->PDA, and OM. The total
bypass time was 143 mins. and the patient was transferred to the
CSRU on Neo and Propofol in stable condition. He was extubated
on his postoop night and was transferred to the floor on POD#1.
His wires and chest tubes were d/c'd on POD#3 and he progressed
fairly well. He was anticoagulated with coumadin and heparin
and on POD#6 he was discharged to rehab in stable condition.
Medications on Admission:
Glypizide 2.5 mg PO daily
ASA 325 PO daily
Lisinopril 20 mg PO daily
Lipitor 40 mg PO daily
Toprol XL 50 mg PO daily
Coumadin 10 mg PO daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
8. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 5 days: Then decrease to 400 mg PO daily for 7
days, then decrease to 200 mg PO daily.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
INR goal 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Coronary artery disease
CHF
s/p MI
PAF/flutter
NIDDM
^chol.
Discharge Condition:
Good.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You may not drive for 4 weeks.
Follow medications on discharge instructions.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 5762**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 1016**] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) 70**] for 6 weeks.
Completed by:[**2116-2-18**]
|
[
"V10.05",
"401.9",
"414.01",
"427.31",
"428.0",
"250.00",
"715.90",
"410.72",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"36.15",
"36.12",
"39.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3940, 4054
|
2198, 2702
|
365, 420
|
4158, 4165
|
1793, 2175
|
4509, 4758
|
1330, 1381
|
2893, 3917
|
4075, 4137
|
2728, 2870
|
4189, 4486
|
1396, 1774
|
283, 327
|
448, 944
|
966, 1222
|
1238, 1314
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,968
| 160,241
|
21749+57257
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-11-4**] Discharge Date: [**2146-11-16**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2146-11-11**] off pump cabg x5 (LIMA to LAD, SVG to OM1 sequentially
to OM 2, SVG to DIAG, SVG to PDA)
History of Present Illness:
Mrs. [**Known lastname **] is an 85 yo woman with lymphoma s/p rituximab/Zevelin
~6 weeks ago (in nadir now) and recent admission to [**Hospital1 18**] with
NSTEMI managed medically who presented to [**Hospital1 18**]-[**Location (un) 620**] on [**11-2**]
with chest pain. There, her CKs were flat, and her chest pain
resolved. She received a bag of platelets for thrombocytopenia
and aspirin 81 mg was started. She also apparently had volume
overload in the setting of a blood transfusion. She responded
well to furosemide. An echocardiogram revealed globally
depressed systolic function (LVEF 35-40%), which is worse than
her echocardiogram during her last admission to [**Hospital1 18**]. In
addition, a Foley catheter was placed for urinary frequency, and
a urine culture grew out >100,000 Enterococcus.
.
She is being transferred for further management.
.
She reports that she awoke from sleep with 2 episodes of chest
pain. She can not quantify the intensity. Seh reports that they
lasted on the order of minutes to half an hour and radiated to
[**Last Name (un) **] back. They were not associated with shortness of breath,
nausea or diaphoresis. She called 911 and was taken to
[**Hospital1 **].
.
She currently denies chest pain or shortness of breath, and
reports that she was chest pain-free at [**Hospital1 **]. She denies
palpitations.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
HTN
High Grade B cell NHL
-Diagnoses [**6-/2146**]
-s/p three cycles R-CHOP on [**8-3**], nadir 4-8 weeks
-Now on rituximab or Zevalin (research protocol)
Colon cancer in [**12/2143**]
B12 deficiency
.
Cardiac Risk Factors: (-) Diabetes, (-) Dyslipidemia, (+)
Hypertension
.
Cardiac History: s/p recent NSTEMI with planned medical
management
Social History:
She denies any tobacco or alcohol use. She used to work as a
factory worker in an elastic factory. Currently lives next door
to her son and daughter in law who provide most of her care.
Family History:
Her brother died of leukemia. Her sister was diagnosed with
uterine cancer and recently died. Her other brother is alive
after having a nephrectomy for renal cancer. She also has family
history of coronary artery disease in many of her seven
siblings.
Physical Exam:
VS - 94.2, 106/60, 64, 18 93% on RA
Gen: Pleasant elderly woman lying in bed, NAD, appropriate
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva had mild pallor
Neck: Supple with JVP of 6 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. Bibasilar
crackles [**2-16**] of the way up
Abd: Soft, NT, ND. No HSM or tenderness. Abd aorta not enlarged
by palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ PT 2+
Left: Carotid 2+ PT 2+
Pertinent Results:
[**2146-11-5**] 07:40AM BLOOD WBC-1.6* RBC-3.51* Hgb-11.5* Hct-31.9*
MCV-91 MCH-32.9* MCHC-36.2* RDW-17.1* Plt Ct-93*#
[**2146-11-5**] 07:40AM BLOOD Gran Ct-710*
[**2146-11-5**] 07:40AM BLOOD Glucose-178* UreaN-27* Creat-0.7 Na-138
K-3.5 Cl-97 HCO3-31 AnGap-14
[**2146-11-5**] 07:40AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.9
Catheterization
1. Selective coronary angiography of this right dominant system
demonstrated multi-vessel coronary artery disease. The LMCA has
a 80%
distal stenosis. The LAD has a 80% stenosis at the origin, 80%
mid
stenosis, and all diagonals diffusely diseased with 100% in the
inferior
branch of the 3rd diagonal. The LCx has a 90% stenosis at the
origin.
The RCA has a 60% stenosis at the origin, a long 90% mid level
stenosis,
and a 80% distal stenosis with left to right collaterals.
2. Limited resting hemodynamic measurement demonstrated normal
systemic
arterial pressures.
FINAL DIAGNOSIS:
1. Multi-vessel coronary artery disease.
Brief Hospital Course:
Mrs. [**Known lastname **] is an 85 yo woman with HTN and NHL s/p recent
chemotherapy and a recent discharge from [**Hospital1 18**] with after an
NSTEMI treated medically. She presented to [**Hospital1 **] [**11-2**] with
intermittent chest pain. Given history of unstable angina and
recent MI she was taken to [**Hospital1 18**] for catheterization. She was
pancytopenic from her recnet chemotherapy, however, and the
procedure had to be delayed several days. Her counts did slowly
recover and when her platelets returned to 100,000 it was
agreed, in conjunction with her oncologist, that catheterization
would be safe.
On catheterization, she was found to have severe distal L main
along with three vessel disease. CABG was indicated. At first
she and her son were unsure whether she wanted to have this
procedure done. She had been DNR/DNI. Eventually, they agreed
to undergo surgery and was taken for bypass surgery on [**11-11**],
Her hospital course is as follows:
.
CAD: s/p recent NSTEMI managed medically. Ruled out for acute MI
with flat CKs at [**Location (un) 620**]. Was stable on transfer with cardiac
enzymes trending down. EKG at OSH with concern for lateral
ischemia, EKGs relatively unchanged here. We continued ASA,
metoprolol, high dose statin. We maintained her Hct near 30+
and her Plts >50. She did have intermittent rest angina
responsive to nitro. After seeing that her counts begna to
stabilize, the decision was made to pursue cardiac cath for
symptoms. She went for cath on [**11-9**] which revealed distal L
main along with 3 vessel disease. She was referred for CABG
.
Pump: Echo at OSH with interval worsening of systolic
dysfunction. Became symptomatically volume overloaded after
receiving PRBCs and Plts at the OSH, which was respsonsive to
Lasix 20mg IV. Was given further IV diuresis and then continued
on Lasix 20mg PO, tolerating this well. She would benefit from
ACE-I if her BP tolerates (baseline in 90s systolic).
.
NHL: Underwent chemo 6 weeks prior to admission. She was
pancytopenic on admission with borderline neutropenia (ANC 710).
She was initially put on neutropenic precautions. Heme/Onc was
consulted who felt that her counts would begin to improve. Over
the course of admission her counts began to improve starting on
[**9-22**]. The issue of anti-platelet therapy was addressed
given her unstable angina.
It was believed the pt had a fair prognosis per the oncology
team and that this prognosis should not imprede her getting
CABG.
.
Pancytopenia/Anemia: Was thought likely due to marrow
suppression from chemotherapy. Her counts improved in house as
expected.
.
Urinary frequency: She was diagnosed with a UTI at the OSH. She
grew >100K of enterococcus sensitive to Ampicillin and
Vancomycin. She was started on Ampicillin to complete a 7 day
course.
.
Code: DNR/DNI now reverted to FULL
Referred to Dr. [**First Name (STitle) **] and underwent off pump cabg x5 on [**11-11**].
Transferred to CVICU in stable condition. Continued to be
followed by the heme/oncology team. Extubated the next day and
transferred to the floor on POD #2 to begin increasing her
activity level. Mediastinal tubes and pacing wires removed, but
left pleural tube remained for a pleural effusion. Swallowing
evaluation also done to assess risk of aspiration and ground
solids and thin liquids were recommended. Left chest tube was
pulled without incident. She was ready for discharge to rehab on
POD #5.
Medications on Admission:
Metoprolol 100 mg tid
Furosemide 20 mg daily
Vitamin B12 100 mcg daily
Simvastatin 80 mg daily
MVI 1 daily
Omeprazole 20 mg daily
Aspirin 81 mg daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
CAD s/p OPCABG x5
lymphoma
HTN
MI
B12 deficiency
Discharge Condition:
stable
Discharge Instructions:
SHOWER DAILY and pat incisions dry
no lotions, creams, or powders on any incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 5292**] in [**2-15**] weeks
see Dr. [**First Name (STitle) **] in [**3-19**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2146-11-16**] Name: [**Known lastname 76**],[**Known firstname 888**] Unit No: [**Numeric Identifier 10639**]
Admission Date: [**2146-11-4**] Discharge Date: [**2146-11-16**]
Date of Birth: [**2061-4-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 265**]
Addendum:
Ms. [**Known lastname **] had a stable small left apical pnuemothorax upon
discharge.
Pertinent Results:
CHEST (PA & LAT) [**2146-11-16**] 10:47 AM
AP UPRIGHT PORTABLE CHEST X-RAY: Small, left apical pneumothorax
is unchanged in size. An 8 mm nodule within the left upper lung
is again identified. The cardiac silhouette is normal and stable
in this patient status post coronary artery bypass graft. A
small/moderate right, and small left pleural effusions are
unchanged. Linear atelectasis at both bases is again noted.
IMPRESSION: No significant interval change. Persistent, small
left apical pneumothorax.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6418**] Healthcare - [**Location (un) 407**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2146-11-28**]
|
[
"284.1",
"V10.05",
"401.9",
"E933.1",
"414.01",
"285.22",
"512.1",
"V16.49",
"V17.3",
"410.72",
"V16.6",
"202.80",
"599.0",
"V16.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"88.56",
"37.22",
"99.04",
"89.60",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10092, 10296
|
4642, 8108
|
279, 388
|
8485, 8493
|
9561, 10069
|
8750, 9542
|
2706, 2959
|
8414, 8464
|
8134, 8286
|
4576, 4619
|
8517, 8727
|
2974, 3636
|
229, 241
|
416, 2120
|
2142, 2486
|
2502, 2690
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,854
| 167,443
|
19252
|
Discharge summary
|
report
|
Admission Date: [**2177-1-20**] Discharge Date: [**2177-1-29**]
Service: [**Last Name (un) 52440**] service then Medical Intensive Care Unit,
then Medical service
REASON FOR ADMISSION: Left hip pain status post fall.
HISTORY OF PRESENT ILLNESS: This is an 82-year-old female
nursing home resident with bipolar disorder, dementia, and
known gait disorder, who presents after a mechanical fall
that was witnessed at a nursing home on [**2177-1-19**]. The
patient did not suffer head trauma or loss of consciousness.
The left leg was noted to be shortened. The patient was
unable to ambulate. A x-ray at the nursing home revealed a
left hip intertrochanteric fracture, and the patient was
referred to the [**Hospital1 **] [**First Name (Titles) 2142**] [**Last Name (Titles) **] for
further management.
Additional history is limited as the patient answers yes to
every question and has known dementia at baseline. She does
note leg pain, chest pressure, shortness of breath, and
abdominal pain. In the Emergency Room, the patient was
anxious in mild distress and was diaphoretic. Heart rate was
noted to be in the 120s, oxygen saturation 95% on 6 liters
with a respiratory rate of 26. ECG showed sinus tachycardia
with Q waves in leads V4 through V6 without prior for
comparison. Patient was given aspirin and Morphine.
CT of the head was performed, and was negative. C spine
x-ray was performed and was negative for fractures or
displacement. Chest x-ray showed a question of diffuse
infiltrates without evidence of pulmonary edema.
Given the patient's hemodynamic instability, a right femoral
line was placed for access. The Orthopedic service was
consulted for further management and plan for open reduction,
internal fixation after the medical team had performed a
preoperative risk stratification and optimization.
PAST MEDICAL HISTORY:
1. Bipolar disorder.
2. Atypical psychosis.
3. Dementia.
4. Seizure disorder.
5. COPD/emphysema: Pulmonary function tests unknown.
6. Coronary disease.
7. Angina, further details unknown.
8. Congestive heart failure: Ejection fraction unknown.
9. Tardive dyskinesia.
10. Gait disorder.
11. Rectocele/detrusor hyperactivity.
MEDICATIONS AT TIME OF ADMISSION:
1. Risperdal 3 mg b.i.d.
2. Depakote 250 mg q.a.m., 500 mg q.p.m.
3. Ativan 1 b.i.d.
4. Lasix 20 mg p.o. q.d.
5. Theophylline 200 mg b.i.d.
6. Detrol LA 4 mg q.d.
7. Peri-Colace 100/30 b.i.d.
8. Enulose [**9-12**] 30 q.d.
9. Albuterol nebulizers t.i.d.
ALLERGIES: Naprosyn, Relafen, Wellbutrin, and Clozaril.
Reactions unknown.
SOCIAL HISTORY: The patient is a nursing home resident, and
tobacco and alcohol history are unknown. The patient's next
of [**Doctor First Name **] and healthcare proxy is [**Name (NI) 1328**] [**Name (NI) 38320**], who is her
daughter, [**Telephone/Fax (1) 52441**], cell phone #[**Telephone/Fax (1) 52442**].
FAMILY HISTORY: Unknown.
PHYSICAL EXAM AT TIME OF ADMISSION: Temperature 98.5, blood
pressure 118/79, heart rate 109, respirations 20, and oxygen
saturation 97% on 1 liter, subsequently 98% on 6 liters.
Physical exam reveals an elderly female in no apparent
distress, alert and oriented to person only, able to
converse, but answers yes to all questions. No evidence of
scleral icterus. Pupils are equal, round, and reactive to
light and accommodation. Moist mucous membranes. No
evidence of head lacerations or ecchymosis appreciated.
Lungs: Positive wheezes bilaterally. Cardiac exam:
Tachycardic, regular rhythm without evidence of murmurs,
rubs, clicks, or gallops. Abdomen is soft, mildly tender to
palpation, no obvious distress with palpation of the abdomen,
normoactive bowel sounds. No masses or hepatosplenomegaly.
Extremities: No lower extremity edema. The left leg is
shortened. There are prominent dorsalis pedis pulses
appreciated bilaterally.
DATA: White blood cells 9.1 with a differential of 83%
neutrophils, 10% lymphocytes, 6% monocytes, hematocrit 34.1,
platelets 326. INR is 1.2. Chem-7: 140, 4.6, 102, 28, 31,
0.6, 175. The CK was 88 with an initial troponin-T of less
than 0.01. Urinalysis revealed a specific gravity of 1.025,
pH of 7.0, negative leukocyte esterase, negative nitrite,
negative glucose, 15 ketones.
Chest x-ray shows a question of a patchy opacity at the right
costophrenic angle and possible evidence of aspiration
pneumonia versus atelectasis without evidence of CHF.
CT of the head shows no intracranial hemorrhage, no mass
effect, chronic microvascular infarctions.
C spine x-ray demonstrates no evidence of fracture.
Hip x-ray at the nursing home demonstrates a left
intertrochanteric fracture with normal mid distal femur. The
hip x-ray at [**Hospital3 **] demonstrates a left femur
trochanteric fracture with avulsion of the lesser trochanter.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was initially
admitted to the Medicine service.
1. Orthopedic: The Orthopedic service was consulted, and
planned for open reduction, internal fixation with
preoperative medical evaluation. Perioperative beta-blockers
were used and this surgery was considered a medium-risk
surgery with the patient could perform less than 4 mets and
had probably suffered a prior myocardial infarction.
However, showed no evidence of active ischemia.
As the patient was a DNR/DNI, the DNR/DNI status was reversed
pending the operation.
On [**2177-1-20**], an open reduction, internal fixation of the left
intertrochanteric fracture was performed by Dr. [**First Name (STitle) 1022**]. The
postoperative course was complicated by apparent myocardial
ischemia with the patient complaining of chest pressure on
the morning following the operation with a CPK rise to 653
with a negative troponin. She was started on aspirin and
Heparin drips. Nevertheless, as well as beta-blocker to keep
the heart rate in the 60s-70s range. The patient then
developed hypotension with a mean arterial pressure in the
60s and was started on Neo-Synephrine at 1-2 mcg.
Patient was also hypoxic with an arterial blood gas
demonstrating a pH of 7.37, pCO2 of 39, and a pO2 of 63 on
50% face mask. It was felt that the patient's decompensation
was secondary to combination of preoperative pneumonia on top
of intraoperative blood loss, hypovolemia, and underlying
COPD. There was also a question of aspiration of pills while
in the PACU.
2. Hypotension: The patient was transfused 1 unit of packed
red blood cells with good hematocrit response to keep her
hematocrit greater than 30. The Neo-Synephrine drip was
weaned as tolerated, and as of [**2177-1-23**], the patient was off
of pressors.
3. Pulmonary status: As stated above, the patient had
underlying COPD and probably underlying pneumonia prior to
her surgery as well as aspiration in the perioperative
period. She was started on albuterol nebulizers, IV
steroids, levofloxacin, and continued to be intubated and was
taken, intubated to the Medical Intensive Care Unit, where
she initially did quite well and was extubated on [**2177-1-24**].
However, on [**2177-1-25**], the patient developed increasing
tachypnea and had oxygen desaturation to the low 80s. She
was initially placed on BiPAP, weaned to a face mask, and had
aggressive nasotracheal suctioning of tenacious secretions.
This was not sufficient to allow output oxygenation and
ventilation. The patient was reintubated on [**2177-1-26**].
Given the patient's prior expressed wishes that she have her
goals of care oriented towards to non-aggressive treatment, a
family meeting was held at which time her healthcare proxy
was present and it was decided that the patient would be made
comfort measures only and electively extubated with the
realization that she would probably not be able to sustain
her respiratory function without the use of the endotracheal
tube.
4. Infectious disease: The patient was thought to have an
aspiration pneumonia, and there was a question of septic
shock as she once again required pressors as of [**2177-2-24**].
She was placed on triple antibiotic coverage with
clindamycin, cefazolin, and levofloxacin to cover for
gram-negative organisms, anaerobic species, as well as
perioperative coverage of Staphylococcus aureus and
Streptococcal species. She remained afebrile throughout this
period with a white count within normal limits.
5. Neurologic: The patient was continued on her outpatient
regimen of Risperdal and depakote. She was noted on [**1-25**]
not to have evidence of a gag reflex, and therefore all
medications were given through nasogastric tube. The
placement of a PEG tube was considered, however, given the
patient's goals of care and likely prognosis, this was
deferred.
6. Glucose control: The patient was maintained euglycemic
with the use of an insulin-sliding scale and q.i.d.
fingerstick glucose checks.
7. Goals of care: As stated above, the patient had been do
not resuscitate/do not intubate prior to her left open
reduction, internal fixation surgery. Given her prior stated
wishes in a time where she did have capacity for judgement
regarding this decision and these issues, a family meeting
was conducted on [**2177-1-28**], at which time two of her sons and
her daughter, [**Name (NI) 1328**] (her healthcare proxy) were present
and decided to make comfort the primary goal. She was
changed to comfort measures only, and she was extubated on
[**2177-1-29**], and placed on a Morphine drip titrated to comfort.
A scopolamine patch was used to minimize secretions and
improve the patient's level of comfort. She was then
transferred to the Medical floor, where the Morphine drip was
titrated to 8 mg/hour, and the patient appeared comfortable
with her family at the bedside.
At 8:45 p.m. on [**2177-1-29**], the patient was pronounced
dead at the bedside with no spontaneous heart sounds or
respirations. No evidence of pulse. Pupils were fixed and
dilated bilaterally. The family declined a postmortem
examination. Dr. [**First Name8 (NamePattern2) 2184**] [**Last Name (NamePattern1) **], her primary care doctor was
notified. The inpatient attending was notified, and
admitting was notified per standard protocol.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ADZ
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2177-3-18**] 12:18
T: [**2177-3-20**] 06:54
JOB#: [**Job Number 52443**]
|
[
"518.81",
"413.9",
"E884.9",
"296.7",
"507.0",
"428.0",
"E849.7",
"496",
"820.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.04",
"79.35",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2889, 4796
|
4825, 10366
|
258, 1845
|
1867, 2558
|
2575, 2872
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,104
| 140,707
|
20887
|
Discharge summary
|
report
|
Admission Date: [**2140-2-27**] Discharge Date: [**2140-3-15**]
Date of Birth: [**2080-10-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Hepatitis C with cirrhosis here for liver transplant offer
Major Surgical or Invasive Procedure:
[**2140-3-1**] liver transplant
History of Present Illness:
58 year old male with history of hepatitis C and cirrhosis and
hepatocellular carcinoma presents for liver transplant offer. Pt
was most recently evaluated for declined liver transplant offer
on [**2140-2-14**]. Since then pt noted no changes in his overall health
status other than continued improvement of his bronchitis
after Z pack treatment 2 weeks ago noted at his last evaluation.
Also of note Earlier in an anterolateral right-sided
hemi-diaphragmatic hernia was reported with herniation of the
hepatic flexure, the middle colonic artery, and mesenteric fat.
He has evidence of splenic and esophageal varices. On ROS he
notes LE edema, nocturnal cough since his bronchitis. He has
been afebrile, without chills, nausea/ vomiting diarrhea,
constipation, no episodes of encephalopathy He continues on
Methadone 8 years out from heroin relapse, no other drugs used
recently. He walks five miles daily and can ascend 2 flights of
stairs with ease.
Past Medical History:
PAST MEDICAL HISTORY
metabolic bone disease
hepatic encephalopathy
chronic hepatitis C
resultant cirrhosis
chronic pancreatitis.
Interstitial lung disease
Reflux
Chronic pain
BLE edema
fatigue
psoriasis
.
PAST SURGICAL/PROCEDURAL HISTORY
[**2138**] RFA of liver lesion
[**2132**] lung biopsy
[**2131**] Extensive burns&#[**Numeric Identifier 25684**];skin graft surgeries
[**2140-2-28**] liver transplant with repair of chronic
diaphragmatic hernia.
[**2140-3-1**] Exploratory laparotomy, repair of
ventral hernia with mesh and liver biopsy.
Social History:
Patient lives alone in subsidized housing on modest social
security income. He has a supportive brother [**Doctor First Name **]. He
spends time at a motorcycle repair shop helping with repairs.
Mother lives on [**Location (un) **]. History of IVDA and ETOH abuse. He has
abstained from both for over 5 years each. + smoker (1PPD x 48
years). Daily methadone.
Family History:
Mother, 85: No known illness
Father, dead 76: Liver cancer
Twin brother, dead 18: Murdered
Brother, 35: No known illness
Brother, 46: No known illness
Physical Exam:
VS: 98.4 70 114/65 18 99 % RA
General: NAD, A & O X3.
HEENT: PERRLA, EOMI, mild scleral icterus, MMM
Card: RRR, II/VI systolic murmur at LSB.
Lungs: CTAB no w/r/r
Abdomen: No scars noted, + BS, no distention or tenderness no
organomegaly.
Extr: 1+ bilateral lower extremity edema, 2+ DPs, warm, well
perfused with significant skin scaling b/l LE from knee down.
Skin: burn scars on back
scars.
Neuro: No Focal deficits
Labs: Hepatitis from [**2136**]
HBsAg HBsAb HBcAb HAV Ab HIV
NEGATIVE NEGATIVE POSITIVE POSITIVE NEGATIVE
HCV VIRAL LOAD (Final [**2136-2-8**]): 441,000 IU/mL.
CMV- Negative, EBV Positive ([**2136**])
Pertinent Results:
On Admission: [**2140-2-27**]
WBC-4.7 RBC-3.04* Hgb-11.5* Hct-32.7* MCV-108* MCH-37.8*
MCHC-35.1* RDW-14.3 Plt Ct-52*
PT-20.7* PTT-149.0* INR(PT)-2.0*
Glucose-221* UreaN-16 Creat-0.7 Na-142 K-4.8 Cl-102 HCO3-25
AnGap-20
ALT-71* AST-112* AlkPhos-125* TotBili-1.8*
Initial post op [**2140-2-28**]
ALT-771* AST-1486* AlkPhos-52 Amylase-27 TotBili-4.5*
DirBili-1.9* IndBili-2.6
Albumin-2.5* Calcium-7.6* Phos-4.0 Mg-2.1
At Discharge:
CXR [**2-27**]
The cardiomediastinal silhouette is stable. There is a
right-sided pleural effusion. There is no focal consolidation or
pneumothorax. Pulmonary vascularity is not increased.
Right pleural effusion with adjacent atelectasis, no
radiographic evidence of pneumonia or CHF
Liver US [**2-28**]
IMPRESSION:
1. Patent portal vein and hepatic veins with no signs of
thrombosis.
2. Normal main hepatic artery with normal systolic upstroke and
no signs of proximal obstruction.
RUE US [**3-3**]
No evidence of deep vein thrombosis in the right arm.
[**2140-3-7**] Swallow
VIDEO OROPHARYNGEAL SWALLOWING EVALUATION: Fluoroscopic video
oropharyngeal swallowing evaluation was performed in conjunction
with speech and swallow pathology. Thin, nectar- thick, thin,
honey, pudding, and barium coated cookie were orally
administered. There was delay in oral transit. There was delayed
initiation in swallowing. There was incomplete epiglottic
deflection during most swallows and marked residual contrast
which could not be cleared after multiple swallows with nectar-
thick contrast, and more significant with pudding- thick and
barium-coated cookie. Attempts to clear the residue with nectar
resulted in silent aspiration which could not be cleared. This
was repeated with thin, nectar, and honey-thick consistencies,
all resulting in aspiration. Aspiration was least during
chin-tuck maneuver.
Brief Hospital Course:
On [**2140-2-27**] he was taken to the OR for cadaveric liver transplant
and repair of chronic diaphragmatic hernia. Surgeon was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 816**] assisted by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He received induction
immunosuppression (solumedrol, cellcept). Dissection was
immediately difficult due to abdominal viscera in his right
chest. This is carefully taken down. There was a significant
amount of fat. The diaphragm was then repaired using a running
2-0 Prolene. The case was difficult and it was not possible to
close his abdomen. There was too much in the way of bowels.
Therefore, he was transferred to the SICU where he received
blood products to maintain hemodynamic stability. 36 hours later
he was brought back to the OR ([**3-1**]) for exploratory laparotomy
with repair of ventral hernia with mesh and liver biopsy.
Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Fascial flaps were mobilized
superiorly and inferiorly and then closed the Chevron incision.
Due to increasing peak airway
pressures further attempts at closing the abdomen would lead to
abdominal compartment syndrome a piece of Vicryl mesh was
incorporated into the abdominal closure. He was then sent to the
SICU intubated.
He was weaned off the vent. He remained hemodynamically stable.
He was extubated on [**3-3**] with some residual hoarseness and ENT
was consulted. Exam showed edema bilat, vocal cord crisp with VC
mobile bilaterally with 2mm central glottic gap. A bedside
swallow eval was done showing aspiration. He was kept NPO, a
feeding tube was placed and tube feedings were started. Chest
tube was to wall suction with stable cxr. Prograf was started on
[**3-1**]. Solumedrol was given per taper and cellcept continued at
1gram [**Hospital1 **]. LFTs increased slightly for a couple days then
trended down. On [**3-3**], an U/S was done to evaluate right arm
swelling. This was negative for DVT.
On [**3-4**], the chest tube and 2 of 3 JP's were removed without
incident. He was transferred out of the SICU to [**Hospital Ward Name 121**] 10. On [**3-6**],
LFTS were up. Duplex U/S was done to evaluate noting patent
hepatic and portal veins with slow flow in portal vein as on
prior study. There were normal arterial and hepatic venous
waveforms. No biliary dilatation was noted. It was difficult to
interrogate the left hepatic artery, as in prior study. Alk phos
continued to stay within a range of 150-164 while other LFTs
decreased. Other labs remained stable.
He continued to cough and raise thick secretions using suction
due to weak cough. A Video swallow was performed on [**3-7**] showing
aspiration of multiple consistencies. On [**3-8**], a videostroboscopy
was done that revealed evidence of significantglottic gap and
lack of vocal fold tension, suspected secondary to fatigue, as
well as glottic hyperfunction and posterior glottic changes
consistent with chronic reflux. No discrete lesions or
restriction in movement of the arytenoids were noted.
Recommendations were for continuation of NPO status per
speech/swallowing team recommendations. Consideration of
muscular strengthening exercises/voice therapy, with repeat
evaluation as indicated.
Methadone was increased to 95mg and MS IR was started as
dilaudid po was ineffective in controlling his abdominal pain.
PT evaluated and found his activity to be limited due to tubings
and edematous state, recommending inpatient rehabilitation. He
was maintained on his immunosuppressants with tacro levels
checked daily. Lasix started to allow for diuresis. Patient
responded appropriately as aimed to diuresis 1-2L daily. Scrotal
and pedal edema decreasing with diuresis.
Physical therapy continued to work with patient and still
recommending inpatient rehab. Voice therapy with voice training,
providing exercises to be worked on while inpatient. Maintained
on tube feeds for nutrition with insulin sliding scale. Foley
was removed [**2140-3-14**]. Continued with rehab screening. Dobhoff
replaced under fluoroscopy. CVL kept due to poor venous access.
Prograf levels increased to 6mg PO BID prior to discharge. JP
drain removed. He will be followed by outpatient clinic closely.
Patient continue on tube feeds with nutren pulm full strength at
his goal of 55ml/hr. He was discharged to [**Hospital **] Rehab at
[**2140-3-15**].
Medications on Admission:
Creon-10 2 cap with meals
Furosemide 40 mg per day (last [**10-10**])
spironolactone 200 mg per day
Lactulose 10G/15ml [**Hospital1 **] prn (last [**10-10**])
methadone85 mg once a day (took dose today)
omeprazole 20 mg per day
rifaximin 200 mg 3 [**Hospital1 **]
magnesium oxide 400 mg b.i.d.
Creon 10 249 mg 10K-37.5k unit [**Unit Number **] capsule by mouth with meals
Testosterone 5mg/24hrs
Caltrate 600-plus Vitamin D3 600mg 400Unit Itab [**Hospital1 **]
Boniva 3mg IVevery other month (not currently taking)
Discharge Medications:
1. Fluconazole 40 mg/mL Suspension for Reconstitution [**Hospital1 **]: Ten
(10) ml PO Q24H (every 24 hours).
2. Prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily):
Continue per [**Hospital 55585**] clinic guidelines.
3. Docusate Sodium 100 mg Capsule [**Hospital **]: One (1) Capsule PO BID (2
times a day).
4. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
[**Hospital **]: Five (5) ml PO BID (2 times a day).
5. Valganciclovir 450 mg Tablet [**Hospital **]: Two (2) Tablet PO once a
day: Please give as suspension.
6. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital **]: One (1) ml
Injection TID (3 times a day): Until patient fully mobile.
7. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension [**Hospital **]:
Ten (10) ML PO DAILY (Daily).
8. Methadone 10 mg/mL Concentrate [**Hospital **]: 9.5 ml PO DAILY (Daily):
for pain.
9. Morphine 10 mg/5 mL Solution [**Hospital **]: 1.5-3 ml PO Q3H (every 3
hours) as needed for pain.
10. Bisacodyl 10 mg Suppository [**Hospital **]: One (1) Suppository Rectal
HS (at bedtime) as needed: for constipation.
11. Insulin Regular Human 100 unit/mL Solution [**Hospital **]: per sliding
scale Injection four times a day.
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
13. Sodium Chloride 0.9 % 0.9 % Syringe [**Last Name (STitle) **]: Ten (10) ML
Injection PRN (as needed) as needed for line flush.
14. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush: per
central line care protocol.
15. Tacrolimus 5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day:
Please provide suspension.
16. Tacrolimus 1 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a day:
Please provide suspension.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**]/Rehab
Discharge Diagnosis:
HCV cirrhosis now s/p orthotopic liver transplant [**2140-2-28**]
malnutrition
glottic hypofunction
vocal cord changes
reflux
Discharge Condition:
Stable/fair
Discharge Instructions:
Please call the Transplant office [**Telephone/Fax (1) 673**] if fever > 101,
chills, nausea, vomiting, increased abdominal distension or
pain, incision redness/bleeding/drainage, malfunction of tube
feeding tube, jaundice, diarrhea
Labs every Monday and Thursday
Keep binder on when patient OOB to chair or ambulating. [**Month (only) 116**]
cover incision with dry gauze when binder in place
Tube feedings continuous per nutrition recommendations
Patient may shower with assist
All medication changes to be cleared with transplant clinic at
[**Telephone/Fax (1) 673**]. Transplant coordinator is [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 8147**] RN
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2140-3-24**] 9:40
[**First Name8 (NamePattern2) 156**] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1046**] Phone [**Telephone/Fax (1) 673**] Date/Time:[**2140-3-24**] 10:00
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2140-3-28**] 9:00
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2140-4-4**] 9:30
|
[
"263.9",
"456.8",
"571.2",
"305.00",
"537.0",
"507.0",
"456.21",
"553.3",
"608.86",
"530.81",
"529.0",
"070.70",
"571.3",
"155.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"00.93",
"50.59",
"50.11",
"53.69",
"99.05",
"38.91",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11922, 11972
|
5034, 9457
|
374, 408
|
12142, 12156
|
3181, 3181
|
12879, 13483
|
2352, 2505
|
10023, 11899
|
11993, 12121
|
9483, 10000
|
12180, 12856
|
2520, 3162
|
3611, 5011
|
275, 336
|
436, 1392
|
3195, 3597
|
1414, 1958
|
1974, 2336
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,099
| 113,989
|
38676
|
Discharge summary
|
report
|
Admission Date: [**2153-4-3**] Discharge Date: [**2153-4-11**]
Date of Birth: [**2071-11-18**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
1. Acute abdominal pain
2. Nausea and vomiting x 2 days
3. Constipation x 5 days
Major Surgical or Invasive Procedure:
[**2153-4-3**]:
Exploratory laparotomy, lysis of adhesions, small bowel
resection, enteroenterostomy washout.
History of Present Illness:
The patient is a 81-years-old female presented in OSH with
complains of abdominal pain for last two days, nausea/vomiting
and constipation. Abdominal CT revealed small bowel obstruction.
Patient was transferred in [**Hospital1 18**] for further surgical
management. Patient denies diarrhea, BRBPR, melena.
Past Medical History:
1. s/p CCY [**2138**]
2. CAD s/p MI [**2138**]
3. HTN
4. Hypercholesterolemia
5. ARF
6. Afib
Social History:
Patient denies EtOH and smoking.
Family History:
Noncontributory
Physical [**Year (4 digits) **]:
On Admission:
VS: 97.9, HR 93, BP 112/63, RR 18, O2 Sat 97% RA
General: Comfortable, NAD, elderly but well appearing
Head/Eyes: PERRL, EOMI, NC/AT
ENT/Neck: Oropharynx within normal limits, MM dry
Chest/Resp: Clear to auscultation
Cardiovascular: RRR, Normal S1/S2
GI/Adbominal: Soft, distended, palpable masses-?stool on mid and
left side of the abd, no R/G, few BSs present. Mild diffuse
tenderness, worse in LLQ
Rrectal: Heme negative, large amount of hard stool in vault
prior to disimpaction.
GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent, AAO x 3, CN 2-12 intact, nonfocal MS [**First Name (Titles) **]
[**Last Name (Titles) **]: Normal mood, normal mentation
On Discharge:
VS [**4-10**]: T 96.2, HR 92, BP 118/60, RR 18, O2 Sat 94% RA
General: Calm, comfortable, NAD
CV: RRR, S1/S2, no m/r/g
Lungs: Diminished on bases b/l
Abd: Soft, normal tenderness around incision. Midline incision
with staples, clean/dry and intact. No discharge or erythema.
Normal BS x 4
Extr: Bilateral lower extremities edema, left upper extremity
swelling. Normal 2+ peripheral pulses.
Neuro: AAO x3, PERRL, CN II-XII grossly intact. No focal deficit
Pertinent Results:
[**2153-4-3**] 08:50PM GLUCOSE-104* UREA N-48* CREAT-1.5* SODIUM-133
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-26 ANION GAP-16
[**2153-4-3**] 08:50PM ALT(SGPT)-12 AST(SGOT)-21 CK(CPK)-73 ALK
PHOS-51 TOT BILI-0.8
[**2153-4-3**] 08:50PM CALCIUM-9.6 PHOSPHATE-4.2 MAGNESIUM-1.7
[**2153-4-3**] 08:50PM WBC-9.5 RBC-5.07 HGB-15.1 HCT-44.8 MCV-88
MCH-29.7 MCHC-33.6 RDW-13.5
[**2153-4-3**] 08:50PM NEUTS-73* BANDS-18* LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2153-4-3**] 08:50PM PLT SMR-NORMAL PLT COUNT-221
[**2153-4-3**] 08:50PM PT-13.7* PTT-25.6 INR(PT)-1.2*
[**2153-4-3**] 08:50PM CK-MB-NotDone cTropnT-0.02*
[**2153-4-3**]: PATHOLOGY:
Distal jejunum:
Ischemic necrosis, focally full thickness; margins of resection
appear viable.
[**2153-4-3**] EKG 9:30:28 PM:
Irregularly irregular rhythm with some periods of regularity.
Atrial fibrillation versus sinus tachycardia with atrial
premature beats. There is a single ventricular premature beat.
Inferior Q waves with
T wave inversions. Consider prior inferior myocardial infarction
of
indeterminate age. Late R wave progression with prominent
lateral precordial voltage consistent with left ventricular
hypertrophy with strain. No previous tracing available for
comparison. Clinical correlation is suggested.
[**2153-4-3**] ECG 11:56:10 PM:
Probable sinus rhythm with atrial premature beats or atrial
tachycardia that may be multifocal. Since the previous tracing
the rate is somewhat slower. Clinical correlation is suggested.
[**2153-4-4**] 01:02PM BLOOD CK-MB-10 MB Indx-5.9 cTropnT-<0.01
[**2153-4-9**] 05:38AM BLOOD WBC-8.8 RBC-3.41* Hgb-10.1* Hct-31.8*
MCV-93 MCH-29.7 MCHC-31.8 RDW-13.6 Plt Ct-375
[**2153-4-9**] 05:38AM BLOOD Plt Ct-375
[**2153-4-10**] 06:10AM BLOOD Glucose-108* UreaN-21* Creat-0.5 Na-136
K-4.9 Cl-103 HCO3-28 AnGap-10
[**2153-4-10**] 06:10AM BLOOD Albumin-2.4* Calcium-8.2* Phos-3.6 Mg-1.9
Iron-PND
[**2153-4-10**] UNILAT UP EXT VEINS US LEFT:
Near-complete occlusive Left axillary DVT. Other veins open.
Mild edema.
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation of the aforementioned problem. On [**2153-4-3**], the
patient underwent exploratory laparotomy, lysis of adhesions,
small bowel resection, enteroenterostomy washout,
which went well without complication (reader referred to the
Operative Note for details). After a brief stay in the PACU, the
patient was transferred in ICU for hypotension, oliguria and
lethargy. Patient was NPO with an NG tube, on IV fluids and
antibiotics (Vancomycin, Flagyl, and Ciprofloxacin), with a
foley catheter, and Morphine IV prn for pain control. Patient's
CRE was 1.5, she received several fluid boluses. On [**4-4**] CRE was
1.2 and continue to trace down, currently CRE 0.5. Urine output
postoperatively was varied between 20-60 cc/hr, stabilized after
fluid boluses and remains within normal limits. PICC line for
TPN and ABX treatment was placed on [**4-5**]. Patient was stable in
ICU and was transferred to the floor. On the floor, nutritional
consult was obtained and patient was started on TPN same day.
.
Post-operative pain was initially well controlled with Morphine
IV prn, which was converted to oral pain medication when
tolerating clear liquids on [**4-9**]. The NG tube was discontinued
on POD# 5, and the patient was started on sips of clears on POD#
5. Diet was progressively advanced as tolerated to a regular
diet by POD# 6, and TPN was discontinued. The foley catheter was
discontinued at midnight of POD# 5. The patient subsequently
voided without problem. [**Name (NI) **] hemodynamically was stable. IV
antibiotics were discontinued on [**2153-4-10**] (POD # 6). PICC line
was removed on [**2153-4-10**]. After PICC line was removed, patient
compained about left upper extremity discomfort and swelling.
Ultrasound was obtained and revealed, left axallary DVT. Patient
was started on 325 mg of Aspirin PO qday, and she will continue
to receive subcutaneous Heparin 5000 units TID after her
discharge in long-term care facility.
.
During this hospitalization, the patient ambulated with
assistance, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. PT
consult was obtained, PT recommended discharge patient in Rehab
to continue PT. 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. 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 a regular
diet, ambulating with assist, voiding without assistance, and
pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. ASA 81 mg PO qday
2. Toprol XL 50 mg PO qday
3. Lisinopril 10 mg Po qday
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
5. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): Discontinue when discharged
to home.
Discharge Disposition:
Extended Care
Facility:
The [**Hospital **] Nursing and Rehab
Discharge Diagnosis:
1. Small-bowel obstruction with closed loop obstruction and
necrotic small bowel.
2. Left upper extremity DVT
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:
General 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 [**5-21**] 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:
1. Please call [**Telephone/Fax (1) 2998**] to arrange a follow up appointment
with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] (General Surgery) in [**2-14**] weeks after
discharge.
.
2. Please call [**Telephone/Fax (1) 5763**] to arrange a follow up appointment
with Dr. [**Last Name (STitle) 5057**] in [**2-14**] weeks after discharge
Completed by:[**2153-4-11**]
|
[
"401.9",
"584.9",
"453.84",
"427.31",
"272.0",
"557.0",
"412",
"458.29",
"789.59",
"414.01",
"560.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"99.15",
"45.91",
"54.59",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8197, 8261
|
4378, 7289
|
395, 507
|
8415, 8415
|
2327, 4355
|
9732, 10132
|
1025, 1075
|
7415, 8174
|
8282, 8394
|
7315, 7392
|
8595, 8595
|
9220, 9709
|
1851, 2308
|
8627, 9205
|
275, 357
|
535, 842
|
1089, 1837
|
8430, 8571
|
864, 959
|
975, 1009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,855
| 103,500
|
40028
|
Discharge summary
|
report
|
Admission Date: [**2105-11-18**] Discharge Date: [**2105-12-1**]
Date of Birth: [**2033-3-4**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
pedestrian struck by car
Major Surgical or Invasive Procedure:
[**2105-11-20**]: s/p Bilateral open reduction internal fixation, tibial
plateaus
History of Present Illness:
72 year old male hit by car on [**2105-11-18**] resulting in bilateral
tibial plateau fractures requiring surgical management.
Past Medical History:
Atrial Fibrillation
COPD
CAD
T2DM
HTN
gout
chronic sinus infections
Social History:
Denies tobacco and drug use. Occ alcohol.
Family History:
n/a
Physical Exam:
On admission:
Temp:97.2 HR:102 BP:100/57 Resp:20 O(2)Sat:98
Constitutional: anxious, unable to follow commands
HEENT: hematoma R occiput
Chest: course BS with crackles, scattered
Cardiovascular: tachycardic, irregular
Abdominal: Soft, Nondistended
Extr/Back: lower extremity edema with ecchymosis around
bilateral malleoli, pulses palpable on L LE; non-dopplerable
PT on R, dopplerable DP on R, compartments soft, demarcation
distal R ankle; R posterior knee: ecchymosis with hematoma
and blistering; swelling along calf and posterior thigh
Neuro: unable to assess neurologic exam
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2105-11-18**] 12:09AM BLOOD freeCa-1.10*
[**2105-11-20**] 09:16AM BLOOD freeCa-1.10*
[**2105-11-20**] 10:49AM BLOOD freeCa-1.08*
[**2105-11-20**] 09:21PM BLOOD freeCa-1.14
[**2105-11-22**] 05:16PM BLOOD freeCa-1.09*
[**2105-11-18**] 12:09AM BLOOD Hgb-13.1* calcHCT-39
[**2105-11-20**] 09:16AM BLOOD Hgb-6.9* calcHCT-21 O2 Sat-83
[**2105-11-20**] 10:49AM BLOOD Hgb-8.1* calcHCT-24 O2 Sat-85
[**2105-11-20**] 09:21PM BLOOD O2 Sat-95
[**2105-11-21**] 05:56AM BLOOD O2 Sat-97
[**2105-11-18**] 12:04AM BLOOD Lactate-2.0 K-5.1
[**2105-11-18**] 12:09AM BLOOD Glucose-233* Lactate-1.9 Na-140 K-5.2
Cl-97*
[**2105-11-20**] 09:16AM BLOOD Glucose-77 Lactate-1.0 Na-140 K-4.1
Cl-99*
[**2105-11-20**] 10:49AM BLOOD Glucose-86 Lactate-1.8 Na-139 K-4.4
Cl-100 calHCO3-33*
[**2105-11-20**] 09:21PM BLOOD Lactate-1.3
[**2105-11-22**] 05:16PM BLOOD Lactate-1.6
[**2105-11-18**] 12:09AM BLOOD Type-ART pO2-73* pCO2-93* pH-7.19*
calTCO2-37* Base XS-4 Intubat-NOT INTUBA
[**2105-11-18**] 04:15AM BLOOD Type-ART Rates-/16 Tidal V-550 FiO2-100
pO2-362* pCO2-69* pH-7.29* calTCO2-35* Base XS-4 AADO2-318 REQ
O2-56 -ASSIST/CON Intubat-INTUBATED
[**2105-11-18**] 09:03PM BLOOD Type-ART Temp-36.4 Rates-22/ Tidal V-550
PEEP-5 FiO2-40 pO2-82* pCO2-52* pH-7.43 calTCO2-36* Base XS-8
-ASSIST/CON Intubat-INTUBATED
[**2105-11-20**] 09:16AM BLOOD Type-CENTRAL VE Tidal V-464 FiO2-54
pO2-53* pCO2-64* pH-7.36 calTCO2-38* Base XS-7 Intubat-INTUBATED
[**2105-11-20**] 09:21PM BLOOD Type-ART PEEP-5 FiO2-50 pO2-100 pCO2-76*
pH-7.29* calTCO2-38* Base XS-6 Intubat-INTUBATED
[**2105-11-20**] 11:55PM BLOOD Type-ART PEEP-5 FiO2-45 pO2-95 pCO2-58*
pH-7.37 calTCO2-35* Base XS-5 Intubat-INTUBATED Vent-SPONTANEOU
[**2105-11-21**] 05:56AM BLOOD Type-ART PEEP-5 FiO2-45 pO2-98 pCO2-58*
pH-7.37 calTCO2-35* Base XS-5
[**2105-11-21**] 09:27PM BLOOD Type-ART pO2-71* pCO2-59* pH-7.39
calTCO2-37* Base XS-7
[**2105-11-22**] 05:16PM BLOOD Type-ART Temp-37.8 Rates-/38 FiO2-50 O2
Flow-4 pO2-65* pCO2-58* pH-7.42 calTCO2-39* Base XS-10
Intubat-INTUBATED Comment-FACE TENT
[**2105-11-22**] 06:29PM BLOOD Type-ART Temp-37.8 Rates-/24 FiO2-40 O2
Flow-4 pO2-86 pCO2-57* pH-7.42 calTCO2-38* Base XS-9 Intubat-NOT
INTUBA Comment-FACE TENT
[**2105-11-17**] 11:00PM BLOOD Digoxin-2.5*
[**2105-11-22**] 02:01AM BLOOD Digoxin-0.8*
[**2105-11-17**] 11:00PM BLOOD Albumin-3.3*
[**2105-11-18**] 06:08AM BLOOD Albumin-2.9* Calcium-7.5* Phos-3.2 Mg-1.6
[**2105-11-18**] 04:50PM BLOOD Calcium-7.8* Phos-1.9* Mg-1.5*
[**2105-11-19**] 02:45AM BLOOD Calcium-7.9* Phos-1.8* Mg-1.5*
[**2105-11-20**] 01:12AM BLOOD Calcium-8.0* Phos-3.9# Mg-2.4
[**2105-11-20**] 04:27PM BLOOD Calcium-7.8* Phos-4.4 Mg-2.1
[**2105-11-21**] 09:06PM BLOOD Calcium-7.9* Phos-1.6*# Mg-2.3
[**2105-11-22**] 02:01AM BLOOD Calcium-7.9* Phos-1.7* Mg-2.4
[**2105-11-22**] 01:41PM BLOOD Phos-2.6*
[**2105-11-23**] 02:11AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.2*
Mg-2.0
[**2105-11-24**] 03:05AM BLOOD Calcium-8.1* Phos-2.4* Mg-1.9
[**2105-11-17**] 11:00PM BLOOD cTropnT-<0.01 proBNP-1450*
[**2105-11-18**] 06:08AM BLOOD Lipase-705*
[**2105-11-19**] 02:45AM BLOOD Lipase-106*
[**2105-11-17**] 11:00PM BLOOD ALT-19 AST-33 LD(LDH)-338* AlkPhos-78
Amylase-585* TotBili-1.5
[**2105-11-18**] 06:08AM BLOOD ALT-20 AST-35 LD(LDH)-309* AlkPhos-67
Amylase-527* TotBili-2.1*
[**2105-11-19**] 02:45AM BLOOD ALT-20 AST-40 AlkPhos-56 Amylase-271*
TotBili-1.9*
[**2105-11-23**] 02:11AM BLOOD ALT-27 AST-54* AlkPhos-65
[**2105-11-17**] 11:00PM BLOOD Glucose-218* UreaN-26* Creat-1.9* Na-139
K-5.4* Cl-100 HCO3-31 AnGap-13
[**2105-11-18**] 04:50AM BLOOD Glucose-2275* UreaN-17 Creat-1.4* Na-74*
K-3.3 Cl-58* HCO3-16* AnGap-3*
[**2105-11-18**] 06:08AM BLOOD Glucose-344* UreaN-29* Creat-2.0* Na-135
K-5.6* Cl-97 HCO3-30 AnGap-14
[**2105-11-18**] 04:50PM BLOOD Glucose-157* UreaN-32* Creat-1.8* Na-142
K-4.2 Cl-102 HCO3-31 AnGap-13
[**2105-11-19**] 02:45AM BLOOD Glucose-80 UreaN-34* Creat-1.7* Na-138
K-3.9 Cl-99 HCO3-30 AnGap-13
[**2105-11-20**] 01:12AM BLOOD Glucose-80 UreaN-34* Creat-1.3* Na-141
K-4.5 Cl-104 HCO3-33* AnGap-9
[**2105-11-20**] 04:27PM BLOOD Glucose-106* UreaN-32* Creat-1.2 Na-144
K-4.5 Cl-106 HCO3-32 AnGap-11
[**2105-11-21**] 02:06AM BLOOD Glucose-66* UreaN-32* Creat-1.3* Na-143
K-4.3 Cl-105 HCO3-34* AnGap-8
[**2105-11-21**] 09:06PM BLOOD Glucose-146* UreaN-30* Creat-1.3* Na-145
K-3.8 Cl-106 HCO3-34* AnGap-9
[**2105-11-22**] 02:01AM BLOOD Glucose-44* UreaN-30* Creat-1.2 Na-142
K-3.5 Cl-105 HCO3-34* AnGap-7
[**2105-11-22**] 11:49AM BLOOD Glucose-144* Na-144 K-4.9 Cl-105
[**2105-11-22**] 01:41PM BLOOD Glucose-132* Na-142 K-4.9 Cl-103
[**2105-11-23**] 02:11AM BLOOD Glucose-116* UreaN-28* Creat-1.1 Na-140
K-4.4 Cl-103 HCO3-34* AnGap-7*
[**2105-11-24**] 03:05AM BLOOD Glucose-92 UreaN-29* Creat-1.0 Na-145
K-4.3 Cl-105 HCO3-34* AnGap-10
[**2105-11-25**] 04:40AM BLOOD Glucose-103* UreaN-34* Creat-1.3* Na-144
K-4.2 Cl-101 HCO3-36* AnGap-11
[**2105-11-26**] 04:46AM BLOOD Glucose-101* UreaN-37* Creat-1.3* Na-141
K-3.8 Cl-98 HCO3-37* AnGap-10
[**2105-11-17**] 11:00PM BLOOD PT-22.7* PTT-28.9 INR(PT)-2.1*
[**2105-11-17**] 11:00PM BLOOD Plt Smr-NORMAL Plt Ct-178
[**2105-11-18**] 04:50AM BLOOD PT-39.6* PTT-60.7* INR(PT)-4.1*
[**2105-11-18**] 04:50AM BLOOD Plt Smr-LOW Plt Ct-126*
[**2105-11-18**] 06:08AM BLOOD PT-22.6* PTT-30.5 INR(PT)-2.1*
[**2105-11-18**] 06:08AM BLOOD Plt Ct-128*
[**2105-11-18**] 04:50PM BLOOD PT-18.9* PTT-29.3 INR(PT)-1.7*
[**2105-11-18**] 04:50PM BLOOD Plt Ct-120*
[**2105-11-19**] 02:45AM BLOOD PT-16.3* PTT-29.0 INR(PT)-1.4*
[**2105-11-19**] 02:45AM BLOOD Plt Ct-127*
[**2105-11-20**] 01:12AM BLOOD Plt Ct-109*
[**2105-11-20**] 04:45AM BLOOD PT-13.2 PTT-27.4 INR(PT)-1.1
[**2105-11-20**] 04:27PM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2105-11-20**] 04:27PM BLOOD Plt Ct-142*
[**2105-11-20**] 04:27PM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2105-11-20**] 04:27PM BLOOD Plt Ct-142*
[**2105-11-21**] 02:06AM BLOOD Plt Ct-127*
[**2105-11-22**] 02:01AM BLOOD Plt Ct-106*
[**2105-11-22**] 05:05PM BLOOD Plt Ct-120*
[**2105-11-23**] 02:11AM BLOOD PT-14.5* PTT-31.6 INR(PT)-1.3*
[**2105-11-23**] 02:11AM BLOOD Plt Ct-119*
[**2105-11-24**] 03:05AM BLOOD Plt Ct-146*
[**2105-11-25**] 04:40AM BLOOD Plt Ct-222#
[**2105-11-26**] 04:46AM BLOOD Plt Ct-199
[**2105-11-17**] 11:00PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2105-11-17**] 11:00PM BLOOD Neuts-93* Bands-0 Lymphs-3* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2105-11-17**] 11:00PM BLOOD WBC-21.5* RBC-4.07* Hgb-12.9* Hct-39.2*
MCV-96 MCH-31.6 MCHC-32.9 RDW-16.1* Plt Ct-178
[**2105-11-18**] 01:17AM BLOOD Hgb-12.2* Hct-38.0*
[**2105-11-18**] 04:50AM BLOOD WBC-13.1* RBC-2.96*# Hgb-9.0*# Hct-32.5*
MCV-110*# MCH-30.5 MCHC-27.8*# RDW-16.2* Plt Ct-126*
[**2105-11-18**] 06:08AM BLOOD WBC-16.7* RBC-3.72*# Hgb-12.0*# Hct-35.4*
MCV-95# MCH-32.1* MCHC-33.7# RDW-16.4* Plt Ct-128*
[**2105-11-18**] 04:50PM BLOOD WBC-16.4* RBC-3.03* Hgb-9.5* Hct-28.6*
MCV-94 MCH-31.4 MCHC-33.4 RDW-16.3* Plt Ct-120*
[**2105-11-19**] 02:45AM BLOOD WBC-17.2* RBC-2.87* Hgb-9.1* Hct-27.4*
MCV-95 MCH-31.6 MCHC-33.2 RDW-16.5* Plt Ct-127*
[**2105-11-20**] 01:12AM BLOOD WBC-17.3* RBC-2.54* Hgb-8.1* Hct-24.3*
MCV-96 MCH-32.0 MCHC-33.4 RDW-16.7* Plt Ct-109*
[**2105-11-20**] 04:27PM BLOOD WBC-17.9* RBC-3.48*# Hgb-10.3*#
Hct-32.1*# MCV-92 MCH-29.5 MCHC-32.0 RDW-17.9* Plt Ct-142*
[**2105-11-21**] 02:06AM BLOOD WBC-14.4* RBC-3.17* Hgb-10.0* Hct-28.6*
MCV-90 MCH-31.4 MCHC-34.8 RDW-18.3* Plt Ct-127*
[**2105-11-22**] 02:01AM BLOOD WBC-8.8 RBC-2.55* Hgb-7.9* Hct-23.2*
MCV-91 MCH-31.2 MCHC-34.2 RDW-17.7* Plt Ct-106*
[**2105-11-22**] 05:05PM BLOOD WBC-13.1* RBC-3.33*# Hgb-10.4*#
Hct-30.2*# MCV-91 MCH-31.4 MCHC-34.6 RDW-17.2* Plt Ct-120*
[**2105-11-23**] 02:11AM BLOOD WBC-10.7 RBC-3.01* Hgb-9.7* Hct-27.5*
MCV-91 MCH-32.3* MCHC-35.3* RDW-17.1* Plt Ct-119*
[**2105-11-24**] 03:05AM BLOOD WBC-10.8 RBC-3.05* Hgb-9.6* Hct-28.3*
MCV-93 MCH-31.6 MCHC-34.1 RDW-16.9* Plt Ct-146*
[**2105-11-25**] 04:40AM BLOOD WBC-10.0 RBC-3.30* Hgb-10.3* Hct-31.5*
MCV-96 MCH-31.1 MCHC-32.6 RDW-16.4* Plt Ct-222#
[**2105-11-26**] 04:46AM BLOOD WBC-8.9 RBC-3.23* Hgb-10.2* Hct-30.5*
MCV-94 MCH-31.5 MCHC-33.4 RDW-16.9* Plt Ct-199
Brief Hospital Course:
Mr. [**Known lastname 1790**] was admitted to the General Trauma Surgery service
on [**2105-11-18**] after being hit by a car. In the ED he was
hypotensive and intubated for hypoxia then transferred to ICU.
The ICU team monitored him and replete his blood, fluid,
electrolytes and placed on pressors for hypotension. On
[**2105-11-20**] he underwent open reduction internal fixation of
bilateral tibial plateaus without complication. Post operatively
he was transferred back to the ICU. He was transfused for post
operative blood loss anemia and placed on sliding scales for his
electrolytes. On [**2105-11-20**] post operatively he went into AFib w/
RVR treated with Lopressor and digoxin. Then Dilt drip started
for AFib w/ RVR due to refractory to Lopressor and digoxin. On
[**2105-11-21**] he was extubated, c-spine cleared, diet advanced to
regular, weaned off dilt drip, started metoprolol 12.5mg. On
that evening he started sundowning. On [**2105-11-22**] he was
transfused 2U pRBC with Lasix in between for post operative
blood loss anemia. He became confused thus Haldol given. On
[**2105-11-23**] he aspirated and became agitated and delirious. The
chest xray did not show any interval change. On [**2105-11-23**] speech
and swallow test performed. On [**2105-11-24**] he was transferred out
of the ICU to the Orthopedic service. He remained confused
therefore the [**Female First Name (un) 1634**] service was consulted for post op delirium.
they recccomended for agigition use
Medications on Admission:
Home Medications:
coumadin,digoxin 250mcg daily, diovan 160mg daily, lasix 20mg
daily, lipitor 20mg daily, Toprol XL 200mg
Discharge Medications:
1. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob, wheeze.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
7. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*28 * Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation.
11. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
13. quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Living
Discharge Diagnosis:
1. Bilateral tibial plateau fractures.
2. Hypercarbia.
3. Post operative Delirium.
4. Post operative blood loss anemia.
5. Fluid volume deficit
6. Hypotension
7. Hypoxia
8. Atrail Fib with rapid ventricular rate.
9. Aspiration
10. Hypoglycemia
11. Leukocytosis
12. Hypocalcemia.
13. Hypomagnesemia.
14. Hypophosphatemia.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Wound Care:
-Keep Incisions dry.
-Do not soak the incisions in a bath or pool.
Activity:
-Continue to be non weight bearing on both legs.
-Keep the braces dry, they may come off while in bed, but need
to be on when up and transferring
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
If urethral bleeding worsens or it becomes difficult/painful to
urinate please come to the ED
Physical Therapy:
Activity: Out of bed
Right lower extremity: Non weight bearing
Left lower extremity: Non weight bearing
[**Doctor Last Name **] braces bilaterally unlocked, ROM knees as tolerated
Treatments Frequency:
remove staples 14 days from date of surgery
Followup Instructions:
2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.
Please call [**Telephone/Fax (1) 1228**] to make this appointment.
...
Follow up with urology in 2 weeks. Please call ([**Telephone/Fax (1) 772**] to
set up an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2105-12-1**]
|
[
"473.9",
"250.00",
"496",
"823.00",
"458.9",
"285.1",
"276.2",
"427.31",
"V49.87",
"293.0",
"414.01",
"788.20",
"821.21",
"922.32",
"274.9",
"401.9",
"E814.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"79.35",
"79.36"
] |
icd9pcs
|
[
[
[]
]
] |
12541, 12601
|
9575, 11072
|
345, 429
|
12966, 12966
|
1439, 9552
|
14899, 15347
|
752, 757
|
11246, 12518
|
12622, 12945
|
11098, 11098
|
13144, 13144
|
772, 772
|
14623, 14809
|
14831, 14876
|
11116, 11223
|
281, 307
|
13156, 14605
|
457, 585
|
787, 1420
|
12981, 13120
|
607, 677
|
693, 736
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,815
| 131,004
|
784+55236
|
Discharge summary
|
report+addendum
|
Admission Date: [**2170-3-6**] Discharge Date: [**2170-3-14**]
Date of Birth: [**2140-8-29**] Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 29-year-old
female with end-stage renal disease on hemodialysis, who was
admitted to the Medical Intensive Care Unit from the
Emergency Department with sepsis. The patient was in her
usual state of health until after her usual Monday
hemodialysis session. The session lasted three hours and was
complicated by line thrombosis.
Upon arriving home, she felt profoundly fatigued, was
vertiginous, and had diffuse long bone pain, felt febrile,
and was nauseated, and vomited once. She also noted mild
shortness of breath with mild pleuritic chest pain. The
patient took Tylenol with no relief.
On the morning of [**3-6**], she presented to the
Emergency Department and was found to have a blood pressure
of 90/60, which was responsive to 1 liter of normal saline.
The patient had generalized weakness and mild abdominal pain.
A left external jugular central line was attempted, but
became infiltrated and was removed with resulting hematoma.
A successful right femoral line was then placed. Her
temperature was 101 with a white blood cell count of 35.8.
She was transiently hypoxic briefly requiring a face mask to
sustain an oxygen saturation of greater than 90%. She was
also found to have a potassium of 9.2. She was given insulin
D50, calcium gluconate, and bicarbonate. An EKG showed
peaked T waves with widening of the QRS intervals. Patient
was taken for hemodialysis during which time blood cultures
were drawn and Vancomycin was given empirically.
REVIEW OF SYSTEMS: Diarrhea. Patient traveled to [**State 108**],
nausea, weakness, mild headache, mild photophobia. Patient
has gained 30 pounds and lost 30 pounds over the past year.
Patient denied shortness of breath, chest pain, dysuria, neck
stiffness, abdominal pain, sick contacts, vision changes, and
leg pain.
PAST MEDICAL HISTORY:
1. End-stage renal disease secondary to IgA nephropathy
diagnosed 12 years ago. Patient has been on hemodialysis
since [**2164**] status post multiple A-V graft revisions.
2. Right Permacath for the past four months status post trial
of peritoneal dialysis. Patient is on the renal transplant
list.
3. Hypertension.
4. Major depressive disorder on Zoloft and Seroquel.
5. Pseudotumor cerebri in [**2164**].
6. Positive PPD status post INH in [**2156**].
7. Left ovarian cyst removal.
8. Hyperkalemia status post A-V graft thrombus in [**2169-3-4**].
MEDICATIONS:
1. Renagel t.i.d.
2. Nephrocaps q.d.
3. Sertraline 150 mg p.o. q.h.s.
4. Atenolol 25 mg p.o. b.i.d.
5. Zestril 5 mg p.o. b.i.d.
6. Epogen with hemodialysis.
7. Seroquel 100 mg p.o. q.d.
ALLERGIES: Patient has a questionable allergy to Vancomycin,
which causes pruritus.
SOCIAL HISTORY: The patient lives with her mother and
sister. She works as a cytotechnologist. She denies
smoking. She has limited alcohol use, and she denies any
drug use.
FAMILY HISTORY: No significant family history.
PHYSICAL EXAM ON ADMISSION: Temperature was 101.0, blood
pressure 156/104, heart rate 101, respiratory rate 22, and
oxygen saturation 98% on 2 liters. In general, the patient
was alert and oriented times three in no acute distress.
HEENT: Facial rash consistent with acne. Pupils are equal,
round, and reactive to light. Extraocular muscles are
intact. Visual fields were full bilaterally. Conjunctivae
were injected diffusely on the right. Oropharynx showed no
lesions. Neck was supple without bruits, masses, or
thyromegaly. There was no lymphadenopathy. Cardiovascular:
Nondisplaced PMI, S1 greater than S2, no murmurs, rubs, or
gallops. Pulmonary: Clear to auscultation bilaterally, no
wheezes or egophony. Abdomen: Normoactive bowel sounds,
soft, nontender, nondistended, no hepatosplenomegaly, no
masses, and no bruits. Groin: Right femoral line clean,
dry, and intact. Extremities: No clubbing, cyanosis, or
edema. 2+ dorsalis pedis and radial pulses bilaterally.
Skin: No rashes or bruises. Neurologic: Motor [**6-6**] in all
extremities. Sensation grossly intact to light touch.
Patellar and brachial reflexes 1+ bilaterally. Cranial
nerves II through XII are grossly intact. No meningismus in
the neck, no photophobia.
LABORATORY STUDIES: White blood cell count 35.1 with 22%
bands, hematocrit 46.3, platelets 159. INR 1.5. Sodium 130,
potassium 6.4, chloride 90, bicarbonate 23, BUN 32,
creatinine 9.6, glucose 70, calcium 11.6, magnesium 1.9. CK
45. Lactate 7.8. AST 40, ALT 17, alkaline phosphatase 126,
total bilirubin 1.0, amylase 40, lipase 22.
Chest x-ray showed no abnormalities.
EKG showed junctional rhythm with rate at 74 beats per minute
with a few retrograde P waves versus third degree block with
ventricular escape. There is a wide QRS with marked T waves,
increase.
Patient was admitted to the Medical Intensive Care Unit for
further workup.
HOSPITAL COURSE:
1. Bacteremia: Blood cultures from [**3-6**] were [**5-6**]
positive for Staphylococcus aureus. Patient was continued on
Vancomycin until speciation and specificities were obtained.
On [**3-8**], Staphylococcus aureus was found to be
methicillin sensitive. Therefore, the patient was switched
to oxacillin, and maintained on oxacillin throughout her
hospital stay.
Her Permacath was removed on [**3-7**], and the tip was
sent for culture, which came back positive for
methicillin-sensitive Staph aureus. Blood cultures were
obtained daily until [**3-11**]. Blood cultures from
[**3-7**] showed 1/4 bottles positive for Staphylococcus
aureus. Blood cultures from the 5th and onward were negative
for any bacterial growth.
The patient underwent transthoracic echocardiogram to rule
out endocarditis, which was negative. The patient then
underwent transesophageal echocardiogram to rule out
endocarditis. This too showed no valvular vegetations. The
patient defervesced, and blood pressure responded immediately
to fluid resuscitation. The patient will be discharged on a
course of total of 14 days of oxacillin from the first
negative blood cultures.
2. Access: The patient's Permacath was removed as well as
her femoral catheter that was placed in the Emergency
Department. It was thought that the patient should be left
without any access for several days so that her bacteremia
was cleared. Patient was dialyzed intermittently with a
femoral catheter, which was then removed after dialysis.
On [**3-13**], the patient had negative blood cultures for
four days. Therefore, she went to the OR for tunneled
Permacath for dialysis. In addition, a PICC line was placed
for continued oxacillin as an outpatient. The patient
tolerated these procedures well.
3. End-stage renal disease: Patient was dialyzed as needed
in-house. Her initial hyperkalemia on presentation responded
well to Kayexalate with resolution of her EKG changes. The
patient was continued on Renagel and amphojel. She continued
to have hypercalcemia and hyperphosphatemia with some
hyponatremia that was all thought to be due to her end-stage
renal disease and that was resolved with dialysis. PTH was
obtained, which was 1,055.
4. Left neck hematoma: The patient was noted to have a large
hematoma at the site of the external jugular venous attempt
and thrombosis. This increased in size during her hospital
stay. Therefore, the patient underwent repeated ultrasound
evaluation to ensure that there was no compromise of the
vessels in that area. Ultrasounds were negative for any
obstruction of flow in the vessels, and did show a large
hematoma. Patient also underwent CT of the neck which showed
a large hematoma with no compromise of vessels. The hematoma
began to reabsorb. The patient's pain was treated with
oxycodone and OxyContin, and was resolving by the time of
discharge.
5. Patient initially complained of diarrhea and abdominal
pain. She had three Clostridium difficile toxins, which were
negative. Her diarrhea resolved without any treatment.
6. Psychiatry: The patient was maintained on Zoloft and
Seroquel.
7. Hypertension: The patient had elevated blood pressures on
days when she was not dialyzed up to 160/110. Patient was
maintained on her outpatient regimen of atenolol and Zestril.
DISCHARGE STATUS: Home.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Methicillin-sensitive Staphylococcus aureus bacteremia.
2. Methicillin-sensitive Staphylococcus aureus line
infection.
3. End-stage renal disease.
4. Hematoma.
5. Hypercalcemia.
6. Hyperphosphatemia.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg one p.o. q.d.
2. B complex.
3. Vitamin C.
4. Folic acid one p.o. q.d.
5. Quetiapine 100 mg p.o. q.d.
6. Sevelamer 800 mg two tablets p.o. t.i.d.
7. Atenolol 25 mg one p.o. b.i.d.
8. Lisinopril 5 mg one p.o. q.d.
9. Sertraline 100 mg 1-1/2 tablets p.o. q.d.
10. Docusate sodium 100 mg one p.o. b.i.d.
11. Percocet 5/325 mg p.o. 1-2 tablets every six hours as
needed for pain.
12. Oxacillin 2 grams IV q.4h. for eight days.
FOLLOWUP: The patient is to followup with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5612**] in one week. She is to followup with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 **] on [**3-21**] at
11 a.m.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. [**MD Number(2) 5614**]
Dictated By:[**Last Name (NamePattern1) 5615**]
MEDQUIST36
D: [**2170-3-13**] 17:30
T: [**2170-3-14**] 07:09
JOB#: [**Job Number 5616**]
Name: [**Known lastname 657**], [**Known firstname 658**] Unit No: [**Numeric Identifier 659**]
Admission Date: [**2170-3-6**] Discharge Date: [**2170-3-14**]
Date of Birth: [**2140-8-29**] Sex: F
Service: MEDICINE
ADDENDUM: After discussion with the patient's primary
nephrologist, Dr.[**Doctor Last Name 660**] and the patient's renal fellow, it
was decided that the patient would benefit more from
preserving her right arm for future arteriovenous fistula
formation than she would be from receiving oxacillin
antibiotics for her now resolve Staphylococcus aureus
bacteremia. Therefore, the patient's right arm peripherally
inserted central catheter was removed on [**2170-3-14**]
and the patient was discharged home to receive intravenous
cefazolin 1 gram after each hemodialysis session for an
additional eight days. This will give the patient a full 14
day course of antibiotics for her bacteremia, while still
preserving her right arm for any future hemodialysis access
needs.
There was also some though that the patient's right
subclavian Perma-Cath should be removed in one to two weeks
and replaced with a left internal jugular left subclavian
Perma-Cath as this would be preferable in order to preserve
her right arm for future arteriovenous fistulas. At this
time, a left IJ could not be placed due to the patient's
evolving hematoma. Therefore, the patient will follow-up
with Dr.[**Name (NI) 660**] and Dr. [**First Name (STitle) **] at a later date for
replacement of the Perma-Cath and for IV fistula formation.
DR.[**Last Name (STitle) 661**],[**First Name3 (LF) **] 12-AHU
Dictated By:[**Last Name (NamePattern1) 662**]
MEDQUIST36
D: [**2170-3-14**] 11:28
T: [**2170-3-14**] 11:34
JOB#: [**Job Number 663**]
|
[
"038.11",
"996.62",
"785.52",
"998.12",
"276.7",
"583.9",
"296.20",
"276.1",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8341, 8350
|
3026, 3072
|
8371, 8575
|
8598, 11400
|
4981, 8319
|
1667, 1970
|
165, 1647
|
3087, 4964
|
1992, 2831
|
2848, 3009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,593
| 128,378
|
24013
|
Discharge summary
|
report
|
Admission Date: [**2147-12-13**] Discharge Date: [**2147-12-19**]
Date of Birth: [**2069-8-5**] Sex: M
Service: NEUROSURGERY
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 78 year old man well known to the neurosurgery
service with a history of oligoastrocytoma s/p resection,
chemo/radiation, most recently admitted [**2147-11-9**] for elective VP
shunt revision. He returned to an extended care facility after
that admission, then was readmitted on [**2147-12-13**] complaining of
headaches after a reported fall.
Past Medical History:
Oncologic History:
Anaplastic oligoastrocytoma s/p gross total resection on
[**2147-3-28**], s/p involved-field cranial irradiation with
temozolomide to 6,000 cGy from [**2147-5-4**] to [**2147-6-16**], and s/p 2
cycles of adjuvant temozolomide. Initially had presented with
word-finding difficulty and memory difficulty. His PCP did an
MRI which showed an enhancing mass in the left frontal brain
with mild mid-line shift.
Past Medical History:
1. non-operative carotid artery stenosis
2. hypercholesterolemia
Past Surgical History:
1. left knee operation a few years ago
2. appendectomy in [**2077**].
Social History:
He currently lives in an extended care facility. He is a
retired truck driver. He used to smoke 1 to 4 cigars per day,
and used to drink alcohol. He no longer does either. He does
not use any illicit drugs.
Family History:
Both of his parents are deceased (his mother had coronary artery
disease, asthma, dementia and his father had a heart attack).
His sister has emphysema and breast cancer while his 2 brothers
also have emphysema. His daughter and his son are healthy.
Physical Exam:
NAD
RRR
CTAB
Soft NTND
No C/C/E
Alert and oriented
Follows commands
CN II-XII intact
Tongue midline
Shoulder shrug [**4-27**]
Motor [**4-27**] throughout
No sensory deficits
DTRs [**1-25**] throughout
Pertinent Results:
[**2147-12-13**] 08:52PM PLT COUNT-343
[**2147-12-13**] 08:52PM PT-12.4 PTT-25.4 INR(PT)-1.0
[**2147-12-13**] 07:00PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]->=1.035
[**2147-12-13**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2147-12-13**] 07:00PM URINE RBC->50 WBC-[**2-25**] BACTERIA-FEW YEAST-NONE
EPI-0
[**2147-12-13**] 09:30AM GLUCOSE-108* UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-30 ANION GAP-10
[**2147-12-13**] 09:30AM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-1.9
[**2147-12-13**] 09:30AM WBC-8.6 RBC-3.37* HGB-10.7* HCT-30.7* MCV-91
MCH-31.8 MCHC-34.9 RDW-14.9
[**2147-12-13**] 09:30AM NEUTS-82.4* LYMPHS-8.4* MONOS-3.7 EOS-5.2*
BASOS-0.3
[**2147-12-13**] 09:30AM PLT COUNT-308
[**2147-12-13**] 09:30AM PT-11.7 PTT-24.3 INR(PT)-0.9
Brief Hospital Course:
The patient was admitted to the neurosurgery service. A CT scan
of the head revealed acute on subacute subdural hematomas
bilaterally, larger on the right than the left. Two subsequent
CT scans of the head showed no change in the hematoma. The
patient remained clinically stable, at his baseline neurologic
and functional status. Radiologic studies of his thoracic,
lumbar, and sacral spine revealed no injuries. An incidental
finding of a right upper lobe lung spiculation was discovered,
and it is recommended he follow up with his primary care
physician [**Last Name (NamePattern4) **] 6 months regarding this finding. He was maintained
in a rigid c-collar until flexion/extension films were obtained.
No fractures were identified, and the c-collar was removed. A
swallow evaluation was performed, it is recommended he maintain
a diet of ground solids and prethickened nectar liquids.
Physical therapy worked with the patient and recommended he
return to an extended care facility for rehabilitation. He was
deemed fit for discharge on hospital day 3. He stayed in the
hospital due to the holiday weekend and at times was alert and
orientated X3, following commands and tolerating a regular diet.
Medications on Admission:
Lamotrigine, Reglan, Atorvastatin, Quetiapine, Methylphenidate
and Decadron
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for loose stools.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: Hold for loose stools.
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
10. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO QAM (once a
day (in the morning)).
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): To be given at 4pm every day.
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Sliding scale as needed.
13. Dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Chronic subdural hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please call if you have a fever >101.4, any changes in mental
status, weakness, difficulty speaking, changes in vision, or any
other concern.
Followup Instructions:
Please see Dr. [**Last Name (STitle) **] in 4 weeks with a CT scan of your head.
Call [**Telephone/Fax (1) 2992**] to schedule the scan and the appointment.
Please follow up with your primary care physician [**Last Name (NamePattern4) **] 6 months
regarding a lung nodule revealed on CT scan of your chest.
Please keep the following appointments:
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2148-1-1**]
1:45
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2148-1-1**]
3:00
Completed by:[**2147-12-19**]
|
[
"E884.3",
"V45.2",
"272.0",
"331.3",
"433.10",
"852.20",
"599.0",
"V10.85"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5525, 5622
|
2942, 4144
|
285, 292
|
5692, 5716
|
2045, 2919
|
5906, 6545
|
1556, 1809
|
4270, 5502
|
5643, 5671
|
4170, 4247
|
5740, 5883
|
1238, 1311
|
1824, 2026
|
237, 247
|
320, 678
|
1149, 1215
|
1327, 1540
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,355
| 161,709
|
34149
|
Discharge summary
|
report
|
Admission Date: [**2113-10-28**] Discharge Date: [**2113-11-1**]
Date of Birth: [**2074-4-21**] Sex: M
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
right internal jugular catheter placement
Esophagogastroduodenoscopy with botox injection of pylorus
History of Present Illness:
39yo male with pmhx of T1DM complicated by gastroparesis who has
been almost constantly in the hospital for the past 6 months.
The patient was transferred to [**Hospital1 18**] in the middle of [**Month (only) 216**]
[**2113**] after 6 week hospitalization at [**Hospital1 189**], he was then
discharged on [**2113-9-27**] and was re-admitted to [**Hospital1 189**] the
following day. He was discharged from that hospitalization the
day prior to admission at [**Hospital1 18**]. The patient says that he was
having a UGIB at [**Hospital1 189**], but he did not have any treatment and
no scopes. He says that "they were not doing anything for me
there," so when he was discharged, he had a hamburger, which he
tolerated fine. He then had a tomato soup for dinner, which was
also well tolerated. He then was up all night having nausea and
vomiting and came to the [**Hospital1 18**] ED today. He says that he has
abdominal pain which is radiating to his back. He says that this
episode is very similar to prior episodes. In the ED, he did
endorse burning chest pain but he denied this on examination in
the MICU.
In the ER, the patient had an EKG which revealed sinus
tachyardia. He had a CXR to confirm line placement after a RIJ
was placed. He received 5L in the ED but only had 200cc of urine
out (per patient report). He received pantoprazole for GERD. He
also received insulin. His troponin was negative.
In the ED, initial VS were:
96.6 141 132/94 16 100% RA
11:18 133 153/101 22 100%
11:41 10 118 151/84 22 100%
12:25 10 140 149/91 24 100%
12:44 8 138 22 100%
13:10 126 163/107 24
14:00 10 136 153/103 16 100%
15:13 9.5 97 124 149/91 14 100%
15:59 8 124 125/84 14 100%
17:15 8 98.3 120 120/80 14 100%
17:15 8 98.3 120 120/80 14 100%
On arrival to the MICU, the patient appeared in pain. He was
having hiccups. He was alert, oriented and appropriate.
Past Medical History:
# T1DM - w/ recurrent DKA and diagnosed 17 yrs ago, being
evaluated for pancreas transplant
# Multiple recent hospitalizations for severe gastroparesis
# CAD s/p multiple stents and multiple MIs (one secondary to
cocaine abuse), last in [**2104**]
# Depression
# Benign Hypertension
# Diabetic nephropathy
# Hyperthyroidism
# Hyperlipidemia
# GERD
# hiatal hernia
# Erosive esophagitis
Social History:
Recently separated from his wife. On disability. Denies h/o
smoking or etoh use. Uses marijuana btu stopped 2 weeks ago,
smokes [**2-6**] joints a day. H/o cocaine use, none since [**2101**]. No
other illicit drugs.
Family History:
One cousin with diabetes.
Physical Exam:
ADMISSION EXAM
Vitals: T:98.7 BP: 176/98 P: 130 R: 21 O2: 100%
General: Alert, oriented, appears in pain but in no acute
respiratory distress.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: RIJ
CV: Regular rhythm, tachycardia, 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: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred
DISCHARGE EXAM:
Afebrile, stable vital signs, normotensive.
General: Alert, oriented, lying in bed in no apparent distress
Neck: RIJ in place, no erythema
Chest: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, nontender, non-distended, bowel sounds present,
no organomegaly
Ext: IV line R anterior shoulder. warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema
Pertinent Results:
ADMISSION STUDIES
[**2113-10-28**] 11:50AM BLOOD WBC-6.9 RBC-4.74 Hgb-13.9* Hct-41.0
MCV-87 MCH-29.4 MCHC-34.0 RDW-13.6 Plt Ct-148*
[**2113-10-28**] 11:50AM BLOOD Neuts-81.2* Lymphs-11.2* Monos-6.9
Eos-0.4 Baso-0.3
[**2113-10-28**] 06:42PM BLOOD PT-11.5 PTT-33.0 INR(PT)-1.1
[**2113-10-28**] 11:50AM BLOOD Glucose-398* UreaN-9 Creat-0.8 Na-136
K-3.3 Cl-92* HCO3-28 AnGap-19
[**2113-10-28**] 11:50AM BLOOD ALT-18 AST-15 AlkPhos-105 TotBili-0.6
[**2113-10-28**] 11:50AM BLOOD Lipase-9
[**2113-10-28**] 11:50AM BLOOD cTropnT-<0.01
[**2113-10-28**] 11:50AM BLOOD Albumin-3.6 Calcium-7.9* Phos-2.4* Mg-1.7
[**2113-10-28**] 12:04PM BLOOD Type-ART Temp-36.9 pO2-103 pCO2-30*
pH-7.56* calTCO2-28 Base XS-5 Intubat-NOT INTUBA
[**2113-10-28**] 12:02PM BLOOD Lactate-1.3
[**2113-10-28**] BLOOD CULTURE X2 PENDING
[**2113-10-28**] CXR : Multiple AP chest radiograph demonstrates a right
internal jugular catheter terminating in the low SVC. The left
PICC is no longer present. There is no pneumothorax. The lungs
are clear. The cardiomediastinal silhouette is normal.
INTERVAL/DISCHARGE STUDIES:
[**2113-10-29**] 09:54AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-2* pH-8.5* Leuks-NEG
[**2113-10-29**] 09:54AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2113-10-29**] 09:54AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2113-10-29**] 09:54AM URINE Mucous-RARE
[**2113-10-29**] 9:54 am URINE Source: CVS.
**FINAL REPORT [**2113-10-30**]**
URINE CULTURE (Final [**2113-10-30**]): <10,000 organisms/ml.
[**2113-10-30**] 07:30AM BLOOD %HbA1c-8.8* eAG-206*
EGD REPORT [**2113-10-31**]:
Findings: Esophagus:
Mucosa: Diffuse moderate erythema was noted in the esophagus
consistent with moderate esophagitis. Streaks of white plaques
were noted, which had the appearance of [**Female First Name (un) **]. Cold forceps
biopsies were performed for histology at the middle third of the
esophagus.
Stomach:
Contents: A significant amount of undigested food was noted in
the stomach consistent with history of gastroparesis.
Mucosa: Normal mucosa was noted in the stomach. 4 cc of Botox
was injected (1 cc in each quadrant) at the pylorus given
history of severe gastroparesis.
Duodenum:
Mucosa: Normal mucosa was noted in the bulb.
Impression: Diffuse moderate esophagitis with streaks of plaques
with appearance suggestive of [**Female First Name (un) **]. (biopsy)
Food in the stomach
Normal mucosa in the stomach. 1cc of botox injected into each
quadrant of pylorus (total of 4ccs) (injection)
Otherwise normal EGD to duodenal bulb
Recommendations: Follow up biopsy results from esophagus.
Recommend empiric fluconazole for treatment.Continue management
from inpatient GI team.
[**2113-11-1**] 05:18AM BLOOD WBC-8.1 RBC-4.25* Hgb-12.6* Hct-36.9*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.0 Plt Ct-180
[**2113-11-1**] 05:18AM BLOOD Glucose-285* UreaN-6 Creat-0.7 Na-135
K-4.5 Cl-97 HCO3-32 AnGap-11
Pathology Report Tissue: GI BX (1 JAR) Procedure Date of
[**2113-10-31**]
Report not finalized.
PENDING AT DISCHARGE:
1) Blood cultures x2
2) Pathology of EGD biopsy
Brief Hospital Course:
Mr [**Known lastname 12130**] is a 39yo male with pmhx T1DM, CAD, gastroparesis,
pancreatitis and hx of frequent DKA presenting with
nausea/vomiting, tachycardia and abdominal pain.
ACTIVE ISSUES:
# Tachycardia: Patient initially admitted to ICU for narrow
complex, sinus tachycardia, likely multifactorial including
dehydration, possible pancreatitis, abd pain, this improved with
IV boluses. He was initially admitted to the MICU for
tachycardia to 140s, which improved to the 120s with 4L NS and
then to the 110s with 2 more liters.
#Gastroparesis: Patient hospitalized frequently for
gastroparesis. The patient's home medications from the prior
hospitalizations include Zofran and Reglan, which per prior
discharge summaries, he has not taken in the past because he
says that it does not help. Patient continued on Reglan and
Zofran. Gastroenterology was consulted regarding options for
treatment and performed EGD with Botox injections of the
pyloris, as patient reported good results with that in the past.
A nutrition consult was placed as patient has not been compliant
with diet. Patient was educated and given handouts that explain
diet. He was put on a clear liquid diet and advanced to regular
diet by day of discharge.
# ?Esophageal Candidiasis: EGD findings were concerning for
[**Last Name (LF) 78719**], [**First Name3 (LF) **] patient was started on daily fluconazole for
empiric treatment until biopsy results return. Risk factors for
this patient are his diabetes. HIV testing as an outpatient may
be warranted.
# Abdominal pain: Patient presented with abdominal pain.
Initial differential included pancreatitis, DKA, PUD,
gastroparesis. Patient stated that pain was compatible with
usual pancreatitis pain. Lipase low on admission, but likely
due to 'burnt-out' pancrease with little parenchyma left to
generate elevation in lipase. Pain also may have been secondary
to gastroparesis and vomiting prior to admission. Patient was
treated conservatively with clear liquid diet and advanced as
tolerated.
CHRONIC ISSUES:
# Diabetes: Patient did not have signs of DKA on admission
without a gap and with normal blood sugars. The patient was
initially continued on his home Lantus sliding scale, half dose
lantus while NPO. [**Last Name (un) **] was consulted for poor blood sugar
control on current regimen and he was discharged on an adjusted
regimen.
#) CAD: The patient had no active CP on admission. His troponins
were negative. His EKG did not show signs of acute ischemia.
Continued home metoprolol, lisinopril and simvastatin.
#) Depression: Continued home Cymbalta. Social Work saw patient
for coping with multiple stressors and frequent
hospitalizations.
#) Chronic normocytic anemia, possibly ACD vs anemia secondary
to acute blood loss: -Early this admission his HCT dropped from
39-->35 earlier this admission. Likely due to dilution from IV
hydration, but may also have slow GI bleed (blood apparently
observed in vomit at OSH). There were no signs of active
bleeding here, and patient hemodynamically stable. Patient
remained clinically stable by day of discharge.
TRANSITIONAL ISSUES:
1) HIV testing given finding of esophageal candidiasis.
2) Patient did not have his appointments finalized by time of
discharge, and was instructed to have close follow up with Dr.
[**Last Name (STitle) 78720**] for his diabetes and Dr. [**Last Name (STitle) 76850**] his PCP.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 5 mg PO DAILY
hold for SBP < 90
2. Gabapentin 600 mg PO TID
3. Duloxetine 30 mg PO DAILY
4. Glargine 25 Units Breakfast
Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Metoprolol Tartrate 25 mg PO BID
hold for SBP < 90, HR < 55
6. Omeprazole 20 mg PO Q12H
7. Metoclopramide 10 mg PO QIDACHS
8. Nortriptyline 25 mg PO HS
Discharge Medications:
1. Duloxetine 30 mg PO DAILY
2. Gabapentin 600 mg PO TID
3. Glargine 25 Units Breakfast
Glargine 25 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Lisinopril 5 mg PO DAILY
hold for SBP < 90
5. Metoclopramide 10 mg PO QIDACHS
6. Metoprolol Tartrate 25 mg PO BID
hold for SBP < 90, HR < 55
7. Nortriptyline 25 mg PO HS
8. Fluconazole 200 mg PO Q24H
RX *fluconazole [Diflucan] 200 mg 1 tablet(s) by mouth daily
Disp #*28 Tablet Refills:*0
9. Omeprazole 20 mg PO Q12H
10. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: gastroparesis, diabetes type I, uncontrolled; candidal
esophagitis
Secondary: hypertension, coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a gastroparesis flare (sluggish stomach).
You were evaluated by the GI team and had an endoscopy with
botox injection, which provided relief. You were able to
tolerate small and frequent meals. It is very important to
adjust your eating habits to prevent further flares.
The diabetes team was also involved in your care given high
blood sugars. You were provided with a new insulin scale. You
should follow-up with [**Last Name (un) **] Diabetes for further care.
It was also discovered that you had fungus in your esophagus.
You will take a medication called fluconazole for this
condition.
Followup Instructions:
****Please continue to contact your primary diabatologist, Dr
[**Last Name (STitle) 78721**] office([**Telephone/Fax (1) 78722**]) until you are able to reach them to
book a follow up appt within 2 days of discharge (or as close as
you can).
***It is also recommended you follow up with your Primary Care
Doctor, Dr [**Last Name (STitle) 76850**] ([**0-0-**]) within a week of discharge to
discuss your inpatient stay. Please call them once you are home
to arrange an appt.
Department: GASTROENTEROLOGY
When: TUESDAY [**2113-12-5**] at 10:40 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Please consider making an appointment with the below GI provider
at [**Name9 (PRE) **] for further evaluation of gastroparesis therapies
if you would like more opinions:
[**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **]
[**Hospital3 27447**] Center
Gastroenterology
One [**Street Address(1) 78723**]
[**Country 1684**], [**Numeric Identifier 78724**]
Phone: ([**Telephone/Fax (1) 78725**]
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2113-11-2**]
|
[
"785.0",
"250.43",
"414.01",
"250.63",
"412",
"V85.30",
"401.1",
"311",
"278.00",
"V45.82",
"583.81",
"272.4",
"357.2",
"112.84",
"362.01",
"285.9",
"276.51",
"250.53",
"530.81",
"536.3",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.29",
"45.16",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
11791, 11797
|
7259, 7442
|
286, 389
|
11966, 11966
|
4078, 7173
|
12758, 14148
|
2945, 2972
|
11187, 11768
|
11818, 11945
|
10701, 11164
|
12117, 12735
|
2987, 3604
|
3620, 4059
|
7187, 7236
|
10396, 10675
|
231, 248
|
7457, 9295
|
417, 2287
|
11981, 12093
|
9311, 10375
|
2309, 2696
|
2712, 2929
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,003
| 189,234
|
47552
|
Discharge summary
|
report
|
Admission Date: [**2116-7-23**] Discharge Date: [**2116-8-6**]
Date of Birth: [**2057-3-17**] Sex: M
Service: MEDICAL
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
status post total knee replacement on [**7-23**] with a past
medical history notable for atrial fibrillation, diabetes,
non-ischemic cardiomyopathy, and chronic renal insufficiency,
who was transferred to the Medicine unit on [**7-28**]. Briefly,
complicated by intraoperative hypotension and atrial
fibrillation with rapid ventricular rate. The patient was
initially treated with esmolol drip that did not achieve
effective rate control. He required increasing
Neo-Synephrine doses to maintain his blood pressure. At this
time, an intraoperative transesophageal echocardiogram was
performed, revealing severe global ventricular hypokinesis
discontinued, and the patient was given 150 mg bolus followed
by 1 mg/minute of amiodarone. An arterial line was placed at
that time. Following the procedure, the patient was
transferred to the Post-Anesthesia Care Unit with full
monitoring, and better rate control was achieved. A
transthoracic echocardiogram was done at this time, since the
previous transesophageal echocardiogram had also been
suggestive for a left ventricular thrombus. However, the
transthoracic echocardiogram ruled out a left ventricular
thrombus.
Mr. [**Known lastname **] remained in the Surgical Intensive Care Unit over the
next five days, until transfer on [**2116-7-28**]. His Surgical
Intensive Care Unit course was most notable for management of
fluid overloaded status complicated by a rising creatinine
level. On [**7-25**], the patient was started on dobutamine to
increase cardiac index, while continuing to manage fluid
status with lasix 80 intravenously. His creatinine was 1.9,
however, and Renal recommended diuresing with caution due to
probable pre-renal state.
The following day, [**7-26**], his creatinine was 1.4, and more
aggressive diuresis was pursued due to continued increase in
his central venous pressures. His creatinine continued to
trend down to 1.1 on [**7-28**], allowing for continued diuresis,
but the patient has remained in volume overload state. His
last recorded Swan creatinine readings on [**7-27**] were pulmonary
arterial pressure of 60/31, central venous pressure 14,
cardiac output 6.5, cardiac index 3.11, systemic vascular
resistance 794.
Throughout the patient's course in the Surgical Intensive
Care Unit, his rate and rhythm were managed with Digoxin,
Lopressor and Coumadin. However, he frequently remained
tachycardic. On [**7-28**], when he was transferred to the
Medicine team, he was still in volume overloaded state, in
atrial fibrillation, with mildly impaired renal function.
PHYSICAL EXAMINATION: His examination on transfer, showed
vitals of a current temperature of 99.3, T-max 102.9, heart
rate 98, respiratory rate 16, blood pressure 117/68. His
neck showed markedly increased jugular venous pressure,
approximately 16 cm. His cardiovascular examination revealed
an irregularly irregular rhythm, no murmurs. His lungs had
inspiratory crackles at the left base, decreased breath
sounds at the right base. His abdomen had hypoactive bowel
sounds, was soft and nontender. His left leg was in the
exercise machine. His right leg was cool, with trace tense
edema.
LABORATORY DATA: Glucose 192, sodium 135, BUN 38. White
count slightly elevated at 12.9, hematocrit 30.0, platelets
251. He had an INR of 2.5. His calcium was also a little
bit low at 7.4. A portable chest x-ray on [**7-28**] revealed a
linear opacity at the right base, consistent with
atelectasis. Previously, on [**7-25**], he had also received a
portable chest x-ray which revealed a patchy nonspecific
increased density at the right base.
HOSPITAL COURSE: His most active issues included atrial
fibrillation, for which he was managed on Lopressor 50 twice a
day, Digoxin .25 once a day. His Warfarin was decreased to 2.5
once a day. Due to his persistent volume overload status, he was
switched to intravenous lasix starting at 40 twice a day.
On [**7-29**], the following day, he was running low-grade fevers.
His white count was elevated to 22.8. At that point, gout
was suspected, and the patient was started on colchicine as
well as Toradol. In addition, he continued to be markedly
volume overloaded. His lasix was increased to 80 every
morning and 40 every evening intravenously. The R ankle pain
responded to the above treatment.
In the early morning of [**7-30**], the patient was complaining of
chest pain, at which point cardiac enzymes were sent for a
possible myocardial infarction, which eventually all came
back negative. Later that day, his gout was showing
significant improvement on colchicine and Toradol. In
addition, cardiovascularly, he was continued to be managed on
intravenous lasix at 80 every morning and 40 every evening.
His Lopressor was decreased to 25 mg twice a day. In
addition, due to the persistent volume overloaded status,
Natrecor drip was added at 0.01 mcg/kg/minute for seven days.
On [**7-31**], due to some elevated finger sticks, his NPH was
started at 10 units every morning, 4 units every evening,
along with the insulin sliding scale. In addition, he was
started on iron supplementation due to the discovery that he
was markedly iron deficient. In general, however, on the
30th, he showed some signs of clinical improvement, but
continued diureses was needed, and his lasix was increased
further to 120 intravenously twice a day, as well as
Zaroxolyn was added at 5 mg one time a day by mouth. Toradol
60 mg intravenously x 1 was given for his gout, and he was
also started on Motrin 800 mg three times a day.
He continued to improve the next day, [**8-1**], putting out
almost 4 liters from the day before, so his lasix was
decreased to 80 once a day intravenously. On [**8-2**], he was
slightly hypotensive, so his Zaroxolyn was held, and his
lasix was continued at 40 twice a day. His NPH was also
increased, and he was switched from ibuprofen to naproxen per
the patient's request.
The patient continued to improve clinically, with daily
impressive diuresis and improved fluid volume overloaded
status. On [**8-4**], he complained of tremendous
itchiness in his right knee, at which point it was thought
that he had developed some cellulitis. Cephalexin 250 mg by
mouth every six hours was started. In addition, his
Lopressor was discontinued, the Natrecor was discontinued at
this point due to very impressive continued diuresis. His
lasix was changed to 80 mg by mouth once daily, and
metolazone was restarted at 5 mg by mouth once daily. In
addition, his NPH was increased to 14 units in the morning, 8
units in the evening.
On [**8-5**] in the morning, he complained of worsening pruritus,
for which eventually he was diagnosed by a Dermatology
consult as having a drug reaction, thought to be due to
colchicine. Colchicine was discontinued, and betamethasone
cream was started. In addition, the antibiotics were also
discontinued, and he was started on Atarax as needed for
itchiness.
The patient is being discharged in stable condition, with the
following diagnoses:
1. Non-ischemic cardiomyopathy
2. Atrial fibrillation
3. Insulin-dependent diabetes
4. Chronic renal insufficiency
5. Previous history of arthritis
6. Total knee replacement status post [**2116-7-23**]
7. Iron-deficiency anemia
8. Gout
For emphasis: His CHF will be managed with digoxin, lasix and
metolozone and an angiotensin receptor blocker given the possible
association of the rash to the ACE-I although we feel that the
colchicine was the more likely culprit. Consideration can be
given to starting a beta blocker when the patient is euvolemic.
For atrial fibrillation he was be maintanined on digoxin for rate
control and coumadin for stroke prohylaxis. Will hold aspirin
given his anticoagulation with coumadin.
For gout he will c/w naprosyn prn. He should be started on
allopurinol as an outpatient in ~ 4 weeks after the acute flare
completely resolves. At that time he should be placed on
standing dose naprosyn as not to precipitate a gouty flare. Of
note his uric acid was 10.5 and he has bilateral elbow tophi.
The right sided crackles on exam are likely atelectasis vs.
residual CHF.
DISCHARGE MEDICATIONS:
1. Pantoprazole 40 mg once daily
2. NPH 14 units in the morning and 8 units in the evening
Regular 10 units qam standing
3. Insulin sliding scale starting at blood sugar of 125
4. Zolpidem tartrate 5 to 10 mg by mouth once daily as
needed
5. Lorazepam 1 mg by mouth every four to six hours as needed
6. Capsaicin 0.025% three times a day
7. Digoxin 0.25 mg by mouth once daily
8. Gabapentin 300 mg by mouth every morning, 600 mg by mouth
every evening
9. Tylenol 325 to 650 mg by mouth every four to six hours
as needed
10. Aluminum magnesium hydroxide simethicone 15 to 30 ml by
mouth daily at bedtime as needed
11. Docusate sodium one capsule by mouth twice a day
12. Bisacodyl 10 mg per rectum once daily
13. Ferrous sulfate 325 mg by mouth twice a day
14. Naproxen 375 mg by mouth every eight hours as needed
15. Warfarin 4 mg by mouth once daily
16. Metolazone 5 mg by mouth once a day
17. Lasix 80 mg by mouth once daily
18. Lactulose 30 ml by mouth every eight hours as needed
19. Valsartan 80 mg po qd
20. Morphine sulfate 15 to 30 mg by mouth every four to six
hours as needed
21. Hydroxyzine HCl 25 mg by mouth every four to six hours
as needed
22. Betamethasone Bipro 0.05% ointment four times a day
Follow up at [**Company 191**] [**2116-9-4**], ortho [**9-3**] with Dr. [**Last Name (STitle) **]
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern1) 100514**]
MEDQUIST36
D: [**2116-8-5**] 23:14
T: [**2116-8-6**] 01:21
JOB#: [**Job Number 100515**]
|
[
"250.00",
"274.0",
"427.31",
"280.9",
"715.95",
"593.9",
"780.39",
"425.4",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.54",
"42.23",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8369, 10005
|
3832, 8346
|
2788, 3812
|
167, 2765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,018
| 139,528
|
3362
|
Discharge summary
|
report
|
Admission Date: [**2161-12-20**] Discharge Date: [**2161-12-23**]
Date of Birth: [**2107-6-7**] Sex: M
Service: MEDICINE
Allergies:
Motrin / Iodine; Iodine Containing / Naprosyn
Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization and primary stent to distal RCA
History of Present Illness:
54yo man with pmh significant for CAD, h/o CABG [**2158**] (LIMA and
SVG to LAD, SVG to OM, SVG to PDA) presented to the ED c/o
midsternal chest pain radiating between shoulders. Pain [**7-28**],
sudden onset lasting for 30 minutes prior to arrival at ED,
associated with SOB, without
N/V/diaphoresis/parasthesias/fever/chills. EMS administered NTG
with subsequent BP drop. ECG revealed 1 mm STE inferiorly with
hyperdynamic T waves. In cath lab, LMCA with mild disease, LAD
totally occluded after second septal, graft to LAD not engaged,
presumed occluded. Left cx widely patent, SVG occluded, RCA
with patent proximal stent, total occlusion of mid RCA with left
to right collaterals to PL. All SVG occluded (to OM) or
presumed occluded (LAD, RCA). RCA was stented with cypher
stent, PL was dilated with balloon. Pt transferred to unit for
monitoring.
Social History:
Patient lives with his wife
and two daughters.
Physical Exam:
T 98.9 BP 112/67 HR 76 RR 18 O2Sat 98% 2L; General appearance:
no apparent distress. Head and neck is nonicteric, mucosa
moist. No JVD. Lungs are clear to auscultation
bilaterally.
Cardiac examination: Distant heart sounds, regular rate and
rhythm. Abdomen is obese, nontender, and nondistended.
Extremities had no clubbing, cyanosis, or edema. Neurologic
examination: Is alert and oriented times three, grossly
nonfocal exam. Groin: cath site without hematoma or bruit.
Pertinent Results:
Cardiac Cath - COMMENTS:
1. Selective coronary angiography revealed a right dominant
system
with acute occlusion of the RCA. THe LMCA had mild diffuse
disease. The
LAD was totally occluded after the second septal. The composite
SVG-LIMA graft to the LAD was not engaged or seen on aortography
and is
presumed occluded. The LCx had a widely patent stent in the
native OM1
artery. The SVG to OM is stump occluded. THe RCA had a patent
proximal
stent and total occlusion of the mid RCA with left to right
collaterals
to the PL branch. The SVG to RCA is known occluded from prior
cath.
2. Hemodynamics revealed significantly elevated left and right
heart
filling pressures, pulmonary hypertension and preserved cardiac
index.
3. Left ventriculography was note performed.
4. Successful PCI of the RCA with a 3.5 x 33 mm Cypher DES,
post-dilated with a 4.0 mm balloon. Successful balloon
angioplasty of
the RPL with a 2.5 x 15 mm balloon.
FINAL DIAGNOSIS:
1. Acute inferior myocardial infarction, managed by primary PCI.
2. Elevated left and right heart pressures with preserved
cardiac
output.
3. Successful PCI of the RCA.
.
.
Echo - Conclusions:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is mildly dilated with mild
regional left
ventricular systolic dysfunction including severe hypokinesis of
the basal
half of the inferior and inferolateral walls. The remaining
segments contract
well. The ascending aorta is mildly dilated. The aortic valve
leaflets (3)
appear structurally normal with good leaflet excursion. Trace
aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild
to moderate ([**12-20**]+) mitral regurgitation is seen. There is mild
pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Left ventricular cavity enlargement with regional
systolic
dysfunction c/w CAD. Mild-moderate mitral regurgitation. Mild
pulmonary artery
systolic hypertension. Milldly dilated ascending aorta.
.
.
[**2161-12-20**] 10:51PM WBC-5.5 RBC-4.38* HGB-12.1* HCT-35.8* MCV-82
MCH-27.6 MCHC-33.8 RDW-13.0
Brief Hospital Course:
Pt was admitted and was taken to the cardiac catheterization lab
where he received a cypher stent to the RCA. His hospital
course was significant only for demonstrating several episodes
of junctional rhythm which responded to atropine. Routine post
myocardial infarction echo demonstrated an ejection fraction of
40 %. He was discharged to home to continue care with his
cardiologist on an outpatient basis.
Medications on Admission:
Aspirin 325 mg
Atorvastatin Calcium 80 mg
Metoprolol Tartrate 25 mg [**Hospital1 **]
Zetia 10 mg
Moexipril 7.5 mg [**Hospital1 **]
Celebrex 100 mg [**Hospital1 **]
Zoloft 100 mg
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Moexipril HCl 15 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
myocardial infarction
hypertension
hypercholesterolemia
gastro esophageal reflux disease
Discharge Condition:
stable
Discharge Instructions:
Adhere to 2 gm sodium diet
Followup Instructions:
1)Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2161-12-28**] 9:40
2)Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-1-5**] 1:20
3)Dr.[**Name (NI) 9388**] office will contact you to make an appointment
with him within the next several weeks
Completed by:[**2162-1-11**]
|
[
"311",
"410.71",
"729.1",
"530.81",
"V45.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.42",
"37.23",
"36.07",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
5449, 5455
|
4028, 4440
|
326, 384
|
5588, 5596
|
1855, 2803
|
5672, 6224
|
4668, 5426
|
5476, 5567
|
4466, 4645
|
2820, 4005
|
5620, 5649
|
1353, 1836
|
276, 288
|
412, 1273
|
1289, 1338
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,013
| 163,930
|
5709
|
Discharge summary
|
report
|
Admission Date: [**2112-10-11**] Discharge Date: [**2112-11-7**]
Date of Birth: [**2047-11-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Traumatic motor vehicle collision
Major Surgical or Invasive Procedure:
1. Placement of inferior vena cava filter.
2. Fluoroscopic control for vena cava filter placement.
3. ORIF Right posterior wall transverse acetabular fracture.
4. ORIF Right proximal tibia unilateral fracture.
5. Open reduction internal fixation of nasal orbital
ethmoid fracture.
6. Open reduction internal fixation of right zygomatic
maxillary fracture.
7. Open tracheostomy (#8 [**Last Name (un) 295**]).
8. Open G-tube (#24 Foley with 30 cc balloon).
History of Present Illness:
Pt is a 64M who drifted into a 10-[**Doctor Last Name **]; he was a restrained
driver with no LOC. The patient oringinally presented to [**Location (un) 21541**] hospital and was subsequently transferred to [**Hospital1 18**] for
further care in the setting of multiple bony fractures, a
splenic laceration, decreasing hematocrit, and questionable
aortic rupture. He was intubated and sedated on arrival in the
ED with a GCS of 3.
Past Medical History:
DMII
HTN
Depression
Hypothyroidism
Prostate CA
GERD
Hyperlipidemia
Social History:
Lives with wife on [**Hospital3 **]. Has three children. Son is an
internist at [**Hospital1 2025**]. Occasional EtOH, no tobacco, no recreational
drug use.
Family History:
Noncontributory
Physical Exam:
Vitals: 98.2/96.0 HR 78 BP 130/67 RR 20 SAT 100 on Trach Mask
WN/WD 64 y/o male in NAD
CV RRR, no m/r/g
Pulm CTA B with transmitted upper airway noise, no obvious r/r/c
Abd NT/ND, (+) BS, G-tube site C/D/I
Ext warm and well perfused, RLE in knee brace, no c/c/e
Neuro:
Overall improving strength and awareness
Eyes open spontaneously, will follow and show interest
Moves all four extremities spontaneously
Will follow simple commands
Babinski negative
Pertinent Results:
[**11-2**] MR HEAD W/O CONTRAST: IMPRESSION: 1. No acute
intracranial abnormality; sphenoid sinus blood is
redemonstrated. 2. No MR explanation for focal weakness.
.
[**10-31**] CXR: IMPRESSION: AP chest compared to [**10-30**]: 1. Tip
of the tracheostomy tube is within 2 cm over the carina. Lung
volumes are low, but lungs are grossly clear. Heart is mildly
enlarged but stable. Tip
of the left subclavian line ends in the upper superior vena
cava.
Tracheostomy tube is midline.
.
[**10-28**] EEG: IMPRESSION: Abnormal EEG due to diffuse theta slowing
with shifting asymmetries but no consistent or lateralized
slowing. The record is consistent with a moderate diffuse
encephalopathy.
.
[**10-26**] CT CHEST ABD PELVIS: IMPRESSION: 1. Trach tube with its
tip in the origin of the right main stem bronchus. 2.
Nondisplaced comminuted superior sternal fracture is unchanged.
3. Multiple bilateral rib fractures. 4. Right acetabulum
hardware is new since [**2112-10-11**]. 5. Grade 3 splenic laceration
without evidence of extravasation. 6. Unchanged appearance of
focal dissection at the aortic arch. 7. Slightly increased
bilateral pleural effusions (now moderate) and pericardial
effusion (small).
.
[**10-26**] CT HEAD: IMPRESSION: No intracranial bleed or
pneumocephalus but sinus fractures and likely hemorrhage in the
maxillary sinus; please refer to the today's dedicated CT of the
sinus for further details.
.
[**10-11**] CT Head: No ICH or edema. Complex facial fractures (nasal
fractures, anterior ethmoid wall, BL maxilla, and BL inferior
orbital)
.
[**10-11**] CTA chest/torso: Focal aortic dissection distal to left
subclavian artery. Minimal mediastinal hematoma. Small
intramural hematoma involving left common carotid artery. Grade
III splenic laceration. Right acetabular comminuted fracture.
.
[**10-13**] CTA chest (repeat): New large right pneumothorax occupying
approximately 50% of the hemithorax, with deep tissue air on the
right. Overall unchanged appearance of the focal dissection at
the aortic arch with outpouching measuring 5 x 10 mm,
representing possible small pseudoaneurysm just distal to the
left subclavian artery takeoff, unchanged since prior
.
[**10-19**] CXR: No PTX s/p chest tube removal; New left plate-like
atelectasis mid lung zone,
.
[**10-19**] RUQ US: GB is unremarkable, no wall edema or
pericholecystic fluid. Liver with fatty infiltration. no intra-
or extra-hepatic biliary dilatation. The portal vein is patent
.
[**2112-11-7**] CBC
White Blood Cells 15.0* K/uL
Red Blood Cells 2.98* m/uL
Hemoglobin 9.2* g/dL 14.0 - 18.0
Hematocrit 27.1* % 40 - 52
MCV 91 fL 82 - 98
MCH 30.8 pg 27 - 32
MCHC 33.8 % 31 - 35
RDW 16.8* % 10.5 - 15.5
Platelet Count 459*
.
[**2112-11-7**] 06:10AM BLOOD Glucose-89 UreaN-26* Creat-0.8 Na-133
K-3.8 Cl-101 HCO3-21* AnGap-15
Brief Hospital Course:
The patient was admitted to the trauma team after preliminary
evaluation. The patient was evaluated with CT scans, and
orthopedics was consulted for evaluation of the right acetabular
and RLE fractures.
Neuro: The patient was intubated and sedated on arrival to the
[**Hospital1 18**] ED with a GCS of 3. Follwoing extubation and cease of
sedation, his neurologic status has made steady improvement over
the course of his stay. He has become increasingly more aware
of his surroundings with now all four extremities moving
spontaneously, following of simple commands, and nodding yes to
simple questions. He is Babinksi negative. All head scans
(MRI, CT) have been nonfocal. His EEG was read significant only
for moderate diffuse encephalopathy.
.
CV: Vascular surgery was consulted for evaluation of aortic and
carotid injury; a carotid ultrasound was performed, as well as a
CTA. He was put on strict blood pressure and heart rate
restrictions, whcih were maintained with various
antihypertensives and beta blockers with good result. No
surgical intervention was deemed warranted. The patient's vital
sign parameters were liberalized when appropriate with good
result. At the time of discharge, Mr. [**Known lastname 22204**] was restarted on
his home PO blood pressure medication with a standing
breakthrough order for IV lopressor as necessary. His rate and
pressure were within normal limits.
.
Pulm: The patient was intubated and sedated for much of his ICU
stay. He failed to wean from the vent initially, and
subsequently had a tracheostomy placed with no complications and
good result. The patient was weaned as [**Known lastname 8337**] from the vent
to trach mask. He was routinely evaluated with chest x-rays for
pneumonia and other issues. The patient initially required a
chest tubefollowing his accident for pneumothorax secondary to
rib fractures. This chest tube was managed and removed in the
standard fashion without complication. At the time of
discharge, Mr. [**Known lastname 22204**] was satting 100 percent on 0.35 FiO2 trach
mask with no issues.
.
Prior to discharge, Mr. [**Known lastname 22204**] was evaluated by [**Hospital1 18**] Speech and
Swallow with the following summary:
SUMMARY: Mr. [**Known lastname 22204**] [**Last Name (Titles) 8337**] placement of the PMV with stable
vital signs and safe tracheal pressures, but made few attempts
to speak [**12-25**] his MS. The pt can wear the valve, but would
suggest wearing it with supervision at this point. I also
discussed with the MDs that the pt may have a cuff leak as I
attempted to inflate the cuff several times without success.
There was no concern for aspiration of oral or pharyngeal
secretions and he can likely tolerate an essentially cuffless
trach at this time.
.
RECOMMENDATIONS:
.
1. ALWAYS DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE!
.
2. Monitor O2 Sats / respiration while valve is in place.
.
3. Do not allow the patient to sleep with the valve in place.
.
4. PMV wear schedule is up to the discretion of the nurse
and/or respiratory therapist.
.
5. Remain NPO with continued tube feedings until pt's MS
improves further.
.
GI: Tube feeds were started when appropriate, and an open G tube
was placed as the patient was tube feed dependent initially.
The patient received motility agents such as Reglan when his
tube feed residuals were elevated with good result. Mr. [**Known lastname 22204**]
did stuggle intermittently with hypernatremia and osmotic
diarrhea, which was resolved by decreasing his tube strength to
[**1-24**] normal and giving multiple free water boluses. At the time
of discharge he was tolerating this regimen well and not
requiring supplemental boluses.
.
GU: The pt's urinary output was closely monitored; he received
colloid when appropriate, adn was diuresed when fluid
overloaded. His electrolyte and metabolic status was routinely
examined, adn treated if necessary. Heme: The patient's
hematocrit and coagulation profiles were monitored adn the pt
received transfusions as necessary. The patient had episodes of
epistaxis for which ENT was consulted; he received AFrin with
good result.
.
ID: The patient routinely spiked fevers, and was pan cultured
during these episodes. He had positive sputum cultures for
which he was put on antibiotics. He was routinely monitored for
c. diff, and other signs of infection. At one point, his right
ankle was noted to be erythematous, warm and edematous; ortho
was consulted, however the cellulitic appearance gradually
disappeared without treatment. Uric acid levels at that time
were normal. ID was consulted, and the patient was put on
prophylactic vanco for presumed c.diff infection as the patient
was having copious bowel movements.
.
Endo: The patient was put on an appropriate sliding scale
insulin regimen to maintain blood glucose control. He was
followed by the [**Last Name (un) **] diabetes clinic with excellent blood
sugar management.
.
Musculoskeletal: The patient's R acetabulum was pinned and put
in traction by orthopedics. A cast was put on his right wrist.
The patient went to the operating room for an ORIF of the pelvis
with ortho; for details, please see operative note. A wound vac
was placed to the right hip and was removed at POD 10.
.
Proph: The patient had an IVC filter placed and received DVT and
GI prophylaxis throughout his stay.
.
Other: The patient had multiple facial fractures which were
repaired surgically by the PRA/plastic surgery team. The
patient was put on prophylactic antibiotics when appropriate.
.
Medications on Admission:
Atenolol 50' cymbalta 30" diovan 80' doxazosin 4' elavil 100 QHS
glyburide 5" levoxyl 100mcg' neurontin 800" prilosec 20' zocor
20'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (un) **]: 5000 (5000)
units Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet [**Last Name (un) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
3. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Last Name (un) **]: One (1)
Appl Ophthalmic PRN (as needed).
4. Influenza Tri-Split [**2111**] Vac 45 mcg/0.5 mL Suspension [**Year (4 digits) **]:
One (1) ML Intramuscular ASDIR (AS DIRECTED).
5. Therapeutic Multivitamin Liquid [**Year (4 digits) **]: Five (5) ML PO DAILY
(Daily).
6. Bisacodyl 10 mg Suppository [**Year (4 digits) **]: One (1) Suppository Rectal
DAILY (Daily) as needed.
7. Docusate Sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: Ten (10) mL PO BID (2
times a day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
10. Ibuprofen 100 mg/5 mL Suspension [**Last Name (STitle) **]: Twenty (20) mL PO Q6H
(every 6 hours) as needed for fever.
11. Levothyroxine 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
treatment Inhalation Q6H (every 6 hours) as needed for wheezing.
14. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) treament
Inhalation Q6H (every 6 hours) as needed for wheezing.
15. Valsartan 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
16. Doxazosin 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
17. Atenolol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
18. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
19. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
20. Amitriptyline 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime).
21. Psyllium 1.7 g Wafer [**Last Name (STitle) **]: One (1) Wafer PO BID (2 times a
day).
22. Bacitracin Zinc 500 unit/g Ointment [**Last Name (STitle) **]: One (1) Appl
Topical TID (3 times a day).
23. Insulin Sliding Scale:
0-60 mg/dL [**11-24**] amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 6 Units
141-160 mg/dL 9 Units
161-180 mg/dL 12 Units
181-200 mg/dL 15 Units
201-220 mg/dL 18 Units
221-240 mg/dL 21 Units
241-260 mg/dL 24 Units
261-280 mg/dL 27 Units
281-300 mg/dL 30 Units
301-320 mg/dL 33 Units
321-340 mg/dL 36 Units
341-360 mg/dL 39 Units
26. Insulin Standing dose:
Glargine Q24 hrs 50 Units.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right acetabular fracture
Right tibial plateau fracture
Grade II splenic laceration
Left carotid hematoma
Type B focal aortic dissection vs. pseudoaneurysm
Discharge Condition:
Stable, to rehab
Discharge Instructions:
Please report to the ED for any of the following: shortness of
breath, chest pain, increased work of breathing, fever > 100.5
F, persistent nausea and vomiting, increasing abdominal pain,
increased drainage to your wound site or increasing redness, or
obvious signs of infection.
Take your medications exactly as prescribed.
Attend all follow up appointments as scheduled.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 519**], Trauma Surgery [**Hospital1 18**], in 2 weeks after
your discharge. Please call ([**Telephone/Fax (1) 22750**] to schedule an
appointment.
Follow up with Dr. [**Last Name (STitle) **].K. [**Doctor Last Name 1005**], Ortho Trauma [**Hospital1 18**], in 2
weeks after your discharge. Please call ([**Telephone/Fax (1) 2007**] to
schedule an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"807.09",
"518.81",
"401.9",
"244.9",
"808.0",
"861.21",
"873.20",
"E812.0",
"250.00",
"802.4",
"801.01",
"823.00",
"865.00",
"482.41",
"008.45",
"530.81",
"443.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"43.19",
"79.36",
"21.81",
"76.72",
"38.7",
"96.6",
"33.27",
"93.46",
"79.39",
"38.93",
"96.72",
"02.02"
] |
icd9pcs
|
[
[
[]
]
] |
13570, 13649
|
4904, 10463
|
350, 814
|
13849, 13867
|
2062, 3288
|
14290, 14825
|
1558, 1575
|
10646, 13547
|
13670, 13828
|
10489, 10623
|
13891, 14267
|
1590, 2043
|
277, 312
|
842, 1276
|
3514, 4881
|
1298, 1366
|
1382, 1542
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,682
| 154,763
|
27249
|
Discharge summary
|
report
|
Admission Date: [**2191-4-25**] Discharge Date: [**2191-5-9**]
Date of Birth: [**2116-9-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain and back pain
Major Surgical or Invasive Procedure:
s/p endo stent-grafting of descending thoracic aortic aneurysm
[**4-25**]
s/p right hemothorax with VATS washout [**4-28**]
History of Present Illness:
74 yo male with history of chest pain and back pain, followed by
syncope. He was taken to [**Hospital3 **] and CT of chest
revealed a 8 cm descending thoracic aneurysm. He was intubated
at the scene and taken to ER. He was hypotensive in the ER at
[**Hospital1 392**], and had fluid resuscitation and dopamine drip.
Transferred to [**Hospital1 18**] for definitive treatment. He was in Afib on
arrrival here.
Past Medical History:
Hypertension
Coronary Artery Disease
Hypercholesteolemia
Obesity
s/p AAA repair in past
Social History:
lives with wife
Physical Exam:
AFib 110 ST 110/40
decreased breath sounds right base
S1 S2 abd soft, NT, ND
2+ radials, bilat fem pulses
biphasic doppler bilat. DPs
Pertinent Results:
Echo [**4-25**]: Resting regional wall motion abnormalities include
global mild hypokinesis. The descending thoracic aorta is
markedly dilated. A large dissection flap is seen with mural
clot and extravasated blood. The dissection begins just distal
to the left subclavian artery. The distal end is beyond the
range of the TEE. 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. The
tricuspid valve leaflets are mildly thickened. Post procedure
(aortic endograft): Preserved biventricular systolic function.
Overall LVEF is 55%
CT [**4-27**]: 1) S/p stent graft repair of the descending thoracic
aorta. 2) Large thrombosed native thoracic aneurysm sac; within
it, there are multiple ill-defined hyperdensities, which may
represent calcium as they appear unchanged on the early arterial
and delayed-phase images. However, without a non-contrast phase,
it is difficult to definitively exclude endoleak. 3) Hyperdense
focus within the false lumen of the upper abdominal aorta,
adjacent to the distal portion of the graft stent, more
suspicious for a small endoleak, though again not completely
evaluated without a non-contrast phase. 4) Moderate residual
right-sided hemothorax with associated atelectasis. 5) Distended
gallbladder containing dependent sludge/stones. 6) S/p
infrarenal AAA repair. 7) Atrophic native kidneys with multiple
small likely simple cysts. 8) Left adrenal adenoma. 9)
Thrombosed saccular aneurysm of the left proximal common iliac
artery. Mild aneurysmal dilatation of the right iliac artery.
Preserved distal flow.
CXR 5/18:1. No pneumothoraces. 2. Right lower lobe focal
atelectasis versus developing pneumonia.
Abd U/S [**5-6**]: 1. Cholelithiasis without evidence of
cholecystitis. Normal bile ducts. 2. Limited visualization of
the liver without definite abnormality.
[**2191-4-25**] 03:20AM BLOOD WBC-18.4* RBC-3.54* Hgb-10.6* Hct-31.7*
MCV-90 MCH-30.0 MCHC-33.5 RDW-14.3 Plt Ct-142*
[**2191-5-8**] 05:17AM BLOOD WBC-9.6 RBC-3.55* Hgb-10.9* Hct-31.3*
MCV-88 MCH-30.6 MCHC-34.8 RDW-14.2 Plt Ct-298
[**2191-4-25**] 03:20AM BLOOD PT-14.5* PTT-29.3 INR(PT)-1.3*
[**2191-5-6**] 08:35AM BLOOD PT-14.2* PTT-24.9 INR(PT)-1.3*
[**2191-4-25**] 03:20AM BLOOD Glucose-285* UreaN-26* Creat-1.6* Na-143
K-3.3 Cl-113* HCO3-19* AnGap-14
[**2191-5-8**] 05:17AM BLOOD Glucose-121* UreaN-29* Creat-1.1 Na-145
K-3.7 Cl-106 HCO3-32 AnGap-11
[**2191-5-6**] 08:35AM BLOOD ALT-76* AST-56* AlkPhos-90 Amylase-93
TotBili-0.7
[**2191-5-5**] 04:15PM BLOOD Calcium-9.2 Phos-3.8 Mg-2.4
[**2191-4-25**] 03:20AM BLOOD Lipase-514*
[**2191-5-6**] 08:35AM BLOOD Lipase-103*
Brief Hospital Course:
Admitted on [**4-25**] and taken directly to OR for repair of rupturing
TAA. Underwent thoracic endo stent-grafting with Drs. [**Last Name (STitle) 914**]
and [**Name5 (PTitle) **]. Transferred to CSRU in stable condition on
epinephrine, Neo-Synephrine, insulin and propofol drips.
Remained intubated and on neo and insulin drips on POD #1 and
Swan removed. Beta blockade and gentle diuresis started.
Developed a right hemothorax and had bronchoscopy and chest tube
placement. This was ultimately evacuated by Dr. [**Last Name (STitle) **] via
right VATS and thoracoscopic washout on [**4-28**]. Lumbar drain
removed on POD #4 and a left chest tube was placed for a pleural
effusion. Tube feeds were advanced per nutritional needs.
Extubated on POD #7. BP managed with hydralazine and IV NTG
also. Chest tubes removed on [**5-3**] and off all drips. Transferred
to the floor on POD #10 to start increasing his activity level.
Had RUQ pain with slight rise in LFTs on [**5-6**]. KUB and
ultrasound revealed only some sludging in gall bladder. Cleared
for discharge to home with VNA services and the appropriate
follow-up appointments on post op day thirteen.
Medications on Admission:
unknown
? zocor
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily) for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. 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*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*4 * Refills:*1*
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*4 * Refills:*1*
10. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
s/p endo stent-grafting of descending thoracic aortic aneurysm
[**4-25**]
s/p right hemothorax with VATS washout [**4-28**]
Hypertension
Coronary Artery Disease
Hypercholesteolemia
s/p AAA repair in past
Discharge Condition:
good
Discharge Instructions:
may shower over incision and pat dry
no lotions, creams or powders on any incision
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 66826**] in [**12-20**] weeks
follow up with Dr. [**Last Name (STitle) 914**] (cardiac) in 4 weeks [**Telephone/Fax (1) 170**]
follow up with Dr. [**Last Name (STitle) **] (vascular) in 4 weeks
[**Telephone/Fax (1) 3121**]
Completed by:[**2191-6-3**]
|
[
"272.0",
"441.01",
"511.8",
"518.81",
"998.11",
"441.6",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.24",
"96.6",
"93.90",
"39.73",
"33.22",
"34.09",
"34.27",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
6759, 6809
|
3939, 5098
|
343, 469
|
7057, 7063
|
1223, 3916
|
7194, 7489
|
5164, 6736
|
6830, 7036
|
5124, 5141
|
7087, 7171
|
1066, 1204
|
279, 305
|
497, 907
|
929, 1018
|
1034, 1051
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,431
| 137,423
|
3244
|
Discharge summary
|
report
|
Admission Date: [**2170-3-14**] Discharge Date: [**2170-3-14**]
Date of Birth: [**2092-11-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Ciprofloxacin
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
cardiac catheterization. intra-aortic balloon pump placement
History of Present Illness:
Mr. [**Known lastname 3271**] is a 77 yo man with mulitvessel CAD s/p numerous
PCI, CHF (EF 30%), pulmonary hypertension, PVD, DM, who
presented to the ED with back pain since the night before,
consistent with his prior angina. Further questioning
impossible due to critical illness.
.
In the ED his presenting vitals were: HR 120, BP 77/11, RR 25.
He rapidly decompensated with a Wide-complex tachycardia,
hypotension, respiratory distress. At somepoint he had a
bradycardic arrest and was given atropine, he was intubated,
started on dopamine & norepinephrine drips and was taken to the
cath lab for concern of ACS given his positive troponin.
.
In the cath lab he had what appeared to be a chronic LCX
occlusion which appeared to be chronic and was unable to be
crossed with a wire. He had an IABP placed, no other
interventions occurred. He remained hypotensive in the cath lab,
requiring dopamine drip at 20 & levophed at 0.25. He was given
vancomycin + ceftriaxone for concern of urosepsis.
Past Medical History:
-CAD status post silent MI in [**2156**] (found to have 100% mid LAD
stenosis)
-Status post NSTEMI in [**2166-11-23**] -> staged percutaneous
interventions of multivessel disease. Left main distal 40%
lesion. LAD long 90% lesion in the mid vessel. Ostial left
circumflex had a 90% lesion; ostial right coronary artery had a
probable 70% lesion.
- Severe pulmonary HTN with a systolic PA pressure of 83 mmHg
and
a mean pressure of 53 mmHg. His overall LVEF was 40-45%. Status
post PCI of the left main into the left circumflex with
rotational atherectomy (drug-eluting stent). Status post
angioplasty of the left main/left circumflex stent and
rotational atherectomy and stenting of the ostial right coronary
with a drug- eluting stent. In [**2167-6-23**], cardiac cath
revealed moderate diastolic ventricular dysfunction, severe
pulmonary hypertension, and successful PCI of the LCx.
-DM2 x 34 yrs
-PVD s/p LLE bypass graft in [**2162**], with subsequent revision in
[**2164**].
-Pulmonary HTN
-Chronic LE neuropathy
-Chronic constipation
-h/o substance abuse - cocaine and EtOH
-h/o MRSA RLE abscess- [**2163**]
Social History:
The patient currently works as an instructor in the Finance
Department at [**University/College **]. For several decades, he worked in [**State 531**] at
the stock exchange. He left that job to retire and moved to the
[**Location (un) 511**] area. He is married; both he and his currentwife are
in their second marriages. They have five children between the
two of them, along with nine grandchildren. Mr. [**Known lastname 3271**]
describes himself as a former heavy smoker; he stopped about ten
years ago after his first heart attack. He indicated that he
never smoked cigarettes, only cigars. He did not believe that he
inhaled them on a regular basis. The patient is a recovering
alcoholic and also a former cocaine
abuser. However, he has not used either substance in nearly 20
years.
Family History:
Family history is remarkable for mother who died at age [**Age over 90 **] of
complications of diabetes. The patient's father died in his 60s
secondary to lung cancer; he was a smoker. Mr. [**Known lastname 3271**] has only
one sibling, a sister who is currently age 59. She was diagnosed
with lung cancer.
Physical Exam:
Critically ill. Balloon pump in place, intubated. vitals
unstable with hypotension and tachycardia. unable to examine
further.
Pertinent Results:
[**2170-3-14**] 01:12PM TYPE-ART PO2-85 PCO2-36 PH-7.02* TOTAL
CO2-10* BASE XS--21
[**2170-3-14**] 01:12PM GLUCOSE-348* LACTATE-10.3* NA+-134* K+-4.4
[**2170-3-14**] 01:10PM GLUCOSE-391* UREA N-39* CREAT-1.9* SODIUM-136
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-9* ANION GAP-25*
[**2170-3-14**] 01:10PM ALT(SGPT)-150* AST(SGOT)-197* CK(CPK)-1019*
ALK PHOS-77 TOT BILI-0.8
[**2170-3-14**] 01:10PM CK-MB-105* MB INDX-10.3* cTropnT-4.63*
[**2170-3-14**] 01:10PM CALCIUM-6.8* PHOSPHATE-5.5*# MAGNESIUM-1.9
[**2170-3-14**] 01:10PM WBC-43.1* RBC-3.72* HGB-11.1* HCT-35.6*
MCV-96 MCH-29.8 MCHC-31.2 RDW-13.6
[**2170-3-14**] 01:10PM NEUTS-89.0* LYMPHS-7.7* MONOS-3.0 EOS-0.1
BASOS-0.3
[**2170-3-14**] 01:10PM PLT COUNT-221
[**2170-3-14**] 01:10PM PT-21.1* PTT-137.3* INR(PT)-2.0*
[**2170-3-14**] 01:03PM TYPE-ART PO2-110* PCO2-21* PH-7.23* TOTAL
CO2-9* BASE XS--16
[**2170-3-14**] 01:03PM LACTATE-7.8*
[**2170-3-14**] 11:15AM TYPE-ART RATES-/14 TIDAL VOL-500 PEEP-5
PO2-62* PCO2-35 PH-7.18* TOTAL CO2-14* BASE XS--14 -ASSIST/CON
INTUBATED-INTUBATED
[**2170-3-14**] 11:15AM LACTATE-6.4*
[**2170-3-14**] 11:15AM O2 SAT-86
[**2170-3-14**] 10:16AM TYPE-ART RATES-/14 TIDAL VOL-500 O2 FLOW-100
PO2-125* PCO2-32* PH-7.15* TOTAL CO2-12* BASE XS--16
INTUBATED-INTUBATED VENT-CONTROLLED
[**2170-3-14**] 10:16AM HGB-13.0* calcHCT-39 O2 SAT-97
[**2170-3-14**] 09:38AM PH-7.39
[**2170-3-14**] 09:38AM GLUCOSE-271* LACTATE-6.7* NA+-136 K+-4.2
CL--102 TCO2-19*
[**2170-3-14**] 09:38AM freeCa-0.97*
[**2170-3-14**] 09:30AM GLUCOSE-278* UREA N-40* CREAT-1.8* SODIUM-135
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
[**2170-3-14**] 09:30AM estGFR-Using this
[**2170-3-14**] 09:30AM CK(CPK)-195*
[**2170-3-14**] 09:30AM cTropnT-0.27*
[**2170-3-14**] 09:30AM CK-MB-16* MB INDX-8.2*
[**2170-3-14**] 09:30AM CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-1.8
[**2170-3-14**] 09:30AM WBC-34.6*# RBC-4.57* HGB-13.7* HCT-41.9
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.5
[**2170-3-14**] 09:30AM NEUTS-78* BANDS-14* LYMPHS-6* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2170-3-14**] 09:30AM CALCIUM-8.8 PHOSPHATE-3.3 MAGNESIUM-1.8
[**2170-3-14**] 09:30AM WBC-34.6*# RBC-4.57* HGB-13.7* HCT-41.9
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.5
[**2170-3-14**] 09:30AM NEUTS-78* BANDS-14* LYMPHS-6* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2170-3-14**] 09:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL
[**2170-3-14**] 09:30AM PLT SMR-NORMAL PLT COUNT-210
[**2170-3-14**] 09:30AM PT-16.6* PTT-26.6 INR(PT)-1.5*
Brief Hospital Course:
Mr [**Known lastname 3271**] was transferred from the cath lab to the CCU in
critical condition. Shortly after arrival he went into PEA
arrest. He was unable to be resuscitated despite CPR, numerous
rounds of epinephrine, atropine, calcium, and bicarbonate. His
family was present and CPR was terminated at 1:30 PM. He died
at 1:32 PM. Autopsy was declined.
Medications on Admission:
Lipitor 80 mg daily
Plavix 75 mg daily
folic acid daily
Lasix 80 mg twice a day
Lantus insulin 20 units in the morning, 14 units in the evening
Humalog per sliding scale
Cozaar 100 mg daily
Toprol-XL 25 mg daily
spironolactone 25 mg daily
eyedrops daily
aspirin 325 mg daily
and stool softeners up to twice a day, iron daily
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
sepsis and shock
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"995.92",
"427.5",
"V58.67",
"305.63",
"599.0",
"414.01",
"V15.82",
"428.20",
"V45.82",
"V02.54",
"416.8",
"414.2",
"410.91",
"305.03",
"038.0",
"785.51",
"412",
"443.9",
"355.8",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"96.71",
"37.23",
"99.60",
"99.20",
"37.61",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7257, 7266
|
6485, 6849
|
321, 384
|
7326, 7335
|
3850, 6462
|
7387, 7393
|
3375, 3685
|
7225, 7234
|
7287, 7305
|
6875, 7202
|
7359, 7364
|
3700, 3831
|
272, 283
|
412, 1413
|
1435, 2551
|
2567, 3359
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,786
| 151,092
|
53679
|
Discharge summary
|
report
|
Admission Date: [**2138-7-14**] Discharge Date: [**2138-7-19**]
Date of Birth: [**2078-3-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa(Sulfonamide Antibiotics) / Wellbutrin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
[**2138-7-15**] CABG X2(LIMA->mLAD,SVG->PDA)AVR(mechanical 25 mm)
History of Present Illness:
This is a 60yo male with history of
dilated aortic root and aortic insufficiency. Serial
echocardiograms have shown worsening aortic insufficiency and
increasing left ventricular dimensions. Based upon
echocardiogram
findings, he has been referred for cardiac surgical evaluation.
He presents to [**Hospital1 18**] today for cardiac cath preop Bentall on
[**2138-7-15**] with Dr.[**Last Name (STitle) **].
Past Medical History:
- Short term memory loss s/p MVA
- Dilated Aortic Root with Aortic Insufficiency
- Hypertension
- Dyslipidemia
- Prostatism
- PTSD with Anxiety/Depression
- Obesity
- Sleep Apnea, wears CPAP
- Chronic Low Back Pain
- History of MVA
- History of renal stones
Past Surgical History
- Ureter surgery s/p renal stones.
Physical Exam:
Physical Exam
BP: 134/59 Heart Rate: 64 Resp. Rate: 18 O2 Saturation%: 97.
Height: 70.5inches Weight: 214 lbs
General: NAD, alert and oriented x 3, sitting in a chair.
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade III/VI diastolic
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x].
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: Left:
Carotid Bruit Right: + Left: +
Pertinent Results:
[**2138-7-14**] 03:19PM GLUCOSE-128* UREA N-20 CREAT-0.9 SODIUM-141
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-29 ANION GAP-11
[**2138-7-14**] 03:19PM WBC-6.7 RBC-4.84 HGB-13.9* HCT-42.5 MCV-88
MCH-28.7 MCHC-32.7 RDW-12.8
ECHO:
PRE-CPB:1. No spontaneous echo contrast is seen in the body of
the left atrium. No mass/thrombus is seen in the left atrium or
left atrial appendage. No thrombus is seen in the left atrial
appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal.
4. Right ventricular chamber size and free wall motion are
normal.
5. The aortic root is mildly dilated at the sinus level. The
sinuses of Valsalva are dilated.
6. The ascending aorta is mildly dilated.
7. There are three aortic valve leaflets. There is no aortic
valve stenosis. Severe (4+) aortic regurgitation is seen. The
aortic regurgitation jet is eccentric, directed toward the
anterior mitral leaflet.
8. Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB:
1. Well seated Mechanical valve with washing jets visible, no
paravalvular leak.
2. Preserved LV systolic function.
3. No sign of aortic dissection.
4. Mitral regurgitation and tricuspid regurgitation remained
trace.
Dr. [**Last Name (STitle) **] was notified in person of the results.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2138-7-15**] 12:11
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2138-7-15**] where the patient underwent Aortic
valve replacement with a 25-mm St. [**Male First Name (un) 923**]
mechanical valve. Reference #[**Serial Number 110221**]. Serial #[**Serial Number 110222**].
Coronary artery bypass grafting x2: Left internal mammary
artery to left anterior descending artery, and reverse saphenous
vein graft to the posterior descending artery.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable. Low dose beta blocker was initiated and
unable to be increased due to bordeline low systolic blood
pressure. The patient was gently diuresed toward the
preoperative weight. Coumadin therapy with heparin bridge was
initiated due to the placement of his mechcanical AVR. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD #4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home in good
condition with appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral q4h prn
headache
2. modafinil *NF* 100 mg Oral [**Hospital1 **]
3. Metoprolol Tartrate 50 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN prn
5. Multivitamins 1 TAB PO DAILY
6. Ibuprofen 800 mg PO Q8H:PRN pain
7. Pantoprazole 40 mg PO Q24H
8. Cetirizine *NF* 10 mg Oral daily
9. Tamsulosin 0.4 mg PO HS
10. Fluoxetine 20 mg PO DAILY
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Ibuprofen 800 mg PO Q8H:PRN pain
3. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg [**1-8**] tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*1
4. modafinil *NF* 100 mg Oral [**Hospital1 **] Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
hold tonights dose, thx
5. Multivitamins 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Tamsulosin 0.4 mg PO HS
8. Aspirin EC 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
9. Atorvastatin 10 mg PO DAILY
RX *atorvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
10. HYDROmorphone (Dilaudid) 2-4 mg PO Q3H:PRN pain
RX *hydromorphone 2 mg [**1-6**] tablet(s) by mouth every four (4)
hours Disp #*65 Tablet Refills:*0
11. Warfarin 2.5 mg PO DAILY16
Dose will be based on INR and determined by Dr. [**Last Name (STitle) **]
RX *warfarin 2.5 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
12. butalbital-acetaminophen-caff *NF* 50 mg ORAL Q4H PRN
headache
13. Cetirizine *NF* 10 mg Oral daily
14. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN prn
15. Furosemide 40 mg PO DAILY Duration: 5 Days
RX *furosemide 20 mg 2 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
16. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
RX *Klor-Con M20 20 mEq 20 mEq by mouth once a day Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
[**2138-7-15**] CABG X2(LIMA->mLAD,SVG->PDA)AVR(mechanical 25 mm)
Short term memory loss s/p MVA, Dilated Aortic Root with Aortic
Insufficiency, Hypertension, Dyslipidemia, Prostatism, PTSD with
Anxiety/Depression, Obesity, Sleep Apnea, wears CPAP, Chronic
Low Back Pain, History of MVA, History of renal stones, Ureter
surgery s/p renal stones
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 Right- healing well, no erythema or drainage.
Edema; trace lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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:
The following appointments have been made for you:
Your surgeon: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2138-8-21**] 1:00 in the [**Hospital **] medical office building,
[**Doctor First Name **], [**Hospital Unit Name **]
wound check [**2138-7-24**] at 10:45a in the [**Hospital **] medical office
building, [**Doctor First Name **], [**Hospital Unit Name **]
cardiologist: [**Doctor First Name 110223**] Butte [**2138-8-25**] at 4:00p
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 11992**] in [**4-10**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechcanical AVR
Goal INR 2.5-3.0
First draw [**2138-7-21**]
Results to Dr. [**Last Name (STitle) **] phone [**Telephone/Fax (1) 11992**] fax [**Telephone/Fax (1) 6808**]
Completed by:[**2138-7-19**]
|
[
"309.81",
"278.00",
"300.00",
"724.2",
"311",
"441.2",
"401.9",
"327.23",
"424.1",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.61",
"37.22",
"35.22",
"36.11",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7392, 7441
|
3671, 5189
|
318, 386
|
7830, 8081
|
1921, 3648
|
8922, 10017
|
5752, 7369
|
7462, 7809
|
5215, 5729
|
8105, 8899
|
1176, 1902
|
271, 280
|
414, 822
|
844, 1161
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,430
| 127,988
|
41161
|
Discharge summary
|
report
|
Admission Date: [**2110-3-7**] Discharge Date: [**2110-3-12**]
Date of Birth: [**2079-10-8**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Right arm pain
Major Surgical or Invasive Procedure:
[**2110-3-7**]
Right thoracostomy tube placement
[**2110-3-8**]
1. Irrigation and debridement of right open humerus
fracture.
2. Irrigation and debridement of open olecranon fracture.
3. Open reduction internal fixation of right humerus
fracture.
4. Open reduction internal fixation of right olecranon
fracture.
History of Present Illness:
30M s/p ten foot fall from tree and right arm injury. The
patient reports using a psychogenic drug called Salvia and
cannot
recall the full details of the event. Per med flight, he was
found lodged between a chainlink fense and cement structure and
had been in a tree ten feet above ground. He is complaining of
right arm pain, chest pain and abdominal pain. No head strike,
no loss of consiousness. Denies numbness or tingling.
Past Medical History:
none
Social History:
Lives with roommates, works at a hotel in [**Location (un) 86**] at the front
desk.
+ ETOH, + drugs no tobacco
Family History:
non contributory
Physical Exam:
Temp 97 HR 100 BP 94/50 RR 16
Constitutional: collar and backboard
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Neck is nontender
Chest: Clear to auscultation, equal breath sounds,
nontender
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, right upper quadrant tenderness but no
rebound or guarding
Extr/Back: Right upper extremity has normal pulses. There
is a 1.5 cm laceration at the mid humerus the lateral
aspect. At the left medial wrist there is a 5 cm laceration.
Again the pulses are intact. He is neurovascularly intact at
the left upper extremity.
Neuro: Speech fluent, he is awake alert oriented, nonfocal
Pertinent Results:
[**2110-3-7**] 05:30PM WBC-12.3* RBC-4.67 HGB-14.5 HCT-42.4 MCV-91
MCH-31.1 MCHC-34.3 RDW-13.1
[**2110-3-7**] 05:30PM PLT COUNT-206
[**2110-3-7**] 05:30PM PT-13.3 PTT-24.2 INR(PT)-1.1
[**2110-3-7**] 05:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2110-3-7**] 05:34PM GLUCOSE-448* LACTATE-2.3* NA+-132* K+-2.9*
CL--92* TCO2-23
[**2110-3-7**] 05:30PM UREA N-16 CREAT-1.7*
[**2110-3-7**] 05:34PM HGB-14.5 calcHCT-44
[**2110-3-7**] 10:35PM HCT-39.0*
[**2110-3-7**] CT Abd/pelvis :
1. Large grade IV liver laceration involving 25-75% of the right
liver lobe. No active extravasation or other overt vascular
injury identified.
2. Moderate hemoperitoneum.
3. Moderate right hemothorax with bibasilar contusions and right
basilar lung parenchymal laceration.
4. Only minimal residual right apical pneumothorax with right
chest tube
ending at the right lung apex.
5. Eighth through twelfth right rib fractures, some fractured at
more than
one site (segmental), which could predispose Flail chest.
Correlate
clinically.
[**2110-3-7**] Right humerus :
1. Minimally comminuted oblique fracture of the mid diaphysis of
the right
humerus.
2. Minimally comminuted but significantly distracted fracture of
the right
olecranon with extensive associated soft tissue injury raising
the concern of a compound injury. Correlate clinically.
[**2110-3-7**] Right wrist :
1. Right triquetral fracture with associated soft tissue
swelling.
2. Foreign bodies within the superficial soft tissues along the
ulnar aspect of the distal forearm just proximal to the left
wrist.
Brief Hospital Course:
On [**2110-3-7**], the patient was evaluated by the Trauma team in
the Emergency Room as well as the Orthopedic service. Following
placement of a right chest tube to relieve a tension
pneumothorax he was admitted to the TSICU on the Trauma service
for blunt trauma and intoxication and serial hematocrits in
light of his liver laceration. He continued to remain
hemodynamically stable and required no blood transfusions. On
[**2110-3-8**], he underwent ORIF of his right humerus and olecranon.
He tolerated the procedure well and returned to the TSICU in
stable condition. His pain was well controlled. On [**2110-3-9**],
his chest tube was removed with no residual pneumothorax. His
hematocrit was stable as were his hemodynamics and he was
transferred to the Trauma floor.
He continued to do well with adequate pain control. He is right
handed so the long arm cast makes tasks difficult for him but he
is adapting. He is walking independently without any abdominal
pain but still has right flank tenderness and bruising. He is
using his incentive spirometer effectively and his RA
saturations are 97%. He was seen by the Social Worker for
counselling due to his use of hallucinogenics and to evaluate
his coping mechanism. He was given appropriate information for
out patient follow up should he choose to seek further
counselling. He was discharged to home on [**2110-3-12**] and will
follow up with the Orthopedic surgeons in 2 weeks and the Trauma
service in [**1-24**] weeks.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Roxicet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
S/P Fall
1. Right tension pneumothorax
2. Right rib fractures [**8-4**]
3. Grade IV liver laceration
4. Open right humeral fracture.
5. Open right olecranon fracture.
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 after a serious fall with
multiple injuries.
* Your fall caused right rib fractures 9 thru 12 which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
* You also had a liverlaceration from your fall.
1. AVOID contact sports and/or any activity that may cause
injury to your abdominal area for the next 6-8 weeks.
2. If you suddenly become dizzy, lightheaded, feeling as if
you are going to pass out go to the nearest Emergency Room as
this could be a sign that you are having inernal bleeding from
your liver or spleen injury.
3. AVOID any blood thinners such as Motrin, Naprosyn,
Indocin, Aspirin, Coumadin or Plavix for at least 3-5 days
unless otherwise instructed by the MD/NP/PA.
* Your right arm fracture was repaired by the Orthopedic service
and you will follow up with them in 2 weeks. Do NOT bear any
weight on the right arm and keep it elevated.
* Do NOT drink alcohol or take ANY recreational drugs. Do not
drive a car while on narcotic pain medication and also with your
arm in a full arm cast.
* If you develop any symptoms that concern you please call your
doctor or return to the Emergency Room.
Followup Instructions:
Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment in 2 weeks.
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**1-24**] weeks.
Completed by:[**2110-3-12**]
|
[
"305.90",
"868.03",
"969.8",
"813.11",
"E854.8",
"861.22",
"812.31",
"E884.9",
"807.04",
"864.04",
"881.01",
"860.4",
"E849.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"79.31",
"34.04",
"79.32",
"79.61",
"79.62"
] |
icd9pcs
|
[
[
[]
]
] |
5468, 5474
|
3693, 5189
|
316, 643
|
5685, 5685
|
2064, 3670
|
8118, 8361
|
1280, 1298
|
5244, 5445
|
5495, 5664
|
5215, 5221
|
5836, 8095
|
1313, 2045
|
262, 278
|
672, 1108
|
5700, 5812
|
1130, 1136
|
1152, 1264
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,135
| 160,768
|
9241
|
Discharge summary
|
report
|
Admission Date: [**2126-10-24**] Discharge Date: [**2126-10-30**]
Date of Birth: [**2063-1-14**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 63 year old gentleman
who has a prior history of myocardial infarction in [**2122-2-17**] who underwent stent to his left anterior descending and
right coronary artery at the time with subsequent multiple
episodes of instant restenosis, requiring brachytherapy. The
patient underwent a routine stress test, which showed
reversible anterior ischemia and was referred to [**Hospital1 346**] for cardiac catheterization.
PAST MEDICAL HISTORY: Hypercholesterolemia. Status post
myocardial infarction. Status post multiple PCI.
Hypertension. Status post removal of colonic polyps. Status
post appendectomy. Status post removal of lipoma. Status
post removal of precancerous lesion from his back.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Accupril 40 mg p.o. q. Day.
2. Hydrochlorothiazide 25 mg p.o. q. Day.
3. Toprol XL 50 mg p.o. twice a day.
4. Verapamil SA 240 mg p.o. q. Day.
5. Aspirin 325 mg p.o. q. Day.
6. Plavix 75 mg p.o. q. Day.
7. Lipitor 40 mg p.o. q. Day.
8. Folic acid 1 mg p.o. twice a day.
9. Tums.
10. Multi-vitamin supplements.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2126-10-24**] and underwent
cardiac catheterization which showed left ventricular end
diastolic pressure of 17, which rose to 22 after the LV gram;
ejection fraction of 50 percent; 90 percent left main lesion
and patent stents in the left anterior descending, left
circumflex and right coronary artery. The patient was
referred to cardiac surgery for operative management. The
patient was taken to the operating room on [**2126-10-25**]
with Dr. [**Last Name (STitle) **] for coronary artery bypass graft times two;
left internal mammary artery to left anterior descending and
saphenous vein graft to ramus. Total cardiopulmonary bypass
time was 61 minutes; cross clamp time 44 minutes. The
patient was transferred to the Intensive Care Unit in stable
condition. The patient was weaned and extubated from
mechanical ventilation on his first postoperative evening.
On postoperative day number one, the patient was transferred
from the Intensive Care Unit to the regular part of the
hospital. The patient began ambulating with physical
therapy. The patient was started on low dose Lopressor. On
postoperative day number two, the patient's chest tubes and
pacing wires were removed without incident.
On postoperative day number three, the patient complained of
seeing flashing lights when he was trying to read. He had no
history of this sensation prior. An ophthalmology consult
was obtained. It was determined that the patient's blood
vessels in his eyes were normal. He had a posterior vitreous
detachment in the left eye which required no intervention and
was probably an old finding. They recommended that the
patient follow-up as needed. The patient was restarted on
ace inhibitor for hypertension control. By postoperative day
number four, the patient was able to ambulate 500 feet and
climb one flight of stairs with physical therapy. ON
postoperative day number five, the patient was cleared for
discharge to home.
CONDITION ON DISCHARGE: Temperature maximum of 100.3; pulse
87 and sinus rhythm; blood pressure 140/90; respiratory rate
16; oxygen saturation 95 percent on room air. The patient's
weight was 95.5 kg. Neurologically, the patient was awake,
alert and oriented times three. Cardiovascular: Regular
rate and rhythm without murmur or rub. Respiratory breath
sounds are decreased at bilateral bases without rhonchi,
wheezes or rales. Abdomen: Soft, nondistended, nontender.
Sternal incision was clean, dry and intact. Sternum is
stable. Right lower extremity vein harvest site with
significant ecchymosis in the right thigh, mildly tender to
palpation. No apparent hematoma. The incision was clean,
dry and intact.
LABORATORY DATA: White blood cell count of 10.9; hematocrit
of 28.3; platelet count of 316. Sodium of 140; potassium of
3.8; chloride 107; bicarbonate of 24; BUN 14; creatinine 0.7;
glucose 139.
DISPOSITION: The patient was discharged home in stable
condition.
DISCHARGE DIAGNOSES: Coronary artery disease.
Status post coronary artery bypass graft.
Hypertension.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q. Day times 7 days.
2. Potassium chloride 20 mEq p.o. q. Day times 7 days.
3. Colace 100 mg p.o. twice a day.
4. Zantac 150 mg p.o. twice a day.
5. Aspirin 325 mg p.o. q. Day.
6. Plavix 75 mg p.o. q. Day.
7. Lipitor 40 mg p.o. q. Day.
8. Dilaudid 2 mg tablets, one p.o. every four to six hours
prn.
9. Accupril 40 mg p.o. q. Day.
10. Toprol XL 150 mg p.o. q. Day.
The patient is to be discharged home in stable condition. He
is to follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
in one to two weeks. He is to follow-up with his
cardiologist, Dr. [**Last Name (STitle) **], in two to three weeks. He is to follow-
up with Dr. [**Last Name (STitle) **] in three to four weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2126-10-30**] 18:05:44
T: [**2126-10-30**] 21:26:14
Job#: [**Job Number 31718**]
|
[
"401.9",
"272.0",
"414.01",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.22",
"88.53",
"88.55",
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
4281, 4365
|
4388, 5396
|
1279, 3270
|
941, 1261
|
167, 597
|
620, 915
|
3295, 4259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,622
| 137,688
|
17350
|
Discharge summary
|
report
|
Admission Date: [**2163-6-3**] Discharge Date: [**2163-6-11**]
Date of Birth: [**2147-2-21**] Sex: M
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: This is a 16 year old male
transferred from outside hospital for further management of
gallstone pancreatitis and thyrotoxicosis.
This is a 16 year old male who presented to outside hospital
complaining of about two days of intermittent abdominal pain.
The patient states that he has had a two year history of
periodic midline/epigastric abdominal pain associated with
eating that usually lasts about forty-five minutes and
resolves spontaneously. On the two days prior to admission,
the patient had five out of ten pain after intake of a fatty
meal. The pain subsided with Mylanta and Riopan. The second
day he felt nauseous and had emesis, however, on the day of
admission, the patient felt better, ate some pancakes
followed by two cheeseburgers which led to the onset of ten
out of ten abdominal pain followed by emesis.
Review of systems is significant for dark green urine and
lighter stools at this time. At the outside hospital
Emergency Department, the patient had a pulse of 120, blood
pressure 166/90 and was found to be afebrile. His physical
examination was notable for an abdominal examination with
decreased bowel sounds, tenderness in the right upper
quadrant, left upper quadrant, epigastrium, no masses, no
rebound.
Laboratory data at that time significant for an elevated AST
of 322 and ALT 596, alkaline phosphatase 208, serum lipase
7500, total bilirubin 5.3. Chemistries notable for a glucose
of 164. White blood cell count was 20.6, hematocrit 49.6 and
platelet count 254,000.
The patient had right upper quadrant ultrasound that noted
common bile duct dilation, 8 millimeters with cholelithiasis,
however, no evidence of cholecystitis.
The patient was admitted to the outside hospital and treated
for pancreatitis. He had thyroid function tests done after a
persistent tachycardia and was noted to be profoundly
hyperthyroid with a T4 of 17.0 and T3 of 2.43, free T4 of
3.07 and undetectable TSH. The [**Hospital 228**] hospital course was
complicated by hypotension which led to an Intensive Care
Unit transfer. Subsequent to his diagnosis of
hyperthyroidism, he was seen by the endocrine service who
noted asymmetric and large thyroid consistent with Graves'
disease and he was started on PTU iodine drops p.o. and
Propranolol with noted improvement in his heart rate. He had
an echocardiogram with an ejection fraction of approximately
57%, trace mitral regurgitation and tricuspid regurgitation
but no wall motion abnormalities. The patient was started on
antibiotics for a temperature of 101 in association with his
pancreatitis. The patient was complicated by a drop in his
hematocrit and brown stool that was guaiac positive. No
further workup was done at that time. He also had an episode
of volume overload likely secondary to the fluid
resuscitation which responded to Lasix and supplemental
oxygen therapy. There was further concern for possible
pulmonary embolism. The patient also had a positive D-dimer,
however, spiral CT was inadequate study and the patient had
negative lower extremity ultrasound.
PHYSICAL EXAMINATION: Subsequently, the patient was
transferred to the SICU for one night at the [**Hospital1 346**]. The patient's physical examination
at [**Hospital1 69**] showed a large male
in no apparent distress, height six feet four inches, weight
155 kilograms, temperature 100.8, pulse 96, blood pressure
142/76, respiratory rate 21, oxygen saturation 93% in room
air. His physical examination was significant for morbid
obesity. Pulmonary examination with decreased breath sounds
throughout. Mild left lower quadrant tenderness on abdominal
examination.
PAST MEDICAL HISTORY:
1. Status post left knee arthroscopy [**2163-5-20**], for knee
injury.
2. History of ear infections and sinus infections past one
to two years, followed at the outside hospital by ENT,
diagnosed with allergies and large adenoids requiring
surgical removal.
3. History of toenail infection.
4. Overweight since [**2159**], per family and pediatrician has
had significant weight gain since the age of eight or nine.
Last weighed by primary care physician in [**2162-10-19**], at
304 pounds.
5. No routine medical care, only episodic visits with the
pediatrician when ill and no prior laboratory results
available.
FAMILY HISTORY: Notable for thyroid disease in both sides of
the family. Father with deep vein thrombosis post motor
vehicle accident.
SOCIAL HISTORY: The patient has a complex social history.
Currently, he lives with grandmother who is his health care
decision maker. Father is currently incarcerated and has
been so since the year [**2160**]. The patient's mother is also
involved in his care and has custody of all his other
siblings. The patient has poor dietary habits, does not
exercise, is not sexually active, and does not consume
alcohol, use intravenous drugs or smoke tobacco.
MEDICATIONS ON ADMISSION: The patient was on no medications
at home. At the time of transfer, the patient was on:
1. Pepcid.
2. Propranolol 60 mg p.o. four times a day.
3. PTU 20 mg p.o. q8hours.
4. Clindamycin 600 mg q8hours.
5. Exacta two grams q8hours.
6. Lugol iodine solution 10 drops three times a day.
7. Milk of Magnesia.
8. Sleep enemas.
9. Zofran p.r.n.
10. Morphine p.r.n.
11. Benadryl p.r.n.
ALLERGIES: Unasyn which causes a rash consistent with
erythroderma. Demerol causes severe nausea.
HOSPITAL COURSE:
1. Gastrointestinal - Gallstone pancreatitis - On admission
to our hospital, the patient had a hematocrit of 32.0, normal
coagulation studies, and ALT, AST, alkaline phosphatase,
amylase and lipase and total bilirubin had all normalized.
He underwent endoscopic retrograde cholangiopancreatography
which showed positive biliary sludge in the common bile duct.
The patient had a sphincterotomy. The patient then
proceeded to cholecystectomy by the surgical service and was
discharged on postoperative day number two.
2. Pulmonary - The patient was easily weaned off minimal
oxygen. He had intermittent pleuritic chest pain without
hypoxia or tachycardia even in the setting of being on a beta
blocker. Since the patient's family history is notable for
deep vein thrombosis, the patient had had decreased mobility,
the patient had an inconclusive CT angiogram at the outside
hospital, a repeat CT angiogram was done to evaluate for
pulmonary embolus. This was negative although slightly
limited given the patient's body habitus. The patient was
noted to have small left sided pleural effusion consistent
with his known pancreatitis and history of volume overload.
3. Endocrine - The patient was followed by the endocrine
service for his initial hyperglycemia and hyperthyroidism.
Hyperglycemia rapidly resolved with resolution of gallstone
pancreatitis. His hemoglobin A1C was 5.1%.
His hyperthyroidism was followed by the endocrine service.
He had thyroid function tests that demonstrated on the day
prior to discharge a TSH of 8.3, total T4 of 4.3, free T4 of
0.7 and T3 of 77. The patient was noted to have a goiter,
however, no other signs or symptoms of hyperthyroidism. He
had a HCG that was negative for evidence of gonadal or other
tumor as etiology of his hyperthyroidism. His thyroglobulin
level was low and his thyroglobulin antibodies were elevated
which can be consistent with Hashimoto's thyroiditis but is
inconsistent with the patient's Graves' disease. Anti-TSH
receptor antibody was pending at the time of discharge. The
patient's medications were titrated given his laboratory data
and the patient was discharged on Propranolol 40 mg p.o. four
times a day and PTU 50 mg two tablets p.o. three times a day.
4. Gastrointestinal - anemia - The patient had iron studies
that were consistent with an iron deficiency anemia without
any evidence of hemolysis. Given his history of guaiac
positive stools, the patient may have had an occult
gastrointestinal bleed or he may have had colitis given his
episode of significant diarrhea. Gastroenterology service
recommended outpatient colonoscopy and
esophagogastroduodenoscopy to further evaluate this as well
as follow-up of his hematocrit.
The [**Hospital 228**] hospital course was complicated by initial
profuse diarrhea which was only noted once the patient was
hospitalized. The patient had two negative Clostridium
difficile toxin assays.
DISCHARGE DIAGNOSES:
1. Hyperthyroidism.
2. Pancreatitis.
3. Cholelithiasis.
4. Iron deficiency anemia.
5. Atypical chest pain.
6. Status post laparoscopy cholecystectomy.
FOLLOW-UP:
1. The patient should follow-up with [**Hospital 1800**] Clinic and
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48559**] office, [**Telephone/Fax (1) 48560**], and schedule
a follow-up appointment in the next two weeks.
2. The patient is to call pediatrician, Dr. [**First Name (STitle) 3459**], for
follow-up or establish a new primary care physician.
3. The patient should call Dr.[**Name (NI) 1482**] office, [**Telephone/Fax (1) 48561**], to schedule follow-up with surgery within the next two
weeks.
MEDICATIONS ON DISCHARGE:
1. Protonix 40 mg p.o. once daily.
2. Percocet one to two tablets q4-6hours p.r.n. pain, total
40 tablets given.
3. PTU 100 mg p.o. three times a day.
4. Propranolol 40 mg p.o. four times a day.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2163-6-13**] 19:26
T: [**2163-6-15**] 20:08
JOB#: [**Job Number **]
zcc: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
[**Name6 (MD) 48562**] [**Name8 (MD) **], M.D.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
|
[
"278.01",
"578.1",
"280.9",
"276.6",
"577.0",
"242.91",
"458.9",
"787.91",
"574.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.23",
"38.93",
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
4463, 4584
|
8524, 9226
|
9252, 9905
|
5069, 5559
|
5576, 8503
|
3259, 3806
|
174, 3236
|
3828, 4446
|
4601, 5042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,397
| 199,863
|
21883
|
Discharge summary
|
report
|
Admission Date: [**2125-9-9**] Discharge Date: [**2125-9-27**]
Date of Birth: [**2095-1-24**] Sex: F
Service: SURGERY
Allergies:
Claritin
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
portal venous thombosis from OSH
Major Surgical or Invasive Procedure:
Portal venogram, SMA, hepatic artereogram, mechanical
thrombectomy,
thrombolysis X3
chest tube
History of Present Illness:
30yo F portal venous, splenic venous, SMV thrombosis, s/p
pregnancy 6months ago and on OCP. She pressented to OSH 4 weeks
ago with abdominal pain. She was started on PO pain meds and 2
CT scans showed above mentioned diagnosis including some bowel
edema. She was transferred to [**Hospital1 18**] under the care of Dr.
[**Last Name (STitle) **] and evaluated by IR Dr. [**Last Name (STitle) 19420**]. She is s/p angiography
in R groin on [**2125-9-5**] with overnight tPA via SMA. This showed
collateral flow seen in the region of superior mesenteric and
splenic vein with cavernous transformation of the portal vein
which did not resolve. On [**2125-9-14**] she was taken to IR and the
thrombus was accized via transhepatic insertion of catheter into
the portal vein. Thrombus was cleaned by angiojet and by tPA
via the sheath and a lysis catheter into the splenicvein. She
was taken to ICU for frequent checks on tPA->ok overnight.
Past Medical History:
noncontributory
Social History:
no alcohol
no job
1 child
married
Family History:
mother and cousin h/o DVT
Physical Exam:
temp 37.8 HR 103 BP 130/80 RR 16 O2 98%
Gen: alert and oriented
CV: RRR
Lungs: clear to auscultation
abd: soft nt nd
R flank catheter
ext: WWP, SCD
Pertinent Results:
[**2125-9-9**] 09:41PM ALT(SGPT)-15 AST(SGOT)-10 ALK PHOS-64 TOT
BILI-0.2
[**2125-9-9**] 09:16PM POTASSIUM-4.1
[**2125-9-9**] 09:16PM PTT-130.7*
[**2125-9-9**] 04:15PM GLUCOSE-92 UREA N-2* CREAT-0.5 SODIUM-142
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17
[**2125-9-9**] 04:15PM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2125-9-9**] 04:15PM WBC-5.32 RBC-3.76* HGB-11.2* HCT-33.7*
MCV-89.6 MCH-29.8 MCHC-33.3 RDW-12.3
[**2125-9-9**] 04:15PM PLT COUNT-315
[**2125-9-9**] 04:15PM PTT-60.8*
[**2125-9-25**] 07:50AM BLOOD WBC-3.6* RBC-3.18* Hgb-9.8* Hct-28.5*
MCV-90 MCH-30.7 MCHC-34.3 RDW-14.6 Plt Ct-169
[**2125-9-24**] 07:43PM BLOOD WBC-4.8# RBC-3.39* Hgb-10.6* Hct-30.5*
MCV-90 MCH-31.3 MCHC-34.7 RDW-14.6 Plt Ct-172
[**2125-9-24**] 06:05AM BLOOD Hct-31.5* Plt Ct-174
[**2125-9-23**] 04:45AM BLOOD WBC-3.0* Hct-29.4*
[**2125-9-22**] 08:40AM BLOOD Hct-30.4*
[**2125-9-21**] 04:05AM BLOOD Hct-29.5*
[**2125-9-20**] 04:19AM BLOOD WBC-4.3 Hct-30.6* Plt Ct-146*
[**2125-9-19**] 03:53AM BLOOD WBC-6.5 RBC-3.28* Hgb-10.4* Hct-29.9*
MCV-91 MCH-31.7 MCHC-34.9 RDW-15.0 Plt Ct-120*
[**2125-9-18**] 10:00PM BLOOD Hct-30.7* Plt Ct-111*
[**2125-9-18**] 12:12PM BLOOD WBC-7.6 RBC-3.33* Hgb-10.3* Hct-30.1*
MCV-90 MCH-31.0 MCHC-34.4 RDW-15.4 Plt Ct-116*
[**2125-9-18**] 03:49AM BLOOD WBC-5.5 RBC-3.05* Hgb-9.4* Hct-27.3*
MCV-90 MCH-31.0 MCHC-34.5 RDW-15.5 Plt Ct-116*
[**2125-9-18**] 12:05AM BLOOD Hct-28.5*
[**2125-9-17**] 08:02PM BLOOD Hct-27.9* Plt Ct-100*
[**2125-9-17**] 03:34PM BLOOD Hct-28.5*
[**2125-9-17**] 11:16AM BLOOD Hct-27.3*
[**2125-9-17**] 08:22AM BLOOD Hct-28.8* Plt Ct-109*
[**2125-9-17**] 04:01AM BLOOD WBC-6.5 RBC-3.37*# Hgb-10.5*# Hct-29.4*
MCV-87 MCH-31.3 MCHC-35.8* RDW-15.2 Plt Ct-122*
[**2125-9-16**] 11:46PM BLOOD Hct-27.2* Plt Ct-120*
[**2125-9-16**] 07:18PM BLOOD WBC-5.2 RBC-2.64* Hgb-8.1* Hct-23.2*
MCV-88 MCH-30.6 MCHC-34.8 RDW-14.7 Plt Ct-88*
[**2125-9-16**] 03:21PM BLOOD WBC-5.0 RBC-2.73* Hgb-8.5* Hct-23.9*
MCV-88 MCH-31.2 MCHC-35.6* RDW-14.6 Plt Ct-83*
[**2125-9-16**] 02:26PM BLOOD Hct-25.1* Plt Ct-97*
[**2125-9-16**] 01:18PM BLOOD Hct-24.7*
[**2125-9-16**] 11:52AM BLOOD WBC-5.2 RBC-2.85* Hgb-8.8* Hct-24.7*
MCV-87 MCH-30.9 MCHC-35.7* RDW-14.4 Plt Ct-96*
[**2125-9-16**] 07:47AM BLOOD Hct-27.6* Plt Ct-107*
[**2125-9-16**] 05:16AM BLOOD Hct-27.1* Plt Ct-105*
[**2125-9-16**] 02:53AM BLOOD WBC-6.2 RBC-3.25* Hgb-10.4* Hct-28.2*
MCV-87 MCH-32.2* MCHC-37.1* RDW-14.3 Plt Ct-76*
[**2125-9-16**] 12:23AM BLOOD WBC-5.9 RBC-3.39* Hgb-10.8* Hct-29.0*
MCV-85 MCH-32.0 MCHC-37.5* RDW-13.9 Plt Ct-79*
[**2125-9-15**] 10:20PM BLOOD WBC-6.2 RBC-3.34* Hgb-10.6* Hct-29.0*
MCV-87 MCH-31.8 MCHC-36.6* RDW-14.0 Plt Ct-82*
[**2125-9-15**] 06:35PM BLOOD Hct-25.9* Plt Ct-112*
[**2125-9-15**] 04:13PM BLOOD Hct-28.9* Plt Ct-134*#
[**2125-9-15**] 01:23PM BLOOD Hct-27.8* Plt Ct-77*
[**2125-9-15**] 11:49AM BLOOD WBC-8.9 RBC-2.80* Hgb-8.8* Hct-24.6*
MCV-88 MCH-31.4 MCHC-35.7* RDW-13.7 Plt Ct-72*
[**2125-9-15**] 10:10AM BLOOD Hct-29.3*# Plt Ct-84*#
[**2125-9-15**] 08:40AM BLOOD Hct-16.6*
[**2125-9-15**] 07:45AM BLOOD Hct-15.4*#
[**2125-9-15**] 05:22AM BLOOD WBC-12.6* RBC-3.09* Hgb-9.5* Hct-27.8*#
MCV-90 MCH-30.8 MCHC-34.3 RDW-12.9 Plt Ct-191
[**2125-9-15**] 02:32AM BLOOD Hct-21.6* Plt Ct-295
[**2125-9-14**] 10:53PM BLOOD Hct-27.2* Plt Ct-217
[**2125-9-14**] 04:10PM BLOOD WBC-10.6# RBC-3.44* Hgb-10.6* Hct-31.2*
MCV-91 MCH-30.9 MCHC-34.1 RDW-13.1 Plt Ct-184#
[**2125-9-14**] 02:00PM BLOOD WBC-5.0 RBC-3.16* Hgb-9.8* Hct-28.4*
MCV-90 MCH-30.8 MCHC-34.3 RDW-13.1 Plt Ct-87*#
[**2125-9-13**] 06:30AM BLOOD WBC-5.6 RBC-3.69* Hgb-11.2* Hct-32.8*
MCV-89 MCH-30.4 MCHC-34.2 RDW-12.8 Plt Ct-243
[**2125-9-12**] 05:05AM BLOOD WBC-5.1 RBC-3.41* Hgb-10.2* Hct-30.4*
MCV-89 MCH-29.8 MCHC-33.4 RDW-12.8 Plt Ct-253
[**2125-9-11**] 11:50PM BLOOD WBC-5.3 RBC-3.38* Hgb-10.2* Hct-30.1*
MCV-89 MCH-30.1 MCHC-33.7 RDW-12.8 Plt Ct-233
[**2125-9-11**] 04:04PM BLOOD WBC-4.7 RBC-3.41* Hgb-10.2* Hct-30.3*
MCV-89 MCH-29.8 MCHC-33.6 RDW-12.9 Plt Ct-239
[**2125-9-11**] 04:04PM BLOOD WBC-5.2 RBC-3.47* Hgb-10.5* Hct-30.7*
MCV-89 MCH-30.1 MCHC-34.0 RDW-12.8 Plt Ct-248
[**2125-9-11**] 09:08AM BLOOD WBC-6.1 RBC-3.73* Hgb-11.4* Hct-33.7*
MCV-90 MCH-30.5 MCHC-33.8 RDW-13.0 Plt Ct-272
[**2125-9-11**] 03:27AM BLOOD WBC-5.9 RBC-3.53* Hgb-10.7* Hct-32.0*
MCV-91 MCH-30.3 MCHC-33.4 RDW-12.5 Plt Ct-285
[**2125-9-10**] 05:58PM BLOOD WBC-5.0 RBC-3.68* Hgb-11.0* Hct-33.1*
MCV-90 MCH-29.7 MCHC-33.1 RDW-12.6 Plt Ct-323
[**2125-9-9**] 04:15PM BLOOD WBC-5.32 RBC-3.76* Hgb-11.2* Hct-33.7*
MCV-89.6 MCH-29.8 MCHC-33.3 RDW-12.3 Plt Ct-315
[**2125-9-24**] 07:43PM BLOOD Neuts-72.7* Lymphs-17.8* Monos-6.4
Eos-2.9 Baso-0.3
[**2125-9-13**] 06:30AM BLOOD Neuts-69.0 Lymphs-22.8 Monos-5.5 Eos-2.4
Baso-0.3
[**2125-9-10**] 05:58PM BLOOD Neuts-57.6 Lymphs-34.4 Monos-6.1 Eos-1.5
Baso-0.3
[**2125-9-10**] 05:58PM BLOOD Hypochr-1+
[**2125-9-25**] 07:50AM BLOOD Glucose-97 UreaN-7 Creat-0.4 Na-140 K-4.0
Cl-107 HCO3-26 AnGap-11
********COAGS**********
[**2125-9-27**] 07:30AM BLOOD PT-19.5* PTT-95.0* INR(PT)-2.4
[**2125-9-27**] 12:22AM BLOOD PTT-68.3*
[**2125-9-26**] 05:40AM BLOOD PT-16.6* INR(PT)-1.7
[**2125-9-25**] 07:50AM BLOOD Plt Ct-169
[**2125-9-25**] 07:50AM BLOOD PT-16.7* PTT-66.5* INR(PT)-1.8
[**2125-9-24**] 07:43PM BLOOD Plt Ct-172
[**2125-9-24**] 07:43PM BLOOD PTT-57.8*
[**2125-9-24**] 06:05AM BLOOD Plt Ct-174
[**2125-9-24**] 06:05AM BLOOD PT-15.1* PTT-57.3* INR(PT)-1.4
[**2125-9-23**] 04:45AM BLOOD PT-14.6* PTT-50.4* INR(PT)-1.3
[**2125-9-23**] 12:30AM BLOOD PTT-40.8*
[**2125-9-22**] 05:20PM BLOOD PTT-30.5
Brief Hospital Course:
(see HPI)
[**9-15**]:: Selective and superselective hepatic arteriograms did
not show
any sign of active bleeding. No bleeding was detected from
intercostal
arteries nor from the percutaneous intrahepatic system. The
findings were
discussed with Dr. [**Last Name (STitle) **] who represented the surgical team.
Decision was
made to perform a tagged red blood cell scan which showed no
evidence of active bleeding from the liver or gastrointestinal
tract initially.
[**9-16**]: A 18hr delay scan showed accumulation of radiotracer
activity in the gallbladder fossa and since the first study
performed, surrounding an area consistent with a hematoma or
large gallbladder. This is presumably related to a extravasation
since the first study. No areas of hyper-acute bleeding seen
following reinjection.
A third angiogram was performed to localize the bleeding
sight. Right and left hepatic arteriograms did not show an
active bleeding site. Injection through the portal catheter also
did not show evidence of active bleeding.
Patient developed a Right hemopneumothorax. CXR
showed:: Rapidly accumulating right-sided pleural effusion. This
could be due to hemothorax given clinical suspicion
[**9-24**] Low grade temp 101.5 at 1500. CXR showed small lower left
pleural effusion with minimal crackles in bases. Pt was
encourage to ambulate and use IS. CVL was taken out and sent for
culture. Blood cultures sent. UA neg.
[**9-25**] Pt has depervesed with max of 100.3. Pt ambulating well
and lungs sound clear. Cultures no growth to date.
[**9-26**] Follow up triple phase CT of abd and pelvis showed new
acute DVT in the left external iliac vein extending to the mid
common iliac vein. Thrombus again seen within the superior
mesenteric vein, splenic vein, and portal vein. Interval
increase in degree of cavernous transformation in the portal
hepatis. Two hematomas within and adjacent to the liver,
unchanged in size and appear more organized. Interval decrease
in free intraperitoneal fluid. Resolution right pleural
effusion. Stable trace left pleural effusion.
[**9-27**] INR 2.4
coumadin [**9-26**] 7.5mg; [**9-25**] 5mg; [**9-24**] 7.5mg; [**9-23**] 7.5;10/28,29,20
5mg
Medications on Admission:
OCP
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. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*4 Tablet(s)* Refills:*0*
3. Coumadin 2.5 mg Tablet Sig: Three (3) Tablet PO once a day:
INR goal 2.5.
Disp:*90 Tablet(s)* Refills:*0*
4. percs
Discharge Disposition:
Home
Discharge Diagnosis:
portal vein thrombosis
splenic vein thrombosis
superior mesenteric vein thrombosis
external iliac and common iliac
hepatic hematoma
Discharge Condition:
Good: afebrile, tolerating regular diet, ambulating without
difficulty, pain well controlled on oral medication,
anticoagulated on coumadin.
Discharge Instructions:
1. Please monitor for the following: fever, chills, nausea,
vomiting, inability to tolerate food/drink. If any of the these
occur, please contact your physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2125-10-22**] 11:00
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 273**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2125-10-22**]
11:00
Follow up with your PCP [**Name9 (PRE) 57386**] to have your INR drawn and
arrange coumadin dosing schedule.
Completed by:[**2125-9-27**]
|
[
"442.84",
"289.59",
"V17.4",
"557.0",
"453.41",
"452",
"511.8",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.72",
"99.04",
"38.93",
"99.10",
"99.05",
"34.04",
"96.04",
"88.47",
"99.29",
"99.15",
"88.64",
"38.91",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
9853, 9859
|
7238, 9438
|
299, 399
|
10036, 10178
|
1688, 7215
|
10419, 10904
|
1477, 1504
|
9492, 9830
|
9880, 10014
|
9464, 9469
|
10202, 10396
|
1519, 1669
|
227, 261
|
427, 1371
|
1393, 1410
|
1426, 1461
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,778
| 153,438
|
10176
|
Discharge summary
|
report
|
Admission Date: [**2162-6-8**] Discharge Date: [**2162-6-18**]
Date of Birth: [**2091-10-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain/Three vessel disease
Major Surgical or Invasive Procedure:
[**2162-6-11**] - CABGx4 (left internal mammary artery to left anterior
descending coronary artery; reverse saphenous vein double
sequential graft from the aorta to the 1st diagonal and 1st
obtuse marginal coronary arteries; as well as reverse saphenous
vein single graft from the aorta to the distal right coronary
artery).
History of Present Illness:
The patient is a 70-year-old gentleman who complained of
unstable angina symptoms. Cardiac catheterization demonstrated
severe 3-vessel coronary
disease. The patient was therefore referred for coronary artery
bypass grafting. The patient understood the risks and benefits
of the procedure including, but not limited to, bleeding,
infection, myocardial infarction, stroke, death, renal and
pulmonary insufficiency, as well as the possibility
of a blood transfusion and future revascularization procedures,
and agreed to proceed.
Past Medical History:
Diabetes
Chronic pneumonia
HTN
Hyperlipidemia
CVD
Obstructive sleep apnea
Prostate cancer
Neuropathy
Social History:
Does not smoke or drink alcohol. Lives with wife.
Family History:
Father died of MI at age 52
Physical Exam:
GEN: NAD 125/74
CARD: RRR, No murmur
LUNGS: Clear
ABD: Benign
EXT: No edema, 1+ distal pulses, no varicosities, cool Bilat LE
NEURO: Nonfocal
Pertinent Results:
[**2162-6-8**] 05:32PM PT-13.1 PTT-23.0 INR(PT)-1.1
[**2162-6-8**] 05:32PM WBC-6.8 RBC-4.60 HGB-13.5* HCT-40.0 MCV-87
MCH-29.3 MCHC-33.6 RDW-14.1
[**2162-6-8**] 05:32PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-59
AMYLASE-92 TOT BILI-0.5
[**2162-6-8**] 05:32PM GLUCOSE-120* UREA N-25* CREAT-1.2 SODIUM-140
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-15
[**2162-6-8**] 09:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG\
[**2162-6-9**] Carotid Study
1. 40-59% stenosis was demonstrated in the right internal
carotid artery associated with mild-to-moderate calcified
plaques.
2. No stenosis or calcified plaques were noted in the left
internal carotid artery.
[**2162-6-11**] ECHO
PREBYPASS
The left atrium is mildly dilated. The left atrium is elongated.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction. Overall left ventricular systolic function
is moderately depressed. Resting regional wall motion
abnormalities include an akinetic anterior and anteroseptal
walls, and a severely hypokinetic inferoseptal wall and apex.
The right ventricular cavity is mildly dilated. There is mild
global right ventricular free wall hypokinesis. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-21**]+) mitral regurgitation is seen.
[**Name (NI) 33958**] PT is receiving dobutamine at 2.5 ucg/kg/min RV
systolic function now appears normal. Poor esophageal LV windows
post bypass, however there appears to be improvement of the
anterior and septal walls [**Name (NI) **] in the setting of low dose
inotropes. LVEF ~45-50%. The LV and RV are less dilated. MR is
now trace-mild. Study is otherwise unchanged from prebypass.
[**2162-6-16**] CXR
Mild cardiomegaly and widening of the mediastinal contours are
unchanged. Left-sided chest tube is in place in unchanged
position. A small left pleural effusion has decreased slightly
in size. Bilateral lower lobe atelectasis appears approximately
stable.
Brief Hospital Course:
Mr. [**Known firstname **] was admitted to the [**Hospital1 18**] on [**2162-6-8**] via transfer
from [**First Name8 (NamePattern2) 4527**] [**Last Name (Titles) 620**] for surgical management of his
coronary artery disease. He was worked-up in the usual
preoperative manner which included a carotid duplex ultrasound
which showed a 40-59% stenosis was demonstrated in the right
internal carotid artery associated with mild-to-moderate
calcified plaques and a normal left internal carotid artery. An
echocardiogram was performed which showed a mildly dilated
ascending aorta and an ejection fraction of 40-45%. A CT scan
was performed for an abnormal right main stem nodule seen on
chest x-ray. The CT scan did not reveal any nodule however
showed mild interstitial disease predominantly in the right and
left lower lobes. On [**2162-6-11**], Mr. [**Known lastname **] was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels. He tolerated the procedure well and
please see operative note for further detail. Postoperatively he
was taken to the cardiac surgical intensive care unit for
monitoring. By postoperative day one, Mr. [**Known firstname **] was awake,
extubated and neurologically intact. He was slowly weaned from
pressors. Plavix was resumed for his prior history of transient
ischemic attacks. On postoperative day two, Mr. [**Known firstname **] was
transferred to the cardiac surgical step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. The physical therapy service was consulted for
assistance with his postoperative strength and mobility.
Vancomycin was started for sternal drainage. An IP consult was
obatined for thoracentesis of a left pleural effusion. After
several attempts, the thoracentesis was unsuccessful and a left
chest tube was placed. [**6-17**]. 1100 ml of dark bloody drainage
was obtained. The tube stopped draining, and was removed on
[**2162-6-17**]. He has remained hemodynamically stable and is ready to
be discharged home today.
Medications on Admission:
On transfer:
Lopressor 25mg [**Hospital1 **]
ECASA 325mg QD
Plavix 75mg QD
Glyburide 10mg [**Hospital1 **]
Flovent
Lisinopril 5mg [**Hospital1 **]
Metformin 500mg [**Hospital1 **]
Avandia 8mg QD
Folate 1mg QD
Cartia 180mg QD
Lipitor 80mg QD
Flomax0.4mg QD
Doxycycline 100mg [**Hospital1 **]
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(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: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 MDI* Refills:*0*
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Rosiglitazone 8 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
16. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD
DMII
Prostate Cancer
HTN
Hyperlipidemia
CVD
Sleep Apnea
Chronic pneumonia
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
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 lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
Followup Instructions:
Follow-up with cardiologist Dr. [**Last Name (STitle) 1295**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 914**] in 4 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 33959**]
Please call all providers for appointments.
Completed by:[**2162-6-18**]
|
[
"424.0",
"327.23",
"V10.46",
"511.9",
"411.1",
"357.2",
"515",
"401.9",
"414.01",
"250.60",
"272.4",
"491.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
8455, 8504
|
3975, 6033
|
352, 679
|
8626, 8633
|
1651, 3952
|
8965, 9332
|
1444, 1473
|
6374, 8432
|
8525, 8605
|
6059, 6351
|
8657, 8942
|
1488, 1632
|
281, 314
|
707, 1237
|
1259, 1361
|
1377, 1428
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,976
| 149,657
|
15974
|
Discharge summary
|
report
|
Admission Date: [**2146-10-22**] Discharge Date: [**2146-10-25**]
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
History of Present Illness:
[**Age over 90 **] male with h/o PVD, CAD, AFib s/p ablation, recent GIB, who
presents with several episodes of BRBPR. He was recently
discharged from [**Hospital1 18**] on [**2146-10-20**]. He had several episodes of
hematochezia at his nursing home today, and was subsequently
sent in to the ED. He denied any chest pain, SOB,
lighthededness, diarrhea, abdominal pain, fevers, chills, back
pain.
.
Last week he also presented with BRBPR, and he was discharged
yesterday. Initially, a tagged red blood cell scan showed
bleeding from the rectum. However, subsequent angiography was
unable to localize and embolize the source of bleed. A fexible
sigmoidoscopy showed an actively bleeding Dielafoys lesion which
was successfully clipped. The patient subsequently remained
hemodynamically stable, with minimal further RBC transfusions.
Coumadin, aspirin, and Plavix were initially held. Aspirin and
Plavix were resumed prior to discharge.
.
ED course: He was found to have a stable hct from last
admission. He had several large BRBPR episodes in ED, and his
SBP went from 140 to 110. He was give 1 liter of NS. GI was
called, and planned for scope in AM. He was admitted to MICU
for close observation.
Past Medical History:
1.Severe PVD: [**9-9**]: R BKPO-DP bypass w/ RSVG
2.10/2 Achilles tendon w/ abscess excision w/ VAC placement
3.Aortic Stenosis: Echo: [**12-19**]: moderate AS, aortic regurg,
mitral regurg, moderate pericardial effusion.
4.CAD: s/p cardiac cath: 90% distal LMCA, 80% LCX, Stent in
LMCA/LAD Cypher drug-eluting stent.
5.Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
6. Hypercholesterolemia
7. Hypothyroidism
8. Chronic low back pain
9. AFib s/p ablation
[**48**]. s/p cholecystectomy
[**49**]. s/p bilateral carotid endartectomies
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy
15. s/p Dielafoys lesion banding [**10-19**]
Social History:
Previous 30 pack-year tobacco, quit 40 [**Month/Year (2) 1686**] ago. Occasional EtOH.
Currently at [**Hospital 169**] Center. Previously lived in the
basement of his daughter's house. Walks with a cane.
Family History:
Non-contributory
Physical Exam:
On admission:
Vs- 145/55 65 12 100% 2L NC
Gen- Well appearing elderly male lying in bed, NAD
Heent- dry MM, anicteric, PERRL
Neck- Supple, no LAD, no JVP elevation, bilateral carotid
bruits, bandage on right neck from prior IJ
Cor- RRR, high pitched SEM at LLSB, heard throughout precordium
Chest- Relatively clear bilaterally
Abd- soft, NT, ND, pos BS, ventral hernia, no organomegaly
Ext- Right heel with 1+ edema, open wound on heel, boot on,
wound vac in place. Left with no swelling.
Neuro- AAO x 2, confused about place and exact date.
Skin- Hyperpigmented lesion on left anterior chest, mildly
raised
On discharge:
VS: 97.4 124/60 74 18 96%RA
Exam was largely unchanged on discharge. Patient was oriented
to self and place. He is slightly confused about the date.
Pertinent Results:
ECG: NSR, nl axis, nl interval, STd V4-V6. Compared with prior,
ST depressions new.
.
Studies~
Flexible sigmoidoscopy [**2146-10-24**]: Stool in the rectum. The scope
was advanced up to proximal rectum. There was yellow stool
noticed. No evidence of active bleeding noted. Otherwise normal
sigmoidoscopy to rectum.
.
Bleeding scan [**2146-10-13**] (prior admission): Positive bleeding scan,
from rectum within the first 5 minutes
.
Mesenteric angiogram [**2146-10-13**]:
1. Diffuse atherosclerotic disease including extensive [**Month/Day/Year 1106**]
calcification.
2. Selective angiograms of the superior mesenteric artery and
inferior mesenteric artery demonstrate no foci of active
bleeding. Incidental note is made of probable occlusion of the
celiac artery as evidenced by collaterals formed between the
common hepatic artery and superior mesenteric artery.
[**2146-10-22**] 07:39PM HCT-28.4*
[**2146-10-22**] 11:59AM HCT-29.3*
[**2146-10-22**] 05:20AM GLUCOSE-88 UREA N-11 CREAT-0.9 SODIUM-137
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-26 ANION GAP-9
[**2146-10-22**] 05:20AM CK(CPK)-45
[**2146-10-22**] 05:20AM CK-MB-NotDone cTropnT-0.05*
[**2146-10-22**] 05:20AM CALCIUM-7.8* PHOSPHATE-2.4* MAGNESIUM-2.0
[**2146-10-22**] 05:20AM WBC-5.2 RBC-3.12* HGB-9.6* HCT-28.3* MCV-91
MCH-30.9 MCHC-34.0 RDW-17.6*
[**2146-10-22**] 05:20AM PLT COUNT-157
[**2146-10-22**] 05:20AM PT-12.8 PTT-30.3 INR(PT)-1.1
[**2146-10-22**] 02:35AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2146-10-22**] 02:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2146-10-22**] 02:35AM URINE RBC-0 WBC-[**11-1**]* BACTERIA-OCC YEAST-MANY
EPI-<1
[**2146-10-22**] 02:25AM WBC-5.0 RBC-3.26* HGB-10.2* HCT-29.5* MCV-91
MCH-31.5 MCHC-34.7 RDW-17.6*
[**2146-10-22**] 02:25AM NEUTS-65.3 LYMPHS-23.4 MONOS-7.2 EOS-4.1*
BASOS-0.1
[**2146-10-22**] 02:25AM PLT COUNT-155
[**2146-10-21**] 08:43PM GLUCOSE-109* UREA N-13 CREAT-1.0 SODIUM-135
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-12
[**2146-10-21**] 08:43PM CK(CPK)-50
[**2146-10-21**] 08:43PM cTropnT-0.03*
[**2146-10-21**] 08:43PM WBC-6.4 RBC-3.51* HGB-10.9* HCT-32.1* MCV-91
MCH-31.1 MCHC-34.1 RDW-17.5*
[**2146-10-21**] 08:43PM NEUTS-70.5* LYMPHS-19.3 MONOS-6.4 EOS-3.6
BASOS-0.2
[**2146-10-21**] 08:43PM PLT COUNT-176
[**2146-10-21**] 08:43PM PT-12.5 PTT-32.8 INR(PT)-1.1
Brief Hospital Course:
[**Age over 90 **] male with CAD, severe PVD, Achilles abscess on Zosyn, who was
recently admitted with a lower GIB presented with another
episode of BRBPR from his extended care facility.
.
#GI Bleed: This was most likely a re-bleed from his Dieulafoy's'
lesion that was banded last admission. Flexible sigmoidoscopy
did not demonstrate any further bleeding from his previously
banded lesion. The patient was initially admitted to the MICU
for close monitoring, where he was transfused one unit of blood.
Since transfer from the MICU, the patient has not had any
further episodes of GI bleeding. His Plavix was stopped, per
cardiology recs, and aspirin is being held for another week in
the setting of recent bleeding. His hematocrit remained stable
while on the floor.
.
#CAD: The patient has been chest pain free since his admission.
He was ruled out for MI with cardiac enzymes. In the MICU, he
was noted to have some lateral ST depressions/TWF, but V4 was
suspected to be due to lead placement changes. No further
intervention occurred. Per his cardiologist, aspirin should be
restarted in one week. Plavix has been stopped permanently (per
cardiology recommendations).
.
#Urinary retention: He was seen by Urology in [**Month (only) **], and had
failed several voiding trials. He failed another voiding trial
in the MICU. He will be discharged with a foley catheter to
follow up as an outpatient with urology. His Foley catheter was
changed on [**10-23**] without difficulty, and Flomax was restarted.
.
#Nonhealing heel ulcer: He was recently operated on by [**Month/Year (2) 1106**]
surgery for bypass. He also has a nonhealing ulcer. Secondary
to pseudomonas on wound culture, the patient was started on
Zosyn to complete a course until [**2146-11-2**]. His wound vac was
replaced while in the hospital.
.
#AFib: The patient carries a history of atrial fibrillation,
status post ablation. He has been stable in sinus rhythm
throughout his hospitalization. His coumadin was stopped during
his previous hospitalization. We continued to hold his coumadin
in light of his GI bleeding.
.
#Hypothyroidism: His outpatient thyroid replacement was
continued. Based on thyroid studies from previous admission
(high TSH, low T4), the patient may require titration of his
medications when not in an acute setting.
.
# HTN: In the setting of acute bleeding, antihypertensives were
initially held, prior to discharge the patients home dose of
Imdur and metoprolol.
.
Medications on Admission:
1. Aspirin 81 mg
2. Cyanocobalamin 500 mcg Tablet Sig: Four (4) Tablet PO DAILY
3. Acetaminophen 325 mg prn
4. Zinc Sulfate 220 (50) mg qd
5. Tamsulosin 0.4 mg Capsule, qhs
6. Piperacillin-Tazobactam 2.25 gram 1 q 6h until [**2146-11-2**]
7. Ascorbic Acid 500 mg Tablet daily
8. Prilosec 40 mg Capsule, qd
9. Toprol XL 50 mg Tablet Sustained Release qd
10. Clopidogrel 75 mg Tablet qd
11. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. Levothyroxine 150 mcg qd
13. Isosorbide Mononitrate 30 mg qd
14. Docusate Sodium 100 mg [**Hospital1 **]
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis: Bleeding from a rectal Dieulafoy lesion
.
Secondary diagnoses:
Right achilles tendon pressure ulcer
PVD s/p PO-DP bypass graft
Aortic stenosis
Hypercholesterolemia
Hypothyroidism
Hypertension
Discharge Condition:
Stable, with no active bleeding
Discharge Instructions:
You were admitted to the hospital for gastrointestinal bleeding.
You had a sigmoidoscopy that showed your Dieulefoy lesion was
bleeding. You received one unit of blood while you were in the
hospital.
Please do not take your Coumadin. Please restart your aspirin
in seven days, on [**2146-11-1**].
The remainder of your home medications have been continued.
You will also need to complete three weeks of antibiotics for
your
ankle wound, until [**11-2**].
You should also follow up with gastroenterology as needed.
If you experience any additional bleeding, changes in thinking
or behavior, experience shortness of breath, chest pain, or
lightheadedness, or other concerning symptoms please consult
your primary care physician or return to the emergency room.
Please follow up with the following doctors once [**Name5 (PTitle) **] are
discharged from the rehabilitation hospital.
Watch for the following signs and symptoms in your wound and
notify your doctor if these occur:
Temperature over 101.5 F or chills
Foul-smelling drainage or fluid from the wound
Increased redness or swelling of the wound or skin around it
Increasing tenderness or pain in or around the wound.
Followup Instructions:
You will need to make follow up appointments with the following
providers once you are discharged from rehab.
Gastroenterology (as needed): [**Telephone/Fax (1) 13246**]
[**First Name4 (NamePattern1) 21976**] [**Last Name (NamePattern1) 11679**] (primary care): [**Telephone/Fax (1) 26860**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiology): [**Telephone/Fax (1) 2394**]
Dermatology: ([**Telephone/Fax (1) 45763**]
.
You have the following appointments scheduled:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2146-11-10**] 1:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2146-11-10**] 2:00
You also have an appointment with Dr. [**Last Name (STitle) 11679**] on Monday,
[**10-31**] at 2:45 pm. Please have him check a hematocrit
level at that time. Please also discuss your thyroid medication
with him at that time.
Please call Dr[**Name (NI) 23059**] office at ([**Telephone/Fax (1) 4335**] to schedule an
appointment within the next two weeks.
Please have patient follow up with [**Hospital 159**] Clinic [**Telephone/Fax (1) 164**]
in two weeks for Foley management.
|
[
"V45.82",
"707.06",
"427.31",
"396.8",
"569.86",
"244.9",
"433.10",
"285.1",
"788.20",
"599.0",
"414.01",
"443.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
8962, 9052
|
5778, 8257
|
224, 249
|
9307, 9341
|
3322, 5755
|
10573, 11907
|
2487, 2505
|
9073, 9073
|
8283, 8939
|
9365, 10550
|
2520, 2520
|
9155, 9286
|
3147, 3303
|
179, 186
|
277, 1484
|
9092, 9134
|
2534, 3133
|
1506, 2249
|
2265, 2471
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,022
| 134,285
|
30526
|
Discharge summary
|
report
|
Admission Date: [**2201-3-7**] Discharge Date: [**2201-3-24**]
Date of Birth: [**2126-10-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Right upper lobe mass
Major Surgical or Invasive Procedure:
Redo right thoracotomy with right upper lobectomy.
Cervical mediastinoscopy with biopsy.
Mediastinal lymph nodal dissection.
Flexible bronchoscopy.
IV TPA
Right arm PICC
History of Present Illness:
The patient is a 74-year-old woman who has had a persistent
cough for several
years. Recently, she was admitted on [**2201-1-16**] to
[**Hospital 2079**] Hospital with progressive dyspnea and cough and was
felt to have a right upper lobe pneumonia. She was treated with
antibiotics and subsequent CT scan demonstrated no resolution of
the opacity. She underwent extensive biopsies of the lesion
including the right exploratory thoracotomy with all pathology
negative. Workup with MRI and PET showed no evidence of
metastasis. The right upper lobe lesion was FDG avid. The
patient was transferred postoperatively from [**Hospital 2079**] Hospital
to [**Hospital1 69**] for further evaluation
and
treatment.
Past Medical History:
CVA 5 years ago, for which she has no persistent sequelae, she
has been on Coumadin since
Chronic atrial fibrillation
Hypertension
Hyperlipidemia
Hysterectomy for uterine cancer approximately 12 years ago
Seasonal allergies
Recent RUL PNA
Social History:
The patient is married, lives with her husband.
She is a retired antique dealer. She smoked for 17 pack years,
quit in [**2163**].
She drinks 2-3 glasses of wine a day
Family History:
NC
Physical Exam:
On Admission:
The patient is a well-appearing female, in no acute
distress. She is resting comfortably in the hospital bed. She
has two right-sided chest tubes and a dressing over her right
thoracotomy incision. She is awake and alert and interactive.
VITAL SIGNS: Temperature 100.7, heart rate of 122 in afib,
blood
pressure 146/78, respiratory rate of 25, and oxygen saturation
96% on 3 liters.
HEENT: Her pupils are equal, round, and reactive. Her sclerae
are anicteric.
NECK: Cervical exam reveals no supraclavicular or cervical
adenopathy.
LUNGS: Clear to auscultation, bilaterally equal, except for
some
diminished breath sounds on the right.
HEART: Irregularly irregular with no murmur.
CHEST: Her thorax examination demonstrates no skin lesions.
She
has a dressing over her right-sided mini thoracotomy incision
with two chest tubes.
ABDOMEN: Benign without masses.
EXTREMITIES: No clubbing or edema.
NEUROLOGIC: Grossly nonfocal with intact and appropriate mental
status.
Pertinent Results:
[**2201-3-8**] 06:16AM BLOOD WBC-16.3* RBC-3.71* Hgb-10.8* Hct-31.6*
MCV-85 MCH-29.1 MCHC-34.2 RDW-13.9 Plt Ct-404
[**2201-3-8**] 06:16AM BLOOD PT-13.4* PTT-29.7 INR(PT)-1.2*
[**2201-3-8**] 06:16AM BLOOD Glucose-120* UreaN-10 Creat-0.6 Na-141
K-3.9 Cl-102 HCO3-29 AnGap-14
[**2201-3-9**] 07:16PM BLOOD CK(CPK)-296*
[**2201-3-9**] 07:16PM BLOOD CK-MB-5 cTropnT-<0.01
[**2201-3-10**] 02:02AM BLOOD PT-12.9 PTT-26.4 INR(PT)-1.1
[**2201-3-11**] 02:15AM BLOOD PT-14.4* PTT-28.5 INR(PT)-1.3*
[**2201-3-13**] 10:50AM BLOOD PT-28.8* INR(PT)-3.0*
[**2201-3-14**] 04:30PM BLOOD PT-53.4* PTT-43.5* INR(PT)-6.4*
[**2201-3-15**] 03:57AM BLOOD PT-44.7* PTT-41.0* INR(PT)-5.2*
[**2201-3-15**] 02:37PM BLOOD PT-41.6* PTT-37.4* INR(PT)-4.7*
[**2201-3-16**] 02:33AM BLOOD PT-29.1* PTT-35.8* INR(PT)-3.0*
[**2201-3-17**] 06:25AM BLOOD PT-14.4* PTT-25.8 INR(PT)-1.3*
[**2201-3-18**] 10:15AM BLOOD PT-13.8* PTT-28.0 INR(PT)-1.2*
[**2201-3-19**] 02:02AM BLOOD PT-15.5* PTT-26.1 INR(PT)-1.4*
[**2201-3-20**] 02:02AM BLOOD PT-17.5* PTT-43.8* INR(PT)-1.6*
[**2201-3-20**] 09:42AM BLOOD PT-16.3* PTT-53.8* INR(PT)-1.5*
[**2201-3-20**] 05:33PM BLOOD PT-17.7* PTT-70.2* INR(PT)-1.7*
[**2201-3-21**] 09:20AM BLOOD PT-18.3* PTT-121.2* INR(PT)-1.7*
[**2201-3-22**] 04:10AM BLOOD PT-16.9* PTT-100.4* INR(PT)-1.6*
[**2201-3-23**] 07:15AM BLOOD PT-17.9* PTT-88.7* INR(PT)-1.7*
[**2201-3-23**] 10:45AM BLOOD PT-18.3* PTT-97.6* INR(PT)-1.7*
[**2201-3-24**] 06:00AM BLOOD PT-21.7* PTT-66.9* INR(PT)-2.1*
[**2201-3-21**] 04:45AM BLOOD %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE
RADIOLOGY
[**3-8**] CT Chest: 4.2 x 7.5 x 7.3 cm mass within the right lung
apex which has findings consistent with invasion of the
mediastinum with loss of fat planes at the esophagus, trachea,
and superior vena cava.
Multiple enlarged mediastinal lymph nodes measuring up to 1.9
cm.
Multiple pleural-based mass lesion in the posterior right pleura
measuring up to 2.8 cm in maximal dimension.
Small right pleural effusion. Small pleural air anterior to the
right middle lobe.
Lytic lesion in the L1 vertebral body suspicious for metastatic
disease.
[**3-8**] CXR: Dense opacification at the right lung apex, possibly
with mild volume loss. No pneumothorax detected.
[**3-9**] CXR: Endotracheal tube tip is seen in standard position.
Two right chest tubes remain in place. There is a moderate right
pleural effusion. There are postoperative changes with right
shifting of the cardiomediastinal silhouette and widening of the
mediastinum and right hilum. Left lower lobe atelectasis is
unchanged.
[**3-10**] CXR: Postoperative widening of the upper mediastinum and
right hilus are essentially unchanged due in part to fluid
loculation. Pleural fluid is also collected at the apex where
there is partially resected right lung. I see no definite
pleural air collection although I would assume some is present.
Left lung is grossly clear. Skinfold should not be mistaken for
a left pneumothorax. Heart size top normal, unchanged. Two right
pleural drains in place.
[**3-11**] CXR: Appearance of the chest is essentially unchanged
compared to one-day prior. Post-operative widening of the upper
mediastinum and right hilus are unchanged, likely due to fluid
loculations. A band of pleural fluid crosses the right upper
hemithorax, with a more lucent area superiorly that could be
overexpanded lung or pleural air. A true upright chest
radiograph should be obtained to differentiate between the
possibilities, looking for a fluid level. Two right pleural
drains are in unchanged position. Small, dependent right- sided
effusion is stable. Left lung is clear.
[**3-12**] CXR: The two right chest tubes have been removed in the
meantime interval with subsequent marked increase in right
predominantly apical but also basal pneumothorax. The pleural
effusion is grossly unchanged. The postoperative right
mediastinal shift is again demonstrated. The right lower lung
atelectasis is present.
[**3-12**] CXR: AP and lateral chest views obtained with patient in
sitting upright position are analyzed in direct comparison with
two preceding chest examinations of [**3-11**] and [**2201-3-12**], the latter approximately seven hours earlier. On the next
previous study, the right-sided chest tubes had been removed and
a pneumothorax occupying the upper third of the hemithorax was
identified. On the present study, two new chest tubes have been
placed and appear in rather similar position as on the chest
examination of [**2201-3-11**]. A smaller apical air-fluid
level remains but the pneumothorax seen earlier has markedly
improved. The left chest remains unchanged and is within normal
limits.
[**3-13**] CXR: Comparison with [**2201-3-12**], the two right chest
tubes have been removed. There is persistent shift of the
trachea and mediastinum towards the right. There is a large
air-fluid level in the right apex, with smaller air-fluid levels
within the right apex. There may also be a basilar component of
this right pneumothorax. There is increased prominence of the
pulmonary vasculature within the left lung and probably a small
left pleural effusion.
[**3-13**] CT Chest: Status post right upper lobe resection. Large
right apical hydropneumothorax. Ill-defined soft tissue and
fluid density is seen within the mediastinum tracking
subcarinally likely post-operative, residual tumor cannot be
excluded.
Mucus plugging of right middle and right lower lobe bronchi with
complete right middle lobe and near complete right lower lobe
atelectasis.
Atypical filling defect within left upper lobar pulmonary artery
consistent with pulmonary embolus.
Large splenic infarct.
[**3-14**] CXR: Right apical pneumothorax, right middle lobe collapse.
[**3-15**] CXR: Single AP view of the chest is obtained [**2201-3-15**] at 08:00
hours and compared with the prior morning's radiograph. There
appears to be increasing opacification in the right upper chest
which is consistent with accumulating fluid. The pneumothorax
previously identified is not apparent on the current examination
in this projection. Increased density in the right mid lung
fields due to right middle lobe collapse may be improving with
better aeration. There appears to be patchy atelectasis or
airspace disease of the right base which is unchanged. The left
lung is unchanged in appearance
[**3-16**] CXR: No change in right apical hydropneumothorax. Persistent
right middle lobe atelectasis but improving aeration in right
lower lobe.
[**3-18**] CT Head/neck: Acute left posterior cerebral aratery
distribution infarct, with posterior occipital- temporal edema.
Filling defect within proximal left posterior cerebrla artery
(likely P2 branch) and blood volume- blood flow mismatch on
perfusion images suggest ischemic penumbra. Given the clinical
history and relative sparing of remaining intracerebral vessels
from atherosclerotic disease, the filling defect may be embolic
in origin.
Old right posterior cerebral artery territory infarct.
Right apical hydropneumothorax and right sided atelectasis.
[**3-19**] CT Head: No evidence of hemorrhage s/p IV TPA. Evolving left
PCA infarction, slightly more prominent than on the prior day's
study.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the Thoracic Surgery service under the
care of Dr. [**Last Name (STitle) 952**] on [**2201-3-8**]. She underwent a redo right
thoracotomy with right upper lobectomy, cervical mediastinoscopy
with biopsy, mediastinal lymph nodal dissection, and flexible
bronchoscopy. Please refer to the operative note for details of
this procedure. She was cared for in the CSRU, intubated
secondary to postoperative acidosis. She was extubated POD1,
without event. Her pain was well controlled with an epidural
with IV dilaudid supplementation. On POD2, she was transferred
to the [**Hospital Ward Name 121**] 2 floor unit.
On POD4, she was readmitted to the CSRU due to respiratory
distress. She underwent a bronchoscopy which found copious
heavy secretions in both lungs, most marked in the right lower
lobe. On POD5, she was noted to be much improved after her
bronchoscopy.
On POD6, her heparin drip was stopped due to a supratherapeutic
INR (of 6). Her antibiotic coverage was changed from
Clindamycin (which she had been on since admission) to
Vancomycin due to Gram positive cocci in her sputum. She was
also diuresed with lasix and acetazolamide.
Her INR was allowed to drift towards a therapeutic range. On
POD7, she was transferred back to [**Hospital Ward Name 121**] 2. Her Foley catheter
was removed. Her sputum cultures grew Aspergillus, but all
subsequent evaluation was negative for infection. Per
infectious disease, her vancomycin was continued, due to MSSA in
her sputum, with a penacillin allergic patient.
On POD9, Mrs. [**Known lastname **] suffered a left PCA stroke. She was briefly
transferred to the stroke service for acute stroke management.
She was transferred to the SICU, and administered IV TPA.
On POD10, a repeat head CT demonstated no hemorrhage after
receiving TPA. A heparin drip was reinitiated. She was
transferred back to the [**Hospital Ward Name 121**] 2 floor.
She continued to remain stable as her INR became therapeutic.
Her heparin drip was stopped on POD15. A right upper extremity
PICC was placed on POD14 for continued IV vancomycin.
On POD15, she was deemed stable to discharge to a rehabilitation
facility. She will follow up with Dr. [**Last Name (STitle) 952**] in [**7-21**] days.
Medications on Admission:
Diovan 80mg daily
HCTZ 25mg daily
Verapamil 180mg [**Hospital1 **]
Coumadin 5mg daily
Multivitamin
Glucosae
Milk of Magnesia
Discharge Medications:
1. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Vancomycin HCl 1000 mg IV Q 12H
Per ID for MSSA in lungs.
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO ONCE (Once):
Please adjust dose to achieve an INR of [**2-14**].
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP<100, HR<60.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: Five (5) mL
Inhalation Q6H (every 6 hours) as needed.
13. Albuterol Sulfate 0.083 % Solution Sig: Five (5) mL
Inhalation Q4H PRN as needed.
14. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
scale Injection ASDIR (AS DIRECTED): 0-60 mg/dL [**1-13**] amp D50
61-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 4 Units
201-240 mg/dL 6 Units
241-280 mg/dL 8 Units
281-320 mg/dL 10 Units
321-360 mg/dL 12 Units
361-400 mg/dL 14 Units
.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever/ pain.
16. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every
2 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Lung cancer, Left PCA CVA, MSSA pneumonia
CVA, Afib, HTN, uterine CA s/p hysterectomy, hyperlipidemia,
seasonal allergies
Discharge Condition:
good
Discharge Instructions:
call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] if you develop chest pain,
shortness of breath, fever, chills, redness or drainage from
your chest incision.
You may shower. After showering, cover the chest tube site with
a clean bandaid daily until healed.
No tub bathing or swimming for 3-4 weeks.
Followup Instructions:
Call Dr.[**Name (NI) 1816**] office [**Telephone/Fax (1) 170**] for a follow up
appointment in [**7-21**] days
Have you INR checked daily until your INR is [**2-14**] and stable for
48-72 hours, then have it checked weekly
|
[
"482.41",
"427.31",
"997.3",
"997.1",
"512.1",
"162.3",
"276.2",
"997.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"33.23",
"32.4",
"99.10",
"40.3",
"40.11",
"34.22",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14123, 14204
|
9912, 12202
|
331, 504
|
14371, 14378
|
2736, 9756
|
14741, 14967
|
1703, 1707
|
12377, 14100
|
14225, 14350
|
12228, 12354
|
14402, 14718
|
1722, 1722
|
270, 293
|
532, 1239
|
9765, 9889
|
1736, 2717
|
1261, 1501
|
1517, 1687
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,308
| 105,870
|
44193
|
Discharge summary
|
report
|
Admission Date: [**2118-4-4**] Discharge Date: [**2118-4-19**]
Date of Birth: [**2038-7-8**] Sex: F
Service: MEDICINE
Allergies:
Interferon Alfa
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
shortness of breath, chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
central line placement
Swan-Ganz line placement
History of Present Illness:
79 year old F, hx renal cell CA s/p R nephrectomy and s/p chemo
for recurrence, adrenal insuffiency, anemia with intermittent
outpt transfusions. Pt was admitted to OSH, c/o four days of SOB
and chest pain, palpitations, increased when lying down. Pt had
CXR c/w pulmonary edema, BNP 83K, treated with diuresis BIPAP
with some improvement.
This morning developed chest pain at 10AM, EKG with T wave
inversions, echo performed with LVEF 25%, 3+ MR and 3+ TR (nl
last year), found to have elevation in troponin to 0.09.
Subsequently pt developed AFib with RVR in the 200s, resistant
to small doses of lopressor. Started on heparin qtt, nitro qtt,
given [**First Name3 (LF) **].
Arrived to [**Hospital1 18**], found to have AFib with RVR at 150 bpm,
started on amiodarone, cardioverted to NSR, had cardiac
catheterization showing LCx with large ramus 80% lesion, tx with
BMS x2. LAD with 60% DI lesion, RCA without stenosis.
Aorta: 101/72/84
RV: 42/9/15
PA: 42/27/34
PCwp: 22
CO: 2.88 (CI 1.88)
Upon transfer to CCU patient denies any chest pain, palpitations
or shortness of breath. She attributes the beginning of her
breathing problems to the weight gain she experienced after
starting on hydrocortisone for adrenal insufficiency leading to
15 lb weight gain.
Past Medical History:
1. Renal cell CA s/p right nephrectomy [**2104**]
2. 2nd primary renal cell CA L kidney: clear cell path, treated
w/ IFN x 12 weeks ([**4-13**] - [**7-13**]), s/p sorafenib ([**8-13**] - [**9-13**])
d/c'd [**2-10**] rash; 6mm met in RML
3. HTN
4. Depression
5. Hyperlipidemia
6. Anemia [**2-10**] IFN: baseline HCT 25 over past 2 months,
transfusion dependent
7. Adrenal insufficiency, dx 1 month ago after presenting with
weight loss.
Social History:
retired teacher; remote smoking history (quit 45 years ago);
drinks 1 glass of wine daily. Has 5 children who live nearby.
She lives at home with husband, independent with ADLs.
Family History:
NC, no hx of cardiac disease, no hx of cancers
Physical Exam:
VS T , BP 123/77, HR 96 (NSR), RR 22, O2 sat 97% RA on NRB
Gen: elderly, frail appearing woman, lying in bed flat,
conversant in full sentences without getting short of breath,
NAD
HEENT: anicteric, OP clear, MMM
Neck: JVP 9-10cm
CV: reg s1/s2, II/VI systolic murmur at LLSB
Pulm: CTA b/l, bibasilar crackles
Abd: +BS, soft, NT, ND
Ext: warm, 2 distal pulses b/l, no pedal edema, R groin with
a-line, no hematoma, non-tender.
Pertinent Results:
Echo ([**Hospital1 **] [**Location (un) 620**]) [**4-4**]: LF fxn severely depressed, hypokinesis
of distal anteroseptum and inferoseptum, apex akinetic. 3+ MR,
3+ TR.
[**2118-4-4**] 07:36PM BLOOD WBC-15.3* RBC-2.79* Hgb-7.4* Hct-23.4*
MCV-84 MCH-26.6* MCHC-31.7 RDW-17.0* Plt Ct-479*
[**2118-4-12**] 06:25AM BLOOD WBC-11.0 RBC-3.43* Hgb-9.3* Hct-29.0*
MCV-85 MCH-27.1 MCHC-32.1 RDW-16.5* Plt Ct-254
[**2118-4-15**] 05:45AM BLOOD WBC-12.5* RBC-3.15* Hgb-8.7* Hct-26.8*
MCV-85 MCH-27.6 MCHC-32.5 RDW-16.3* Plt Ct-261
[**2118-4-7**] 05:20AM BLOOD Neuts-93.9* Bands-0 Lymphs-3.5* Monos-2.4
Eos-0.1 Baso-0.1
[**2118-4-10**] 07:10AM BLOOD PT-14.1* PTT-27.3 INR(PT)-1.2*
[**2118-4-15**] 05:45AM BLOOD PT-30.9* PTT-42.7* INR(PT)-3.3*
[**2118-4-4**] 05:15PM BLOOD Glucose-155* UreaN-19 Creat-0.9 Na-137
K-3.5 Cl-97 HCO3-26 AnGap-18
[**2118-4-9**] 07:10AM BLOOD Glucose-172* UreaN-43* Creat-1.3* Na-144
K-2.9* Cl-103 HCO3-27 AnGap-17
[**2118-4-12**] 06:25AM BLOOD Glucose-78 UreaN-34* Creat-1.0 Na-145
K-2.6* Cl-97 HCO3-37* AnGap-14
[**2118-4-15**] 05:45AM BLOOD Glucose-97 UreaN-36* Creat-1.1 Na-142
K-4.0 Cl-100 HCO3-33* AnGap-13
[**2118-4-5**] 06:50AM BLOOD ALT-17 AST-107* CK(CPK)-30 AlkPhos-253*
TotBili-2.3*
[**2118-4-8**] 03:52AM BLOOD ALT-31 AST-37 AlkPhos-197* TotBili-0.5
[**2118-4-4**] 05:15PM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2118-4-5**] 06:50AM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2118-4-5**] 03:00PM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2118-4-6**] 05:37AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2118-4-4**] 07:36PM BLOOD Calcium-8.2* Phos-5.7* Mg-1.7
[**2118-4-14**] 03:55AM BLOOD Calcium-8.3* Phos-2.4* Mg-1.6
[**2118-4-5**] 06:50AM BLOOD calTIBC-113* Ferritn->[**2112**] TRF-87*
[**2118-4-5**] 06:50AM BLOOD TSH-1.1
[**2118-4-5**] 06:50AM BLOOD PEP-HYPOGAMMAG IgG-1066 IgA-149 IgM-101
IFE-NO MONOCLO
[**2118-4-9**] 10:54PM BLOOD Type-ART pO2-85 pCO2-44 pH-7.47*
calHCO3-33* Base XS-7
[**2118-4-4**] 05:07PM BLOOD Type-ART pO2-91 pCO2-46* pH-7.43
calHCO3-32* Base XS-4
[**2118-4-5**] 08:17AM BLOOD Lactate-17.3*
[**2118-4-5**] 11:15AM BLOOD Lactate-11.9*
[**2118-4-5**] 03:09PM BLOOD Lactate-2.0
[**2118-4-6**] 04:06PM BLOOD Lactate-1.2
.
CXR [**4-4**]:
1. Asymmetric pulmonary edema, right greater than left.
2. Left basilar consolidation in the left retrocardiac region
which may represent some atelectasis or edema.
3. Pulmonary artery catheter is directed into left main
pulmonary artery.
4. Residual contrast persisting in the left renal collecting
system and left renal parenchyma - question time of contrast
administration.
.
C. Cath [**4-4**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
2 vessel coronary artery disease. The LMCA had no
angiographically
apparent flow limiting lesions. The LAD had mild luminal
irregularities
and gave rise to a moderate sized D1 which had a 60% stenosis.
There was
a large ramus which had a 80% ulcerated proximal stenosis. The
LCX did
not give off any other branches. The RCA was a dominant vessel
with mild
luminal irregularities.
2. Resting hemodynamics revealed elevated left sided filling
pressures
with PCWP of 22mmHg with depressed cardiac index and low
systemic blood
pressure.
3. Left ventriculography was deferred.
4 The proximal lesion in the ramus intermedius was predilated
with a
2.5 X 15mm Voyager balloon, stented with overlapping 2.5 X 12mm
and 2.5
X 08mm Minivision (Bare metal) stents with lesion reduction from
80% to
0%. the final angiogram showed TIMI III flow with no dissection
and no
embolisation. (see PTCA comments)
5. On arrival to teh cath lab pateint with in atrial
fibrillation with a
rapid ventricularresponse. She was started on IV amiodarone and
constinued to be tachycardic. ANesthesia was called and she was
successfully cardioverted with 300J-->NSR. She developed AF
again atthe
completion of the procedure with rates of 120-140bpm.
.
0FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Elevated left sided filling pressures, reduced cardiac
index.
3. Systemic hypotension.
4. Rapid atrial fibrillation.
5. Successful stenting of the ramus intermedius lesion with bare
metal
stents
.
CXR [**4-5**]: IMPRESSION: AP chest compared to [**4-4**]:
Pulmonary edema is markedly asymmetric, severe in the right
lung, though improved since [**4-4**], and mild on the left.
Mild-to-moderate cardiomegaly with suggestion of left atrial
enlargement is unchanged. Small bilateral pleural effusions
stable. No pneumothorax. An ascending Swan-Ganz catheter tip
projects over the left descending pulmonary artery. No
pneumothorax.
.
Echo [**4-5**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with severe hypokinesis of the
inferior wall, mid inferolateral wall, distal half of the septum
and apex . No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened. There is a minimally increased
gradient consistent with minimal aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad.
.
CXR [**4-13**]: IMPRESSION: Resolving asymmetrical combined alveolar
and interstitial process, likely due to resolving asymmetric
edema. Underlying infection in the right lung is not excluded in
the appropriate setting.
.
Echo [**4-18**]: Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is mildly depressed with inferior hypokinesis. The mid
to distal septum has borderline systolic thickening. No masses
or thrombi are seen in the left ventricle. Right ventricular
systolic function is borderline normal. 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. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**1-10**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2118-4-5**], LV
systolic
function has improved.
Brief Hospital Course:
79 y.o. F hx renal CA s/p nephrectomy, chemo presented with 1 wk
of CHF sx's, found to have new cardiomyopathy, combination of
ischemic and non-ischemic.
.
# Cardiac -
Cardiomyopathy/systolic CHF - at presentation to outside
hospital, pt was reportedly found to have both mitral and
tricuspid severe regurgitation, , severely depressed LVEF and
anteroseptal and inferoseptal hypokinesis. Her cardiac enzymes
had increased slightly, and her cardiac cath revelaed only a
ramus lesion, which was stented with 2 bare metal stents.
However, this was not thought to be sufficient to explain her
extensive echocardiographic changes. Work-up for other
non-ischemic causes of her cardiomyopathy reveal a normal TSH,
iron labs showed Fe 326, TIBC 113, and although she had required
some transfusions as outpatient since chemotherapy, this was not
thought to be sufficient to cause iron overload or
hemochormatosis type CM. Given that the patient presented with
AFib and tachycardia, tachycardia induced CM was thought to be
the most likely secondary explanation. However, multiple
routine EKGs on outpatient basis did not reveal resting
tachycardia.
The patient was treated with agressive diuresis using
Swan-Ganz line for hemodynamic monitoring. Her symptoms
improved significantly. She was started on metoprolol, which
was titrated up as tolerated by her HR, and also started on
ACE-I, titrated as tolerated by BP. The patient's toprol dose
was decreased [**2-10**] mood depression, and on 50mg of Toprol XL at
time of discharge. Her ACE-I was held in light of increased Cr
to 1.4, although improving at time of discharge. Fluid status
needs to be monitored carefully. Pt appears to be euvolemic at
time of discharge. Echo on day before discharge showed markedly
improved systolic function, suspect that this is related to the
resolved tachycardia.
.
# CAD - ramus lesion stented, started on [**Last Name (LF) **], [**First Name3 (LF) **] need plavix
for 1 month. Started on lipitor 80mg initially in setting of
MI, but outpt labs on [**1-14**] revealed normal lipids with LDL of
43, decreased lipitor to 10mg. She was started on BB, ACE-I as
above, ACE-I currently on hold.
.
# Rhythm - initially found to have AFib in the setting of
decompensated CHF, started on metoprolol which was insufficient
to rate control, and amiodarone was added. She was loaded for
one week with 200mg three times daily dosing, this was decreased
to 200mg daily on day of discharge because of persistent nausea
and poor po intake. She converted to NSR early on and remained
in this rhythm during remainder of hospitalization. She was
initially started on heparin for anticoagulation after
discussion of anticoagulation risks with her oncologist, who did
not find any contraindications to this. She was switched to
coumadin, INR increased rapidly after 2 doses of 5mg, decreased
to 2.5mg. She did experience an episode of significant R sided
anterior nasal bleeding while on heparin, however her PTT at
this time was 41.8 and INR was 1.9. The nose bleeding was
controlled with pressure, Afrin, and silver nitrate localized
cauderization. This was thought to be most likely related to
irritation from oxygen and the nasal cannula, however she may
need to have a goal INR slightly lower of 1.8-2.5. No further
nose bleeds noted over next few days. At time of discharge on
2mg of coumadin, INR 2.4.
.
# UTI - she was complaining of dysuria, U/A was sent and found
to have >200 WBC, + bacteria, started on bactrim on [**4-14**], her Cr
jumped slightly and Bactrim was switched to cipro starting on
[**4-18**] for a 5 day course.
.
# Renal carcinoma - in the past pt has been on experimental
chemotherapy, however was intolerant to side effects. Currently
plans are ongoing to find other chemotherapy regimen, possibly
at [**Hospital 3340**] Clinic. She has known metastases to lungs, and
adrenal gland. Given malignancy, the thought of pulmonary
embolus to exlain her shortness of breath was entertained,
however given her improvement with diuresis thought less likely.
In addition, given her single kidney, and worsened renal
function while inpatient, in addition to her having a solitary
kidney, and her already being anticoagulated, CTA was not
performed. On previous CT images, she is noted to have a
possible IVC thrombus, cardiac echo did not demonstrate
extensive progression of this. She has chronic anemia related
to past chemo, epo has been tried in past and ineffective, needs
occassional outpt transfusions.
.
# Depression - continued celexa, pt had poor nutrition and flat
affect, although this seemed to improve at the time of
discharge. Psychiatry was consulted to recommend something for
mood and possibly for appetite. Recommended continuing Lexapro.
Would consider psychiatry consult at rehab. Consider remeron
7.5 mg depending on whether her mood depression persists.
.
# FEN - cardiac diet, bowel regimen, required a lot of K
repletion during diuresis, would follow closely after discharge.
.
# Ppx - bowel meds, on coumadin
.
# Code - full
Medications on Admission:
Hydrocortisone 20mg QAM, 10mg QPM
Lexapro 10mg
Citracal
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 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).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Coronary artery disease
Congestive Heart Failure
Atrial Fibrillation
Acute Renal Failure
Secondary:
Depression
Anemia of chronic disease
Stage IIIb Renal Cell Carcinoma
Hypertension
Adrenal Insufficiency
Discharge Condition:
Fair
Discharge Instructions:
Please continue antibiotics until [**4-22**]. Please continue taking
Plavix (clopidogrel) unless directed otherwise by your doctor.
Take your other medications as prescribed. Follow-up with your
doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. Call your PCP to make [**Name Initial (PRE) **] follow-up
appointment as needed. You should seek medical attention if you
develop chest pain, worsened shortness of breath, fever, or any
other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2118-6-1**] 12:30
Follow-up with PCP as needed
Completed by:[**2118-4-19**]
|
[
"198.7",
"401.9",
"425.4",
"599.0",
"410.71",
"584.9",
"285.9",
"785.51",
"V10.52",
"197.0",
"255.4",
"414.01",
"997.1",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.46",
"00.66",
"37.23",
"38.93",
"36.06",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
15702, 15781
|
9455, 14517
|
305, 378
|
16037, 16043
|
2851, 6718
|
16570, 16783
|
2341, 2389
|
14624, 15679
|
15802, 16016
|
14543, 14601
|
6735, 9432
|
16067, 16547
|
2404, 2832
|
234, 267
|
406, 1668
|
1690, 2129
|
2145, 2325
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,889
| 199,955
|
50678
|
Discharge summary
|
report
|
Admission Date: [**2197-7-4**] Discharge Date: [**2197-7-5**]
Date of Birth: [**2142-3-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Cardiac arrest/found down in field
Major Surgical or Invasive Procedure:
Central line placed
Multiple resuscitations
History of Present Illness:
55 yo M with HTN nephropathy s/p renal tx in [**4-15**], on
immunosuppressants, h/o DM, CHF, CAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 2 in [**6-13**]
brought in to ED after a witnessed cardiac arrest. Per records,
the family heard a noise and found pt down. He c/o arm pain
before falling. The patient had been down for about 10 minutes.
EMS arrived at 20:45. Pt intubated in the field. CPR was
initiated. Pt in asystole. Received calcium, bicarb, albuterol,
epi/atropine x 3. Transferred to [**Hospital1 18**]. On arrival to [**Hospital1 18**],
patient in sinus. BP 210/122 HR 111 RR 18. Then dropped BP to
61/36, HR 44. Femoral line placed. Dopamine was started. Pt went
into PEA arrest then asystole. He was given atropine x 3, epi
x4, bicarb, calcium chloride. EKG showed nl sinus rate 93; nl
axis, peaked [**Last Name (LF) 105445**], [**First Name3 (LF) **] depressions in I, II, V4-V6. CXR with
increased interstital markings. Labs notable for K 6.1,
BUN 13, Cr 2, lactate 14, Ca [**04**], PO4 10.
.
On arrival to ICU, BP 70s/50s, HR 130s. Pupils were fixed and
dilated. Levophed, Neo, Vasopressin added for BP support. Per
family, the patient had been in USOH until the incident. In the
ICU, bedside echo showed thickened LV and RV, but no effusion.
Past Medical History:
1. ESRD on HD Tues/Thurs/Sat at [**Location (un) 4265**] in [**Location (un) **]
2. s/p 2 [**Location (un) **] in [**6-13**] (LAD and ramus), exercise MIBI [**2-14**] limited
by poor exercise tolerance. No definite evidence of reversible
perfusion defects. Slightly enlarged cavity size. Global
hypokinesis. LVEF of 38%
3. CHF: TTE ([**2196-5-5**]) showed EF=45% to 50%, mild symmetric left
ventricular hypertrophy, overall left ventricular systolic
function mildly depressed, inferior hypokinesis, moderate (2+)
mitral regurgitation is seen, moderate pulmonary artery systolic
hypertension.
4. HTN
5. DM2 followed by [**Last Name (un) **]
6. Hyperlipidemia
7. GERD
8. Anemia, baseline hematocrit 30-36%
9. TIA on aspirin
Social History:
Per chart: Pt lives with his wife and children. Does not work.
Denies tobacco, Etoh or other drugs. Born and raised in [**Country 2045**],
lived in [**Country 2560**] 2 years before moving to [**Location (un) 86**].
Family History:
Per chart: HTN, no diabetes or heart disease
Physical Exam:
VS: T 100.1, HR 128; BP 80/50
Vent: 600 x 18 (total 29), PEEP 5, FiO2 1.0
GEN: Intubated
HEENT: NC, AT, pupils are fixed and dilated
CV: regular, nl S1S2, no M/r/g
PULM: fine crackles bilaterally
ABD: protuberant, soft, NT, ND, renal transplant scar in RLQ
EXTR: lower extremities cool, no edema; fistula in LLE w/o thril
NEURO: pupils are fixed and dilated, no corneal reflexes, does
not withdraw to pain
Pertinent Results:
HEMATOLOGY
[**2197-7-4**] 11:32PM BLOOD WBC-6.8# RBC-5.21 Hgb-15.2 Hct-48.9
MCV-94# MCH-29.1 MCHC-31.0# RDW-17.0* Plt Ct-216
[**2197-7-4**] 11:32PM BLOOD Neuts-81* Bands-3 Lymphs-14* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2197-7-4**] 11:32PM BLOOD PT-13.3* PTT-44.8* INR(PT)-1.2*
CHEMISTRY
[**2197-7-4**] 09:39PM BLOOD Glucose-715* UreaN-13 Creat-2.0* Na-140
K-6.1* Cl-100 HCO3-15* AnGap-31*
[**2197-7-5**] 04:04AM BLOOD Glucose-200* UreaN-18 Creat-2.5* Na-141
K-3.8 HCO3-20*
[**2197-7-4**] 11:32PM BLOOD ALT-764* AST-656* CK(CPK)-432*
AlkPhos-185* Amylase-99 TotBili-0.4
[**2197-7-5**] 04:04AM BLOOD Calcium-9.9 Phos-2.0*# Mg-2.2
[**2197-7-5**] 01:15AM BLOOD Cortsol-17.0
CARDIAC ENZYMES
[**2197-7-4**] 09:39PM BLOOD cTropnT-<0.01
[**2197-7-4**] 09:39PM BLOOD CK-MB-3
[**2197-7-4**] 11:32PM BLOOD CK-MB-5 cTropnT-0.06*
ARTERIAL BLOOD GAS RESULTS
[**2197-7-4**] 11:45PM BLOOD Type-ART pO2-116* pCO2-69* pH-7.09*
calTCO2-22 Base XS--10 Comment-ABG ADDED
[**2197-7-5**] 01:17AM BLOOD Type-ART pO2-112* pCO2-51* pH-7.25*
calTCO2-23 Base XS--5
[**2197-7-5**] 03:46AM BLOOD Type-ART PEEP-10 pO2-175* pCO2-37
pH-7.32* calTCO2-20* Base XS--6 Intubat-INTUBATED
Vent-CONTROLLED
[**2197-7-5**] 04:39AM BLOOD Type-ART pO2-91 pCO2-48* pH-7.21*
calTCO2-20* Base XS--8
[**2197-7-4**] 10:23PM BLOOD Glucose-637* Lactate-14.3* Na-141 K-6.1*
Cl-108 calHCO3-19*
[**2197-7-5**] 03:46AM BLOOD Lactate-3.5*
Brief Hospital Course:
Femoral central line placed in ED. Insulin drip started. Patient
broadly covered empirically for possible respiratory infection
or sepsis with Vanco/Levo/Zosyn.
Coded in ED. We ordered multiple pressors (dopamine, norepi,
vasopressin) to keep his blood pressure within acceptable
limits. Phenylephrine added during his time in the CCU.
Multiple codes (primarily PEA/asystole) while in CCU. Patient
continued to be unresponsive with pupils fixed and dilated.
Family called, plans of care discussed. Early in admission,
patient had been stabilized, family felt full code was
appropriate because patient was so recently s/p transplant and
had been doing well. After family had gone home, patient coded
again (PEA) and family was called back. Attending ([**Doctor Last Name **])
discussed evolving situation and worsening prognosis with wife
and son. Wife in room s/p resuscitation, witnessed ongoing
efforts to stabilize and treat patient.
After several additional codes including many chest compressions
and courses of ACLS medications appropriate to evolving rhythms,
patient's wife agreed that resuscitation efforts should be
suspended if situation did not improve. Patient continued to
re-enter PEA/asystole, and soon expired. Family asked for
autopsy without brain findings in order to find out what had led
to patient's relatively sudden death.
Medications on Admission:
1. Prograf 2 mg po bid (being transitioned to rapamune)
2. Myfortic 750 [**Hospital1 **]
3. Valcyte 450 qd
4. Bactrim SS
5. Nystatin prn
6. Protonix 40 mg po qd
7. Rapamune 3 mg po qd
8. Carvedilol 50 mg po bid
9. amlodipine 5 mg po qd
10. insulin 70/30 14 units ad
11. Humalog SS
.
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest, leading to death.
Discharge Condition:
Expired.
Discharge Instructions:
N/A.
Followup Instructions:
N/A.
|
[
"250.02",
"427.5",
"V45.82",
"403.91",
"272.4",
"428.0",
"530.81",
"585.6",
"424.0",
"414.01",
"V42.0",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.17",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6364, 6373
|
4647, 6000
|
348, 393
|
6450, 6460
|
3223, 4624
|
6513, 6520
|
2733, 2780
|
6334, 6341
|
6394, 6429
|
6026, 6311
|
6484, 6490
|
2795, 3204
|
274, 310
|
421, 1736
|
1758, 2482
|
2498, 2717
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
178
| 196,159
|
49751
|
Discharge summary
|
report
|
Admission Date: [**2163-1-7**] Discharge Date: [**2163-1-15**]
Date of Birth: [**2115-12-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
Ventral Hernia
Major Surgical or Invasive Procedure:
[**2163-1-7**] Ventral Hernia repair
[**2163-1-7**] Hematoma Evacuation
History of Present Illness:
This is a 47 year old gentleman with ulcerative colitis
status-post a J-pouch operation in '[**57**] with a reversal of
ileostomy later that year who presents with recurrence of a
ventral incisional hernia. He last had this operated on in [**2159**]
and now presents with hernia repair with separation of
components. He consented after it was explained that he might
loose sensation in his abdominal wall and would lose his
umbilicus. Symptomatically he denies abdominal pain, nausea,
vomitting, or constipation.
Past Medical History:
Ulcerative Colitis [**2136**]
J-pouch [**2157-7-5**]
Ileostomy Reversal [**2157-11-4**]
Ventral Hernia repair [**2159**]
Atrial Fibrillation
Mitral Valve annuloplasty
Pace-maker
Social History:
The patient is a Rabbi and happily married with children. He
does not smoke or drink alcohol.
Family History:
Negative for inflammatory bowel disease or colon cancer
Physical Exam:
ON admission:
v/s 96.5, 62, 97% room air, RR 18, 107/69
Gen: no acute distress, well-nourished middle aged male
HEENT: moist mucous membranes, PERRLA
Neuro: CN 2-12 grossly intact
CV: irregular rhythm, v-paced, no murmurs appreciated
Abd: soft, palpable swelling at midline,prior laparotomy
incisions well healed, non-tender, non-distended, normoactive
bowel sounds
Extr: no edema,warm
Pertinent Results:
SEROLOGIES
[**2163-1-7**] 08:22AM BLOOD Hgb-13.7* Hct-38.4* Plt Ct-166
[**2163-1-8**] 02:08AM BLOOD WBC-9.0# RBC-2.93*# Hgb-9.0*# Hct-25.7*
MCV-88 MCH-30.9 MCHC-35.1* RDW-13.4 Plt Ct-91*
[**2163-1-9**] 03:24AM BLOOD WBC-8.4 RBC-3.46* Hgb-10.8* Hct-30.6*
MCV-88 MCH-31.2 MCHC-35.3* RDW-13.9 Plt Ct-85*
[**2163-1-10**] 03:00AM BLOOD WBC-7.2 RBC-3.50* Hgb-10.7* Hct-30.9*
MCV-88 MCH-30.7 MCHC-34.7 RDW-13.7 Plt Ct-94*
[**2163-1-11**] 08:43AM BLOOD WBC-8.8 RBC-4.01* Hgb-12.8* Hct-35.3*
MCV-88 MCH-31.9 MCHC-36.2* RDW-13.2 Plt Ct-149*#
[**2163-1-12**] 05:15AM BLOOD WBC-7.9 RBC-3.53* Hgb-10.9* Hct-31.1*
MCV-88 MCH-30.9 MCHC-35.1* RDW-13.3 Plt Ct-145*
[**2163-1-13**] 05:25AM BLOOD WBC-7.0 RBC-3.37* Hgb-10.5* Hct-29.6*
MCV-88 MCH-31.1 MCHC-35.4* RDW-13.0 Plt Ct-155
[**2163-1-7**] 08:22AM BLOOD PT-15.7* PTT-36.0* INR(PT)-1.6
[**2163-1-7**] 09:00PM BLOOD PT-16.2* PTT-30.3 INR(PT)-1.7
[**2163-1-8**] 05:42AM BLOOD PT-14.3* PTT-33.4 INR(PT)-1.3
[**2163-1-9**] 03:24AM BLOOD PT-13.7* PTT-29.4 INR(PT)-1.2
[**2163-1-10**] 03:00AM BLOOD PT-13.2 PTT-28.5 INR(PT)-1.1
[**2163-1-13**] 05:25AM BLOOD PT-13.7* PTT-29.1 INR(PT)-1.2
[**2163-1-14**] 05:55AM BLOOD PT-14.1* PTT-30.6 INR(PT)-1.3
[**2163-1-7**] 06:50PM BLOOD Glucose-222* UreaN-14 Creat-0.9 Na-134
K-5.2* Cl-100 HCO3-26 AnGap-13
[**2163-1-8**] 02:08AM BLOOD Glucose-103 UreaN-13 Creat-0.8 Na-139
K-4.3 Cl-108 HCO3-22 AnGap-13
[**2163-1-9**] 03:24AM BLOOD Glucose-132* UreaN-6 Creat-0.7 Na-140
K-3.7 Cl-105 HCO3-31* AnGap-8
[**2163-1-10**] 03:00AM BLOOD Glucose-134* UreaN-5* Creat-0.7 Na-139
K-3.3 Cl-102 HCO3-31* AnGap-9
[**2163-1-11**] 08:43AM BLOOD Glucose-131* UreaN-9 Creat-0.8 Na-140
K-3.4 Cl-99 HCO3-33* AnGap-11
[**2163-1-12**] 05:15AM BLOOD Glucose-107* UreaN-11 Creat-0.7 Na-140
K-3.5 Cl-105 HCO3-26 AnGap-13
[**2163-1-13**] 05:25AM BLOOD Glucose-89 UreaN-12 Creat-0.6 Na-139
K-4.2 Cl-104 HCO3-27 AnGap-12
[**2163-1-14**] 05:55AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
RADIOLOGY:
[**2163-1-11**] Abdominal Xray:1. Mildly dilated loops of small bowel
consistent with postoperative ileus. 2. No definite foreign body
identified.
MICROBIOLOGY
[**2163-1-10**] MRSA, VRE screen: negative
Brief Hospital Course:
This is a 47 year old male who presented for operative
management of a recurrent ventral hernia. He underwent ventral
hernia repair with component separation on [**2163-1-7**]. Both
plastics surgery and GI surgery were involved in this procedure,
which went well with no complications. Anticoagulation was held
in the perioperative period because of risk for bleeding. On the
evening of post-operative day 0 he had an obvious abdominal wall
hematoma and a drop in hematocrit from 35 to 25 and he was
returned to the operating room for re-exploration . There he was
found to have a rectus muscle bleed with was cauterized and
[**Last Name (un) **]-seal was added to improved hemostasis. He was given 4 units
of PRBC and 4 units of FFP. He was transferred to the ICU
post-operatively and extubated on post-op day 1. His hematocrit
was stable for the next few days. He was transferred to the
floor after a 2 day ICU stay in stable condition. He was started
on a clear liquids diet on post-operative day 4 but vomitted and
an NGT was placed. This was clamped on POD 5 and removed and the
patient was again started on a PO diet with slow advancement. He
tolerated this well with no further episodes of emesis and was
on a regular diet by post-operative day 7; he had several bowel
movements prior to discharge. His cardiologist was consulted and
he was restarted on Coumadin on post-operative day 5 with
planned followup with cardiology and home INR checks at the
[**Hospital 197**] clinic. He was discharged in fair condition on [**2163-1-15**]
with planned followup with both GI and Plastic surgery. His JP
drains were removed on the day of his discharge.
Medications on Admission:
Toprol 200mg oral daily
Immodium prn
Ciprofloxacin 500 mg oral [**Hospital1 **]
Zestril 10mg oral daily
Coumadin 10 mg oral x daily x 6 days and 7.5 mg oral daily x 1
day
Digoxin 0.375 oral daily
Folate
Fergon
Discharge Medications:
1. Coumadin 10 mg Tablet Sig: One (1) Tablet PO once/day for 6
days/weeks.
2. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO one day/week.
3. Digoxin Oral
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
6. Zestril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Loperamide HCl 2 mg Capsule Sig: One (1) Capsule PO QID (4
times a day) as needed.
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*40 Capsule(s)* Refills:*0*
10. Fergon Oral
11. Folic Acid Oral
12. Multi-Vitamin Oral
Discharge Disposition:
Home
Discharge Diagnosis:
(1) Ventral Hernia
(2) Atrial Fibrillation
(3) Ulcerative Colitis
(4) s/p Mitral Valve Repair
Discharge Condition:
Good
Discharge Instructions:
Please contact the office or come to the emergency room with any
worsening abdominal pain, nausea/vomitting, inability to
tolerate a regular diet, or fever > 101.5. You may remove your
dressings in 48 hours.
Followup Instructions:
Please contact the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 9**] to set-up a follow-up appointment within 2 weeks.
Please contact the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (plastics
surgery) at [**Telephone/Fax (1) 1416**] to set up a follow-up appointment
within 2 weeks.
Please see your cardiologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) for follow-up
within a month. He has been notified about your surgery and
post-operative care.
Please follow-up in the [**Hospital 197**] Clinic on Monday [**2163-1-17**] to
have your INR checked as per pre-op.
Completed by:[**2163-1-17**]
|
[
"427.31",
"285.1",
"553.21",
"998.12",
"V45.01",
"401.9",
"556.9",
"394.9",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"54.72",
"86.67",
"99.04",
"54.0",
"53.51"
] |
icd9pcs
|
[
[
[]
]
] |
6690, 6696
|
3915, 5569
|
326, 400
|
6834, 6840
|
1749, 3892
|
7096, 7820
|
1270, 1327
|
5829, 6667
|
6717, 6813
|
5595, 5806
|
6864, 7073
|
1342, 1342
|
272, 288
|
428, 942
|
1357, 1730
|
964, 1143
|
1159, 1254
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,962
| 146,763
|
48923
|
Discharge summary
|
report
|
Admission Date: [**2156-3-15**] Discharge Date: [**2156-3-18**]
Date of Birth: [**2082-5-21**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Latex
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt. is a 73yo woman with metastatic pulmonary neuro-endocrine
carcinoma, large-cell type, progressive following two cycles of
palliative chemotherapy with carboplatin and etoposide. Most
recently on irinotecan weekly, last dose on [**3-10**]. Patient has
been progressing through recent chemo. She also has a h/o HTN
and recent MAT with hospitalization from [**Date range (1) 31835**] during which
her BB was increased from daily to tid. She was recently
referred to hospice care. At home the patient reports that she
has been having diarrhea while getting chemo. Stools 3-4 times
per day. Also with nausea and decreased PO. One episode of
vomiting a few days ago. She reports that VNA noted her to be
more tachycardic yesterday and encouraged her to come in. She
continues to have baseline SOB and gets daily pleural fluid
drained from her pleurex catheter. She denies fevers, chest pain
or cough.
In the ED VS were T 96.7 BP 79/62 HR 140 RR 8 100% RA. She was
given 1.5L of IVF with improvement in HR to 120s. Patient
initially refusing admission, however husband insisted given
need to see her oncologist in am. Given hypotension and
tachycardia, need for CVL was discussed with patient and patient
refused. Labs were notable for ARF with Cr 3.4 and K 5.8. She
was given 1 amp D50 and insulin 10 units.
On admission the patient appeared tired. She had no complaints.
She refused central line placement.
Past Medical History:
1. L4/L5 spondylolisthesis with synovial cyst resected in
01/[**2154**].
2. Left piriformis syndrome.
3. Hypertension.
4. Status post total hysterectomy in [**2147**] for leiomyomata with
foci of atypical hyperplasia of the endometrium, focally
involving an endometrial polyp.
5. Pulmonary neuroendocrine carcinoma diagnosed as below in [**1-2**]
6. s/p R pleurex catheter placement [**2156-2-6**]
.
Past Oncology History:
- Initial symptoms: cough, supraclavicular lymph node, nodular
mass lower abdomen
- CXR demonstrated R hilar mass. CT on [**2156-1-1**] showed 3.5 X 3.7
cm R hilar mass with marked narrowing of the right upper lobe
bronchus and apparent obstruction of the posterior bronchus to
the right upper lobe. Bulky bilateral mediastinal
lymphadenopathy was noted. The dominant lymph node mass in the
right paratracheal region measured 2.9 x 2.7 cm, with a dominant
conglomerate nodal mass in the precarinal lesion measuring 3.3 x
2.8 cm. Multiple lymph nodes were identified throughout the
mediastinum including the prevascular space bilaterally, the
posterior subcarinal space, and the right hilum. There was a
moderate dependent right pleural effusion and a small left
pleural effusion as well as a small pericardial effusion. Also
noted was a 2.8 x 1.9 cm nodule within the periphery of the
right upper lobe. Heterogeneous enhancement of the left adrenal
gland was seen, measuring 1.9 x 1.8 cm. In addition, an enlarged
left supraclavicular lymph node measured 1.4 x 1 cm. Several
lucent vertebral body lesions were identified in the lower
thoracic spine.
- Excisional biopsy of the right supraclavicular lymph node on
[**2156-1-5**].
- Pathology: poorly differentiated neuroendocrine carcinoma of
pulmonary origin, probably best characterized as large cell
type, although there is considerable variation in cell size. No
e/o lymphoproliferative disorder.
Social History:
The patient is married and lives in [**Location **] with her husband.
They have a 47-year-old son who lives in [**Name (NI) 108**]. She spends her
time playing cards and socializing. She has smoked cigarettes
for the past 60 years, approximately a pack per day on average.
She drinks two glasses of wine each night.
Family History:
The patient's mother died at age 86 from squamous cell
carcinoma of the oral cavity. Her father died of congestive
heart failure at age 85. She has no siblings. Her paternal aunt
was diagnosed with breast cancer in her 70s.
Physical Exam:
Vitals: T: 95.8 BP: 84/49 HR: 127 RR: 6 O2Sat: 91% 2L
GEN: Chronically ill-appearing, tired, lying in bed with eyes
closed, arousable, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MM dry, OP Clear
NECK: No JVD, no lymphadenopathy, trachea midline
COR: Regular, tachy, no M/G/R
PULM: Decreased BS [**12-26**] way up on R, crackles [**12-27**] way up on L
ABD: Soft, firm soft tissue mass present on anterior abdominal
wall, NT, ND, hyperactive BS
EXT: 1+ edema bilateral LE
NEURO: oriented to person, place, and time. CN II ?????? XII grossly
intact. Moves all 4 extremities. Strength 4+/5 in upper and
lower extremities.
Pertinent Results:
ADMISSION LABS:
[**2156-3-15**] 09:10PM BLOOD WBC-4.5# RBC-3.78* Hgb-11.1* Hct-34.2*
MCV-91 MCH-29.4 MCHC-32.5 RDW-18.7* Plt Ct-396
[**2156-3-15**] 09:10PM BLOOD Neuts-85* Bands-0 Lymphs-6* Monos-5 Eos-4
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-3-15**] 09:10PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Spheroc-1+ Ovalocy-1+
Stipple-1+ Tear Dr[**Last Name (STitle) **]1+
[**2156-3-15**] 09:10PM BLOOD PT-14.2* PTT-29.1 INR(PT)-1.2*
[**2156-3-15**] 09:10PM BLOOD Glucose-136* UreaN-45* Creat-3.4*#
Na-132* K-5.8* Cl-92* HCO3-24 AnGap-22*
[**2156-3-15**] 09:10PM BLOOD CK(CPK)-596*
[**2156-3-15**] 09:10PM BLOOD cTropnT-0.03*
[**2156-3-15**] 09:10PM BLOOD CK-MB-6
[**2156-3-15**] 09:10PM BLOOD Calcium-8.9 Phos-8.7*# Mg-2.4
==============
CXR [**2156-3-15**]:
Since [**2156-2-24**], right chest tube is still in place. Right
pleural
effusion is likely unchanged but pneumothorax is improved. Left
pleural
effusion is unchanged, still small-to-moderate. Left basilar
opacity
increased, could be aspiration or infection. Right upper lobe
and right
middle lobe are still collapsed but slightly better aerated.
Left perihilar
mass is hard to differentiate from adjacent consolidation.
Brief Hospital Course:
This was a 73 year old female with metastatic pulmonary
neuro-endocrine carcinoma diagnosed approximately three months
ago. She was receiving palliative chemotherapy up until the
beginning of [**Month (only) 958**] until her performance status became so poor
that she enrolled in home hospice. She presented to the
emergency department because of progressive diarrhea, up to 7
stools daily. She was admitted to the ICU with hypotension,
tachycardia and acute renal failure. The patient made it clear
that she did not want aggressive measures taken, including
central line placement or imaging studies such as CTA. Patient
and her family decided to make her comfort measures only. She
was given intravenous fluid hydration. She was also continued on
octreotide as a comfort measure to control her diarrhea.
Palliative care was consulted for recommendations and for
patient coping. The patient was pronounced dead on [**2156-3-18**] at
10:29 am. Immediate cause of death was felt to be respiratory
arrest. [**Name (NI) **] husband was notified of his wife's death. He
did not wish to have an autopsy.
Medications on Admission:
(per OMR):
Hydrocodone-acetaminophen [**12-26**] q6hr prn
Lorazepam 1mg prn
Toprol 25mg daily
Mirtazapine 15mg [**12-26**] qhs prn
Ondansetron 8mg q8hr prn
Prochlorperazine 10mg q6hr prn
Tylenol prn
ASA 81mg daily
Colace 100mg [**Hospital1 **]
Ibuprofen 600mg [**Hospital1 **] prn
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic neuroendocrine carcinoma, large cell type
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2156-3-20**]
|
[
"V16.0",
"198.81",
"V16.3",
"276.51",
"305.1",
"799.1",
"V66.7",
"276.7",
"300.00",
"427.31",
"V45.89",
"787.91",
"401.9",
"198.89",
"197.2",
"584.9",
"196.8",
"162.3",
"197.8",
"E933.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7576, 7585
|
6111, 7212
|
289, 295
|
7682, 7688
|
4878, 4878
|
7740, 7775
|
3983, 4210
|
7544, 7553
|
7606, 7661
|
7238, 7521
|
7712, 7717
|
4225, 4859
|
241, 251
|
323, 1736
|
4894, 6088
|
1758, 3634
|
3650, 3967
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,365
| 198,008
|
48240
|
Discharge summary
|
report
|
Admission Date: [**2129-3-30**] Discharge Date: [**2129-4-10**]
Date of Birth: [**2054-8-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
transferred to [**Hospital Unit Name 153**] for GIB
Major Surgical or Invasive Procedure:
colonoscopy, video enteroscopy, tagged RBC scan.
History of Present Illness:
74 yo M with CAD s/p CABG in '[**15**] and repeat Cath with known 3vd
with one failed graft, as well as afib on coumadin and previous
hx of GIB of unknown origin presents with anemia. The pt reports
he has been feeling weak and short of breath over the last
5-7days. He had noted DOE - inability to ambulate more than 10
steps without getting short of breath or weak in the arms and
legs. He had previously been able to ambulate more than one
block prior to onset of sx. The pt also reports LH, dizziness,
orthostasis and generalized fatigue as well as increased sx of
palpitations. He had previously had brown stool however since
initiation of Iron supplementaion one week prior, he had since
had black stools. The stools are described as formed and without
significantly different odor than previous. He denies any chest
pain, sob at baseline or n/v, diaphoresis. He also denies any
abd pain or change in appetite. He also denies any f/c/r, night
sweats, weight loss. No use of NSAIDS. The pt had presented to
his PCP yesterday at which time, he was found to have a Hct of
21 and subsequently he was referred in to the ED.
.
In the ED, the pt was found to be intermittently hypotensive to
SBP of 80s. He was neither tachycardic nor symptomatic with
these BPs. PE was significant for no significant hemorrhoids on
ext exam but brown guaiac positive stools with streaks of blood.
2 large bore IVs were placed, the pt was typed and crossed
4units and started on 2units of PRBC as wellas 2000L of NS. He
was also given 2mg Vitamin K sub Q for an INR of 2.8 as well as
protonix 40mg IV x1. The GI fellow as called and given his
previous negative EGD/Colonoscopy as well as capsule study,
suspicion was low for an UGIB. In addition, as he had an
elevated INR, a NGL was deferred until the AM. The pt was
transferred directly to the MICU.
Past Medical History:
1. GIB in [**2128**]
2. CAD s/p CABG x3 in [**2115**] and cath with 1 graft down
3. Afib on Coumadin
4. Anemia- normocytic, normochromic attributed to chronic
disease and mild renal insufficiency baseline 33-37
5. Chronic hematuria - likely from renal cysts
6. CHF: last ef approx 43% by mibi with 1-2+MR
7. DM2 - diet controlled
8. Hypertension
9. Hyperlipidemia
10. PVD with venous stasis ulceration
11. CKD
12. Chronic back pain from disc disease/nerve root compression
on oxycontin
13. s/p hip replacements x2
[**37**]. s/p ccy
15. Colonic polyps with adenoma on path on c-scope [**2124**] with neg
EGD in [**2126**]
Social History:
Tob: Pt admits to smoking 2+ppd x 40+ years but quit in [**2109**]
EtOH: rare
Illicit drugs: denies
Divorced, lives alone in [**Location (un) **]
Family History:
Unknown as parents, brothers and sisters died in Holocaust.
Physical Exam:
VS in ED: Tc: 97.9, HR: 92, BP: 140/57, RR: 18, SaO2: 98% on RA
GEN: Pale well nutritioned male in NAD, conversing fluently in
full sentences
HEENT: PERRLA, EOMI, pale conjunctiva, mmm, op clear, no
telangiectasias
CV: RRR, S1, S2, no m/r/g
Chest: CTA bilaterally
Abd: obese, soft, NT, ND, BS+
Ext: wwp, +1 edema bilaterally R>L
Rectal exam (as per verbal report from ED resident): no
hemorrhoids on external exam, rectal tone OK, brown stool,
guaiac positive with some streaks of blood.
Skin: occasional cherry hemangiomas as well as multiple skin
tags especially over back of neck, chest and axilla. no
acanthosis nigricans
Neuro: A+O x3
Pertinent Results:
capsule endoscopy: 1. Dark blood in the duodenum 2. Distal small
bowel obscured by dark blood 3. Etiology of bleeding cannot be
determined due to obscured mucosa.
.
tagged RBC scan: No evidence of active GI bleeding.
.
c-scope: Moderate amounts of old black stool were noted
throughout the colon. The black stool could be because of blood
or old iron. Similar material was noted in the terminal ileum,
suggesting that if is blood, the source is most likely small
bowel. Otherwise normal colonoscopy to cecum and terminal ileum.
.
EGD: Normal push enteroscopy to mid-jejunum.
.
[**2129-3-30**] 11:47AM BLOOD WBC-6.1 RBC-2.29*# Hgb-7.0*# Hct-21.7*#
MCV-95 MCH-30.4 MCHC-32.1 RDW-17.3* Plt Ct-147*
[**2129-3-30**] 11:47AM BLOOD Neuts-75.0* Bands-0 Lymphs-18.4 Monos-4.8
Eos-1.6 Baso-0.2
[**2129-3-30**] 11:47AM BLOOD Plt Ct-147*
[**2129-3-30**] 08:00PM BLOOD PT-27.6* PTT-37.6* INR(PT)-2.8*
[**2129-3-30**] 11:47AM BLOOD ESR-20*
[**2129-4-5**] 12:55PM BLOOD Ret Aut-6.2*
[**2129-3-30**] 08:00PM BLOOD Glucose-142* UreaN-77* Creat-2.4* Na-138
K-4.7 Cl-104 HCO3-24 AnGap-15
[**2129-4-3**] 12:02PM BLOOD ALT-23 AST-24 LD(LDH)-125 AlkPhos-48
TotBili-1.9* DirBili-0.7* IndBili-1.2
[**2129-3-31**] 07:24AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.2
[**2129-4-3**] 12:02PM BLOOD calTIBC-291 VitB12-342 Folate-GREATER TH
Hapto-79 Ferritin-56 TRF-224
Brief Hospital Course:
A 74yoM, hx of GIB 1 yr. ago without clear etiology identified
after EGD, colonoscopy and capsule endoscopy. Presented to PCP
with complaint of fatigue and malaise, found to have Hct 21,
sent to ED. Received total of ~10U of PRBCs during entire
hospitalization. Hct finally stabilized without intervention,
presumably bleeding stopped. Pt. noted to have persistent black,
guaiac positive watery stools. He underwent capsule endoscopy,
EGD, and colonoscopy, and tagged RBC scan, all of which were
essentially negative; GI believed however, that the bleed might
be originating from the duodenum based on review of the capsule
study. Pt. was continued on PPI, and his ASA and coumadin (for
Afib) were held. Will need to discuss with his PCP/cardiologist
whether to restart coumadin in setting of 2 recent GI bleeding
episodes. Beta-blocker and [**Last Name (un) **] were initially held so as not to
mask reflex tachycardia in the setting of a bleed, BB was
restarted upon discharge. [**Last Name (un) **] can be restarted as outpt. if
necessary.
Medications on Admission:
1. ASA 81mg once daily
2. Coumadin 1.5 to 2mg once a day
3. Irbesartan 75mg once a day.
4. Atenolol 25 mg once a day.
5. Lasix 40 mg once a day
6. Atorvastatin Calcium 10 mg Daily.
7. Nexium 40 mg PO once a day.
8. Oxycodone 10 mg Sustained Release every 8 hours.
9. Tamsulosin HCl 0.4 mg PO HS.
10. Fe 150mg once a day
11. Precose (Acarbose) 50mg PRN if FS >120.
12. Glucosamine 500mg once a day
13. MVA
14. Vit C
15. Bilberry
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
7. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release 12HR(s)* Refills:*2*
8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
Please check hematocrit on [**2129-4-12**].
Discharge Disposition:
Home
Discharge Diagnosis:
1. GI bleed
2. CAD s/p MI
3. Afib
4. anemia
5. CHF
6. DM2
7. PVD
8. CKD
9. chronic back pain
Discharge Condition:
fair, stable.
Discharge Instructions:
Please continue to take all medications as prescribed. If you
experience any symptom concerning for ongoing bleeding such as
dizziness, lightheadedness, changes in vision, chest pain,
palpitations, or shortness of breath, please call your PCP or
return to the hospital.
Followup Instructions:
Please make an appt. to see your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 2946**] S.
[**Telephone/Fax (1) 2936**], within the next week.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**]
Date/Time:[**2129-4-19**] 2:45
.
Please have your hematocrit (blood level) checked on tuesday.
If it is less than 25, return to the hospital.
Completed by:[**2129-4-11**]
|
[
"V43.64",
"V45.81",
"V12.72",
"459.81",
"412",
"458.0",
"578.1",
"403.91",
"250.00",
"428.0",
"724.2",
"443.9",
"427.31",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
7782, 7788
|
5200, 6251
|
366, 417
|
7925, 7941
|
3844, 5177
|
8260, 8701
|
3106, 3167
|
6730, 7759
|
7809, 7904
|
6277, 6707
|
7965, 8237
|
3182, 3825
|
275, 328
|
445, 2281
|
2303, 2926
|
2942, 3090
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,857
| 108,624
|
31020+57731
|
Discharge summary
|
report+addendum
|
Admission Date: [**2158-10-20**] Discharge Date: [**2158-10-24**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
[**2158-10-20**] Coronary Artery Bypass Graft x1 (saphenous vein graft),
Aortic Valve replacement (21mm CE tissue valve)
History of Present Illness:
86 year old female with known heart murmur, recent dyspnea on
exertion, dizziness, and lightheadedness. Underwent cardiac
workup revealed aortic stenosis and one vessel coronary artery
disease.
Past Medical History:
Aortic stenosis
Hypertension
coronary artery disease
anemia
arthritis
pneumonia [**2145**]
gastrointestinal bleed
AV malformation
Gastric ulcer
Social History:
Retired
Lives alone - support systems brothers
ETOH 1 glass wine/week
Tobacco denies
Family History:
father deceased at 80 from myocardial infarction
Physical Exam:
General NAD
Skin warm dry intact
HEENT EOMI PEERLA
Neck supple full ROM
Chest CTA
Heart RRR 3/6 murmur
Abd soft, NT, ND, +BS
Ext warm well perfused, spider varicosities bilat
Neuro a/o x3, MAE
Discharge
General NAD 98.1, 80 SR, 112/48, 18 RA sat 95%
Skin warm dry intact except sternal inc healing, CDI sternum
stable
HEENT EOMI PEERLA
Neck supple full ROM
Chest CTA
Heart RRR no murmur/rub/gallop
Abd soft, NT, ND, +BS
Ext warm well perfused, spider varicosities bilat
Neuro a/o x3, MAE, face symmetrical, right arm drift with
clumsiness
Pertinent Results:
[**2158-10-23**] 06:35AM BLOOD WBC-11.0 RBC-3.28* Hgb-10.3* Hct-30.9*
MCV-94 MCH-31.5 MCHC-33.4 RDW-14.1 Plt Ct-136*
[**2158-10-20**] 10:50AM BLOOD WBC-11.5*# RBC-2.74*# Hgb-8.5*#
Hct-25.8*# MCV-94 MCH-31.0 MCHC-33.0 RDW-14.2 Plt Ct-124*
[**2158-10-20**] 10:50AM BLOOD Neuts-78.6* Bands-0 Lymphs-17.3*
Monos-2.7 Eos-0.7 Baso-0.8
[**2158-10-23**] 06:35AM BLOOD Plt Ct-136*
[**2158-10-21**] 03:57AM BLOOD PT-12.2 PTT-29.3 INR(PT)-1.0
[**2158-10-20**] 10:50AM BLOOD PT-17.4* PTT-38.5* INR(PT)-1.6*
[**2158-10-20**] 10:50AM BLOOD Fibrino-155
[**2158-10-23**] 06:35AM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-143
K-4.2 Cl-105 HCO3-31 AnGap-11
[**2158-10-20**] 12:09PM BLOOD UreaN-18 Creat-0.8 Cl-117* HCO3-21*
[**2158-10-23**] 06:35AM BLOOD Calcium-8.9 Phos-1.4* Mg-1.9
[**2158-10-21**] 03:57AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.8*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2158-10-23**] 11:29 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman s/p avr cabg
REASON FOR THIS EXAMINATION:
evaluate effusion
TWO VIEW CHEST OF [**2158-10-23**]
COMPARISON: [**2158-10-22**].
INDICATION: Pleural effusions. Postop.
The patient is status post median sternotomy and aortic valve
replacement. Cardiac and mediastinal contours are stable in the
postoperative period. Bibasilar atelectasis and small pleural
effusions are again demonstrated, with no substantial change
allowing for technical differences between the studies.
Additionally, a hazy area of opacity is present in the right
upper lobe just above the minor fissure, slightly more
conspicuous than on the prior study but not evident on the prior
preoperative study from [**2158-10-17**].
IMPRESSION:
1. Bibasilar atelectasis and small pleural effusions.
2. Subtle right upper lobe opacity. Attention to this area on
short-term followup CXR is recommended to exclude an early focus
of pneumonia.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2158-10-23**] 2:36 PM
Cardiology Report ECHO Study Date of [**2158-10-20**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: avr
Status: Inpatient
Date/Time: [**2158-10-20**] at 09:13
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW-1:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aortic Valve - Peak Gradient: 92 mm Hg
Aortic Valve - Mean Gradient: 62 mm Hg
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic
valve leaflets. Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
(1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
was under
general anesthesia throughout the procedure. The TEE probe was
passed with
assistance from the anesthesioology staff using a laryngoscope.
No TEE related
complications.
Conclusions:
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage.
Right ventricular chamber size and free wall motion are normal.
LV systolic
fxn is globally midlly depressed.There are simple atheroma in
the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve
leaflets are severely thickened/deformed. Trace aortic
regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened.
There is no pericardial effusion.
[**Location (un) **] PHYSICIAN:
Cardiology Report ECG Study Date of [**2158-10-20**] 12:46:20 PM
Normal sinus rhythm. Q waves in leads III and aVF consistent
with old inferior
myocardial infarction. Downward sloping ST segment depressions
and T wave
inversions in leads I, aVL and V4-V6 suggest possible
anterolateral ischemia.
Delayed R wave transition and possible lead reversal in leads
V2-V3. Compared
to the previous tracing of [**2158-10-17**] the prominent Q waves in the
inferior leads
with slight ST segment elevations and downsloping ST segment
depressions in
the lateral precordial leads are new. Clinical correlation is
suggested.
Read by: [**Last Name (LF) **],[**First Name8 (NamePattern2) 2206**] [**Doctor Last Name **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 138 84 412/415 68 -9 115
Brief Hospital Course:
Ms. [**Known lastname 73286**] was admitted through same day admission and was
brought to the operating room where she underwent a coronary
artery bypass graft x 1 and aortic valve replacement. Please see
operative report for surgical details. She tolerated the
procedure well and was transferred to the CSRU for invasive
monitoring in stable condition. Later on op day she was weaned
from sedation, awoke and was extubated. On post-op day one she
started on beta blockers and diuretics. She was gently diuresed
towards her pre-op weight. She was found to have right arm
clumsiness and neurology was consulted. Head CT scan was done
that ruled out intracranial bleed and no ischemia noted. She
continued to progress and right arm drift and clumsiness
decreased. Physical therapy followed her during entire post-op
course for strength and mobility. She continued to make steady
process and was ready for discharge to rehab on post operative
day 4.
Medications on Admission:
lisinopril
iron
vitamin d
omega 3
tylenol
lecithin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
8. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. medication
please consider starting ACE inhibitor when b/p increased
Discharge Disposition:
Extended Care
Facility:
Radius
Discharge Diagnosis:
Aortic Stenosis s/p AVR
Coronary artery disease s/p CABG
Right sided weakness
Hypertension
Anemia
Arthritis
h/o Gastrointestinal bleed, AV malformation, gastric ulcer
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**First Name (STitle) **] after discharge from rehab ([**Telephone/Fax (1) 23083**]) please call
for appointment
Dr [**Last Name (STitle) **] after discharge from rehab
Completed by:[**2158-10-24**] Name: [**Known lastname 12190**],[**Known firstname 12191**] Unit No: [**Numeric Identifier 12192**]
Admission Date: [**2158-10-20**] Discharge Date: [**2158-10-24**]
Date of Birth: [**2071-11-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Previous discharge summary states "Head CT scan was done
that ruled out intracranial bleed and no ischemia noted." This
is incorrect. Head CT was deferred given that it would not
change management.
Discharge Disposition:
Extended Care
Facility:
Radius
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2158-10-25**]
|
[
"426.0",
"412",
"V45.02",
"715.98",
"285.9",
"414.8",
"401.9",
"244.9",
"428.0",
"424.1",
"428.32",
"729.89",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
10836, 10993
|
7111, 8062
|
286, 409
|
9395, 9402
|
1544, 2486
|
9914, 10813
|
918, 968
|
8163, 9128
|
2523, 2554
|
9205, 9374
|
8088, 8140
|
9426, 9891
|
3721, 6266
|
983, 1525
|
231, 248
|
2583, 3695
|
437, 633
|
6300, 7088
|
655, 800
|
816, 902
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,832
| 173,648
|
2381
|
Discharge summary
|
report
|
Admission Date: [**2179-4-27**] Discharge Date: [**2179-5-4**]
Date of Birth: [**2109-9-30**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Acute gait disturbance
Major Surgical or Invasive Procedure:
CT head
History of Present Illness:
69yo RH M who presented to the ED yesterday after a fall. He
reports that he woke in the morning to go to the bathroom and
then after taking a few steps he fell, because he "wasn't paying
enough attention". He cannot specify further details or provide
a
better explanation; he denies that his legs were weak or that he
felt off balance. Per Dr.[**Name (NI) 12343**] note, his wife noted
that
his left arm was hanging and that he could not dress himself
(patient denies) and that he could not figure out how to walk or
"how to use his legs". He was taken here for evaluation and head
CT revealed an intracerebral hemorrhage.
He denies that he had headache or vertigo. No nausea or
vomiting.
It is unclear whether he lost consciousness but there were no
shaking movements.
He presented to our ED and was given decadron and loaded with
dilantin.
Past Medical History:
?TIA [**2176-5-11**]
HTN & DM, both resolved after he lost weight per his wife
Hyperlipidemia
Prostate CA [**2176**] s/p resection
TB s/p treatment
TBI from MVA in [**2159**], with persistent facial asymmetry, L eye
injury, personality changes and cognitive dysfunction
Dementia (ApoE 4+), followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**]
Cataracts
Waldenstrom macroglobulinemia, on chlorambucil
s/p gunshot wound to right face (no residual deficits)
Latent TB - started INH and pyridoxine in [**2178-1-11**]
Social History:
Walks with cane (was not using it yesterday morning when he
fell). No etoh, tob, drugs. Lives with his wife and attends an
adult day program.
Family History:
mother had a stroke in 70's
Physical Exam:
VS 97.7/97.7 69-83 117-140/58-69 [**12-28**] 99% 490/275
Gen Lying in bed in NAD
Neck supple
CV rrr no bruits
Pulm ctab
Abd soft benign
Ext no edema
NEURO
MS Awake, alert. Fully oriented. MOYB intact. Speech fluent,
with
normal naming, [**Location (un) 1131**], writing, comprehension and repetition.
Counts two people on the right side of the cookie jar picture.
When asked if anything is pink in his room (it is to his left),
he searches to the right side predominantly and does not find
it.
Nor does he find the computer to his left. And he counts chairs
only to his right side. He denies all deficits, apart from those
which are old. L arm apraxic.
CN
CN I: not tested
CN II: VFF to confrontation, no extinction. Pupils 3->2 on R,
non-reactive on the L.
CN III, IV, VI: L eye has upgaze paresis and on downgaze, it
intorts (due to IV action). The left eye is esotropic
CN V: intact to LT throughout, but extinguishes on the left to
DSS
CN VII: L facial droop, with incomplete eye closure on the left
CN VIII: hearing intact to FR b/l (no extinction to DSS)
CN IX, X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**5-15**] and symmetric
CN XII: tongue midline and agile
Motor
Normal bulk and tone. Needs encouragement for
power testing on the left ( motor impersistence)
D B T WE FE FF IP Q H DF PF TE
R 4 5 5 4- 3 5 4 5 5- 5- 5 5-
Sensory intact to LT, PP, JPS, vibration throughout.
Extinguishes
to DSS in the left arm and left leg.
Reflexes 2+ throughout, toes mute
Coordination R action tremor. L arm apraxic.
Gait deferred
Pertinent Results:
Imaging
NCHCT [**4-28**]: Comparison with [**2179-4-27**], 19:46 p.m. Similar
appearance of the frontoparietal intraparenchymal hemorrhage.
No
significant interval change in size. Scattered opacification of
scattered ethmoid air cells is noted. Evidence of previous
frontal sinus surgery. No significant change since examination
of eight hours prior.
.
NCHCT [**4-27**]: Acute right frontoparietal intraparenchymal
hemorrhage with questioanble fluid level and small subarachnoid
component. Mild surrounding edema and leftward subfalcine
herniation. Differential for this lesion includes amyloid
angiopathy with underlying intraparenchymal mass and sequelae of
trauma felt slightly less likely. The fluid level within the
hemmorhage is suggestive of a coagulopathy
.
.
LABS on Admission:
WBC-4.4 RBC-3.97* HGB-11.6* HCT-33.3* MCV-84 MCH-29.2 MCHC-34.7
RDW-14.0
PLT COUNT-253
PT-12.7 PTT-32.0 INR(PT)-1.1
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
.
A1c 6.9*1
Cholest 213* Triglyc 381 HDL 109 CHOL/HD 2.0 LDL 96
.
Labs on discharge [**2179-5-4**]
Chemistry
143 107 9 88 AGap=11
3.5 29 0.7
Ca: 8.5 Mg: 2.2 P: 2.9
Hematology
87
4.4 10.7 257
31.4
Brief Hospital Course:
Mr. [**Known lastname 1661**] is a 69-year-old right-handed man with a history of
traumatic brain injury, dementia, Waldenstrom's
macroglobulinemia, hypertension, and diabetes who was brought to
the ED after a fall at home following the acute onset of
dressing apraxia and gait apraxia. His exam was also notable for
left-sided neglect and extinction to double simultaneous
stimuli. His brief hospital course by problem is as follows:
.
1. Intraparenchymal hemorrhage. During evaluation of his
neurologic symptoms, a non-contrast head CT revealed a right
frontoparietal hemorrhage with a small subarachnoid component
and surrounding edema causing a 2-3 mm subfalcine herniation.
Based on the radiographic appearance, it was thought that the
most likely underlying etiology is amyloid angiopathy. He was
initially admitted to the neuro ICU for frequent monitoring.
Aspirin and chlorambucil were held due to concerns of
exacerbating the bleeding. Blood pressure was closely monitored,
and there was no need to restart antihypertensives, which he had
been on in the distant past but not recently. He was initially
loaded with dilantin. No seizures occurred and this was
discontinued on [**2179-4-28**]. Repeat head CTs showed stable
appearances of hemorrhage. MRI/MRA was not performed due to
facial shrapnel following previous gun shot wound.
.
His stay in the ICU was uncomplicated and he was transferred to
the floor on [**2179-4-29**]. He continued to recover on the [**Hospital1 **],
receiving PT and OT. On discharge, the LL quadrantanopia remains
in addition to mild LUE weakness. He will benefit from further
inpatient rehabilitation and has neurology follow-up arranged
with his neurologist Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
Given the risk of further bleeding with amyloid angiopathy, we
would not recommend restarting aspirin unless he should develop
some clear vascular indication requiring secondary prevention.
.
2. Diabetes mellitus, type 2. This continues to be
diet-controlled.
.
3. Dementia. He was continued on donepezil.
.
4. Waldenstrom's Macroglobulinemia. The chlorambucil was also
held due to concern regarding altered platelet function. This
was discussed with his oncologist Dr [**Last Name (STitle) **], who was in
agreement with short term holding of this medication. This
should be restarted around [**5-11**].
.
5. Mr [**Known lastname 1661**] had several loose stools prior to discharge. C.
diff negative and symptoms settling.
.
6. CODE: FULL
.
7. Dispo: He was discharged to an extended-care facility for
further physical and occupational therapy.
Medications on Admission:
Aricept 10
ASA 81
Chlorambucil 6mg daily
.
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*50 Tablet(s)* Refills:*2*
3. Chlorambucil 2 mg Tablet Sig: Three (3) Tablet PO once a day:
Take 3 pills once a day in the morning, starting from [**5-11**]
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Intracranial hemorrhage
Amyloid angiopathy
Discharge Condition:
Stable. Mild left arm weakness persists.
Discharge Instructions:
You have had an episode of bleeding in the brain. You have not
been restarted on aspirin because of this. Chlorambucil was also
held to minimize risk of worsening the bleeding. You should
restart the chlorambucil on [**5-11**]. Please take other
medications as prescribed and keep follow up appointments.
Please seek further medical assistance for any new symptoms of
weakness or altered sensation, speech or swallowing
difficulties, unsteadiness or visual difficulties or any other
concerns.
Followup Instructions:
Please arrange to see your PCP DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4844**] in the next
week, phone number [**Telephone/Fax (1) 250**]
.
Neurologist: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time: [**2179-5-10**] 12:30
[**Hospital Ward Name 860**] Building, [**Location (un) 551**], Rm 253, [**Hospital Ward Name 516**] of [**Hospital1 18**]
.
You also have the following appointments scheduled:
1. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 8914**] Phone:[**Telephone/Fax (1) 1047**]
Date/Time:[**2179-5-5**] 10:00
2. Provider: [**Name10 (NameIs) **] FERN, RNC
Date/Time:[**2179-5-5**] 9:00
|
[
"250.00",
"277.30",
"431",
"401.9",
"294.8",
"272.4",
"273.3",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7952, 8022
|
4820, 7437
|
338, 347
|
8109, 8153
|
3597, 4376
|
8694, 9457
|
1969, 1998
|
7530, 7929
|
8043, 8088
|
7463, 7507
|
8177, 8671
|
2013, 3578
|
276, 300
|
375, 1222
|
4390, 4797
|
1244, 1791
|
1807, 1953
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,346
| 197,210
|
26026
|
Discharge summary
|
report
|
Admission Date: [**2118-11-1**] Discharge Date: [**2118-11-10**]
Date of Birth: [**2093-6-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
pain left chest, SOB
Major Surgical or Invasive Procedure:
[**2118-11-1**] MVRepair (#36 annuloplasty band)
History of Present Illness:
25 yo M with history of [**Month/Day/Year 64661**], myxomatous mitral valve and
moderate to severe MVP.
Past Medical History:
[**Month/Day/Year **]
Social History:
unemployed
- current tobacco, quit 5 cigs/day approx 1 year ago.
- etoh x 1 year
Family History:
NC
Physical Exam:
thin man in NAD 78 20 130/86
Skin unremarkable
HEENT unremarkable
Neck Supple Full ROM
Chest CTAB
Heart RRR
Abd Benign
Extrem warm, no edema, no varitcosities
Pertinent Results:
[**2118-11-10**] 05:50AM BLOOD WBC-9.2 RBC-2.90* Hgb-8.6* Hct-24.2*
MCV-84 MCH-29.7 MCHC-35.5* RDW-15.8* Plt Ct-477*
[**2118-11-10**] 05:50AM BLOOD Plt Ct-477*
[**2118-11-10**] 05:50AM BLOOD WBC-9.2 RBC-2.90* Hgb-8.6* Hct-24.2*
MCV-84 MCH-29.7 MCHC-35.5* RDW-15.8* Plt Ct-477*
[**2118-11-10**] 05:50AM BLOOD Plt Ct-477*
[**2118-11-10**] 05:50AM BLOOD Glucose-96 UreaN-8 Creat-0.8 Na-136 K-4.4
Cl-102 HCO3-24 AnGap-14
[**2118-11-1**] ECHO
PRE-BYPASS:
1. Left ventricular wall thicknesses and cavity size are normal.
Regional left ventricular wall motion is normal.
2. The mitral valve leaflets are myxomatous. There is moderate
mitral valve prolapse. Mild (1+), late systolic mitral
regurgitation is seen.
3. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The aortic
root is moderately dilated measuring 4.2 cm. The dilatation
normalizes at the sinotubular junction with normal diameter of
the ascending aorta.
4. Small secundom ASD seen on color Doppler.
5. Right ventricular chamber size and free wall motion are
normal.
POST-BYPASS:
1. Preserved [**Hospital1 **]-ventricular systolic function.
2. Repaired mitral valve is seen. No mitral regurgitation. Mild
[**Male First Name (un) **] of the tip of the anterior leaflet, without gradient across
the LVOT .
3. No evidence of aortic dissection post de-cannulation.
4. No evidence of ASD on color Doppler.
5.. Rest of study is unchanged from pre-bypass
[**2118-11-9**] CXR
Comparison is made to prior day. The patient is status post
sternotomy. A prosthetic mitral valve is again visualized. There
is persistent volume loss with atelectasis and effusion at the
left lung base, which is unchanged. A right-sided pleural
effusion is somewhat smaller. The lung fields are otherwise
clear. There is no pneumothorax.
[**Last Name (NamePattern4) 4125**]ospital Course:
He was taken to the operating room on [**2118-11-1**] where he
underwent a mitral valve Repair (#36 annuloplasty band) and and
ASD closure. He awoke and was extubated that day. He was weaned
from his neosynephrine and transferred to the floor on POD #2.
He remained tachycardiac with a BP in the 90s. On POD #5 he had
a temperature of 102.5 for which he was panculatured. He had a
enterobactor UTI for which he was placed on Bactrim. He was seen
in consultation by medicine for his weight loss, nausea and
vomiting. They recommended adding Boost, changing diet to soft
solids, Reglan, discontinuing NSAIDS and changing H2 blocker to
PPI. He continued to improve and was ready for discharge on POD
#8. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and
his primary care physician as an outpatient.
Medications on Admission:
Atenolol 25mg QD
Lisinopril 5mg QD
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
Disp:*2 Tablet(s)* Refills:*2*
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Myxomatous MV, mod-severe MVP, 2+MR
[**First Name (Titles) **]
[**Last Name (Titles) 64662**] ectasia
GERD
L para-renal cyst
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving until follow up with surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
[**Name6 (MD) **] [**Last Name (NamePattern4) 1401**], M.D. 2 weeks
Dr. [**First Name (STitle) **] as planned prior to surgery
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2118-11-18**]
|
[
"759.82",
"745.5",
"796.2",
"747.29",
"424.0",
"599.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"35.71",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
4876, 4882
|
343, 394
|
5051, 5059
|
885, 2722
|
686, 690
|
3684, 4853
|
4903, 5030
|
3624, 3661
|
5083, 5321
|
5372, 5571
|
705, 866
|
2773, 3598
|
283, 305
|
422, 527
|
549, 572
|
588, 670
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,586
| 187,528
|
13622
|
Discharge summary
|
report
|
Admission Date: [**2134-8-11**] Discharge Date: [**2134-8-26**]
Date of Birth: [**2061-3-16**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Reglan
Attending:[**First Name3 (LF) 8810**]
Chief Complaint:
weakness, fatigue
Major Surgical or Invasive Procedure:
PICC Line placed [**8-18**]
History of Present Illness:
Mr. [**Known lastname 41105**] is a 73-year-old retired [**State 350**] superior
court judge who was in his usual state of health until
approximately one month ago when he noticed progressive
weakness, nausea, and constipation following inguinal hernia
repair in early 07/[**2133**]. Initially, his symptoms were
attributed to parkinsonism and medication adjustments were made.
However, on [**2134-8-11**], he became progressively weak and was
brought to the [**Hospital1 69**] emergency
room with chief complaint of syncope x 2 at home, where he was
found to have acute renal failure with a creatinine of 3.6 and
hypercalcemia with a calcium of 13. He was treated with
aggressive hydration and was noted to have peripheral
lymphadenopathy. CT of the torso on [**2134-8-13**] demonstrated two
enlarged lymph nodes in the left axilla. The largest measuring
3.2 x 1.8 cm. The 1.5 cm in the right axilla
pretracheal and prevascular lymph nodes as well as precarinal
and subcarinal lymph nodes. There is also bilateral hilar
lymphadenopathy and a markedly enlarged spleen with multiple
lymph nodes in the splenic hilum. Bone windows demonstrated a
3.5 x 3.3 cm lytic lesion in the right ileum extending to the
sacroiliac joint and 3.0 x 2.2 cm lytic lesion in the left
superior posterior acetabulum. There are additional smaller
lytic lesions present in both iliac bones and there is a right
hip prosthesis. Lymph node biopsy was performed [**8-16**] with
excision of the right axillary lymph node. This biopsy
demonstrated a CD10 positive kappa restricted B-cell
lymphoproliferative disorder.
Past Medical History:
1. CAD s/p CABG in 82, stent - lmca-prox lcx (patent [**8-27**]), last
streess [**2130**] nl w/o perfusion defects
2. CHF - 67% EF, mild-mod MR, thickened aortic, but no stenosis
or insufficiency on echo in [**2130**]
3. S/P R MCA CVA [**12-27**]-- on coumadin for 6mos
4. Parkinson's Disease
5. Spinal Stenosis
6. S/P L hernia repair [**2134-7-14**]
7. BPH, with known elevated PSA but nl biopsies, followed by
urology
8. Hypercholesterolemia
9. GIbleed- [**8-/2131**], presumed small bowel source in setting of
coumadin
10. Diverticuli
11. s/p cholecystectomy in 80's
12. s/p right hip replacement
Social History:
He is a retired judge. He continues to work as
a mediator. He has a 40-pack-year smoking history. He quit in
[**2098**] but has smoked a periodic cigar or pipe. He drinks wine
or
beer occasionally. He lives with his wife.
Family History:
His mother had [**Name2 (NI) 499**] cancer in early 40s. His
brother has prostate cancer. His routine healthcare maintenance
is significant for colonoscopies and endoscopy without findings
of malignancy.
Physical Exam:
ROS: (+) weight loss 40 lbs in 2 years, 8 lbs in 2 weeks. No
chest pain, shortness of breath, cough. No PND, orthopnea. No
abdominal pain, melena, hematochezia. He does report
intermittent constipation since his surgery, then diarrhea and
now with nl BMs. He also reports back pain at the area of his
known spinal stenosis which is worse, but is planning on seeing
his neurosurgeon for possible surgery. No other
f/c/cough/SOB/dysuria or other changes.
.
GENERAL: He appears well.
HEENT: Sclerae are anicteric. Oropharynx with moist mucous
membranes without lesions.
NECK: Supple. There is no spinal or paraspinal tenderness in
the cervical, thoracic, or lumbar spine.
LYMPHATICS: There are 0.5 cm submandibular and cervical lymph
nodes. There is a two to three centimeter left axillary lymph
node. The right axillary region has a dressing. It is clean,
dry, and intact.
LUNGS: Clear to auscultation and percussion bilaterally.
HEART: Regular with a [**1-31**] murmur. PMI is nondisplaced.
ABDOMEN: Soft, nontender, nondistended. The spleen extends
approximately three centimeters below the costal margin.
EXTREMITIES: Well perfused without edema. There are no skin
changes or petechiae.
Pertinent Results:
LABORATORY DATA: Today are significant for white blood cell
count of 9.1 with a differential of 72% neutrophils, 20% lymphs,
5.5% monocytes, 1.6% eos, 0.3% basophils. His hematocrit is
34.3
with an MCV of 85. Platelets are 163,000. Glucose of 77, BUN
is
12, creatinine is 0.8, sodium 135, potassium 4, chloride 105.
Bicarbonate is 20, LDH is 297. Calcium is 9.1 down from 13,
phos
is low at 1.0, magnesium is 1.6. Ferritin is 238. TSH is 0.85.
PTH is low at 10. PSA is elevated at 6.9. SPEP shows no
specific abnormalities. UPEP shows no specific abnormalities.
PTHRP is pending, vitamin D 125 is pending. Uric acid has not
been measured. His iron is low at 41.
EKG: NSR at 67bpm, nl axis and intervals, small q's inferiorly
with TWI in III
MRI of the brain shows no evidence of malignancy.
Ultrasound confirms bilateral renal cysts and infiltrating
lesions of the
spleen.
[**2134-8-11**] 02:57PM PT-12.8 PTT-21.0* INR(PT)-1.1
[**2134-8-11**] 02:57PM PLT COUNT-250
[**2134-8-11**] 02:57PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL BURR-2+
ACANTHOCY-2+
[**2134-8-11**] 02:57PM NEUTS-81* BANDS-2 LYMPHS-12* MONOS-4 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2134-8-11**] 02:57PM WBC-8.2 RBC-3.93* HGB-11.8* HCT-32.5* MCV-83
MCH-30.1 MCHC-36.4* RDW-13.1
[**2134-8-11**] 02:57PM cTropnT-0.03*
[**2134-8-11**] 02:57PM CK(CPK)-78
[**2134-8-11**] 02:57PM GLUCOSE-109* UREA N-90* CREAT-3.6* SODIUM-133
POTASSIUM-6.7* CHLORIDE-95* TOTAL CO2-17* ANION GAP-28*
[**2134-8-11**] 04:00PM ALT(SGPT)-9 AST(SGOT)-32 ALK PHOS-119* TOT
BILI-0.4
[**2134-8-11**] 05:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2134-8-11**] 05:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
At time of discharge:
[**2134-8-26**] 12:01AM BLOOD WBC-7.0 RBC-2.97* Hgb-8.9* Hct-25.7*
MCV-86 MCH-29.9 MCHC-34.6 RDW-15.0 Plt Ct-223
[**2134-8-26**]- C-diff negative
URINE CULTURES/BLOOD CULTURES- NEGATIVE
[**2134-8-26**] 12:01AM BLOOD Neuts-95.8* Bands-0 Lymphs-3.6*
Monos-0.6* Eos-0 Baso-0
[**2134-8-26**] 12:01AM BLOOD Plt Smr-NORMAL Plt Ct-223
[**2134-8-26**] 12:01AM BLOOD Gran Ct-6690
[**2134-8-26**] 12:01AM BLOOD Glucose-107* UreaN-26* Creat-0.8 Na-136
K-3.8 Cl-105 HCO3-23 AnGap-12
[**2134-8-26**] 12:01AM BLOOD ALT-14 AST-14 LD(LDH)-199 AlkPhos-92
TotBili-0.5
[**2134-8-26**] 12:01AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.2*
Mg-1.6 UricAcd-2.9*
[**2134-8-11**] 04:00PM BLOOD TSH-0.85
Brief Hospital Course:
Hypotension causes thought to be either iatrogrenic(BP meds), or
hypovolemia/dehydration. Patient was rehydrated with IVF and
blood pressure meds were initially held. Blood pressure
improved and remained hemodynamically stable.
.
Lymphoma: As mentioned, axillary LN biopsy results were c/w
Burkitt's Lymphoma which correlates with the constellation of
symptoms that the pt presented with. Hypercalcemia resolved
with adequate hydration. PICC Line placed [**8-18**] for initiation
of chemo. The patient was continued on IVFs and tumor lysis
labs were monitored initially q 6 hours, then [**Hospital1 **]. Given
elevated uric acid, allopurinol 300mg qd was continued, and
patient was administered chemotherapy per protocol. Patient
tolerated the chemotherapy well, with no nausea/vomiting while
tolerating a cardiac diet, and remained afebrile. However, he
did develop some loose stools prior to discharge, which
postponed his discharge as there was concern for patient having
to rush to bathroom, resulting in a fall which would be
extremely traumatic given his lytic bone lesions. This diarrhea
was thought to be secondary to an aggressive bowel regimen as
patient had been previously constipated, and patient was given
some loperamide. C-diff toxins were sent, which were negative.
On day of discharge, the diarrhea had resolved. Twenty-four
hours after completing the chemotherapy protocol, the patient
was started on Filgrastim at 300mcg. In addition, his decadron
was weaned down slowly (given his age) from 20mg-->10mg->4mg,
then was discontinued. Patient was not neutropenic on day of
discharge, but his WBC/TGC had dropped considerably. Patient to
be followed by Dr. [**First Name (STitle) **] for further treatment.
.
New-onset Atrial Fibrillation: On morning of [**8-18**], pt
experienced episode of chest pain and was found to be in atrial
fibrillation w/ rapid ventricular response. Given NTG SL x 2
with resolution of chest pain, then became hypotensive w/ BP in
80's/50's. Pt received fluid boluses of NS and was given 15mg
diltiazem which improved BP to 90's/50's-70's and decreased HR
to 90's, remained in AFib. Throughout this time, pt remained
comfortable without any SOB. Was transferred to the [**Hospital Unit Name 153**] for
closer monitoring, where he was started on Amiodarone 400mg TID
(intent for 3 days, then decrease to 400mg [**Hospital1 **] x 2 weeks). Pt
was also Dig loaded then started on Dig 0.125mg QD. Pt remained
comfortable during ICU stay, BP remained stable at
90-100/50-70's, HR remained stable at 90's, and in and out of
AFib. Etiology of this new onset AFib is unclear - likely
idiopathic vs. [**1-27**] ischemia (without infarct) as ST depressions
anterolaterally seen on EKG during acute episode. Otherwise TSH
on [**8-11**] WNL, electrolytes WNL, CE negative x 3. Cardiology was
consulted and recommended, continuing Amiodarone 400mg TID x 3
days (day 1 = [**8-18**]), then changing to [**Hospital1 **] x 1 week (stop date
[**8-28**]), then change to 400mg daily for one month, at which time
patient has a scheduled follow up appointment with Dr. [**Last Name (STitle) **].
.
CAD s/p CABG/stents: Patient failed to show evidence of acute MI
as source of AFib (cardiac enzymes negative) but the question of
cardiac ischemia given EKG findings remained. Pt was without
chest pain after that initial episode which resolved with SL NTG
x 2. Patient was started on metoprolol for rate control (hr
consistently in the 50-60's) and was closely monitored for chest
pain, as well as for rhythm by telemetry. Plavix was held for
chemotherapy but aspirin was continued. Lipitor and folic acid
was continued, but gemfibrozil was discontinued due to effect on
liver and chemotherapy agents that patient received. Patient's
ACE was held to avoid hypotension.
.
Fluid status: Patient developed significant lower extremity
edema once IVF started for chemo, and it was discovered that
patient had been on lasix 20mg daily at home. Therefore, he was
given lasix 20mg IV intermittently with good response, and was
restarted on his home lasix dose on [**8-21**]. Edema somewhat
resolved and patient was kept in negative balance prior to
discharge. Patient did not demonstrate any symptoms of CHF,
oxygen saturation remained 95-99% on room air. Edema was tried
to be minimized as much as possible given that patient was
already at a non-weight bearing status secondary to his lytic
hip lesions. Patient was instructed to strictly adhere to use
of walker for ambulation as his balance may be even more
disrupted with edematous legs.
.
DM: No history of DM but given that patient was to be started
on steroids and receive chemotherapy, he was covered with a
RISS, which was discontinued on day prior to discharge.
.
Parkinson's Disease: The patient was continued on
Carbidopa/Levadopa and Entacapone. Neurology saw patient [**8-19**]
and had no further recommendations
.
BPH - No evidence of hydronephrosis on renal u/s. Finasteride
and terazosin were initially held, but hytrin was then restarted
at half of patient's home dose to avoid any
lightheadedness/precipitate falls.
.
Patient was discharged home with a follow-up appointment
scheduled with Dr. [**First Name (STitle) **] and Dr. [**First Name (STitle) **] on the following day.
Medications on Admission:
Medications
Gemfibrozil 600 mg [**Hospital1 **]
Terazosin 2 mg hs
Stalevo 100 mg qid-- recently increased from TID to QID
Plavix 75 mg daily
Folic acid 1 mg [**Hospital1 **]
Lipitor 10 mg qhs
asa 81 mg daily
omeprazole 10 mg daily
finasteride 5 mg daily
Isosorbide mononitrate 60 mg dialy
Lasix 20 mg dialy
Lisinopril 10 mg dialy (was taking 20 mg daily)
Lodosyn 25 mg qid
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
2. Pantoprazole Sodium 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: Five (5) Tablet PO DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
5. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
6. Filgrastim 300 mcg/mL Solution Sig: One (1) injection
Injection Q24H (every 24 hours) for 2 weeks.
Disp:*14 injection* Refills:*0*
7. PICC line care per protocol
8. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours).
9. Entacapone 200 mg Tablet Sig: One (1) Tablet PO q8hr ().
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): Please take 2 tablets two times a day until [**8-28**].
Then take 2 tablets once a day for one month until your follow
up appointment with cardiology.
Disp:*120 Tablet(s)* Refills:*0*
11. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
Caregroup
Discharge Diagnosis:
hypercalcemia/ARF
lymphoma
CAD s/p CABG
CHF
Spinal Stenosis
BPH
Parkinson's Disease
Discharge Condition:
Pt feeling well, afebrile, hemodynamically stable, eating food,
OOB with ambulation, with normal renal function and calcium
levels.
Discharge Instructions:
Please call your doctor or return to the hospital if you have
any further episodes of dizziness or fainting, chest pain,
nausea & vomiting, increasing abdominal pain, or fever >101 F.
We have started you on two new medications
1.Amiodarone for atrial fibrillation
2.Metoprolol for blood pressure control.
Please continue to take these and all of your home medications
as instructed.
Please refrain from taking Imdur, lisinopril, plavix, aspirin,
and the gemfibrozil until your follow-up appointment with
cardiology.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2134-8-27**] 1:30
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 273**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2134-8-27**]
1:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 2386**] Date/Time:[**2134-10-11**] 2:00pm.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 4223**] [**9-20**] 10:30 am.
Provider: [**Name10 (NameIs) 41106**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1037**] [**Telephone/Fax (1) 41107**] Follow-up
appointment should be in 2 weeks
|
[
"458.29",
"427.31",
"584.9",
"600.00",
"787.91",
"275.42",
"E932.0",
"200.20",
"V43.64",
"332.0",
"V45.81",
"428.0",
"251.8",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.11",
"38.93",
"99.25",
"99.28"
] |
icd9pcs
|
[
[
[]
]
] |
13782, 13822
|
6831, 12131
|
297, 326
|
13949, 14083
|
4286, 6808
|
14647, 15478
|
2840, 3047
|
12555, 13759
|
13843, 13928
|
12157, 12532
|
14107, 14624
|
3062, 4267
|
240, 259
|
354, 1956
|
1978, 2580
|
2596, 2824
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,798
| 180,835
|
643
|
Discharge summary
|
report
|
Admission Date: [**2190-3-15**] Discharge Date: [**2190-3-23**]
Service: CCU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4924**] is an 85-year-old
male with a history of three vessel coronary artery disease
status post coronary artery bypass graft in [**2181**], history of
congestive heart failure with ejection fraction of 34% on
exercise MIBI in [**2189-6-12**], paroxysmal atrial fibrillation,
mitral regurgitation, who presents with two to three weeks of
increasing dyspnea with minimal exertion. Denies dyspnea at
rest, chest pain, paroxysmal nocturnal dyspnea or orthopnea.
His dyspnea on exertion has been worsening over the last
couple of months, but he has noticed over the last couple of
weeks that he is unable to walk even five yards without
significant symptoms. He was directly admitted for elective
Swan-Ganz tailored congestive heart failure therapy.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2181**]
2. Most recent cardiac catheterization [**2187-1-12**]; three
vessel native disease, left main 20% ostial, LAD 60%,
diagonal 1 80%, diagonal 2 70%, left circumflex totally
occluded, OM1 and OM2 with diffuse disease, RCA 40% proximal,
90% distal, PDA totally occluded with collaterals. Saphenous
vein graft to PDA graft occluded, saphenous vein graft to OM3
graft with mild disease, patent left internal mammary artery
to LAD.
3. History of congestive heart failure. Last echocardiogram
in [**2185-12-12**] with ejection fraction of 40%, moderate to
severe mitral regurgitation, pulmonary artery pressure 50.
4. Exercise MIBI in [**2189-6-12**]: Fixed severe inferior, fixed
mild lateral defects, hypokinesis, ejection fraction of 34%,
atrial fibrillation on Coumadin status post failed
cardioversion, status post amiodarone treatment complicated
by neurological symptoms.
5. Colon cancer, status post colectomy in [**2167**]
6. Pacemaker placement in [**2189-7-12**] for symptomatic
bradycardia
7. Diabetes mellitus type II
MEDICATIONS:
1. Aspirin 325 mg po once a day
2. Zestril 20 mg po once ad ay
3. Digoxin 0.125 mg po once a day
4. Aldactone, patient not compliant.
5. Lasix 20 mg po once a day
6. Coumadin 2.5 mg po once a day
7. Glyburide 5 mg po once a day
8. Flagyl 500 mg po 3x a day for positive Clostridium
difficile
ALLERGIES: PENICILLIN, AMIODARONE CAUSES NEUROLOGICAL
SYMPTOMS.
SOCIAL HISTORY: Retired, lives with wife, no smoking or
alcohol.
EXAM:
VITAL SIGNS: Temperature 97.8??????, blood pressure 120/66, heart
rate in the 70s, respirations 20, 93% on 3 liters nasal
cannula.
GENERAL: Pleasant, alert in no apparent distress.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equally round and
reactive to light, moist mucous membranes.
NECK: Jugular venous pressure 9 to 10 cm, no
lymphadenopathy.
LUNGS: Bibasilar crackles.
CARDIAC: Regular rate and rhythm, 3/6 systolic murmur heard
at all auscultation points, maximal at the apex with
radiation to the axilla.
ABDOMEN: Soft, nontender, nondistended, no
hepatosplenomegaly, no masses, normoactive bowel sounds.
GROIN: Right groin with Swan-Ganz catheter. No swelling or
ecchymosis.
EXTREMITIES: 1+ pitting edema bilaterally, cold feet
bilaterally with sluggish capillary refill, but good distal
pulses.
LABS: White count 6, hematocrit 37, platelets 267. INR 2.1,
sodium 142, potassium 5, chloride 104, bicarbonate 30, BUN
42, creatinine 1.5, glucose 88, magnesium 2.2, digoxin 0.9.
SUMMARY OF HOSPITAL COURSE: An 85-year-old male with history
of coronary artery disease, congestive heart failure, mitral
regurgitation and atrial fibrillation presenting with
increasing dyspnea on exertion, admitted for Swan-Ganz
tailored congestive heart failure therapy.
1. CARDIAC PUMP: The patient's initial right heart
catheterization numbers as are follows: Wedge 24, PAP 67/22,
cardiac output 3.8, cardiac index 2, SVR 1600. Clinically
patient appeared to be in failure with jugular venous
distention, crackles on lung exam and 3 liter nasal cannula
oxygen requirement. He was started on a renal dosed
milrinone drip and underwent aggressive diuresis with Lasix
intravenous. His ACE inhibitor Zestril was increased
gradually over the course of his hospitalization to 40 mg.
He was continued on his outpatient digoxin and was restarted
on aldactone at 12.5 mg [**Hospital1 **]. Although he had clinical
improvement with these measures, his Swan-Ganz numbers did
not show remarkable improvement. His Swan-Ganz was re-sited
from his right groin to the right IJ. Just prior to
discontinuation of the Swan-Ganz catheters, his numbers were
as follows: PA diastolic pressures of 17 to 22, cardiac
output 4.5, cardiac index 2.3, SVR 1370, mixed venous O2
saturation of 65 (his initial mixed venous O2 saturation on
admission was 47). The milrinone drip was slowly weaned over
the course of the patient's hospitalization and Coreg was
added to his medical regimen at 3.125 mg po twice a day. At
the time of discharge, the patient is clinically dry with
lungs clear to auscultation, no residual O2 requirement and
negative at least 7 liters over the course of his
hospitalization. He will continue on digoxin, aldactone,
Zestril, Coreg and Lasix as an outpatient with doses to be
titrated as tolerated.
2. CARDIAC ISCHEMIA: Patient with known coronary artery
disease, status post coronary artery bypass graft two of
three grafts patent, continued on aspirin.
3. CARDIAC ELECTROPHYSIOLOGY: Patient with occasional runs
of nonsustained ventricular tachycardia up to 18 beats during
hospitalization. Given his extensive coronary artery
disease, low ejection fraction, he may benefit from EP study
and AICD placement. This will be arranged as an outpatient.
Evaluation for biventricular pacemaker placement will also be
performed at that time.
4. ANTICOAGULATION: The patient has been on Coumadin as an
outpatient for a history of atrial fibrillation. He was
maintained on a heparin drip during this hospitalization and
was restarted back on Coumadin after all procedures were
completed. He will be discharged on Lovenox and Coumadin.
5. PULMONARY: At time of discharge, the patient is stable
on room air and no longer requiring supplemental oxygen.
6. FLUIDS, ELECTROLYTES AND NUTRITION: Patient with
elevated potassium up to 5.5 during hospitalization requiring
Kayexalate. Since he remained on aldactone, Zestril and
digoxin, his potassium levels will need to be monitored
closely as an outpatient.
7. RIGHT GROIN HEMATOMA STATUS POST RIGHT HEART
CATHETERIZATION: The patient had a small hematoma in the
right groin with stable hematocrit throughout his
hospitalization. The patient has had significant right lower
extremity pain from this hematoma occasionally requiring
Percocet.
8. CODE STATUS: The patient is full code.
DISCHARGE STATUS: Discharge to rehabilitation in stable
condition.
DISCHARGE DIAGNOSIS:
1. Congestive heart failure, status post Swan-Ganz tailored
therapy
DISCHARGE MEDICATIONS:
1. Zestril 40 mg po once a day
2. Coreg 3.125 mg po twice a day
3. Aldactone 12.5 mg po twice a day
4. Digoxin 0.125 mg po once a day
5. Lasix 20 mg po twice a day
6. Enteric coated aspirin 325 mg po once a day
7. Coumadin 2.5 mg po q hs
8. Lovenox 1 mg per kg subcutaneous q 12 hours
9. Glyburide 5 mg po once a day
10. Percocet 1 to 2 tablets po q6h prn
DISCHARGE DIET: Cardiac, diabetic
DISCHARGE TREATMENT: The patient will need monitoring of
electrolytes, especially potassium, as well as BUN,
creatinine, INR as outpatient.
DISCHARGE FOLLOW UP: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week. Follow up
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one month.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 4925**]
MEDQUIST36
D: [**2190-3-23**] 11:30
T: [**2190-3-23**] 11:36
JOB#: [**Job Number 4926**]
|
[
"V45.01",
"V10.05",
"427.1",
"998.12",
"414.02",
"427.31",
"250.00",
"424.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
7026, 7580
|
6933, 7003
|
7592, 8040
|
3508, 6912
|
118, 890
|
912, 2410
|
2427, 3479
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,368
| 160,006
|
8313+8346
|
Discharge summary
|
report+report
|
Admission Date: [**2106-8-18**] Discharge Date: [**2106-8-26**]
Service: [**Doctor Last Name **]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] was admitted from his
primary care physician's office with a 1.5-week history of
cough and a 3-day history of shortness of breath.
The patient is a very pleasant 80-year-old male with a
history of hypertension, coronary artery disease, and a
coronary artery bypass graft in [**2095**], who presents as well
with cough and shortness of breath for a total of 1.5 weeks'
duration. The patient describes falling asleep approximately
1.5 weeks ago while eating and there was some question of
aspiration at that time as the patient began coughing and
found to have food in his mouth. For the three days after
that event, the patient did report some hoarseness. There
was no history of hemoptysis; however, the patient was
producing white/yellow phlegm for the 1.5 weeks prior to
admission. The cough also increased in frequency during that
time. There were no subjective fevers; however, the patient
felt that he was "wheezing" at night which he had been in the
past.
The patient presented to his primary care physician's office
on [**8-18**] and had an electrocardiogram done which
showed "PSVT" and was sent to the [**Hospital1 190**] Emergency Room. He did not have chest pain,
palpitations, dyspnea on exertion, or orthopnea.
Per the Emergency Department staff, the patient was
complaining of chest tightness relieved by two sublingual
nitroglycerin; although, the patient himself denied
experiencing chest tightness or pain when speaking to members
of the medical resident staff.
PAST MEDICAL HISTORY:
1. Low back pain.
2. Coronary artery disease.
3. Atrioventricular nodal reentrant tachycardia.
4. Coronary artery bypass graft in [**2095**].
5. Non-A and Non-B hepatitis.
6. Chronic renal insufficiency, question secondary to
hypertension.
7. Left prostate nodule.
8. Hypertension.
9. A left bundle-branch block.
10. Cataract.
11. Macular degeneration.
12. Congestive heart failure.
13. Stress test in [**2104-11-29**] limited by low work load;
however, nondiagnostic for ischemic change. Last
echocardiogram had an ejection fraction of approximately 50%,
question in [**2104-11-29**].
REVIEW OF SYSTEMS: The patient also complained of a
decreased hearing bilaterally for approximately one year
prior to admission; although at times the patient reported a
decrease in hearing for as many as one to three months.
MEDICATIONS ON ADMISSION: Isosorbide dinitrate 20 mg p.o.
t.i.d., Epogen 6000 units three times a week subcutaneous,
Zestril 5 mg p.o. q.d., Lasix 20 mg p.o. q.d.,
Lopressor 50 mg p.o. b.i.d.
ALLERGIES:
PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 149/78,
pulse 88, respirations 27, pulse oximetry 96% on 2 liters.
The patient was in no apparent distress, appeared slightly
cachectic with temporal wasting bilaterally. There was not
noted to be cervical or supraclavicular lymphadenopathy. No
jugular venous distention was noted. The patient did have
slightly dry mucous membranes. Heart rate was noted to be
irregular with a [**2-2**] harsh systolic murmur best heard at the
left lower sternal border. There was felt to be egophony
over the left lower and middle lung fields at the time of
admission; however, the chest was otherwise clear to
auscultation. On examination of the chest there was noted to
be a midline sternotomy scar which was well healed. On
examination of the abdomen, the abdomen was soft, nontender,
and nondistended with positive bowel sounds. There was no
clubbing, cyanosis or edema. Strength was [**4-3**] in the biceps,
triceps, wrist extensors, dorsal interossei, hip flexors and
extensors, as well as ankle dorsiflexion. Extraocular
movements were full. There was no effacement of the
nasolabial fold. The palate elevated symmetrically. The
tongue was midline. Sensation was grossly intact.
LABORATORY DATA ON ADMISSION: At the time of admission,
white blood cell count was 14.6, and they fell by the time of
discharge. Last measurement done on [**8-23**] was 7.2.
Hemoglobin 12.4 at the time of admission, hematocrit 38.1,
platelets were 222. PT was 13.7, PTT was 33.3, INR of 1.3.
Chem-7 was as follows: Sodium 137, potassium 5.5 on
admission (though this specimen was hemolyzed and a repeat
value on [**8-20**] showed a potassium of 4.8),
chloride 101, bicarbonate 23, BUN 50 at the time of admission
decreasing to 42 at the time of discharge, creatinine 2.6 at
the time of admission decreasing to 2.4 at the time of
discharge, glucose 103. Repeated measurements of creatine
kinase was negative for acute muscle injury with values of
50, 45, and 51. Troponin was less than 0.3. Calcium
measured on [**8-19**] was 8.2; although, albumin was
depressed at 2.2, phosphate was 3, magnesium 1.9. Total
cholesterol 141, triglycerides 70, HDL 33, LDL was 94.
RADIOLOGY/IMAGING: Chest x-ray performed on [**8-18**]
and performed again on [**8-19**] showed blunting of the
left costophrenic angle with minimal bibasilar atelectasis as
well as flattened diaphragms. There was not felt to be
evidence of pulmonary consolidation at that time.
Multiple electrocardiograms performed on [**8-18**] were
performed and read as "atrial fibrillation with underlying
left bundle-branch block."
On [**8-22**], electrocardiogram was performed again with
[**Location (un) 1131**] as follows: "Regular wide complex cardiology with
left bundle-branch block configuration." Compared to the
previous tracing of [**8-18**], the QRS morphology remained
unchanged; however, the previously noted atrial fibrillation
has been replaced by regular rhythm underlying mechanism
likely supraventricular tachycardia given identical QRS
morphology clinically.
HOSPITAL COURSE: The patient was admitted to the [**Doctor Last Name **]
Medicine Service with the complaints as above. He was begun
on levofloxacin 500 mg p.o. q.d. empirically for presumed
pneumonia versus bronchitis. The patient's cough improved
over the course of his stay.
The patient was seen by the Electrophysiology Service and was
found to have recurrent supraventricular tachycardia,
probable atrioventricular nodal reentrant tachycardia. On
the morning of [**8-22**], at approximately 2 a.m.,
residence were called to see the patient for recurrent
tachycardia. Despite multiple efforts to control this
tachycardia the patient remained tachycardic and was
transferred to the Coronary Care Unit on the morning of
[**8-22**]. The patient was placed on an esmolol drop with
good effect.
On [**8-23**], the patient was sent for electrophysiology
ablation which was performed without complication, and the
patient was returned to the medical floor following this
procedure in preparation for discharge.
CONDITION AT DISCHARGE: The patient's condition at the time
of discharge was stable.
DISCHARGE STATUS: Discharged to home.
DISCHARGE PLAN: The patient will be instructed to follow up
with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16258**].
MEDICATIONS ON DISCHARGE: (He will be discharged on the
following medications)
1. Levofloxacin 250 mg p.o. q.d. for the remainder of a
10-day course.
2. Aspirin 81 mg p.o. q.d.
3. Metoprolol 50 mg p.o. b.i.d.
4. Isosorbide dinitrate 20 mg p.o. t.i.d.
5. Zestril 5 mg p.o. q.d.
6. Lasix 20 mg p.o. q.d.
DISCHARGE DIAGNOSES:
1. Status post electrophysiology ablation of track for
presumed atrioventricular nodal reentrant tachycardia.
2. Chronic renal insufficiency.
3. Left bundle-branch block.
[**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17144**]
Dictated By:[**Name8 (MD) 2058**]
MEDQUIST36
D: [**2106-8-24**] 11:20
T: [**2106-8-27**] 12:44
JOB#: [**Job Number **]
Admission Date: [**2106-8-18**] Discharge Date: [**2106-8-26**]
Service:
ADDENDUM: On [**8-25**], the patient had an episode of
tachycardia overnight and again had tachycardia during the
day. His beta blocker dose was increased to metoprolol 50 mg
po t.i.d. The patient was noted to have a left-sided ptosis
in addition to the slight effacement of his right nasolabial
fold as well as bilateral hearing loss for approximately one
to one and a half weeks. Because of concern regarding
multiple cranial nerve deficits not localizable to a single
central nervous system location, the patient was sent for MRI
to assess for the possibility of enhancement of the meninges
due to carcinomatosis potentially. Preliminarily, the MRI
has been read as indicating fluid within the left maxillary
sinus and also within the mastoid air cells bilaterally but
without other acute pathology. The final report on this
imaging study is pending at this time and Dr. [**Last Name (STitle) 16258**] will
follow-up on the official report as an outpatient. Because
of fluid within the mastoid air cells, the patient will be
begun on amoxicillin 500 mg po q.d. times ten days. The
patient will follow-up with Dr. [**Last Name (STitle) 16258**] as well as the patient
has been instructed for close follow-up.
[**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 17144**]
Dictated By:[**Name8 (MD) 2058**]
MEDQUIST36
D: [**2106-8-29**] 09:45
T: [**2106-8-29**] 09:45
JOB#: [**Job Number 29528**]
|
[
"466.0",
"426.3",
"V10.46",
"414.01",
"V45.81",
"426.89",
"403.91",
"428.0",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34"
] |
icd9pcs
|
[
[
[]
]
] |
7444, 9444
|
7140, 7423
|
2539, 2739
|
5825, 6834
|
6849, 6953
|
2304, 2512
|
136, 1651
|
3987, 5806
|
6970, 7113
|
1674, 2283
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,013
| 137,697
|
2188
|
Discharge summary
|
report
|
Admission Date: [**2129-12-25**] Discharge Date: [**2129-12-30**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 89 yaer old
Portuguese speaking woman admitted for shortness of breath.
She was recently discharged on [**2129-12-19**] with a
resolving chronic obstructive pulmonary disease exacerbation
and now presents again with shortness of breath.
The patient received nebulizer treatments en route, with
minimal improvement. The patient says she normally sleeps on
two pillows and does not have any problems with swelling of
her feet. She has not had a cough. She also describes some
pain in her back. She denies chest pain or pain radiating to
her jaw.
PAST MEDICAL HISTORY: 1. Coronary artery disease, status
post coronary artery bypass grafting in [**2121**]. 2.
Hypertension. 3. Chronic obstructive pulmonary disease. 4.
Status post cholecystectomy. 5. History of pulmonary
embolism. 6. Peripheral vascular disease. 7. Chronic
renal insufficiency. 8. Diabetes mellitus.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Lisinopril 40 mg p.o.q.d.,
Coumadin 5 mg p.o.q.h.s., Lasix 40 mg p.o.q.d., Isordil 30 mg
p.o.t.i.d., aspirin 81 mg p.o.q.d., NPH 16 units q.a.m. and 6
units q.p.m., regular insulin sliding scale, albuterol and
Atrovent nebulizers, home oxygen, Lipitor 10 mg p.o.q.h.s.,
diltiazem 120 mg p.o.b.i.d., Combivent, Prilosec 20 mg
p.o.q.d., Meclizine 12.5 mg p.o.b.i.d., Paxil 10 mg p.o.q.d.,
iron sulfate 325 mg p.o.t.i.d.
SOCIAL HISTORY: The patient is from [**Country 3587**] and lives
with her daughter.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 98.6, heart rate 110, blood
pressure 153/90, respiratory rate 20 to 25 and oxygen
saturation 98% on two liters. General: Awake and alert.
Neck: No jugular venous distention. Chest: Moderate
end-expiratory wheezes with fair movement, not using
accessory muscles. Cardiovascular: Regular rate and rhythm,
normal S1 and S2, no S3 or S4, 1+ systolic murmur. Abdomen:
Soft, obese, nontender, nondistended. Extremities: Without
edema.
HOSPITAL COURSE: The patient was initially worked up by the
night float and was planned to be admitted to the medical
floor, however, she began to have increasing shortness of
breath during her time in the Emergency Room and she was
eventually admitted to the Intensive Care Unit for
observation.
The patient was admitted to the Intensive Care Unit where,
with her troponin, she ruled in for a non-Q wave myocardial
infarction. The patient also then had an episode of
supraventricular tachycardia. She was started on a diltiazem
drip to control her heart rate. Her Isordil was increased
and she was placed on heparin for 48 hours.
The patient had an echocardiogram, which showed 2+ mitral
regurgitation, 1+ tricuspid regurgitation, mildly depressed
left ventricular function with questionable hypokinetic
septum and a small pericardial effusion; the mitral
regurgitation was new since her echocardiogram in [**2129-6-12**].
The patient's cardiac enzymes showed a CK going from 36 to 42
to 159 and troponin 8.7 increasing up to 25.1. Cardiology
was consulted and made recommendations. After 48 hours on
intravenous heparin, she was switched to Plavix.
Conservative management was chosen at this time, however, she
is going to follow up with a dobutamine echocardiogram.
The patient has poor functional status at baseline. She says
she lives in a [**Location (un) 10043**] apartment, however, she does not
ever leave the apartment due to inability to climb stairs.
The patient also began to have an increasing creatinine up to
1.8 during admission, as well as a BUN which increased to 48.
A renal ultrasound was done which showed no evidence of
hydronephrosis and no stone. Her renal function improved
with intravenous fluids.
The patient was also placed on Prednisone as well as Levaquin
for a possible chronic obstructive pulmonary disease flare
partially contributing to her shortness of breath. She was
placed on a Prednisone taper, which is to gradually taper
over 12 days.
The patient's chest x-rays during admission showed a tortuous
aorta with an enlarged heart size, extensive pleural
calcification and left hemithorax as well as a right lung
which was grossly clear. This was consistent with her prior
chest x-rays.
Cardiology was reconsulted and made recommendations for
discharge medications, including switching Lopressor to
atenolol, restarting the patient's ACE inhibitor now that her
creatinine has come down, and switching over to Imdur.
At this time, we are still waiting for the patient's primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**], to tell us a little bit more
about her history of pulmonary embolism. She had been on
Coumadin in the past, prior to admission, for a pulmonary
embolism that occurred sometime around [**2128-6-12**]. The
question is whether she needs chronic anticoagulation with
Coumadin. If she does, we will discharge her on aspirin and
Coumadin. However, if her primary care physician feels she
no longer needs Coumadin, then we will discharge her instead
on aspirin and Plavix.
DISCHARGE STATUS: The patient is being discharged to a
rehabilitation facility.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Non-Q wave myocardial infarction.
2. Chronic obstructive pulmonary disease exacerbation.
3. Coronary artery disease.
4. Peripheral vascular disease.
5. Diabetes mellitus.
6. Chronic renal insufficiency.
FOLLOW-UP: The patient is scheduled to have a dobutamine
echocardiogram on [**2130-1-31**] at 9:45 a.m. on the
seventh floor of the [**Hospital Ward Name 23**] Building. The patient is
instructed to please come early to that appointment.
DISCHARGE MEDICATIONS:
Imdur 60 mg p.o.q.d.
Atenolol 25 mg p.o.q.d.
NPH 6 units q.a.m. and 4 units q.p.m.
Lisinopril 20 mg p.o.q.d.
Heparin 5,000 units s.c.q.12h.
Prednisone 30 mg p.o.q.d. times three days then discontinued
on [**2130-1-2**].
Protonix 40 mg p.o.q.d.
Klonopin 0.5 to 1 mg p.o.q.d.
Paxil 10 mg p.o.q.d.
Colace 100 mg p.o.q.d.
Plavix 75 mg p.o.q.d.
Aspirin 325 mg p.o.q.d.
Diltiazem 120 mg p.o.b.i.d.
Meclizine 12.5 mg p.o.b.i.d.
Lipitor 10 mg p.o.q.h.s.
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2129-12-30**] 12:42
T: [**2129-12-30**] 13:08
JOB#: [**Job Number 11658**]
|
[
"427.0",
"250.00",
"410.71",
"443.9",
"424.0",
"V45.81",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5327, 5336
|
5357, 5811
|
5834, 6419
|
1100, 1519
|
2157, 5305
|
1628, 2139
|
115, 684
|
707, 1073
|
1536, 1605
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,252
| 181,743
|
36089
|
Discharge summary
|
report
|
Admission Date: [**2108-1-13**] Discharge Date: [**2108-1-18**]
Date of Birth: [**2036-1-15**] Sex: F
Service: SURGERY
Allergies:
Hydrocodone / Zinacef
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Patient admitted on [**1-13**] with fever and abdominal pain. History
of cholelthiasis and possible choledocholithiasis who underwent
elective ERCP in NH on [**2108-1-11**]
Major Surgical or Invasive Procedure:
Percutaneous Cholecystostomy tube placement
History of Present Illness:
Patient admitted to outside hospital with abdominal pain, had
ERCP on [**1-11**] where they were unable to cannulate the ampulla.
Over the following 2 days sh edeveloped worsening RUQ pain,
fevers and nausea. It was decided to transfer her to [**Hospital1 18**] for
further care.
Past Medical History:
Multiple myeloma (stage one)
Gerd
Htn
Hyperlipidemia
Social History:
Denies ETOH or tobacco use.
Family History:
No history of biliary or liver disease.
Physical Exam:
VS 101.6 HR 113 129/69 RR 20 93% RA
Gen: NAD
HEENT:
PERRL, no scleral icterus
CV:
tachycardic, regular
Lungs: clear bilaterally
Abd: soft, non-distended, tender to palpation mid to R
epigastrum and RUQ, rebound and guarding in RUQ
Rectal: quiac neg, no masses, Normal tone
Pertinent Results:
[**2108-1-13**] 03:37PM BLOOD WBC-25.4* RBC-4.56 Hgb-14.0 Hct-39.3
MCV-86 MCH-30.8 MCHC-35.7* RDW-14.2 Plt Ct-308
[**2108-1-15**] 06:15AM BLOOD WBC-10.1 RBC-3.56* Hgb-10.7* Hct-31.5*
MCV-89 MCH-30.1 MCHC-34.0 RDW-14.2 Plt Ct-225
[**2108-1-18**] 05:50AM BLOOD WBC-8.1 RBC-3.59* Hgb-11.0* Hct-31.0*
MCV-87 MCH-30.6 MCHC-35.3* RDW-14.1 Plt Ct-387
[**2108-1-13**] 03:37PM BLOOD PT-14.0* PTT-23.6 INR(PT)-1.2*
[**2108-1-16**] 05:25AM BLOOD PT-13.5* PTT-25.7 INR(PT)-1.2*
[**2108-1-18**] 05:50AM BLOOD Plt Ct-387
[**2108-1-13**] 03:37PM BLOOD Glucose-143* UreaN-23* Creat-0.8 Na-136
K-3.5 Cl-101 HCO3-23 AnGap-16
[**2108-1-15**] 06:15AM BLOOD Glucose-66* UreaN-14 Creat-0.5 Na-139
K-3.6 Cl-104 HCO3-26 AnGap-13
[**2108-1-18**] 05:50AM BLOOD Glucose-103 UreaN-6 Creat-0.5 Na-140
K-3.2* Cl-105 HCO3-25 AnGap-13
[**2108-1-13**] 03:37PM BLOOD ALT-15 AST-27 AlkPhos-84 TotBili-0.8
[**2108-1-16**] 05:25AM BLOOD ALT-14 AST-18 LD(LDH)-206 AlkPhos-67
TotBili-0.5
[**2108-1-18**] 05:50AM BLOOD Amylase-317*
[**2108-1-13**] 03:37PM BLOOD Lipase-21
[**2108-1-17**] 05:45AM BLOOD Lipase-1718*
[**2108-1-18**] 05:50AM BLOOD Lipase-536*
[**2108-1-13**] 03:37PM BLOOD Calcium-9.7 Phos-1.6* Mg-1.6
[**2108-1-16**] 05:25AM BLOOD Albumin-2.7* Calcium-7.4* Phos-2.6*
Mg-1.8
[**2108-1-18**] 05:50AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.7
Brief Hospital Course:
Patient admitted on [**2108-1-13**] and underwent a CT scan that
confirmed [**1-13**] no leak; dilated [**Last Name (LF) **], [**First Name3 (LF) 30272**] foci of air; colonic
wall thickening at hepatic flexure, intra + extra
hepatic/pancreatic ductal dilation. Patient also went for a
RUQ ultrasound that showed a emphysematous cholecystitis +
Murphys, GB wall edema, pericholecystic fluid, hyperechoic foci
in GB wall concerning for gas, GB sludge/stones, intra and extra
hepatic ductal dilation (CBD 9-10mm).
Patient then went for an ERCP where stones were extracted and a
percutaneous cholecystostomy tube placed.
She was supported with intravenous fluids, antibiotics and pain
medication.
On [**2108-1-17**] she underwent an ERCP again where 4 stones were
extracted successfully.
On [**2108-1-18**] it was noted that her amylase and lipase rose
showing an acute pancreatitis.
On [**2108-1-19**] amylase and lipase trending down, denies abdominal
pain, progressed from a clear liquid diet to a regular diet
without nausea. We will send her home today with VNA to monitor
and teach regarding her percutaneous chole. tube. She will
follow up with Dr. [**Last Name (STitle) **] in 2 weeks.
Medications on Admission:
decacron 12mg q week, novasc 5', prilosec
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): please continue to [**2108-1-28**].
Disp:*20 Tablet(s)* Refills:*0*
4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day: Please continue until [**2108-1-28**].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 5450**] and So. NH
Discharge Diagnosis:
Acute cholecystitis/choledocholiathiasis
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**11-30**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**Name (STitle) 23**] Building [**Location (un) 470**] on [**2108-2-3**] at 4 pm
Completed by:[**2108-1-18**]
|
[
"203.00",
"574.31",
"038.49",
"401.9",
"272.4",
"530.81",
"995.91",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.01",
"51.83",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
4400, 4473
|
2626, 3823
|
453, 499
|
4558, 4567
|
1294, 2603
|
5891, 6034
|
945, 986
|
3915, 4377
|
4494, 4537
|
3849, 3892
|
4591, 5522
|
1001, 1275
|
241, 415
|
5534, 5868
|
527, 808
|
830, 884
|
900, 929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,613
| 185,024
|
2886
|
Discharge summary
|
report
|
Admission Date: [**2146-3-8**] Discharge Date: [**2146-3-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
catheterization of the heart
History of Present Illness:
85 yo male with a history of carotid stenosis, pacer placement
for first degree AV block, low grade lymphoma who presents with
chest pain. Patient states he was walking across the street
today when he developed [**7-11**] band like chest pain associated
with SOB, diaphoresis. No N/V/palps or radiating pain. Patient
states pain felt like iron straps constricting his chest. Pain
continued and he drove himself home and called his PCP. [**Name10 (NameIs) **] was
then told to come into the ED. Patient states he had stress
test done yesterday which was positive per his report. His PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], started metoprolol which the patient took today.
Patient was sent for stress test [**1-3**] DOE which had been ocurring
for the past few months. Patient works as a volunteer at [**Hospital 100**]
rehab and was having DOE after 30-45minutes of activity at work.
.
.
In the ED: Temp 96.9, BP 160/86, HR 75, RR 16, 99% RA. CODE
STEMI called, patient was taken immediately to the cath lab.
.
In the cath lab RCA had 95% PDA which had BMS placed. LCx had
90% stenosis which not intervened upon.
.
On arrival to the CCU, patient c/o [**1-11**] continued chest pain. He
denied SOB, N/V, palps, diaphoresis. He denies any recent
fevers, chills, cough, pleuritic pain, abd pain or diarrhea.
.
.
Past Medical History:
First degree AV block
[**Company 1543**] pacemaker, EnPulse E1DR01, placed [**2140-12-8**], DDD mode
with a
lower rate of 60 and an upper track rate of 120 beats per minute
Hyperlipidemia
Low-grade lymphoma
Diverticulitis
Colonic adenomas resected in [**2135**]
History of gastric ulcer bleed in [**2139**]
Degenerative joint disease
Squamous cell carcinoma of the left mandibular region
requiring surgery and radiation therapy in [**2135**].
Hypothyroidism
s/p left sided carotid stenting in [**2142**]
s/p TURP in [**2124**] for BPH
s/p ORIF of both the right and left hips.
Social History:
-Tobacco history: Patient smoked cigars and cigarettes for 5
years, but quit 50
years ago.
-ETOH: He drinks alcohol occasionally.
-Illicit drugs: denies
Family History:
The patient's father died at the age of 59 of acute heart
attack. No family history of arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
GENERAL: NAD, lying comfortably in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVD
CARDIAC: +S1/S2, no m/r/g, RRR
LUNGS: CTAB, no wheezes, crackles or ronchi
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: +2 distal pulses
.
LABS/STUDIES
EKG: First degree AV block PR 280ms, sinus rhythm, left sided
axis, ST elevation in V1 (2mm), V2 (2mm) and AVR, peaked T waves
in V2 and V3, no reciprocal changes
.
Pertinent Results:
[**2146-3-8**] 02:55PM BLOOD WBC-9.4 RBC-4.78 Hgb-14.8 Hct-43.3 MCV-91
MCH-30.9 MCHC-34.2 RDW-14.6 Plt Ct-228
[**2146-3-9**] 05:36AM BLOOD WBC-8.7 RBC-4.34* Hgb-13.4* Hct-38.7*
MCV-89 MCH-30.8 MCHC-34.7 RDW-14.8 Plt Ct-195
[**2146-3-8**] 02:55PM BLOOD PT-14.0* PTT-28.3 INR(PT)-1.2*
[**2146-3-9**] 05:36AM BLOOD PT-13.7* PTT-32.3 INR(PT)-1.2*
[**2146-3-8**] 02:55PM BLOOD Glucose-93 UreaN-21* Creat-1.4* Na-136
K-5.0 Cl-102 HCO3-26 AnGap-13
[**2146-3-9**] 05:36AM BLOOD Glucose-88 UreaN-18 Creat-1.3* Na-134
K-5.5* Cl-100 HCO3-25 AnGap-15
[**2146-3-8**] 02:55PM BLOOD cTropnT-0.02*
[**2146-3-9**] 05:36AM BLOOD CK-MB-NotDone cTropnT-0.04*
Cath
RCA had 95% PDA which had BMS placed. LCx had 90% stenosis
which was not intervened upon
Cath [**2146-3-9**]:
COMMENTS:
1. Selective coronary angiography demonstrated multivessel
coronary
artery disease. The right coronary artery demonstrated a widely
patent
stent in the mid portion of the vessel. The left main
demonstrated a
30% lesion in the distal portion of the left main coronary
artery. The
left anterior descending artery demonstrated a long calcified
70% lesion
in the proximal to mid portion of the vessel. The large first
diagonal
branch had a 70% ostial lesion. The left circumflex
demonstrated a
discrete 70% lesion in the distal portion of the vessel. The
first
obtuse marginal branch demonstrated serial 70% lesions.
2. Pressure wire interrogation of the long lesion in the LAD
demonstrated a resting FFR of 0.78 which dropped to 0.67 with
maximal
hyperemia.
3. Successful PTCA and stenting of the obtuse marginal with a
Minivision (2.75x14mm) bare metal stent.
4. Successful POBA of the first diagonal branch prior to be
jailed with
a 2.0mm balloon.
5. Successful PTCA and stenting of the proximal - mid LAD with
two
overlapping bare metal stents jailing the first diagonal branch
(Minivision 2.75x28mm distally, 2.75x18mm proximally). Final
angiography demonstrated no angiographically apparent
dissection, no
residual stenosis in the LAD and 30% stenosis in the first
diagonal with
TIMI III flow throughout (See PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA and stenting of the obtuse marginal with a
bare metal
stent.
3. Successful POBA of the first diagonal branch.
4. Successful PTCA and stenting of the proximal - mid LAD with
two
overlapping bare metal stents.
TTE:
The left atrium is dilated. There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal for the patient's body size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). There is an abnormal systolic
flow contour at rest, but no left ventricular outflow
obstruction. Right ventricular chamber size and free wall motion
are normal. The right ventricular free wall is hypertrophied.
The diameters of aorta at the sinus, ascending and arch levels
are normal. 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. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe symmetric LVH with even more severe
hypertrophy of the upper septum. Abnormal resting LVOT flow
without obstruction. No regional wall motion abnormality.
Hypertrophied right ventricle with normal size and function.
Mild aortic and moderate tricuspid regurgitation. Biatrial
enlargement. Short E-wave deceleration time. This constellation
of findings could be consistent with an infiltrative process
such as amyloid.
Brief Hospital Course:
85 yo male with a history of questionable CAD, first degree AV
block s/p pacer placement presents with an anterior wall MI.
.
# STEMI: Pt had evidence of anterior wall ST elevation MI on
ECG and in the cath lab. First set of CE's CK 89, Trop 0.02 and
stayed stable. Patient also continued with mild 2/10 chest pain
after his cath. He was started on a Nitro gtt and continued on
integrillin overnight however in the morning he was still
complaining of chest pain. He was taken back to the cath lab and
had BMS placed in LAD after pressure wire demonstrated it to be
a significant lesion. He also had BMS placed in LCx as well as
POBA of first diagonal. Cardiac enzymes continued to be flat. He
was continued on aspirin and plavix. He refused high dose
statins and thus was started on rosuvastatin 20mg every other
day. Low dose beta blockers were re-initiated. His blood
pressure was low so he was not started on an ace inhibitor in
the hospital but his outpatient cardiologist will discuss this
with him at his visit in a few days.
# Hypertrophic cardiomyopathy: On TTE patient had evidence of
septal RV and LV wall thickening consistent with an infiltrative
cardiomyopathy. There was no outflow tract obstruction.
According to his outpatient cardiologist this was not a new
finding. He will follow up with his cardiologist regarding these
findings.
# First Degree AV Block: Per last EP note, the patient is not
pacer dependent. On his last interogation in [**10-9**], he was
atrial and ventricular sensing 80% of the time. The other 20%
was split between atrial pacing and ventricular sensing and
atrial and ventricular pacing. The patient had persistent
prolonged PR during the hospitalization, however was only atrial
pacing at times.
# Carotid Stenosis s/p left sided endarterectomy: Continued
aspirin and statin as above.
# Renal Insufficiency: On admission was at baseline of 1.3-1.4
and did not increase even after dyeloads with caths.
# Hyperlipidemia: Continued rosuvastatin as above
# Hypothyroidism: Continued levothyroxine 100mcg QD
# History of GI bleed/Colonic polyps: Monitored Hct daily, goal
> 30 in the setting of ACS. Omeprazole was changed to
pantoprazole given interaction with plavix.
Medications on Admission:
Aspirin 325mg daily
Synthroid 0.1 mg po daily
Folic Acid 1mg daily
Omeprazole 20mg daily
Allopurinol ?
Crestor ?
Metoprolol 12.5mg [**Hospital1 **], started today
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*30 Tablet(s)* Refills:*2*
7. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
ST elevation Myocardial Infarction
.
Secondary Diagnoses:
First degree AV block
Low-grade lymphoma
Diverticulitis
Degenerative joint disease
Squamous cell carcinoma
Hypothyroidism
Discharge Condition:
The patient was afebrile and hemodynamically stable on
discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for chest pain. You were found to be
possibly having a having a heart attack although there was no
evidence of permanant damage. You underwent cardiac
catheterizations to place stents in your arteries. These stents
are bare metal stents and you will need to continue Plavix and
aspirin for at least one month and possibly longer. Do not skip
any doses or stop taking Plavix unless Dr. [**Last Name (STitle) **] [**Name (STitle) 13969**] you to.
You continued to have mild chest pain following these
procedures, which was thought to residual pain from your
procedures. You will be discharged on medications that are
important for your health, please take them as prescribed.
.
New Medications
- Plavix 75mg daily - to keep your stents open
- Aspirin 325mg daily - to keep your stents open
- Rosuvastatin 20mg every other day-to lower your cholesterol.
Please stop taking your pravastatin.
- Pantoprazole instead of omeprazole - for your stomach. This
was switched because the omeprazole interacts with the plavix.
.
If you experience worsening chest pain, shortness of breath,
lightheadedness, dizziness, fevers, chills or any other
worrisome symptoms please seek medical attention.
.
No lifting more than 7 pounds for one week. No baths or pools
for one week. You may shower and cover the groin site with a
band-aid. Please call Dr. [**Last Name (STitle) **] if you notice any bleeding,
increasing bruising or pain or any other unusual changes in your
groin.
Followup Instructions:
Please follow up with your primary cardiologist, Dr. [**Last Name (STitle) **], on
[**2146-3-15**] at 10:30am. The number to schedule an appointment is
[**0-0-**].
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2146-4-11**]
2:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2146-4-12**] 10:00
Completed by:[**2146-3-11**]
|
[
"272.4",
"V10.83",
"V12.71",
"715.90",
"429.3",
"410.11",
"530.81",
"202.80",
"244.9",
"V17.49",
"V43.65",
"425.4",
"414.01",
"V45.01",
"426.11",
"V12.72",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"88.53",
"00.66",
"00.47",
"99.20",
"36.06",
"37.22",
"00.42",
"88.56",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
10438, 10444
|
7171, 9394
|
272, 302
|
10687, 10755
|
3284, 5390
|
12305, 12763
|
2466, 2638
|
9607, 10415
|
10465, 10465
|
9420, 9584
|
5407, 7148
|
10779, 12282
|
2653, 3265
|
10542, 10666
|
222, 234
|
330, 1677
|
10484, 10521
|
1699, 2278
|
2294, 2450
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,424
| 111,217
|
28745
|
Discharge summary
|
report
|
Admission Date: [**2135-10-10**] Discharge Date: [**2135-10-18**]
Date of Birth: [**2076-2-14**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Prednisone
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Anterior lumbar inerbody fusion with instrumentaiton L2-S1
Posterior lumbar fusion with instrumentation L2-S1
History of Present Illness:
Ms. [**Known lastname 69478**] has a long history of back and leg pain from her
lumbar scoliosis. She has attempted conservative therapy
including physical therapy and has failed. She now presents for
surgical intervetion.
Past Medical History:
HTN
Lumbar scoliosis
Social History:
Denies
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact
distally; reflexes intact at quads and achilles
Pertinent Results:
[**2135-10-14**] 06:00AM BLOOD Hct-32.0*
[**2135-10-13**] 02:30AM BLOOD WBC-8.6 RBC-3.52* Hgb-11.1* Hct-31.0*
MCV-88 MCH-31.5 MCHC-35.8* RDW-15.4 Plt Ct-201#
[**2135-10-12**] 01:34AM BLOOD WBC-6.9 RBC-3.75* Hgb-11.9* Hct-33.0*
MCV-88 MCH-31.8 MCHC-36.1* RDW-15.6* Plt Ct-121*
[**2135-10-11**] 08:30PM BLOOD Hct-35.1*#
[**2135-10-11**] 01:45PM BLOOD Hct-25.5*
[**2135-10-11**] 05:40AM BLOOD Hct-27.2*
[**2135-10-13**] 02:30AM BLOOD Plt Ct-201#
[**2135-10-13**] 02:30AM BLOOD PT-12.7 PTT-35.5* INR(PT)-1.1
[**2135-10-11**] 03:45PM BLOOD PT-14.0* PTT-27.6 INR(PT)-1.2*
[**2135-10-11**] 10:18AM BLOOD PT-13.3* PTT-29.2 INR(PT)-1.2*
[**2135-10-14**] 06:00AM BLOOD Glucose-118* UreaN-9 Creat-0.5 Na-138
K-3.7 Cl-102 HCO3-29 AnGap-11
[**2135-10-13**] 02:30AM BLOOD Glucose-112* UreaN-11 Creat-0.5 Na-142
K-3.3 Cl-107 HCO3-26 AnGap-12
[**2135-10-12**] 02:17PM BLOOD K-4.3
[**2135-10-12**] 01:34AM BLOOD Glucose-132* UreaN-14 Creat-0.6 Na-142
K-3.4 Cl-109* HCO3-27 AnGap-9
[**2135-10-11**] 03:45PM BLOOD Glucose-114* UreaN-12 Creat-0.5 Na-142
K-3.8 Cl-109* HCO3-24 AnGap-13
[**2135-10-14**] 06:00AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.9
[**2135-10-13**] 02:30AM BLOOD Calcium-7.4* Phos-2.2* Mg-1.9
[**2135-10-12**] 02:17PM BLOOD Calcium-7.9* Phos-2.0* Mg-2.1
[**2135-10-12**] 01:34AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8
[**2135-10-11**] 03:45PM BLOOD Calcium-8.3* Phos-2.3* Mg-1.6
Brief Hospital Course:
Ms. [**Known lastname 69478**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for
an anterior/posterior lumbar fusion with instrumentation for her
lumbar scoliosis. She was informed and consented of the risks
and benefits and agreed to proceed. Please see Operative Note
for procdure in detail.
Post-operatively she was transferred to the T/SICU because of
her large blood loss. She required multiple units of packed
cells intraoperatively and postoperatively. Her drains and
epidural were removed POD2 and she was transferred out of the
T/SICU POD3.
On the floor she remained hemodynamically stable. She was
fitted for a lumbar corset and was able to work with physical
therapy. She tolerated PO's well and her pain was controlled.
She was discharged in good condition and will follow up in the
Orthopaedic Spine Clinic during her previously scheduled
appointments.
Medications on Admission:
Triamterene-HCTZ
Diazepam
Protonix
Beconaze
Hydrocodone
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar degenerative scoliosis L2-S1
Post-operative anemia
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Activity as tolerated
Lumbar corset for ambulation. [**Month (only) 116**] be out of bed to chair
without.
Treatments Frequency:
Site: Anterior/Posterior midline
Type: Surgical
Please change daily with dry, sterile gauze.
Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.
Completed by:[**2135-10-18**]
|
[
"721.3",
"737.30",
"780.6",
"998.89",
"285.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"81.06",
"77.39",
"77.89",
"84.51",
"80.51",
"03.90",
"81.08",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
4124, 4130
|
2643, 3574
|
295, 407
|
4232, 4239
|
1251, 2620
|
4750, 4866
|
745, 750
|
3680, 4101
|
4151, 4211
|
3600, 3657
|
4263, 4469
|
765, 1232
|
4487, 4607
|
4630, 4727
|
238, 257
|
435, 661
|
683, 705
|
721, 729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,459
| 113,218
|
43942
|
Discharge summary
|
report
|
Admission Date: [**2148-11-25**] Discharge Date: [**2148-12-5**]
Date of Birth: [**2085-6-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lidocaine / Morphine
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Recurrent right chest wall hernia.
Major Surgical or Invasive Procedure:
[**2148-11-25**]: Right thoracotomy and repair of chest wall hernia.
History of Present Illness:
Mr. [**Known lastname 13646**] is a 63 year old male s/p right chest wall hernia
repair with [**Doctor Last Name 4726**]-tex mesh on [**2148-10-25**] who presented to the
postoperative clinic in pain, with erythematous right thoractomy
and drainage out the chest tube site. A CT chest revealed
rupture of the [**Doctor Last Name 4726**]-tex mesh. Antibiotics were started. He
returns for redo right thoractomy and repair of the hernia.
Past Medical History:
-COPD
-OSA
-Diabetes II, complicated by neuropathy
-Chronic Sinusitis
-Obesity
-BPH
-GERD
-Cold induced asthma
-OA
-Allergic Rhinitis
-HTN
-PTSD
-Hyperlipidemia (on simvastatin)
.
Past Surgical History:
The patient had previous L4-L5 microdiscectomy
in [**2142-4-9**]. He has had multiple discectomies in the past in
[**2118**], [**2124**], and [**2133**].
-Status post operative fusion of his left ankle following a
bimalleolar ankle fracture
-Cervical C3-4 spine fusion with persisting cervical cord
compression and plexopathy
-Lumbar laminectomy for spinal stenosis.
Social History:
He lives at home with his wife and his son [**Name (NI) **]. [**Name2 (NI) **] 4 adult
children who live away and are all described as healthy. He
does not smoke. He uses wine or beer occasionally, and 2 cups of
coffee a day. He reports the use of a regular diet and sleeps 8
hours per night with nocturia interrupting his sleep every [**3-13**]
hours.
Family History:
He has a daughter today sutures old and two sons 19 and 33 years
old all of which are healthy.
Physical Exam:
VS: T: 98.6 HR: 77-95 SR BP: 108-112/60 Sats: 93% RA Wt: 119
kg
BS 121/154/161
General: 63 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Card: RRR. normal S1,S2 no murmur
Resp: bilateral diminshed breath sounds with bibasilar crackles
no wheezes
GI: obese, BS+ abdomen soft non-tender/non-distended
Extre: warm tr edema
Incision: right thoracotomy site with staples, mild erythema
extending downward
Neuro; Awake, alert, oriented. Walks with a walker
Pertinent Results:
[**2148-12-3**] WBC-6.4 RBC-3.37* Hgb-10.4* Hct-31.3 Plt Ct-467*
[**2148-12-1**] WBC-5.4 RBC-3.14* Hgb-9.8* Hct-29.4 Plt Ct-398
[**2148-11-29**] WBC-5.7 RBC-3.11* Hgb-9.8* Hct-29.1 Plt Ct-344
[**2148-11-28**] WBC-6.0 RBC-2.93* Hgb-9.1* Hct-27.2 Plt Ct-283
[**2148-11-25**] WBC-9.1 RBC-3.99* Hgb-12.2* Hct-37.3 Plt Ct-401
[**2148-12-4**] Glucose-113* UreaN-9 Creat-0.9 Na-136 K-4.7 Cl-97
HCO3-31
[**2148-12-3**] Glucose-171* UreaN-10 Creat-0.8 Na-135 K-4.6 Cl-95*
HCO3-32
[**2148-12-2**] Glucose-129* UreaN-8 Creat-0.8 Na-137 K-4.5 Cl-98
HCO3-30
[**2148-12-3**] Calcium-8.3* Phos-4.2 Mg-1.8
[**2148-11-29**] Glucose-117* UreaN-10 Creat-0.7 Na-137 K-4.3 Cl-103
HCO3-26
[**2148-11-28**] Glucose-129* UreaN-15 Creat-1.0 Na-131* K-4.3 Cl-102
HCO3-25
[**2148-11-26**] Glucose-254* UreaN-16 Creat-1.1 Na-125* K-4.9 Cl-95*
HCO3-24
[**2148-11-25**] Glucose-352* UreaN-13 Creat-0.9 Na-136 K-4.7 Cl-100
HCO3-25
[**2148-11-29**] Calcium-8.3* Phos-3.6 Mg-1.8
CXR:
[**2148-12-3**]: Surgical material is again noted along the
inferolateral right chest wall. The amount of pleural fluid
tracking along
the right chest wall and into the medial right apex,
posteriorly, appears to have increased over several days.
Heterogeneous opacities at the right lung base are unchanged.
The left lung remains well aerated. There is no left pleural
effusion or pneumothorax. The cardiomediastinal silhouette is
unchanged.
IMPRESSION:
Apparent increase in right pleural fluid layering along the
lateral right
chest wall, and in a loculated collection at the posterior right
lung apex.
[**2148-11-29**]: Moderate right pleural effusion is again seen that
tracks along the lateral chest wall and the major fissure. The
area of opacification at the right base remains constant. Left
lung is well aerated without evidence of definite effusion or
consolidation. Persistent cardiomegaly without evidence of
vascular congestion.
[**2148-11-27**]: Overall stable right pleural effusion and atelectasis
following
right chest tube removal with no pneumothorax or new
abnormality.
[**2148-11-26**]: some improved aeration bilaterally without evidence of
pneumothorax. Continued enlargement of the cardiac silhouette
with atelectatic changes at the bases. No evidence of pulmonary
vascular congestion.
[**2148-11-25**]: The large right pleural effusion may be
smaller in size, or fluid may have shifted to the medial
hemithorax.
Relatively diffuse opacity at the right lung base may represent
atelectasis. There is no left-sided consolidation or pleural
effusion. There is no pneumothorax. The cardiomediastinal
silhouette is grossly unchanged.
Echocardiogram: [**2148-12-2**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Pulmonary artery systolic hypertension. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function.
Brief Hospital Course:
Mr. [**Known lastname 13646**] is 63 year-old male admitted following right redo
thoracotomy and chest wall hernia repair. He was extubated in
the operating room, and monitored in the PACU prior transfer to
the floor. Once transfer to the floor he was found to be
hypovolemic with low urine output requiring large fluid
challenges. On [**2148-11-27**] he was transferred to the TSICU for
hypotension, which he was given more fluids. He transfer back to
the floor in stable condition on [**2148-11-29**].
Respiratory: The patient required aggressive pulmonary toilet
with around the clock nebulizers. He continued with his home
CPAP for OSA/COPD at night. Pulmonology followed him throughout
his hospital course. On [**2148-12-2**] it was felt he was volume
overloaded gently diuresed with good effect. He was weaned off
oxygen saturating mid 90's on room air. Goal oxygen saturations:
89-94%.
Chest tube was removed on [**2148-11-28**]. Followed by serial chest
films (see above report)
Cardiac: He was tachycardic in the ICU which responded to
Lopressor. On the floor he became hypertensive and his
tachycardia in low 100's persisted. An echocardiogram was done
and showed normal EF with moderate pulmonary artery systolic
hypertension of 45 mm Hg. His home dose lisinopril of 40 mg po
bid was restarted and up titrated his metoprolol to 37.5 mg po
tid, with good effect.
GI: He had normal bowel movements and remained on proton pump
inhibitors.
Renal: He was hyponatremic with sodium of 126, which improved
with normal saline to 137. Renal function remained within
normal range. The Foley was removed on [**2148-11-29**] once the
epidural was removed, and he voided well thereafter. He was
diuresed for volume overload on [**2148-11-29**] once and started daily
on [**2148-12-2**], with positive response in overall clinical status.
Endocrine: His blood sugar range varied 100-400. [**Last Name (un) **] was
consulted and adjusted his insulin to maintain adequate glucose
control.
Pain: Epidural Bupivacaine and morphine PCA was initially used
for pain control. The was transition ed to MS Contin and
lidocaine patch for good pain control. His pain improved on
[**2148-11-29**] the epidural and PCA were stopped. He continued with
MS Contin and morphine immediate release for breakthrough pain.
ID: incision with staples mild erythema extending downward. He
remained afebrile WBC within normal range. A 10 day course
Augmentin 875 [**Hospital1 **] was started for possible cellulitis in a
patient with Gortex mesh. During admission, pt noted tooth pain
and subsequently received panorex which did reveal abscess and
pt was cleared by dental consultation service.
Disposition: He was seen by physical therapy who recommended
short term rehab. He was discharged to [**Hospital1 19286**] in
[**Hospital1 3597**] ([**Telephone/Fax (1) 94339**]) on [**2148-12-5**] and will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
NPH 55 units QHS
Novolog 27 units before dinner
Glipizide 2.5 mg in AM and 7.5 mg in PM
Buspirone 10 mg [**Hospital1 **]
PER LAST D/C summary:
Lisinopril 40 mg [**Hospital1 **]
Oxybutynin Chloride 2.5 mg TID
Paroxetine HCl 50 mg Daily
Simvastatin 20 mg daily
Aspirin 81 mg DAILY
Omeprazole 40 mg daily
Cyanocobalamin (Vitamin B-12) 100 mcg daily
Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Fluticasone-Salmeterol 250-50 mcg/Dose 1 puff [**Hospital1 **]
Pregabalin 25 mg TID
Prednisone 10 mg Tablets, Dose Pack Sig: dose pack, see
instructions Tablets, Dose Pack PO once a day for 6 days: take 4
tablets a day for 2 days, 2 tablets a day for 2 days, 1 tablets
a
day for 2 days then stop.
Azithromycin 250 mg for 4 day
Discharge Medications:
1. oxybutynin chloride 5 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
2. pregabalin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
11. paroxetine HCl 25 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
13. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: for a
week then reevaluate volume status. You should have electrolytes
checked on lasix and replaced as necessary.
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): if immobile in rehab.
16. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
17. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO Q 8H
(Every 8 Hours).
18. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
19. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
20. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days.
21. Humalog sliding scale
71-100 mg/dL 5 Units 5 Units 5 Units 0 Units
101-150 mg/dL 5 Units 5 Units 5 Units 0 Units
151-200 mg/dL 7 Units 7 Units 7 Units 0 Units
201-250 mg/dL 9 Units 9 Units 9 Units 2 Units
251-300 mg/dL 11 Units 11 Units 11 Units 4 Units
301-350 mg/dL 13 Units 13 Units 13 Units 6 Units
351-400 mg/dL 15 Units 15 Units 15 Units 8 Units
22. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
-COPD
-OSA
-Diabetes II, complicated by neuropathy
-Chronic Sinusitis
-Obesity
-BPH
-GERD
-Cold induced asthma
-OA
-Allergic Rhinitis
-HTN
-PTSD
-Hyperlipidemia (on simvastatin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Incision develops drainage or increased redness
-Shortness or breath or cough
Staples will be removed on your follow-up visit.
You may shower. No tub bathing or swimming until all incisions
healed
Antibiotics: Augmentin 875 mg [**Hospital1 **] for 10 days.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2348**] [**2148-12-17**] 1:00pm on
[**Hospital1 18**] [**Hospital Ward Name **] [**Hospital Ward Name 23**] 9
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD Phone:[**Telephone/Fax (1) 142**]
Date/Time:[**2148-12-11**] 3:30
Followup with your dentist if your right back gum lesions to do
disappear. You had a panorex in the hospital showing this area
was not absessed.
Completed by:[**2148-12-5**]
|
[
"996.59",
"276.52",
"309.81",
"682.2",
"250.60",
"428.0",
"998.59",
"428.33",
"E878.8",
"357.2",
"493.20",
"401.9",
"327.23",
"518.89",
"276.2",
"600.00",
"278.00",
"V58.67",
"530.81",
"473.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.79",
"34.03"
] |
icd9pcs
|
[
[
[]
]
] |
12297, 12340
|
5870, 8827
|
324, 395
|
12561, 12561
|
2468, 5847
|
13107, 13693
|
1846, 1942
|
9699, 12274
|
12361, 12540
|
8853, 9676
|
12712, 13084
|
1088, 1457
|
1957, 2449
|
249, 286
|
423, 863
|
12576, 12688
|
885, 1065
|
1473, 1830
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,428
| 165,758
|
641+642
|
Discharge summary
|
report+report
|
Admission Date: [**2176-7-17**] Discharge Date: [**2176-7-22**]
Date of Birth: [**2093-9-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82 y/o F h/o DM2, carotid stent on ASA/plavix, HTN a/w 4 days hx
of worsening SOB. There is some at rest, but more noticable at
exertion. Developed orthopnea, PND, but she did not notice
swelling in her lower extremities. She noticed that today she
had chest tightness, but no chest pain.
.
ROS: no n/v/d/fevers, chills, or URI. No blood in stools, there
have been no changes in her diet or her thyroid medications.
Past Medical History:
1. PVD s/p [**Country **] stent
2. DM II
3. HTN
4. hypothyroidism
5. hyperlipidemia
6. L eye detachment
7. h/o diabetes inspidus after pregnancy - not an active issue
8. hearing loss
Social History:
SH: Denies tobacoo history. Minimal alcohol use. Lives with
husband, very supportive family.
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
PE: 185/54, 77, 38, 99% NR
Gen: resp distress, WDWN.
HEENT: peerla, eomi, ncat on non-rebreather;
Neck: L carotid bruit
Heart: s4, no r/g
lungs: diffuse crackles
ABd; +BS/S/NT/ND/no masses
Back; no CVAT
Ext: no c/c, 2+ pitting edema
Pertinent Results:
Cath [**2172**]:
COMMENTS:
1. Access was obtained via the RFA in a retrograde fashion.
2. Resting hemodynamics showed central aortic hypertension with
a 30
mmHg gradient to the RFA, a 15 mmHg gradient to the right
subclavian and
a 100 mmHg gradient to the left subclavian artery.
3. Thoracic Aorta: Type I arch without critical lesions.
4. Abdominal aorta: Mild disease with a modest lesion in the
distal
aorta.
5. RLE: The CIA had a 70% stenosis.
6. LLE: The CIA had no critical lesions.
7. Subclavian artery: The RSCA was normal. The LSCA had a
tubular,
calcified 95% at the origin. There is retrograde flow from the
[**Female First Name (un) 899**] but
not the vertebral artery.
8. Carotid/vertebral arteries: The RCCA was normal. The ICA had
a 99%
calcified type C lesion. The ICA filled the ipsilateral MCA and
mildly
filled the ACA with competitive flow from the [**Doctor First Name 3098**]. The right
vertebral
artery was small and diffusely diseased. The LCCA was normal.
The [**Doctor First Name 3098**]
had a 95% had a 60% tubular stenosis. The ICA filled the
ipsilateral ACA
and MCA with contralateral filling of the ACA. The left
vertebral artery
was patent without lesions and filled the cerebellar and PCAs
bilaterally.
9. Successful PTCA and stenting of the [**Country **] with a 6-8 mm
Acculink
stent. Final angiography showed a 10% residual stenosis, no
dissection
and normal flow (see PTA comments).
.
[**2176-7-17**] 07:45AM WBC-11.6* RBC-4.26 HGB-12.5 HCT-37.6 MCV-88
MCH-29.4 MCHC-33.3 RDW-16.5*
[**2176-7-17**] 07:45AM NEUTS-91.4* BANDS-0 LYMPHS-4.7* MONOS-2.6
EOS-1.0 BASOS-0.2
[**2176-7-17**] 08:15AM URINE RBC-[**2-14**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-[**2-14**]
[**2176-7-17**] 08:15AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
.
[**2176-7-17**] 07:45AM CK(CPK)-243*
[**2176-7-17**] 07:45AM cTropnT-0.05*
[**2176-7-17**] 07:45AM CK-MB-5 proBNP-8412*
[**2176-7-17**] 03:00PM CK(CPK)-170*
[**2176-7-17**] 03:00PM cTropnT-0.05*
[**2176-7-17**] 09:49PM CK(CPK)-144*
[**2176-7-17**] 09:49PM CK-MB-4 cTropnT-0.06*
[**2176-7-17**] 09:49PM TSH-17*
.
CXR [**2176-7-17**]
FRONTAL CHEST RADIOGRAPH
INDICATION: 82-year-old woman with dyspnea and cough.
COMPARISON: [**2173-3-16**].
FINDINGS: Cardiac silhouette is enlarged. There is widening of
the right
paratracheal stripe. There is a mild interstitial edema. No
focal
consolidation or pneumothorax is present. Osseous structures are
diffusely
demineralized.
IMPRESSION: Mild interstitial edema.
[**2176-7-18**] ECHO
This study was compared to the report of the prior study (images
not available) of [**2173-7-6**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal IVC
diameter (<2.1cm) with >55% decrease during respiration
(estimated RA pressure (0-5mmHg).
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%). TDI E/e' >15, suggesting
PCWP>18mmHg. Transmitral Doppler and TVI c/w Grade III/IV
(severe) LV diastolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. Mild (1+) MR. LV
inflow pattern c/w restrictive filling abnormality, with
elevated LA pressure.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Frequent atrial premature beats.
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade III/IV
(severe) LV diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2173-7-6**], the left ventricular thickness has
increased and the severity of diastolic dysfunction has
worsened.
[**2176-7-18**] RENAL DOPPLER
INDICATION: 82-year-old female with hypertensive urgency.
Evaluate for renal
artery stenosis.
COMPARISON: Abdomen CT, [**2173-4-15**].
FINDINGS: The right kidney is again noted to be atrophic
measuring only 7.4
cm on today's exam. The left kidney measures 10.0 cm. There is
no
hydronephrosis and no stones or solid masses are identified in
either kidney.
DOPPLER EXAMINATION: Note is made that the Doppler study is very
technically
limited due to the patient's atrophic right kidney and the
patient's inability
to hold her breath. Color Doppler and pulsed wave Doppler images
were
obtained. In the right kidney, there is arterial and venous flow
documented;
however, spectral waveforms could not be obtained that could be
evaluated for
renal artery stenosis. On the left kidney, arterial waveforms of
the main
renal artery demonstrate sharp upstrokes. Arterial waveforms of
the
intraparenchymal arteries do not demonstrate any measurable
diastolic flow.
This lack of diastolic flow may be due to the technical
limitations of this
study. Appropriate venous flow is identified in the left main
renal vein.
IMPRESSION:
1. No hydronephrosis. Atrophic right kidney. No stones or renal
masses
identified.
2. Very technically limited Doppler exam documents arterial and
venous flow
in each kidney, but spectral waveforms cannot be evaluated for
renal artery
stenosis.
[**2176-7-19**] RENAL MRI/MRA
INDICATION: Diffuse severe atherosclerotic disease with diabetes
and multiple
stent placements. Assess for renal artery stenosis.
COMPARISON: CT of the abdomen and pelvis of [**2173-4-15**].
TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen
were
obtained, including 3D dynamic images obtained prior to, during,
and after the uneventful intravenous administration of 0.1
mmol/kg of gadolinium-BOPTA. Multiplanar 2D and 3D reformatted
images and subtraction images were generated and reviewed on an
independent workstation.
MRA OF THE KIDNEYS AND AORTA: There is a large atheromatous
plaque at the
origin of the right renal artery, which results in severe right
renal artery stenosis. As expected, the right kidney is smaller
than the left in size, measuring about 7 cm in craniocaudad
dimension (an estimate from axial images and slice thickness).
There is cortical thinning of the right kidney as well. In
contrast, the left kidney measures approximately 10.9 cm,
without cortical thinning. There are two left renal arteries,
without stenosis.
The celiac axis demonstrates a severe stenosis just beyond its
origin.
Contrast does not opacifies the proximal most 2.6 cm of SMA
lumen, which could be related to a stent at this locale.
Alternatively, if no stent has been placed in this area, the
finding represents occlusion. There is flow in the SMA beyond
this level. The inferior mesenteric artery is patent. There is
moderate atherosclerotic stenosis of the proximal right common
iliac artery, and severe atherosclerotic stenosis of the
proximal left common iliac artery.
The imaged portions of the liver, spleen, pancreas, gallbladder,
and adrenal glands are normal. There are small rounded
nonenhancing lesions of the left kidney, which are compatible
with cysts. The largest of these is hyperintense on pre-contrast
T1-weighted images, indicating hemorrhagic or proteinaceous
contents. This lesion is in the lower pole of the left kidney
and measures 1.5 cm.
There are several foci of heterogeneous signal intensity in the
subcutaneous fat of the buttocks, corresponding to calcified
injection granulomas as seen on the prior CT of [**2173-4-11**]. There
is an L1 vertebral body compression fracture, mentioned on prior
chest radiographs.
Multiplanar reformatted images were essential in delineating the
anatomy and pathology in this case.
IMPRESSION:
1. Severe plaque at the origin of the right renal artery,
resulting in severe right renal artery stenosis. The right
kidney is smaller in size, with cortical thinning.
2. No stenosis of the two left renal arteries.
3. Severe atherosclerotic disease elsewhere within the abdomen,
including
severe celiac stenosis just beyond its origin, a moderate
stenosis at the
proximal right common iliac artery and a severe stenosis of the
left proximal common iliac artery.
4. The proximal superior mesenteric artery is not visualized
over a 2.6 cm
segment, but please correlate to the patient's history. If a
stent is present in this locale, this finding may be
stent-related. If there is no history of stent placement, the
findings are compatible with occlusion. The superior mesenteric
artery demonstrates flow beyond this 2.6 cm segment.
5. Patent [**Female First Name (un) 899**].
Brief Hospital Course:
#Acute on chronic diastolic CHF - The reason for the patient's
decompensation remains unclear, although inadequate thyroid
supplementation may have been a contributing factor. Cardiac
markers were negative x 3. TTE revealed diastolic dysfunction
with preservation of LVEF. The patient was placed on a 750 cc
fluid restriction and given loop diuresis with improvement in
her symtoms. She demonstrated adequate RA oxygenation prior to
discharge. She will be discharged with lasix 20 mg daily, VNA to
check daily weights and BP, and instructions to call her
physician regarding [**Name9 (PRE) 4919**] the dose of lasix should she
gain weight or feel subjectively more short of breath.
.
#Orthostatic hypotension - The patient had an episode of
hypotension BP 92/40 upon standing which produced presyncopal
symptoms. Her BP rose to 116/60 after 500 cc NS. Her labetalol
dose was decreased to 100 mg daily.
.
#Acute renal failure - Patient's renal failure was felt to be
multifactorial, resulting from prerenal azotemia in the setting
of overdiuresis, UTI, and gadolinium administration for MRA. MRA
was remarkable for right renal stenosis. Lisinopril was held in
the setting of ARF, and may be restarted at the discretion of
outpatient providers. VNA will draw electrolytes and BUN/Cr two
days after admission, prior to an appointment with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4920**] of [**Last Name (un) **] Dept. Nephrology.
.
#UTI - The patient was partially treated for UTI with Bactrim,
but was given only half the prescribed dose. She was given
Bactrim to complete a 7 day course.
.
#Hypothyroidism - TSH was elevated at 17, and the patient's dose
of synthroid was increased from 88 mcg to 112 mcg daily. TSH
should be rechecked in 6 weeks as an outpatient.
.
# HTN - Per recommendations from neurology, patient's SBP goal
was 140-160 to optimize cerebral perfusion. Continued on
nifedipine and labetalol (at a reduced dose as above).
Lisinopril was held in the setting of ARF. MRA revealed right
RAS.
.
# DM 2- Well-controlled on a RISS
.
# Nutrition - Given a low-Na, heart-healthy diet
.
# PPx: SC Heparin for DVT prophylaxis
Medications on Admission:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO QOD ():
Alternate days with aspirin.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QOD ():
Alternative days with plavix.
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*2*
5. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
6. Labetalol 200 mg qAM, 100 mg qPM Tablet Sig: One (1) Tablet
PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2*
7. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO QOD ():
Alternate days with aspirin.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QOD ():
Alternative days with plavix.
4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
6. Labetalol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary
1) Acute on chronic diastolic heart failure
2) Acute renal failure
3) Right renal artery stenosis
4) Urinary tract infection
Secondary
1) Diabetes mellitus type II
2) Hypertension
3) Peripheral vascular disease
4) Hypothyroidism
5) Hyperlipidemia
Discharge Condition:
good.
Discharge Instructions:
You were admitted to the hospital with extra fluid that built up
because of congestive heart failure. Your symptoms improved with
lasix, a diuretic (water pills). You were diagnosed with a
urinary tract infection which was partially treated with
antibiotics. Please continue taking Bactrim 1 tablet twice daily
for 7 days (through [**7-28**]).
Please begin taking lasix 20 mg once daily. Your labetalol dose
was decreased to 100 mg once daily. Your synthroid was increased
to 112 mcg once daily. Please refrain from taking lisinopril
until you are seen at your follow-up appointment. You may
continue your other medications as prescribed.
Please ensure that your weight and blood pressure are checked
daily. If you gain more than 3 pounds or if you notice that you
are increasingly short of breath, please call your physician
immediately regarding whether you may need to take a higher dose
of lasix. However, all shortness of breath is not necessarily
due to extra fluid, so you may be advised to come to the office
or to the Emergency Department for further evaluation.
Please attend a follow-up appointment with Dr. [**Last Name (STitle) 4921**] colleague
Dr. [**Last Name (STitle) 4922**] on Wednesday [**7-24**] at 10:00 AM. The office
phone number is [**Telephone/Fax (1) 2205**]. Please bring your discharge
paperwork with you so that you may discuss your recent
medication changes at this appointment.
We were unable to schedule a follow up appointment with the
[**Last Name (un) **] Diabetes Center Department of Nephrology. Please call the
office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4920**] at ([**Telephone/Fax (1) 4923**] to schedule an
appointment when it is convenient for you.
Please call your phyisican or return to the Emergency Department
if you experience lightheadeness, dizziness, loss of
consciousness, falls, chest pain, palpitations, shortness of
breath, worsening cough, abdominal pain, or vomiting.
Followup Instructions:
Please arrange a follow-up appointment for this week with Dr.
[**Last Name (STitle) 4920**] of the [**Last Name (un) **] Diabetes Center Department of Nephrology.
The office phone number is ([**Telephone/Fax (1) 4923**].
Please attend a follow-up appointment with Dr. [**Last Name (STitle) 4921**] colleague
Dr. [**Last Name (STitle) 4922**] on Wednesday [**7-24**] at 10:00 AM. The office
phone number is [**Telephone/Fax (1) 2205**].
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2176-7-24**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**]
Date/Time:[**2176-7-30**] 1:00
Completed by:[**2176-7-22**] Admission Date: [**2176-7-23**] Discharge Date: [**2176-7-26**]
Date of Birth: [**2093-9-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 y/o F h/o DM2, carotid stent on ASA/plavix, HTN recently
admitted and discharged from [**Hospital Unit Name 196**] yesterday for CHF exacerbation
and UTI. PT became SOB ~830pm last night as she was going to
bed. Pt's daughter noticed wheezing, given albuterol inh x2 with
no effect. Pt then went to [**Hospital **] Hosp where she was given 40mg
IV lasix and placed on +bypap. Then, pt transferred to [**Hospital1 18**] ED.
.
In [**Hospital1 18**] [**Name (NI) **], pt noted to have BP in L.arm 100's and R arm
190's-NOT NEW. Vitals found to be T98, HR 89, BP 159/64, RR 26,
sat 98% on 50% FM. PT was placed on a nitro gtt and bypap was
resumed for unclear reasons. EKG reportedly showing sinus
rhythm. Pt started on heparin. Pt given Ca gluconate, dextrose,
insulin for K of 5.7. PT reportedly -1.5L since episode began.
.
On review of symptoms, she denies any prior history of stroke,
+TIA, -deep venous thrombosis, -pulmonary embolism, bleeding at
the time of surgery, -myalgias, -joint pains, -cough,
-hemoptysis, black stools or red stools. He denies recent
fevers, chills or rigors. He denies exertional buttock or calf
pain. All of the other review of systems were negative,
including recent fever/chills, LH/dizziness, abdominal
pain/n/v/d/c/dysuria/joint pain or rash.
.
Cardiac review of systems is notable for absence of chest pain,
+dyspnea on exertion, +paroxysmal nocturnal dyspnea, +orthopnea,
-ankle edema, -palpitations, -syncope or presyncope.
Past Medical History:
1. PVD s/p R.ICA stent
2. DM II
3. HTN
4. hypothyroidism
5. hyperlipidemia
6. L eye detachment
7. h/o diabetes inspidus after pregnancy - not an active issue
8. hearing loss
Social History:
Pt lives at home with her husband. Social [**Name2 (NI) 1818**] 30 yrs ago.
Rare ETOH.
Family History:
Non-contributory
Physical Exam:
VS: T 99.8 , BP 154/65 , HR 84 , RR 24 , O2 99 % on bipap 50%,
[**9-15**]
Gen: NAD, on bipap, somewhat somnolent but able to head nod to
answer questions.
HEENT: NC/AT, PERRLA, EOMI, anicteric, MMM, +cpap mask.
Neck: Supple with JVP up to middle of SCM.
CV: s1s2 rrr no M/R/G, but hard to assess secondary to bypap.
Chest: b/l AE, +bypap sounds, +faint expiratory wheezing.
Abd: +bs, soft, NT, ND
Ext: No c/c/e. No femoral bruits. 2+pulses.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
ADMISSION LABS:
[**2176-7-22**] 06:20AM BLOOD WBC-6.5 RBC-3.48* Hgb-10.3* Hct-30.5*
MCV-88 MCH-29.7 MCHC-33.8 RDW-15.8* Plt Ct-199
[**2176-7-23**] 05:00AM BLOOD Neuts-91.1* Lymphs-3.8* Monos-2.3 Eos-2.6
Baso-0.1
[**2176-7-22**] 06:20AM BLOOD Plt Ct-199
[**2176-7-23**] 12:50PM BLOOD PTT-93.7*
[**2176-7-22**] 06:20AM BLOOD Glucose-80 UreaN-51* Creat-2.1* Na-138
K-4.4 Cl-106 HCO3-21* AnGap-15
[**2176-7-23**] 05:00AM BLOOD CK(CPK)-240*
[**2176-7-23**] 05:00AM BLOOD CK-MB-4 cTropnT-0.13*
[**2176-7-22**] 06:20AM BLOOD Calcium-8.9 Phos-4.8* Mg-2.5
[**2176-7-23**] 05:00AM BLOOD TSH-5.7*
[**2176-7-23**] 08:52AM BLOOD Type-ART pO2-122* pCO2-28* pH-7.50*
calTCO2-23 Base XS-0
[**2176-7-23**] 05:06AM BLOOD K-5.7*
PERTINENT LABS:
WBC: 11.5 ([**7-23**]) -> 6.0 ([**7-26**])
Hct: 3.12 -> 33.3 -> 34.0
Cr: 2.5 -> 2.6 -> 2.3 -> 1.9
CK: 240 -> 135 -> 171 -> 223
Troponin: 0.13 -> 0.18 -> 0.19 -> 0.16
TSH: 5.7
Urine Culture: No growth
Blood Culture: No growth
EKG demonstrated [**2176-7-17**] with no significant change compared with
prior dated Sinus rhythm and frequent atrial ectopy. Left atrial
abnormality. Baseline artifact. Compared to the previous tracing
of [**2176-7-17**] no diagnostic interim change.
.
[**7-23**]: Sinus with PAC's. ST depressions in I, AVL, V5, V6 still
present compared to prior [**7-17**].
.
CXR ([**7-23**]): Increasing moderate congestive heart failure
CXR ([**7-24**]): Improved pulmonary edema with persistent effusions,
basilar subsegmental atelectasis, and cardiomegaly.
CXR ([**7-25**]): Interval improvement in now mild interstitial edema,
decrease in the right pleural effusion and improved aeration of
the left lung base.
DISCHARGE LABS:
[**2176-7-26**] 05:15AM BLOOD WBC-6.0 RBC-3.93* Hgb-11.2* Hct-34.0*
MCV-86 MCH-28.4 MCHC-32.9 RDW-15.2 Plt Ct-207
[**2176-7-24**] 12:01AM BLOOD Neuts-84.4* Lymphs-7.0* Monos-3.8
Eos-4.5* Baso-0.4
[**2176-7-26**] 05:15AM BLOOD Plt Ct-207
[**2176-7-26**] 05:15AM BLOOD Glucose-77 UreaN-63* Creat-1.9* Na-137
K-4.7 Cl-104 HCO3-21* AnGap-17
[**2176-7-26**] 05:15AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.5
Brief Hospital Course:
Pt is an 82 year old female with history of diastolic CHF, HTN,
DM2, HL, hypothyroid who was recently admitted for CHF
exacerbation and UTI now readmitted for SOB.
.
# Diastolic Congestive Heart Failure: Pt had a recent ECHO
performed at [**Hospital1 18**] which showed grade [**2-13**] diastolic congestive
heart failure. It is likely that pt's current presentation was
c/w CHF secondary to HTN/LVH. Patient had an episode of SOB on
[**7-23**] and was given 20mg PO Lasix, to which her SOB resolved.
Patient's CXR at this time was also consistent with increased
pulmonary edema, and the CXR improved after her dose of Lasix.
Patient's Labetalol was changed to Metoprolol HCL 12.5 mg [**Hospital1 **],
and this was then changed to Toprol XL 25 mg daily. She was
also started on Lisinopril 2.5 mg daily, and her Lasix was
increased to 40 mg daily. Patient tolerated these medications
changes well and did not have any episodes of orthostatic
hypotension or further episodes of shortness of breath.
.
# Coronary Artery Disease/Ischemia: Pt does not have any known
CAD or history of MI. However, pt with extensive history of
PVD including stent to R.ICA, right renal artery stenosis and
various stenosis of abdominal vessels. Pt was without symptoms
of CP on this admission, but her troponins and CK were slightly
elevated, which was thought to be secondary to her acute on
chronic renal failure. Patient had an ECG performed, which was
normal. Her troponins decreased during this admission, and she
was continued on her home doses of aspirin, Plavix, and
atorvastatin. She remained chest pain free throughout the
duration of this hospital stay.
# HTN: Pt has a history of hypertension. Per neurology,
patient's optimal systolic blood pressure is 120-140. Patient
was on nifedipine, labetalol, and Lasix at home. Patient was
started on Metoprolol XL 25 mg daily, Lisinopril 2.5 mg daily,
and Lasix 40 mg daily during this hospital course, and she
tolerated these medication changes well. She did not have any
acute events during this hospital stay.
.
# ARF. Patient's Cr was 1.2 on her last admission, and had
increased to 2.1 upon discharge. Patient was found to have
right-sided renal artery stenosis. Patient was admitted with a
Cr of 2.6, which was likely secondary to R. RAS in the setting
of Lasix and Bactrim therapy (for UTI). Patient was seen by
nephrology and vascular surgery, who advised against
intervention on her renal artery stenosis, due to the fact that
her right kidney had already significantly atrophied. Patient
was diuresed with Lasix, and her Cr. decreased to 1.9. Patient
remained stable during this hospital course, and did not have
any acute events.
.
# Hypothyroidism: Pt's TSH was found to be elevated on her last
admission. her Synthroid dose was increased. She did not have
any acute events relating to her hypothyroidism during this
admission, and she will be seen by her PCP in [**Name9 (PRE) 702**]..
.
# Type 2 Diabetes: Patient has a history of type 2 Diabetes.
She was maintained on a sliding scale insulin during this
admission, and did not have any acute events while in the
hospital.
.
# Code: full. Discussed with pt's husband and family.
.
Medications on Admission:
1. Atorvastatin 80 mg daily
2. Clopidogrel 75 mg Tablet QOD, alternate days with aspirin.
3. Aspirin 325 mg QOD, alternate days with plavix.
4. Levothyroxine 112 mcg daily.
5. Nifedipine 30 mg Tablet SR daily
6. Labetalol 100 mg Tablet daily
7. Fosamax 70 mg Tablet once a week.
8. Lasix 20 mg daily.
9. Bactrim DS 160-800 mg Tablet [**Hospital1 **] for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
Acute Renal Failure
Acute on Chronic Diastolic Heart Failure
Renal Artery Stenosis
Hypertention
Discharge Condition:
Stable. No O2 requirement, BP=140/72, HR= 67, O2 sat 92% on RA
Able to ambulate 300 feet
BUN=63
Creat= 1.9
K 4.7
Hct=34
Discharge Instructions:
You had an episode of acute congestive heart failure. You were
given diuretics to remove the extra fluid and no longer need
oxygen. Your kidneys were evaluated by a nephrology team and it
was determined that you did not need a stent in your renal
artery.
Medication changes:
Levothyroxine was increased to 112 mcg daily
Lisinopril was changed to Cozaar 25mg daily
Furosemide was increased to 40 mg daily
You should take your Aspirin and Plavix every day
Your blood sugars were high here in the hospital so we have been
giving you insulin twice a day. You probably will not need this
after discharge from rehab.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet: information was given to you during
your hospital stay regarding diet/exercise/medications and
monitoring of your fluid status.
Fluid Restriction: 1.5 liters (about 6 glasses per day)
Followup Instructions:
Neurology:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**]
Date/Time:[**2176-7-30**] 1:00
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2176-8-14**]
11:20
Primary care:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**], MD. Phone: [**Telephone/Fax (1) 2205**] Date/Time:
[**8-6**] at 2:15pm.
Nephrology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4920**], MD Phone: ([**Telephone/Fax (1) 817**] Date/Time: Friday
[**8-22**] at 9am.
Completed by:[**2176-7-29**]
|
[
"440.1",
"443.9",
"458.0",
"250.00",
"428.0",
"V45.82",
"599.0",
"584.9",
"428.33",
"401.9",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
26629, 26744
|
23015, 26217
|
18400, 18407
|
26884, 27006
|
20914, 20914
|
27984, 28694
|
20221, 20239
|
14052, 14857
|
26765, 26863
|
26243, 26606
|
27030, 27285
|
22596, 22992
|
20254, 20895
|
27305, 27961
|
18341, 18362
|
18435, 19902
|
20931, 21626
|
21643, 22579
|
19924, 20100
|
20116, 20205
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,403
| 161,968
|
13867+56492+56493
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2154-4-1**] Discharge Date: [**2154-5-30**]
Service: [**Doctor Last Name 1181**] M.
This discharge summary dictation will cover the portion of
the patient's hospitalization from his admission on
[**4-1**], [**2153**], up until [**2154-4-19**]. As I am going off
service as of [**2154-4-19**], a subsequent discharge summary
dictation will cover the remainder of the [**Hospital 228**] hospital
course including discharge diagnoses, discharge condition,
and discharge medications, and followup.
HISTORY OF THE PRESENT ILLNESS: (per admitting senior
resident, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]): Mr. [**Known lastname **] is a 79-year-old
man with a history of alcohol abuse, who was brought to the
emergency department by his son, who found the patient on the
floor of his apartment on the morning of presentation. The
patient's son reported that the patient's mental status was
not at baseline. Mr. [**Known lastname **] generally consumes a large
quantity of alcohol (greater than ?????? of a pint per day) per
his son, but stopped drinking approximately four days prior
to presentation due to a death in the family. According to
the patient's son, Mr. [**Known lastname **] has never had any withdrawal
seizures or hallucinations nor any delirium tremens; however,
he has not stopped alcohol frequently.
Mr. [**Known lastname 35443**] son stated that on the evening prior to admission,
the patient was not "completely making sense," as the patient
was making references to people who were not present.
Mr. [**Known lastname **], upon presentation, does not recall falling, but
was found down next to his bed by his son on the morning of
presentation, still exhibiting some mental status changes.
The patient's only recent medical problem prior to
presentation was gout times several weeks. (The patient was
taking an herbal medicine from [**State 3908**]. The patient and the
son do not know the name). Otherwise, the patient denied
chest pain, chest pressure, and shortness of breath. He
admitted occasional dry cough, but denied fevers, chills,
dysuria, orthopnea, paroxysmal nocturnal dyspnea, and lower
extremity edema. The patient had been taking less p.o. fluid
since discontinuing alcohol.
PAST MEDICAL HISTORY:
1. The patient has a sporadic and infrequent history of
followup with the primary care physicians. He recently
changed primary care physicians to Dr. [**First Name (STitle) 3510**]. The patient
has poor recall regarding his medical history.
2. Hypertension.
3. Gout.
4. Alcohol abuse, as described above.
5. History of several inpatient hospitalizations related to
alcohol abuse, according to his son.
6. History of "renal impairment," per the patient and his
son.
MEDICATIONS:
1. Famotidine b.i.d.
2. Herbal medication noted in the history of the present
illness, type unknown.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient has a longstanding history of
alcohol abuse as noted above. The patient's son reported
that it may have been possible that the patient drank
moonshine in his youth, when he was growing up in [**State 9512**].
The patient quit cigarettes 30 years ago. The patient lives
alone. His son lives in an apartment above him. The
patient's son is very involved in the patient's care. The
patient had worked in managing a fence-building business.
PHYSICAL EXAMINATION: Examination on presentation revealed
the following: (per admitting senior resident, Dr. [**First Name (STitle) **]:
Temperature 98.7, heart rate 122, blood pressure 111/72,
respirations 18, saturating 98% on room air. GENERAL: The
patient is a pleasant thin man in no acute distress. HEENT:
PERRLA, no jaundice or icterus. Oropharynx moist. NECK:
Supple, without lymphadenopathy. Neck veins flat. CARDIAC:
Regular rhythm, tachycardia; no murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft,
nontender, positive bowel sounds. Liver edge palpable
approximately 4 cm below the costal margin. EXTREMITIES:
1+ pitting edema at the right pretibial level; no edema on
left, positive warmth on the right, especially at the right
first metatarsophalangeal joint with some erythema and
minimal tenderness in this area. NEUROLOGICAL: The patient
was alert and oriented times three. Cranial nerves II
through XII intact with some decreased hearing in the left
ear, which is chronic according to the patient. Normal
sensation to light touch in all four extremities. Strength:
[**3-24**] bilaterally.
LABORATORY DATA: Laboratory data on presentation: CBC
revealed the white count of 7.4, hematocrit 31.6, MCV 103,
platelet count 109,000. Chem 7: Sodium 137, potassium 3.7,
chloride 95, bicarbonate 22, BUN 40, creatinine 4.0, glucose
108. Coagulation studies revealed PT of 13.0, PTT 26.5, INR
1.2. Urinalysis revealed moderate blood, low protein, one
red blood cell, three white blood cells, moderate bacteria,
two epithelial cells. LFTs revealed ALT of 8, AST 35,
alkaline phosphatase of 111, total bilirubin 1.1, lipase 21,
CK 147 with troponin of less than 0.3, CKMB 3.
Head CT performed in the emergency department revealed
generalized atrophy; there was no evidence of bleed, shift,
or cerebral edema. Renal ultrasound performed in the
emergency department revealed bilateral small echogenic
kidneys consistent with chronic medical renal disease.
Specifically, the right kidney measured 8.7 in the long axis
while the left kidney measured 8.2 cm long in the long axis.
There was no hydronephrosis, evidence of stones, or masses in
the kidneys bilaterally. Chest x-ray revealed the heart to
be normal in size with the lungs demonstrating no focal
opacifications, CHF, or pleural abnormalities. There was
slight prominence of the mediastinum with contours
bilaterally. The osseous structures were normal.
EKG revealed sinus tachycardia at a rate of 110; axis was
normal as were intervals. There was early R-wave
progression, without ST or T abnormalities. No prior study
was available for comparison.
HOSPITAL COURSE: As the patient has been hospitalized for
nearly three weeks now, the following summary will address
the patient's major medical issues by system and problem:
However, given the patient's extensive hospitalization, as
well as his numerous medical problems, it is suggested that
the reader peruse the patient's CCC records as well for any
further details that may be desired.
ISSUES:
MENTAL STATUS: As noted above, the patient has a
longstanding history of alcohol abuse; approximately four
days prior to presentation, the patient reportedly stopped
drinking. The patient was fairly alert and oriented on
initial presentation, although the patient's son had noted
that the patient had been acting strangely and somewhat
disoriented on the evening prior to and the morning of
presentation. On the morning following admission, the
patient exhibited significant agitation and disorientation.
Additionally, he exhibited tremulousness. The patient had
been started on IV fluids, thiamine, and vitamins following
admission. Given his above noted agitation, disorientation,
and tremulousness, the patient was started on Ativan p.r.n.
by CIWA scale. The patient was felt to have exhibited these
withdrawal-like symptoms for the following three to four days
after admission. The psychiatric service was consulted
regarding the patient's presentation and condition with
regard to his alcohol withdrawal and mental status changes.
Ultimately, the patient's Ativan was discontinued, and he was
later put on p.r.n. Haldol for agitation. The Haldol, as
well, was discontinued, subsequent to this and currently the
patient is not on any Haldol or Ativan.
Currently, the patient remains disoriented and perhaps
delirious. The exact etiology of his mental status changes
remains unclear. His mental status has waxed and waned
intermittently throughout his hospitalization and it is felt
by the primary consulting teams to be multifactorial in
etiology.
In terms of working up the etiology of the patient's mental
status changes, he has had an exhaustive workup for
infectious disease etiologies as will be described below
including lumbar puncture, which was within normal limits.
Additionally, the patient has had two CT scans of his head,
which have demonstrated diffuse atrophy, but which have
otherwise, not revealed any findings that would explain his
mental status changes. Also, of note, lead level and TSH
levels were within normal limits. Currently, the neurology
service is also following the patient regarding his mental
status changes and overall condition.
ALCOHOL: As described above, the patient exhibited some
evidence of alcohol withdrawal following admission. He was
placed initially on the CIWA scale receiving Ativan on a
scheduled, as well as p.r.n. basis; subsequently the Ativan
was discontinued altogether. Haldol was used intermittently
for agitation, but it has also been discontinued at this
time. The patient received B12, folate and thiamine
following admission. He continues to received nutritional
supplementation and he is being followed by the nutrition
service.
INFECTIOUS DISEASE: The patient's prolonged hospitalization
has been marked by persistent fevers, only some of which can
be explained by infectious etiology. As noted above, the
patient underwent lumbar puncture on [**2154-4-2**], results
of which were within normal limits. Additionally, cultures
of the patient's CSF, blood, sputum, urine, joint, and acidic
fluid have been obtained. Thus far, only two of these
cultures have produced any organisms and these were felt to
be most likely due to contamination. Specifically, the
patient had his left knee joint tapped on [**2154-4-5**]. On
[**2154-4-10**], fluid from this joint grew out rare
Methicillin-resistant Staphylococcus aureus. Also, the
patient had sputum, which grew out some Methicillin-resistant
Staphylococcus aureus as well. The patient has been on a
host of antibiotics during his hospitalization. Currently,
he is on Ceftazidime and Vancomycin, as on [**2154-4-17**], he
spiked a temperature to 103 degrees Fahrenheit rectally and
he was found on chest x-ray to have an infiltrate. Since
beginning Ceftazidime and Vancomycin, the patient has been
afebrile.
Other infectious disease concerns included the initial
apprehension that the patient was suffering from
osteomyelitis. However, as noted above, joint-fluid cultures
have not decisively indicted such; additionally, plain films
of the patient's affected foot were obtained on about [**2154-4-3**] and they were not noted to have evidence of
osteoarthritis. Currently, a CT scan of the patient's
sinuses is pending.
RHEUMATOLOGIC: As noted above, the patient has a
longstanding history of gout. On admission, he was noted to
have some joint swelling, erythema, and tenderness. This
progressed fairly significantly following admission, such
that a number of the patient's joints were affected. The
rheumatology service was consulted regarding these issues;
the consensus among the rheumatology and primary-team
services was that the patient was, in fact, suffering from
gout, albeit in a polyarticular manner. Joint fluid was
obtained from the patient's left and right knees. Analysis
of this fluid reveals gout crystals. As noted above, the
left knee fluid did grow out rare Methicillin-resistant
Staphylococcus aureus, although this was ultimately felt to
have been a contaminate. Subsequently, the patient's joint
symptoms (including tenderness, swelling, and effusion) has
dissipated almost completely. Given concern for the
patient's renal function, he has not been put on any NSAID
treatment for gout. Additionally, given concerns regarding
fevers, as well as mental status issues, the patient has not
been put on steroids therapy for gout. Ultimately, he may
benefit from long-term therapy once his other more pressing
issues are addressed.
RENAL AND ADRENAL: As noted above, the patient had an
elevated creatinine to 4.0 on admission. Following the
admission and with the administration of copious IV fluid,
the patient's creatinine improved. Nonetheless, the
patient's urine output was noted to be tenuous at times. The
renal service was consulted and continues to follow the
patient. The patient was noted to have markedly depleted
bicarbonate levels on several occasions (with levels as low
as 12 noted). Current consensus among the renal and primary
teams is that the patient is suffering from acute tubular
necrosis, perhaps as a result of intermittent hypotension.
The patient has been aggressively hydrated with IV fluids and
at times has required infusion of bicarbonate
supplementation.
In terms of the patient's adrenal issues, a random cortisol
level drawn on [**2154-4-7**] was 15. A subsequent cortisol
stimulation test, performed on [**2154-4-10**] revealed a
pre-stem level of 13; ?????? an hour later, cortisol level was 19.
These results were not felt to represent adrenal
insufficiency and thus the patient remained off stress-dose
steroids (especially given concerns regarding again his
mental status and fevers).
GASTROINTESTINAL: On [**2154-4-8**], the patient's abdomen
was noted to be markedly distended on physical examination.
Thus, a KUB was obtained revealing dilated loops of small
bowel. A subsequent CT scan of the abdomen again confirmed
dilated loops of small bowel, with some subsequent passage of
p.o. contrast to the rectum. The patient was made NPO and NG
tube was placed. The NG tube has remained in place since
that time with copious outpatient of bilious fluid. The
Surgery Service was consulted and followed the patient for
some time. Ultimately, they did not feel that the patient
had any operative issues. Currently, a repeat CT scan of the
abdomen is pending, as there is some persistent concern for
the possibility of small-bowel obstruction (rather than
ileus).
HEPATOLOGY: The Hepatology Service was consulted. The
patient is felt to be suffering from cirrhosis. He has been
receiving lactulose pr, with little effect at this time.
On [**2154-4-12**], the patient exhibited some guarding on
abdominal examination, thus, an abdominal ultrasound was
obtained revealing numerous stones in the gallbladder (as was
also noted on the CT scan); however, there was no evidence of
cholecystitis.
On [**2154-4-15**], the patient underwent paracentesis, as he
was continuing to exhibit fevers. Results of the ascitic
analysis were somewhat equivocal for evidence of
.................... Given the patient's recent course of
antibiotics, there was some concern for partially treated
partially treated ................... thus the patient was
placed on Ceftriaxone (currently he is on Vancomycin and
Ceftazidime).
PULMONARY: The patient has small-to-moderate bilateral
pleural effusion by chest x-ray. These developed
approximately midway through his hospital course to this
point. They have remained fairly stable, overall.
On [**2154-4-17**], as noted above, the patient spiked a
temperature to 103 degree Fahrenheit rectally. He was found
to have a new infiltrate on chest x-ray and he was thus
placed on Ceftazidime and Vancomycin. It should be noted
that the Infectious Disease Service has been following the
patient throughout most of his hospital course.
HEMATOLOGIC: The patient has exhibited anemia since
admission. Iron level was found to be low (18) while TIBC
was low at 191. Ferritin was greater than 1000. Transferrin
was low at 147. B12 and folate were both found to be normal.
Hemolysis labs have been negative. Thus far in the
patient's hospitalization, he has received a total of four
units of packed red blood cells. Overall, the hematocrit has
remained fairly stable.
FLUIDS, ELECTROLYTES, AND NUTRITION: As noted above, the
patient has had copious output from his NG tube. Also, he
has been persistently febrile. Thus, the Medicine Service
has tried to keep up with his copious fluid output via both
IV fluid repletion and TPN, although this has been at times
difficult to accomplish. In terms of electrolytes, the
patient's electrolyte levels have remained, for the most
part, stable. However, the patient has had low levels of
bicarbonate on several occasions and this has required bicarb
repletion by IV fluid and TPN. In terms of nutrition issues,
the patient is followed by the nutrition service. He had a
left arm PIC line placed on about [**2154-4-10**], through
which he receives his TPN. The patient also receives
vitamins and nutrients with his TPN, per the recommendations
of the nutrition service.
PROPHYLAXIS: The patient is on IV Protonix. The patient is
also wearing pneumoboots. Chest PT has been ordered for the
patient to improve his pulmonary status. Additionally, an
air mattress has been ordered for the patient, given his
sedentary status.
COMMUNICATION: The patient's children are very involved in
his care. The patient's son, [**Name (NI) 41589**] ([**Name2 (NI) 679**]) [**Known lastname **], [**Name (NI) 1105**], has
called almost every day to inquire about his father;
additionally, the patient's son has visited him almost daily
as well. The patient's daughter flew in from [**Name (NI) **] to see
her father as well. Various other family members have also
been up to the hospital to see the patient. The medicine
service has been in almost daily contact with the family
regarding updates on the patient's status.
CODE STATUS: The patient's family wishes the patient to be
full code. They noted that ultimately, the patient would not
want to remain on prolonged life support if it were at all
evident that there was little hope of ultimate recovery.
Nonetheless, in the acute setting of decompensation, they do
feel that the patient would want to be intubated and
defibrillated if necessary. Thus, he is full code.
This concludes the patient's discharge summary dictation for
the patient's course from admission to [**2154-4-19**].
Please see subsequent discharge summary addendum regarding
the remainder of the [**Hospital 228**] hospital course. Discharge
diagnoses, discharge status, discharge medications, and
followup.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12157**], M.D. [**MD Number(1) 12158**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2154-4-19**] 10:06
T: [**2154-4-19**] 10:27
JOB#: [**Job Number 41590**]
Name: [**Known lastname 7516**], [**Known firstname 7517**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 201**] Unit [**Name2 (NI) **]: [**Numeric Identifier 7518**]
Admission Date: [**2154-4-1**] Discharge Date: [**2154-5-30**]
Date of Birth: [**2074-11-4**] Sex: M
Service: [**Doctor Last Name **] M.
DISCHARGE SUMMARY ADDENDUM: This discharge summary will cover
the hospital course from [**2154-4-20**] until [**2154-5-11**].
HOSPITAL COURSE: [**2154-4-20**] through [**2154-4-24**]
The patient was transferred to the Surgery service on [**2154-4-19**] and then taken to the operating room on [**2154-4-20**] for
a complete bowel obstruction. Intraoperative findings
included a twisted internal hernia. This was untwisted, no
bowel was resected. The patient was transferred to the ICU
postoperatively, monitored and then transferred to the floor.
During this time he was on the antibiotics of Vancomycin and
Ceptaz. The patient was spiking fevers as high as 103 F on
postoperative days two, three and four. On postoperative day
four his antibiotics were discontinued. On postoperative day
five he was transferred to the Medicine service for further
care of his fevers and change in mental status. Please see
operative note for further details of the surgery.
HOSPITAL COURSE: [**2154-4-24**] through [**2154-5-1**]
INFECTIOUS DISEASE - The patient's antibiotics were stopped
on [**2154-4-23**]. Over the next several days the patient's
fever curve trended down and he was afebrile by [**2154-4-27**].
Given his lack of fever and a stable white count no further
investigations into infection were undertaken. However the
Infectious Disease team felt if the patient was to re-spike
the fever he would need his plural effusions tapped, he would
need his ascites tapped, he would need his gallbladder
re-imaged because he has known gallstones. In addition to the
usual investigations of stool for C difficile, urine, blood
and sputum.
The patient remained afebrile until [**2154-5-1**] when he
spiked a fever to 104 F. At that point in time including
fungal isolators were obtained. These eventually came back
negative. A lumbar puncture was performed out of concern for
meningitis. This came back negative. An ultrasound of the
belly and chest x-rays showed minimal pleural effusions and
ascites and no focal infiltrates. The patient was
hypotensive during this febrile episode and was subsequently
transferred to the Medical ICU for blood pressure support on
[**2154-5-1**].
NEUROLOGY - Prior to admission the patient was functioning in
the outside world without problems. However since admission
he has been disoriented. On the dates in this dictation the
patient was alert and oriented times one. On [**4-28**] and 10 he
was more alert and oriented times one to [**Hospital **] Hospital
and to [**2154-4-20**] and was more interactive. It has always been
difficult to understand the patient. However approaching the
transfer to the MICU the patient became more disoriented and
less interactive. Neurology was re-consulted for further work
up and they suggested an MRI of the brain. They also noted
rigidity on exam which was consistent with frontal disease.
Likely from the patient's chronic alcohol use.
Upon transfer to the Medical ICU on [**2154-5-1**] the patient
was alert and oriented times one.
GASTROINTESTINAL - The patient had ascites noted on abdominal
ultrasound while on the Surgery service. He was started on
Aldactone. He was also started on Lactulose for possible
hepatic encephalopathy. Lactulose was titrated to three to
four loose bowel movements per day. As the patient had a
difficult time taking po secondary to his alertness an NG
tube was placed on [**4-28**] and then again [**4-29**] for
administration of Lactulose. Repeat ultrasound of the abdomen
on [**4-30**] revealed gallstones without cholecystic fluid or
other signs of acute cholecystis and minimal ascites.
Hepatology was re-consulted for possible explanation
regarding his liver failure and change in mental status. The
liver service believed his cirrhosis is secondary to long
term alcohol use and hepatic encephalopathy is likely the
cause and perhaps the only cause of his altered mental status
in the hospital in addition to his chronic alcohol abuse
causing wasting. They did not believe there were any
infectious reasons within the biliary system.
During this time the alkaline phosphatase and T bili trended
up after the temperature spike and further evaluation on [**2154-5-1**] the liver service felt it was cholestasis secondary
to sepsis and not a primary pathologic process.
FLUIDS, ELECTROLYTES AND NUTRITION - The patient continued to
be NPO and maintained on TPN during his stay. Tube feeds were
attempted after the NG tube was put down on [**4-29**] and 11
and the patient had residuals. These were rapidly stopped and
the patient became febrile and never approached greater than
30 cc per hour.
Given the patient's plural effusions and ascites our volume
objective for this patient is to run him on the dry side.
This was achieved with Aldactone and Lasix was subsequently
added approximately on [**4-28**] for further diuresis. The
patient's electrolytes were repleted as needed.
RESPIRATORY - During this time the patient had either trace
or moderate bilateral pleural effusions. However he
maintained good oxygen saturation on room air and did not
require any further interventions. On a chest CT scan
performed on [**2154-4-27**] the CT scan of the chest did reveal
some right upper lobe infiltrate. This was mildly concerning
for possible TB however the remainder of the clinical picture
did not fit the situation. The patient has no granulomas on
chest x-ray so this was deemed unlikely.
There were no other pulmonary processes during this time
frame.
RENAL - The patient's creatinine trended up with the
diuresis. It reached a peak of 2.0 and then after the patient
returned from the Medical ICU and was rehydrated the
creatinine slowly trended down. This chronic renal
insufficiency is mostly likely secondary to his long standing
hypertension.
CARDIOVASCULAR - The patient was maintained on Lopressor for
persistent tachycardia.
RHEUMATOLOGY - The patient had no signs of the acute gouty
flare that was present upon admission. On [**2154-5-1**] as
mentioned before the patient became febrile to 104 F with
rigors and hypotension. Work up included blood cultures,
including fungal isolators, urinalysis, urine culture, chest
x-ray, LP, CT scan of the head. All of these would come back
negative for any infectious source. A ammonia level was also
sent to evaluate for hepatic encephalopathy as the only
reason for the patient's change in mental status. This also
came back normal. The patient was given normal saline however
his blood pressure remained in the 60s to 80s over 40s. The
Medical ICU team was called to assess and the patient was
transferred to the Medical ICU.
The patient was in the Medical ICU from [**2154-5-1**] through
[**2154-5-7**]. This following section of the dictation
summary will cover his hospital course while in the Medical
ICU.
INFECTIOUS DISEASE - The patient was fully cultured as
described previously. He was started empirically on broad
spectrum antibiotics of Vancomycin, Ceptaz and Flagyl. The
patient underwent a CT scan of the abdomen and pelvis to look
for any free fluid or any abscess after the patient's
surgery. This was negative although the CT scan was without
contrast and does not have as high a sensitivities with
contrast, nonetheless no fluid collections were visualized.
The patient was given IV fluids and Neo-Synephrine to support
his blood pressure. A sed rate was sent which returned at
122. There was some concern for vasculitis perhaps temporal
arteritis as the etiology of the patient's persistent and
intermittent fevers and mental status changes. However the
temporal artery biopsy was not done. [**Doctor First Name **] and ANCA antibiotics
were sent and returned negative. Rheumatology was
re-consulted and they did not think the picture was
consistent with vasculitis although obviously a biopsy would
be a more definitive diagnosis.
Because of the patient's persistent hypotension the team
performed a cortisol stim test. This was positive for
adrenal insufficiency and the patient was started on
hydrocortisone stress dose steroid 100 mg q eight hours. The
MICU team also evaluated the patient's chronically low
bicarbonate and found the patient had a proximal RTA and
started Citrate tabs to increase the patient's bicarbonate.
After these interventions the patient was rapidly weaned off
blood pressure support. The ID team was re-consulted and they
agreed with the broad spectrum empiric antibiotics for a
seven to ten day course. The patient was also transfused for
a hematocrit of less than 25.
On [**2154-5-6**] the patient was called out from the Medical
ICU to the floor team. The previous floor team resumed care
of the patient at that time.
Remainder of the dictation summary will cover the [**Hospital 1325**]
hospital course from [**2154-5-6**] through [**2154-5-11**].
GASTROINTESTINAL - The patient was started on tube feeds
however he had high residuals and had perfuse, watery
diarrhea up to 1.4 liters per day. His tube feeds were
stopped on [**2154-5-8**] secondary to this diarrhea. The
patient's lactulose and Aldactone had also been stopped
previously.
On [**2154-5-10**] an NG tube replaced and the patient was
started on semi-elemental tube feed diet. The patient will be
watched closely for stool output. He will be given lactulose
with the target of three loose bowel movements per day. If
needed Reglan will also be started for high residuals. The
patient is not on Aldactone at this time. The long term goals
would be for the patient to be on Aldactone and lactulose for
his hepatic disease. Otherwise he has no signs of partial or
complete bowel obstruction.
INFECTIOUS DISEASE - The patient has been afebrile since [**2154-5-6**]. All cultures came back negative. The broad spectrum
antibiotics were stopped after a seven day course.
NEUROLOGIC - The patient has been alert and oriented times
one. This mental status change from prior to admit may be
chronic secondary to alcohol abuse and to his hepatic
encephalopathy. An MRI of the brain on [**2154-5-3**] showed
no large areas of diffusion weighted or T2 abnormalities
suggesting infarct or edema. However it was a technically
limited study secondary to patient motion.
At this point the patient's change in mental status has been
rather fully worked up and almost all acute processes have
been excluded. It is appropriate to continue this evaluation
as an outpatient at this time.
RENAL - On [**2154-5-8**] the patient became hypernatremic
with a sodium that went as high as 159. The patient was given
D5W and over the next 48 hours the sodium corrected. With
this rehydration the patient's pleural effusions and ascites
increased.
HEMATOLOGIC - The patient's hematocrit remained stable but
low between 26 and 28. He was not transfused for this
hematocrit. Iron studies were sent and the anemia was
consistent with both chronic disease and iron deficiency and
iron was started.
ENDOCRINE - The patient's steroids were tapered by 50% every
two to three days. The outpatient goal for steroids would be
hydrocortisone 20 mg q A.M. and 10 mg q P.M. at approximately
four P.M.
MEDICATIONS AT TIME OF DICTATION [**2154-5-11**]:
1. Iron.
2. Hydrocortisone 25 mg q eight.
3. Insulin sliding scale while patient is on TPN.
4. Albuterol and Atrovent nebulized treatments as needed.
5. Tylenol.
6. Haloperidol as needed.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7519**], M.D. [**MD Number(1) 7520**]
Dictated By:[**Last Name (NamePattern1) 3253**]
MEDQUIST36
D: [**2154-5-11**] 12:33
T: [**2154-5-13**] 08:47
JOB#: [**Job Number 7521**]
Name: [**Known lastname 7516**], [**Known firstname 7517**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 201**] Unit [**Name2 (NI) **]: [**Numeric Identifier 7518**]
Admission Date: [**2154-4-1**] Discharge Date: [**2154-5-30**]
Date of Birth: [**2074-11-4**] Sex: M
Service: [**Doctor Last Name **] M.
THIS IS AN ADDENDUM TO THE DISCHARGE SUMMARIES OF [**2154-4-19**], AND [**2154-5-11**]. THIS ADDENDUM WILL COVER THE
PATIENT'S COURSE IN THE HOSPITAL FROM [**2154-5-12**] UNTIL HIS
DISCHARGE ON [**2154-5-29**]. Please see the subsequent
discharge summaries for course in hospital previous to [**5-12**].
COURSE IN HOSPITAL: The patient has multiple medical
problems; this will be addressed by system.
1. Fluids, Electrolytes and Nutrition: The main concern
during this part of Mr. [**Known lastname 7522**] hospital stay was his
nutritional status. He was tried on many different brands of
tube feeds. These included Peptamen, Isocal, and Optimental.
At various times, Mr. [**Known lastname **] was able to tolerate these tube
feeds. However, he often suffered from high residuals and
the tube feeds were often held. Mr. [**Known lastname **] was on and off of
TPN at various points during his hospital stay.
He was restarted on TPN permanently on [**5-21**]. Tube feeds
were not administered after this time. Of note, Mr. [**Known lastname **]
failed swallowoing studies three times during his admission
to the hospital, thus, he was not able to be fed p.o. During
the time when he was tolerating tube feeds by NG, placement
of a PEG was considered. However, PEG placement was not
possible secondary to Mr. [**Known lastname 7522**] ascites. The Hepatology
Service was consulted as well as the Gastrointestinal
Service.
They both felt that a PEG placement would be not advisable
when ascites was present as it would prevent healing of the
tract. Given Mr. [**Known lastname 7522**] sporadic tolerance of tube feeds, as
well as the inability for rehabilitation facility to accept
him with an NG in place, it was decided that the best way to
feed Mr. [**Known lastname **] would be via TPN. The long-term plan would be
to reduce his ascites via diuresis as an outpatient. Once
the ascites was reduced, a PEG can be placed and Mr. [**Known lastname **] can
be fed this way. A [**Hospital3 7523**] will also be
performed as an outpatient. As soon as it is determined that
Mr. [**Known lastname **] is able to pass a swallow study, he will be able to
take food p.o. This would negate the need for TPN.
2. Gastrointestinal and Hepatology: During this portion of
his hospital stay, Mr. [**Known lastname **] suffered from ascites. This
responded fairly well to Spironolactone and Lasix. However,
the spironolactone was not able to be administered once Mr.
[**Known lastname 7522**] NG tube was removed. Therefore, he remained on Lasix
alone. His ascites has decreased substantially during this
portion of his hospital stay.
Mr. [**Known lastname **] has been given Lactulose to treat his hepatic
encephalopathy. This is being given as enemas. He is
tolerating this well and has remained fairly lucid during his
hospital stay.
On [**5-21**], Mr. [**Known lastname **] was noted to have coffee grounds in his
NG residual. His hematocrit decreased to 24.5. He was
transfused two units of packed red blood cells. He was also
started on Protonix 40 mg intravenously twice a day.
3. Infectious Disease: On [**5-20**], Mr. [**Known lastname **] was noted to
spike a temperature to 101.8 F. A paracentesis was performed
which was negative for infectious causes. His right wrist
joint was noted to be erythematous and painful. An
arthrocentesis was performed. This revealed pus in the right
wrist joint. White count of the fluid was 110,000. Gram
stain revealed no organisms. There was no growth from the
wrist in culture.
The Rheumatology and Orthopedic Services were consulted.
There was some question as to whether this was septic joint
or gout, given that the wrist fluid also contained many
crystals. Mr. [**Known lastname **] was treated with Ceptaz and Vancomycin
for a ten day course. The swelling, erythema and pain in the
wrist resolved during this time.
Mr. [**Known lastname **] was screened for Methicillin resistant
Staphylococcus aureus. He was negative. Of note, he grew
VRE in his urine on [**4-29**]. Multiple urine cultures since
then have been clear. His blood cultures have been negative
to date.
4. Rheumatology: As mentioned, Mr. [**Known lastname **] developed a
swollen, tender, erythematous right wrist on [**5-20**]. He
also spiked a temperature on this day. The fluids contained
110,000 white blood cells. Cultures were negative. The
fluid also contained many crystals. This was treated with
Ceptaz and Vancomycin. Mr. [**Known lastname **] also developed gout in his
left knee. This was on [**5-23**]. Fluids from arthrocentesis
revealed many crystals, no bacteria and culture was negative.
5. Renal: Mr. [**Known lastname **] has chronic renal insufficiency. His
creatinine has ranged from 1.1 to 1.9 during his stay in the
hospital. All of his medications have been renally dosed.
6. Hematology: Mr. [**Known lastname **] was noted to have thrombocytopenia.
The Hematology Service was consulted. Work-up revealed a
negative HIT antibody as well as a negative anti-platelet
antibody. The Hematology Service felt that his
thrombocytopenia was secondary to a splenic sequestration due
to his liver cirrhosis.
7. Endocrine: Earlier in his hospital stay, Mr. [**Known lastname **] was
diagnosed with adrenal insufficiency. His steroid dose had
been tapered down to Hydrocortisone 6 mg intravenous three
times a day. He was given a stress dose of steroids starting
[**5-21**], as he had a septic right wrist as well as a GI
bleed. At the time of dictation, he is on hydrocortisone
12.5 mg intravenously three times a day. This should
continue to be tapered. His goal maintenance steroid dose is
hydrocortisone 10 mg intravenous q. a.m. and 5 mg
intravenously q. 4 p.m.
8. Neurology: Prior to his hospital admission, Mr. [**Known lastname **]
[**Last Name (Titles) 7524**] in the outside world with no difficulties. During
his course in the hospital, he has had episodes of confusion.
This was fully worked up. As explained in the previous
dictations, this is felt to be multi-factorial in nature. At
the time of dictation, Mr. [**Known lastname **] is alert and oriented times
one.
9. Respiratory: During this portion of his hospital stay,
Mr. [**Known lastname **] had no respiratory issues; please see previous
Discharge Summaries for prior problems.
10. Cardiology: Mr. [**Known lastname **] had no cardiac issues during this
portion of his hospital stay.
CODE STATUS: Many discussions have taken place with the
patient's family. The family feels that Mr. [**Known lastname **] would not
want to be treated aggressively should he arrest. They also
do not feel that he would want to be maintained on life
support if it was clear that it was not a bridge to recovery.
However, at this point, the family is still undecided as to
whether they would like their to be resuscitated should he
arrest. Therefore, at this point, Mr. [**Known lastname **] remains a Full
Code.
DISCHARGE DIAGNOSES:
1. Alcoholic cirrhosis, alcohol abuse, ascites.
2. Gout.
3. Hypertension.
4. Chronic renal insufficiency.
5. Alcohol withdrawal.
6. Pneumonia.
7. Adrenal insufficiency.
8. Complete small bowel obstruction requiring surgical
intervention for untwisting of an internal hernia.
9. Gastrointestinal bleed.
10. Hepatic encephalopathy.
11. Intolerance of tube feeds.
12. Failed swallow study.
13. Mental status changes that are multi-factorial in nature.
14. Septic right wrist joint.
MEDICATIONS ON DISCHARGE:
1. Insulin sliding scale.
2. Ipratropium bromide nebulizers p.r.n.
3. Albuterol nebulizers p.r.n.
4. Metoclopramide 5 mg intravenously q. six hours.
5. Pentaprazole 40 mg intravenously twice a day.
6. Tylenol 650 mg per rectum q. four to six hours p.r.n.
7. Lactulose at 300 ml per rectum enema three times a day
p.r.n. until at least one bowel movement per day.
8. Lasix 20 mg intravenously twice a day.
9. Sodium ferric gluconate complex/sucrose 31.25 mg every
Monday.
10. Hydrocortisone.
11. Sodium succinate 12.5 mg intravenously q. eight hours (it
should be noted that this medication will be tapered). On
[**6-5**], it should be reduced to 6 mg intravenously q.
eight hours; on [**6-13**], it should be reduced to 10 mg in
the morning and 5 mg at 4 p.m. in the afternoon.
12. Total parenteral nutrition: His current TPN formula is
[**2151**] cc per day, 55 grams of protein per day, 330 grams of
dextrose per day; 40 grams of fat per day; electrolytes
include: Sodium chloride 154; sodium acetate zero; sodium
phosphate zero; potassium chloride 80; potassium acetate 40;
potassium phosphate 10; magnesium sulfate 25; calcium
gluconate 15; heparin zero; ranitidine zero, insulin 10
units.
DISCHARGE INSTRUCTIONS:
1. Mr. [**Known lastname **] is being discharged to an acute level of
rehabilitation facility. He will be followed by the
attending physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1767**], who is also his
primary care physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7519**], M.D. [**MD Number(1) 7520**]
Dictated By:[**Last Name (NamePattern1) 1170**]
MEDQUIST36
D: [**2154-5-29**] 14:43
T: [**2154-5-29**] 15:11
JOB#: [**Job Number 7525**]
|
[
"552.8",
"572.2",
"571.2",
"291.0",
"486",
"789.5",
"255.4",
"584.5",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.59",
"96.6",
"03.31",
"54.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
37834, 38323
|
38349, 39556
|
19869, 37813
|
39580, 40145
|
3442, 6101
|
6519, 19015
|
2302, 2947
|
2964, 3419
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,901
| 134,306
|
52332
|
Discharge summary
|
report
|
Admission Date: [**2180-8-31**] Discharge Date: [**2180-9-7**]
Date of Birth: [**2119-4-21**] Sex: M
Service:HEPATOBILIARY SURGERY
PRIMARY DIAGNOSIS: Unresectable metastatic colon cancer to
liver.
SECONDARY DIAGNOSIS:
1. Previous coronary artery bypass grafting, coronary artery
disease (myocardial infarction times three).
2. History of ventricular tachycardia with automatic
implantable cardiovascular defibrillator.
3. Hypertension.
4. Partial colon resection.
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
gentleman seen by Dr. [**Last Name (STitle) **] previously for a lower anterior
resection of rectus sigmoid carcinoma on [**2176-6-28**].
Follow-up CT of the chest and abdomen on [**2180-2-21**],
showed a large area of heterogenous perfusion measuring 8.6
x 7.7 cm. Upon subsequently admission to the hospital on
[**7-10**] for chest, abdominal and back pain, he received
another CT scan of the abdomen that displayed a poorly
defined area of heterogenous enhancement located within the
right lobe of the liver that increased in size compared to
the prior exam.
The lesion was deemed to be a metastatic spread of his
previous colon cancer, and he was planned for elective
surgery. He was seen by Cardiology and Anesthesia prior to
surgery and was cleared.
He was admitted on [**2180-8-31**], for exploratory
laparotomy with possible excision of the right hepatic lobe.
The lesion was deemed unresectable at the time of surgery,
and the patient was closed. The patient tolerated the
procedure well.
Postoperatively he complained of some abdominal pain but did
quite well otherwise. He was transferred to the [**Hospital1 **] and
seen by the Acute Pain Service Team. He was continued on
epidural with Meperidine. On [**9-1**], the epidural was
discontinued.
During his stay in the hospital, a right internal jugular
triple-lumen catheter was placed with no complications. He
tolerated the procedure well, and his chest x-ray showed no
evidence of pneumothorax and showed good placement of the
catheter tip.
On [**9-1**], he was transferred to the Intensive Care
Unit as he was found unresponsive, cyanotic and hypoxic. He
was hemodynamically stable but intubated and ventilated.
Chest x-ray at the time showed right upper lobe and right
middle lobe infiltrates but no evidence of pneumothorax. CT
of the chest ruled out the presence of a pulmonary emboli.
Head CT was normal. The patient's troponins were negative as
well.
The patient was diagnosed with aspiration pneumonitis, and he
was diuresed gently with Lasix. He was subsequently
extubated on [**2180-9-3**], and tolerated this procedure
well and remained hemodynamically stable.
The patient was subsequently transferred to the [**Hospital1 **]. On
exam the patient was well. His temperature is 98.9??????, heart
rate 60, blood pressure 140/78, respirations 20, oxygen
saturation 94% on room air. He was alert and oriented times
three. He had clear lung fields. There were normal heart
sounds. His abdomen is soft and nontender and slightly
obese. He has good peripheral pulses. He has been eating a
regular diet and ambulating. He is currently stable for
discharge.
DISCHARGE MEDICATIONS: Heparin 5000 U b.i.d. subcue, Aspirin
81 mg p.o. OD, Zosyn 4.5 mg q.i.d., Axopt, Travatan,
Morphine Sulfate, Cepacol, Metoprolol,
Isosorbide, Mononitrate, Celexa, Zofran, Percocet, Lasix.
This discharge summary will be amended.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,PH.D.[**MD Number(3) 48821**]
Dictated By:[**Last Name (NamePattern1) 12438**]
MEDQUIST36
D: [**2180-9-6**] 19:26
T: [**2180-9-6**] 23:19
JOB#: [**Job Number 108200**]
|
[
"197.7",
"799.1",
"997.3",
"414.8",
"V10.06",
"682.2",
"507.0",
"998.59",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"03.90",
"54.19",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
3225, 3738
|
520, 3201
|
240, 491
|
171, 219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,405
| 124,326
|
9257
|
Discharge summary
|
report
|
Admission Date: [**2133-9-2**] Discharge Date:
Service: GENERAL SURGERY-BLUE TEAM.
HISTORY OF THE PRESENT ILLNESS: This is an 81-year-old
female, status post total colectomy for ulcerative colitis
with an end ileostomy, who presents with pain around her
ileostomy times 48 hours with decreased ileostomy output.
She has had nausea and vomiting time four over the last two
days.
PHYSICAL EXAMINATION: On examination the patient's
temperature was 98.1 degrees. She had bowel sounds present.
There is an ileostomy with an appearance of dusky bowel with
serosanguinous drainage, induration around the ileostomy
site. The white blood cell count was 18, 90% polys. Chest
x-ray showed no free air. The KUB showed dilated loops of
small bowel.
In conclusion, this patient presented with an incarcerated
parastomal hernia. The patient was taken to the operating
room for repair. Thus, on [**9-2**], the patient had a
preoperative diagnosis of parastomal hernia, strangulated
ileostomy. The patient underwent small bowel resection times
three, cholecystectomy, exploratory laparotomy and ileostomy.
Surgeon of record was Dr. [**Last Name (STitle) **], assistant, Dr. [**Last Name (STitle) 16059**].
Estimated blood loss was 50 cc. Postoperative diagnosis was
parastomal hernia, strangulated ileum, and distended
gallbladder consistent with early cholecystitis. The patient
was transported to the PACU intubated. The patient required
a good deal of IV fluid. The patient received two units of
packed red blood cells intraoperatively. The patient had a
bit of a low urine output in the early postoperative period,
thus the patient was kept intubated on postoperative day #1,
while her fluid status was being managed.
On [**9-4**], the patient was doing well from a
respiratory status and was extubated. However, she still had
low urine output despite multiple fluid boluses. Thus, a swc
was inserted on the 19th. The urine output began to pick upl
and improve as of [**9-5**]. The ICU Team continued to
optimize the patient's fluid status and cardiac status. The
PA catheter was discontinued. The patient was continued on
Kefzol and Flagyl, on which she had been put postoperatively
for cellulitis around the area of the former ostomy site.
The patient's urine output improved dramatically.
On [**9-6**], the patient had clearly begun to mobilize
her fluid and was transferred to the floor. On [**9-7**],
the patient continued to do well. Culture came back from the
peritoneal fluid, which revealed MRSA. Thus, the Kefzol and
Flagyl were stopped. The patient was put on Vancomycin. The
nursing home, where the patient resides, requested that the
patient have a PIC line, as opposed to a central venous line,
in her neck. Thus, on [**9-9**], in the a.m. the patient
received a PIC line and the patient's IJCVO was discontinued.
The patient was discharged back to her nursing home. The
patient was discharged on a soft, ground diet with thick
liquid that she should only eat in a 90 degree upright
position secondary to the recommendations made by the swallow
team who felt she was at some minor aspiration risk, thus
they put her on this diet. The patient also will be sent
back to her nursing home on her pre-medications, including
Zantac, Lopressor, Simethecone, Synthroid .175 mg p.o.q.d.,
Wellbutrin, and the patient is put on Vancomcyin 1-g, IV q18
hours, which she should continue for 12 more days for a total
of a 14 day course. The patient will followup with Dr. [**Last Name (STitle) **]
in two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Last Name (STitle) 31751**]
MEDQUIST36
D: [**2133-9-8**] 16:02
T: [**2133-9-8**] 16:39
JOB#: [**Job Number 31752**]
|
[
"317",
"278.01",
"V10.05",
"569.69",
"682.2",
"567.2",
"569.61",
"560.2",
"575.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.23",
"45.61",
"51.22",
"46.42",
"38.93",
"96.71",
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
414, 3815
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,272
| 156,180
|
40297+58363
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-12-14**] Discharge Date: [**2159-12-24**]
Date of Birth: [**2095-12-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Intermittent worsening chest burning for 1 month
Major Surgical or Invasive Procedure:
[**2159-12-17**]
Coronary artery bypass grafting x4,
reverse saphenous vein graft to the left anterior descending
twice and reverse saphenous vein graft to the right coronary
artery into the marginal artery at the circumflex
History of Present Illness:
64 yo F with hx HLD and extensive smoking history (abstaining
for 3 years to date) who presents with chest burning for 1
month.
.
Was in her usual health and exercising regularly at the gym,
able to walk at 3mph on the treadmill and lift weights without
anginal symptoms, until about a month ago when she was on a
cruise to the Caribbean - she starting having intermittent
substernal chest burning on exertion without diaphoresis or
sweating and no radiation. She continued to have these symptoms
with exertion and over the past month she has had them more
frequently, but notes that she could still exercise as usual at
the gym and has not had the symptoms at rest.
.
The day prior to admission, she saw her PCP for [**Name Initial (PRE) **] right handed
palmar cyst on her tendon, and told the physician about her
symptoms - she underwent stress, which showed infero-lateral
ischemia. She was loaded with 300 mg of Plavix the day prior to
admission in preparation for catheterization and took 75 mg the
morning of admission. She was then directly admitted for
catheterization the day of admission, which she underwent today
and which showed 3 vessel disease: -LMCA disease 60-70% -RCA 90%
-Moderate lcx disease.
.
.
<U><b>CARDIAC REVIEW OF SYSTEMS:</b></U>
(+) Per HPI
(-) Denies chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
.
<U><b>OTHER REVIEW OF SYSTEMS:</b></U>
(+) Per HPI
(-) Denies any exertional buttock or calf pain; prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism;
bleeding at the time of surgery, hemoptysis, black or red
stools.
.
Also denies fevers, chills, myalgias, joint pains; cough,
wheezes; diarrhea, or recent change in bowel habits; dysuria or
change in voiding habits; rashes or skin breakdown;
numbness/tingling in extremities; feelings of depression or
anxiety. All of the other review of systems were negative.
Past Medical History:
Hypothyroid
Bursitis R hip
Hyperlipidemia
Arthritis
Ulcerative colitis
Prolapsed bladder and uterus
Past Surgical History
Back surgery x 2
Breast Lumpectomy (benign)
Social History:
-Smoking/Tobacco: 40-50 years 1-1.5 packs daily, stopped 3 years
ago
-EtOH: Occasional
-Illicits: None
-Lives at/with: Husband at home, retired accountant assitant,
with 2 kids and 2 grandkids
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Mother with
hx of AS.
Physical Exam:
VITALS: 97.6 56 125/57 95 RA
.
GENERAL: WDWN in NAD. Alert & Oriented x3. Mood, affect
appropriate. No central or peripheral cyanosis; no jaundice, no
palor.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple; no JVD.
CARDIAC: PMI non-displaced. RR, normal S1, S2; no S3, S4. No
m/r/g. No thrills, lifts.
LUNGS: CTAB, no adventitial sounds. Respirations unlabored, no
accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
GROIN: No femoral bruits.
EXTREMITIES: No cyanosis, clubbing, or edema.
SKIN: No stasis dermatitis, ulcers, scars.
PULSES:
Right: DP 2+
Left: DP 2+
NEURO: CN2-12 intact; moving 4 extremities spontaneously
Pertinent Results:
[**2159-12-23**] 12:45PM BLOOD WBC-7.1 RBC-2.85* Hgb-9.5* Hct-27.4*
MCV-96 MCH-33.2* MCHC-34.6 RDW-15.5 Plt Ct-262
[**2159-12-21**] 08:00AM BLOOD WBC-8.3 RBC-3.03* Hgb-10.3* Hct-29.8*
MCV-98 MCH-34.0* MCHC-34.6 RDW-15.2 Plt Ct-191#
[**2159-12-23**] 12:45PM BLOOD UreaN-19 Creat-0.8 Na-138 K-4.3 Cl-96
[**2159-12-21**] 08:00AM BLOOD Glucose-100 UreaN-25* Creat-0.8 Na-134
K-4.4 Cl-97 HCO3-31 AnGap-10
[**2159-12-17**] Intra-op TEE
Conclusions
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
Post Bypass: Patient is AV paced, later A paced. Initial RV
appears hypokinetic but improves with time and low dose (0.01
mcg/kg/min) epinepherine. LV function unchanged. Aortic contours
intact. MR remains mild. Remaining exam is unchanged. All
Findings discussed with surgeons at the time of the exam.
Brief Hospital Course:
64 yo F with hx HLD and extensive smoking history (abstaining
for 3 years to date) who presents with chest burning for 1 month
- found to have 3VD on Cath and now scheduled for CABG after
Plavix washout.
The patient was brought to the operating room on [**2159-12-17**] where
the patient underwent Coronary Artery Bypass with Dr. [**Last Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
The patient did have an air leak in the pleurevac and chest
tubes remained in place for extra days. Air leak resolved and
chest tubes and pacing wires were discontinued without
complication. She did develop a urinary tract infection which
was treated with ciprofloxacin. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 7, the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to home in
good condition with appropriate follow up instructions.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily
CELECOXIB [CELEBREX] - (Prescribed by Other Provider) - 200 mg
Capsule - 1 Capsule(s) by mouth daily
CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth daily
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 300 mg
Tablet - 1 Tablet(s) by mouth taken on [**2159-12-13**]
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth daily, starting on [**12-14**]
DIPHENOXYLATE-ATROPINE - (Prescribed by Other Provider) - 2.5
mg-0.025 mg Tablet - 1 Tablet(s) by mouth as needed
LEVOTHYROXINE - (Prescribed by Other Provider) - 112 mcg Tablet
- 1 Tablet(s) by mouth daily
MERCAPTOPURINE - (Prescribed by Other Provider) - 50 mg Tablet
-
1 Tablet(s) by mouth daily
MESALAMINE [PENTASA] - (Prescribed by Other Provider) - 250 mg
Capsule, Sustained Release - 3 Capsule(s) by mouth 3 times daily
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily in
the PM
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
ZOLPIDEM [AMBIEN] - (Prescribed by Other Provider) - 5 mg
Tablet
- 1 Tablet(s) by mouth at bedtime
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth daily
FOLIC ACID - (Prescribed by Other Provider) - Dosage uncertain
Plavix - last dose: 300mg [**12-13**]
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. mesalamine 250 mg Capsule, Sustained Release Sig: Three (3)
Capsule, Sustained Release PO TID (3 times a day).
Disp:*270 Capsule, Sustained Release(s)* Refills:*2*
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. mercaptopurine 50 mg Tablet Sig: One (1) Tablet PO QD ().
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
Atrial fibrillation
Hypothyroid
Bursitis R hip
Hyperlipidemia
Arthritis
Ulcerative colitis
Prolapsed bladder and uterus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
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: [**Name6 (MD) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2160-1-10**] 2:30
Cardiologist: [**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 23882**], [**2160-1-22**]
9:30am
Primary Care Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2160-2-28**] 8:30
Follow up with repeat Chest CT to evaluate lung nodules in 3
months
**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:[**2159-12-24**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14018**]
Admission Date: [**2159-12-14**] Discharge Date: [**2159-12-24**]
Date of Birth: [**2095-12-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 741**]
Addendum:
Ms [**Known lastname **] was discharged home with Percocet 5/325 1-2tabs
Q6hrs/prn for pain control. Dilaudid was discontinued
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2333**] Area VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2159-12-24**]
|
[
"530.81",
"556.9",
"599.0",
"512.1",
"305.1",
"411.1",
"715.90",
"727.42",
"496",
"618.4",
"780.52",
"E878.2",
"272.4",
"414.01",
"285.9",
"041.89",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"88.53",
"37.23",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
12322, 12510
|
5207, 6696
|
362, 589
|
9952, 10158
|
3823, 5184
|
11082, 12299
|
2978, 3116
|
8266, 9669
|
9776, 9931
|
6722, 8243
|
10182, 11059
|
3131, 3804
|
2055, 2561
|
273, 324
|
617, 1849
|
2583, 2752
|
2768, 2962
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,171
| 125,124
|
45598
|
Discharge summary
|
report
|
Admission Date: [**2171-10-15**] Discharge Date: [**2171-10-20**]
Date of Birth: [**2095-4-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
endotracheal intubation, femoral and internal jugular central
line placement
History of Present Illness:
76yo W h/o multiple systems atrophy, paroxysmal AF on aspirin,
DM2, HTN, HL, lumbar spinal stenosis who presents with a cardiac
arrest. Per family, the patient was at home and was having some
difficulty with her secretions (choking sounds) when she
suddenly collapsed. CPR was initated by the family, and the fire
department arrived with pads, which advised no shock.
Subsequently she was to be pulseless, with PEA bradycardia, and
was given 1 mg epinephrine, with ROSC. Enroute, she lost pulse
again, with similar pads advising no shock, and was given
another 1 mg epinpehrine, with ROS. At the scene, she was
intubated, a left lower extremity IO was placed. She did not
lose pulses in the emergency department, and was placed with a
right femoral triple lumen, started on amiodarone gtt, as well
as levophed. EKG was ready by cardiology fellow as likely atrial
fibrillation with LBBB. She had a CT head, which was negative.
Of ntoe, she was recently discharge [**2171-10-12**] with a stuttering
course of 24-48 hours of left facial weakness and leaning to the
left in addition to difficulty in swallowing. At that time, a
head CT was negative for acute ischemic or hemorrhagic, and the
team felt that MRI would not change the treatment MRI was not
performed and she was
continued on conservative treatment. She at that tiem was also
noted to have difficulty swallowing, as well as occasionally
SBPs in the 180s, for which she was started on lisinopril. At
that time, she developed fever and as U/A was positive for
bacteria she was started on ceftriaxone for 3 days, but was
subsequently discontinued after urine culture reportedly came
back negative, although cultures here appear to be positive for
VSE.
Labs notable for an ABG with 7.17/58/159, K 2.4, Lactate 8.5,
HCT 95, and a free calcium 0.95. WBC elevated at 15.6, HCT 32,
Plt 188. U/A was very dirty with large leuks, large blood, many
RBCs and WBCs, and mod bacteria.
On arrival to the MICU, she is intubated and sedated.
Past Medical History:
SHY [**Last Name (un) **] SYNDROME
HYPERGLYCEMIA
HYPERLIPIDEMIA [**1-/2164**]
HYPERTENSION
HYPOTHYRIODISM
ARRYTHMIA [**2-/2151**], episode of AF [**8-/2165**], holter [**10-24**] without AF
COLONIC POLYPS [**2164-7-10**]
NEPHROLITHIASIS
OSTEOARTHRITIS
ANXIETY
URINARY INCONTINENCE
GASTROESOPHAGEAL REFLUX
H/O POSTITIVE PPD [**2129**]
LUMBAR STENOSIS [**2-/2162**]
CATARACTS
S/P APPY
S/P TAH
GALLSTONES
PULM NODULE
*S/P C DIFF COLITIS [**8-/2165**]
? TRANSIENT ISCHEMIC ATTACK
Social History:
Lives at home with husband, has a home health aide 6 times per
week for 2.5 hours from [**Hospital6 **]. Remote smoking
hx, <10 pack year history>35 years ago. No ETOH. No illicits.
Wheelchair bound, requires significant help with transfers and
with all ADLs. She is a retired VNA.
Family History:
Diabetes and thyroid disease
Mother died of DM.
Siblings: brother with DM
Physical Exam:
Admission:
General: Intubated, sedated, occasional twitching of the L eye.
HEENT: Sclera are injected
Neck: visualed by U/S JVP are highly compressible.
CV: RRR
Lungs: Mechanical breath sounds B
Abdomen: soft, non-tender, non-distended
GU: foley in place
Ext: cool lower extremities B with 1+ pulses
Neuro: Unresponsive.
Discharge:
Expired
Pertinent Results:
I. Laboratory
A. Admission
[**2171-10-15**] 03:55PM BLOOD WBC-15.6*# RBC-3.49*# Hgb-9.8*#
Hct-32.0*# MCV-92 MCH-28.2 MCHC-30.7* RDW-14.9 Plt Ct-188
[**2171-10-15**] 06:02PM BLOOD Neuts-74* Bands-8* Lymphs-10* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2* NRBC-2*
[**2171-10-15**] 03:55PM BLOOD PT-16.5* PTT-58.8* INR(PT)-1.6*
[**2171-10-15**] 03:55PM BLOOD UreaN-34* Creat-0.9
[**2171-10-15**] 06:02PM BLOOD Glucose-153* UreaN-36* Creat-1.0 Na-146*
K-2.1* Cl-107 HCO3-24 AnGap-17
[**2171-10-15**] 06:02PM BLOOD ALT-74* AST-141* LD(LDH)-573* TotBili-0.4
[**2171-10-15**] 06:02PM BLOOD Calcium-7.2* Phos-3.1 Mg-2.2
[**2171-10-15**] 06:02PM BLOOD Calcium-7.2* Phos-3.1 Mg-2.2
[**2171-10-15**] 04:24PM BLOOD pO2-159* pCO2-58* pH-7.17* calTCO2-22
Base XS--7 Comment-GREEN TOP
[**2171-10-15**] 04:24PM BLOOD Glucose-201* Lactate-8.5* Na-141 K-2.4*
Cl-109*
[**2171-10-15**] 04:24PM BLOOD freeCa-0.95*
II. Microbiology
[**2171-10-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2171-10-16**] STOOL C. difficile DNA amplification
assay-FINAL INPATIENT
[**2171-10-16**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2171-10-15**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2171-10-15**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2171-10-15**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS SP.,
YEAST} INPATIENT
III. Radiology
See webOMR for final reports
Brief Hospital Course:
76F history of multiple systems atrophy, paroxysmal atrial
fibrillation on aspirin, DM2, hypertension, hyperlipidemia,
lumbar spinal stenosis who was admitted for cardiac arrest. The
etiology of cardiac arrest was likely multifactorial and
potentially related to infection such as toxic megacolon and ?
aspiration. It was also noted that she was hypokalemic as well.
Her husband initiated CPR at home although it was noted that the
patient was DNR/DNI during prior hospitalization. The patient
was treated with standard post-arrest protocol including cooling
for neuroprotection. She was started on broad spectrum
antibiotics to cover for possible aspiration pneumonia, C.
difficile given toxic megacolon despite negative stool antigen,
and urinary tract infection. Surgery consultation was deferred
given the patient was not an operative candidate. Continuous EEG
was performed showed minimal cortical activity. Code status was
also changed to DNR/DNI as if the patient were to re-arrest, it
would be unlikely that further resuscitation would be effective.
After re-warming, the EEG remained flat with intact respiratory
drive on pressure support. A discussion was held with her family
including her husband regarding likely poor neurological
prognosis. It was decided to pursue comfort-focus measures. The
patient was extubated and subsequently died on [**2171-10-20**]. Family
was notified and declined autopsy.
Medications on Admission:
Medications (per DC Sum [**2171-10-12**]):
Aspirin 325 mg PO DAILY
Levothyroxine Sodium 50 mcg PO DAILY
Quetiapine Fumarate 25 mg PO HS:PRN agitation
Lisinopril 2.5 mg PO DAILY
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: cardiac arrest, hypoxemic and hypercarbic respiratory
failure, toxic megacolon
Secondary: Shy-[**Last Name (un) **]
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"333.0",
"530.81",
"427.31",
"244.9",
"518.81",
"332.0",
"348.1",
"276.8",
"486",
"286.9",
"300.00",
"427.5",
"788.30",
"V44.1",
"250.00",
"V70.7",
"272.4",
"556.9",
"401.9",
"785.50",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.97",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6764, 6773
|
5088, 6504
|
320, 398
|
6941, 6950
|
3681, 5065
|
7006, 7145
|
3229, 3304
|
6732, 6741
|
6794, 6920
|
6530, 6709
|
6974, 6983
|
3319, 3662
|
266, 282
|
426, 2412
|
2434, 2912
|
2928, 3213
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,167
| 145,310
|
8862
|
Discharge summary
|
report
|
Admission Date: [**2130-3-19**] Discharge Date: [**2130-3-23**]
Date of Birth: [**2075-2-27**] Sex: F
Service: MEDICINE
Allergies:
Doxycycline / Augmentin / E-Mycin / Codeine / Latex / Ms Contin
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Fever and hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 55 year-old female with a history of chronic
pancreatitis who presents with fever. The patient was recently
discharged from [**Hospital3 **] hospital after a nine day stay for
abdominal pain and flare of her chronic pancreatitis. Prior to
that hospitalization she had been consuming a full liquid diet.
She was afebrile during this stay and basically presented for
pain, nausea, and vomiting for which she received analgesics,
antiemetics, and parenteral nutrition. Of note, she also
received influenza vaccination and pneumovax yesterday prior to
discharge. She had improved, though her pain had not resolved,
and she went home yesterday. This morning she woke up with
fevers and chills eling feverish. She checked her temperature
and it was elevated at 104.1 and thus came to the ED for
evaluation. She denies any cough, shortness of breath, chest
pain, diarrhea, dysuria, hematuria, or skin issues. Regarding
abdominal pain she reports her baseline, which is [**9-11**]
epigastric pain that decreases to 2 or 3 with her PRN
hydromorphone dose. She also has her baseline mild nausea.
Otherwise endorsing fatigue and diffuse myalgias.
In the ED, initial vitals wer notable for T 102.6, HR 137, BP
102/60, RR 21, and O2 Sat of 97% on RA. She then had lower
blood pressures mostly in the region of her reported baseline
(90's/50's) but dropping as low as systolic values in the 70's.
Therefore, she received 4 L of fluid with improvement in her
tachycardia. Initially, she received doses of vancomycin and
pipercillin/tazobactam to cover line infections and
intraabdominal pathology respectively. CT abdomen and pelvis
was negative for any signs of necrosing pancreatitis. Because
of her hypotension and fever with concern for a line infection
she was admitted to the [**Hospital Unit Name 153**].
ROS: The patient denies any weight change, vomiting, diarrhea,
constipation, melena, hematochezia, chest pain, shortness of
breath, orthopnea, PND, lower extremity oedema, cough, urinary
frequency, urgency, dysuria, lightheadedness, gait unsteadiness,
focal weakness, vision changes, headache, rash or skin changes.
Past Medical History:
-idiopathic chronic pancreatitis
-anemia - b/l Hct 31-33%
-depression
-GERD
-seasonal allergies
-overactive bladder
-migraines
-s/p CCY
-s/p TAH
Social History:
She is a non-smoker (for 20 years) and was a social drinker
until [**Month (only) 547**] of this year when she stopped consuming alcohol due
to her pancreatitis. She works as a librarian. She is
currently living with friends and is widowed.
Family History:
Mother died of pancreatic cancer. Father's health status
unknown.
Maternal grandmother had multiple myeloma and breast cancer.
Maternal aunt had breast cancer.
Physical Exam:
Vitals:97.5 96/64 74 18 99%RA
Pain: [**3-14**] epigastric
Access: R hickmans IJ, c/d/i
Gen: nad
HEENT: o/p clear, mmm
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, mild epigastric tenderness, no rebound, +BS
Ext; no edema
Neuro: A&OX3, nonfocal
Skin: no changes
psych: calm
.
Pertinent Results:
no leukocytosis
hgb 11.7-->9.8 after 4L IVFs, stable X48hours
chem: BUN 18, creat 0.9
lipase 51
K 3.7, Mag 2.1
LFTs mild elevation on admission-->normalized, alk phos wnl
.
UA negative
UCx negative
.
blood Cx [**3-19**] X2, [**3-20**] X1 NTD
.
.
Imaging/results:
CXR: essentially normal
.
CT a/p c contrast: no pseudocyst or necrotizing pancreatitis.
RML opacities c/w aspiration or infectious process, stable Seg
IV hemangioma, small HH, right upper pole renal cyst stable
Brief Hospital Course:
55year old female with chronic idiopathic pancreatitis on TPN
[**5-10**] via R hickman recently d/c'd from OSH 1 day PTA for
pancreatits flare, presented next am with fevers. States her
pancreatitis was not well managed at OSH but they would not
transfer her to [**Hospital1 18**], so she decided to be discharged. On
discharge, recieved Flu and pneumovax vaccines. Did not resume
TPN that day. Got home and had pain and emesis during which she
may have aspirated and had [**Month (only) **] PO. Next am, had fevers reported
104 at home. Came to [**Hospital1 18**] ER, febrile 102.6, transient
hypotensive in ER to 70SBP (baseline 90SBP), recieved 4L IVFs
and was admitted to [**Hospital Unit Name 153**] for possible sepsis. Empiricallly
started on Vanc/Zosyn. Hickman site looked good. UA negative.
Remained afebrile and HDS throughout MICU stay after the initial
intervention. Admission CT a/p negative but reveal RML
infiltrate c/w aspiration event. Transfered to gen med on [**3-20**].
She remained afebrile, good sats on RA, all cx (including from
Hickman line) remained negative, thus the Abx were stopped by
[**3-21**]. Rest of hospital stay, her biggest complaint is continued
epigastric pain and nausea as she did not feel her flare was
controlled. Was placed on NPO, TPN started, recieved IV
dilaudid/zofran for next 4days. Walk ambulating okay, looked
comfortable. By time of discharge, was tolerating CLD. VNA
services will resume TPN (continuous and will need to wean as
she takes PO) and her previous regimen of PO dilaudid, fentanyl,
and phenergan. No medication changes were made, Rx given for
dilaudid, fentanyl, phenergan for 10day supply.
.
progress note is below for details:
.
Fever: Febrile in ER, no leukocytosis, thus far w/u negative,
blood Cx NTD, no hickman site infection and low suspicion. s/p
vanc/zosyn X1 day, pt has been afebrile. Ddx: viral syndrome vs
aspiration event vs less likely Hickman infection.
-s/p Vanc empirically for possible line infection, d/c'd since
[**3-21**] since Cx negative
-as for possible source of fever, CT on admission with RML
opacities and pt reports recent emesis and possible aspiration
which makes this likely. currently on RA
-CIS
.
.
Hypotension: transient hypotension in setting of fever in ER
concerning for sepsis. Pt had [**Month (only) **] PO, off TPN, insensible losses
for day PTA so likely volume depletion. Normalized after 4L IVFs
and now stable at baseline SBP 90-100s w/o evidence of sepsis
.
.
Chronic Pancreatitis flare: pt states that pain has not been
controlled and flare has been ongoing despite discharge from
OSH. CT a/p on admission no acute process
-on dilaudid 1mg q4IV prn-->PO dilaudid on discharge, fentanyl
patch 75mcg, phenergan 12.5 IV q6prn, zofran IV
-TPN resumed, tolerating some clears, will place on continuous
TPN until tolerates more PO
-Dr [**Last Name (STitle) 3315**] aware of admission.
.
.
[**Last Name (un) **]: creat 1.2 on admission, resolved to baseline with IVFs, 0.8
.
.
Anemia, ACD: hgb 11.7-->9s after IVFs, stable, at baseline,
monitor.
.
.
Depression/insominia: cont zoloft, wellbutrin, trazadone at home
doses
.
.
Bladder hyperactivity: Detrol 1mg [**Hospital1 **]
.
.
Constipation: baseline BM q3-4days
-senna, docusate, add dulcolax prn
.
.
GERD: omeprazole 20mg [**Hospital1 **]
.
.
allergic rhinitis: [**Doctor First Name 130**] 60mg [**Hospital1 **]
Medications on Admission:
1.Tolterodine 1 mg Tablet PO BID
2.Fentanyl 75 mcg/hr Q72 hr
3.Hydromorphone 2 mg PO Q4H
4.Promethazine 25 mg PO Q6H PRN
5.Bupropion sustained release 450 mg PO QAM
6.Sertraline 50 PO DAILY
7.Trazodone 150 mg PO QHS
8.Docusate Sodium 100 mg PO BID
9.Omeprazole 20 mg PO BID
10.Senna 2 Tablets PO QHS
11.Ondansetron 4 mg PO Q8hrs:PRN
12. Fexofenadine 60 mg PO BID
Discharge Medications:
1. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*5 Patch 72 hr(s)* Refills:*0*
3. Bupropion 150 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO QAM (once a day (in the morning)).
4. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours.
Disp:*50 Tablet(s)* Refills:*0*
10. Promethazine 25 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
Disp:*40 Tablet(s)* Refills:*0*
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for constipation.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Aspiration Pneumonitis, transient
Chronic Pancreatitis flare on TPN
Discharge Condition:
good
Discharge Instructions:
you were admitted with fevers likely because you aspirated while
vomiting.
you remained afebrile here. your low blood pressure was likely
from you not taking any PO and no TPN, it improved with IV
fluids and remained at your baseline.
resume your previous meds. you are given prescriptions for
dilaudid, fentanyl, phenergan until your follow up
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2130-4-21**] 10:30
|
[
"530.81",
"507.0",
"577.1",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
8909, 8961
|
3957, 7337
|
346, 352
|
9072, 9078
|
3458, 3934
|
9471, 9626
|
2967, 3128
|
7751, 8886
|
8982, 9051
|
7363, 7728
|
9102, 9448
|
3143, 3439
|
285, 308
|
380, 2521
|
2543, 2690
|
2706, 2951
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,109
| 154,361
|
10350
|
Discharge summary
|
report
|
Admission Date: [**2125-10-13**] Discharge Date: [**2125-10-17**]
Date of Birth: [**2054-5-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
sepsis, febrile neutropenia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt was seen in [**Hospital **] clinic by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who gave [**Last Name (un) **]
2L of NS and Imodium. Patient had improved clinically and was
sent home. The following day the patient started having
voluminous stools. Per family his mental status was completely
altered. He went to an OSH where he received Fortaz 2gm IV, Levo
500 mg IV, Vanc 750 mg IV, and 2L NS. He was then transferred to
[**Hospital1 18**].
Initially in ED, T101.8 HR 105 BP 107/66 RR 23. Lactate 2.83. He
subsequently, spiked to T104.8, BP 81/49, received, 2 gm
Cefepime IV, and a total of 7L NS and transferred to [**Hospital Unit Name 153**].
Of note the patient has had no recent sick contacts, no recent
travel or new foods. Diarrhea differs this time from other times
when he received chemo because it is much more voluminous.
Past Medical History:
Onc Hx:
[**2123-12-11**]: presented with a screening colonoscopy with a mass
obstructing the endoscope, but was not clinically obstructing.
He had a synchronous liver metastasis discovered as well and
underwent
resection of the primary, reanastomosis and resection of liver
metastasis at the same time. One of 12 lymph nodes examined was
positive.
[**2124-3-10**]: he developed obstructive jaundice and imaging
revealed three liver metastasis, one of which was infiltrating
the porta hepatis and was unresectable upon evaluation by
hepatobiliary surgery.
[**2124-9-9**]: underwent ERCP with placement of a metal stent.
Then, his bilirubin elevated and a plastic stent was placed.
[**Month (only) **]-[**2124-9-9**]: Treated with FOLFORI (irinotecan, 5-FU,
leucovorin), but treatment terminated due to diarrhea not
progression of disease. Subsquently took treatment break
starting in [**10-14**].
[**2125-5-10**]: started Xeloda
[**2125-10-1**]: started FOLFORI (irinotecan, 5-FU, leucovorin)
plus Avastin. The irinotecan was dose reduced due to diarrhea on
[**2125-10-8**]. Current Chemotherapy [**Doctor Last Name **](s) and Dose: Avastin 390mg
d1, 15, Irinotecan 230 mg d1,8,15,22, lcv 35 mg d1,8,15,22, 5fu
950 mg d1,8,15,22
[**2125-10-14**]: will be week 2,day 7 or C1D14
.
Other Hx:
1. Colon cancer s/p resection c/b liver mets
2. CVA 6 yrs ago
3. melanoma x 2, back and left chest wall, resected
4. CAD
5. Parkinson's disease, diagnosed 8 yrs ago
6. HTN
Social History:
Social: married with 3 children, 3+EtOH, no tobacco
Family History:
1. F-- colon ca in 70's, died of CVA
2. M--? bowel cancer with liver mets at 56, died at 80's (needs
clarifciation)
3. sibs-- one with prostate cancer
Physical Exam:
VITALS: T 101.1, HR 100, BP 88/70, R17, O2 99% RA
General: shivering, breathing slightly labored
SKIN: poor capillary refill, decreased skin turgor
HEENT: MM dry
Neck: JVP flat
Chest: CTA ant and laterally
Abd: hypoactive BS, soft, nontender, nondistended
Ext: cool to touch, poor perfusion, no edema
NEURO: unable to assess due to patient's mental status
Pertinent Results:
Head CT: IMPRESSION: No acute intracranial hemorrhage or mass
effect. Stable exam compared to [**2124-3-30**] including
redemonstration of right temporal infarct.
.
Abd CT: IMPRESSION:
1. Diffuse subcutaneous soft tissue, retroperitoneal, and
mesenteric stranding with bilateral pleural effusions and
ascites consistent with anasarca. 2. Limited evaluation of the
bowel demonstrates no overt evidence of wall inflammation. 3.
Distended gallbladder may be secondary to a fasting state. If
there is clinical concern for cholecystitis, further evaluation
with a HIDA scan may be performed.
Brief Hospital Course:
# Sepsis: Symptoms initially suggestive of septic shock given
fever, hypotension. GI source more likely given recent increased
diarrhea. Equally important to consider fungal infections given
neutropenia. Other sources to consider include Port(given WBC <1
can't rely on clinical exam for eryhtematous changes), pulmonary
source (although CXR is clear) and urine (cx are pending).
Patient has no evidence of skin breakdown. Sepsis had resolved
by [**10-14**]. Pt had received total of 14 L of fluid, and was
transiently required Levophed for BP support. In addition, he
was given a stress dose of decadron. [**Last Name (un) **] stim was normal. He
was covered with meropenem and vancomycin. Initially concerned
for meningitis b/c of MS changes, family initially refused LP.
On tx for meningitis and MS improving. OSH micro lab
-([**Telephone/Fax (1) 34347**], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 34348**]). on [**10-13**] one set of Bld
cx's NGTD. Ultimately, patient's family felt that the patient
would not be able to recover from this illness given the
inability to maintain hemodynamic stability. He was made Comfort
measures only at 8:30PM [**2125-10-17**]. Several hours later, his BP
began to decline and he died.
.
# Diarrhea: Initally felt to be secondary to irenotecan;
however, patient's family describes a sudden onset of diarrhea
more suggestive of an infectious etiology. Stool cultures were
negatrive for C. Diff X3. For symptomatic treatment, his
immodium was titrated up.
.
# Acute renal insufficiency: Over the hospital course, he
developed ARF.
.
# Anasarca: Felt to be [**1-11**] to residual effects from vasodilation
from sepsis and total body overload coupled with chronic poor PO
intake and hypoalbuminemia.
.
# Abd Pain: Patient complianed of right sided abd pain, but
unable to ocalize further. Abd CT revelaed anasarca and bowel
wall edema. had some abd pain on [**10-14**]-no rebound, checked KUB
for possible perf (known SE of one of his chemo drugs, though
exam not c/w this)
.
#. Pancytopenia: Platelet count at OSH was 107. Here it was 30.
Pt's labs suggested evidence of hemolysis; however, this quickly
resolved. His pancytpenia was felt to be [**1-11**] to chemotherapy
.
#. Parkinsons: unable to re-start meds as patient never awake
enough to tolerate POs
.
#. Glycemic control: controlled with FS qid, ISS
.
8. FEN: aggressive electrolyte repletion in the setting of
diarrhea; maintenence IVFs in setting that pt not taking POs and
having diarrhea; Nutrition consulted and started on TPN.
.
9. PPx: Platelets are low, PPI
.
10. Code: DNR/DNI
.
.
Family Contact
[**First Name8 (NamePattern2) 34349**] [**Known lastname **] [**Telephone/Fax (1) 34350**] (HCP-wife)
[**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 34351**]
[**First Name8 (NamePattern2) 1356**] [**Known lastname **] [**Telephone/Fax (1) 34352**]
[**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 34353**]
.
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 34346**], [**Telephone/Fax (1) 34354**]
[**Telephone/Fax (1) **] on Admission:
Metoprolol 25mg PO QAM (Toprol XL?)
Carbodopa/Levodopa 25/250 mg PO TID
Thiamine 100mg PO daily
Aspirin 325mg QAM
Ativan 0.5mg PO PRN Q4-6
Lasix 80mg PO QAM
Potassium 40meq QAM, 30meq QPM
Metolazone 2.5mg Q-three times weekly
Discharge Disposition:
Expired
Discharge Diagnosis:
expired, cardiac arrest
Discharge Condition:
expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"780.6",
"332.0",
"584.9",
"785.52",
"995.92",
"197.7",
"V10.82",
"V10.05",
"038.9",
"401.9",
"E933.1",
"284.8",
"787.91",
"288.00",
"286.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7373, 7382
|
3973, 7108
|
345, 351
|
7449, 7588
|
3361, 3361
|
2817, 2969
|
7403, 7428
|
2984, 3342
|
278, 307
|
379, 1246
|
3370, 3950
|
7122, 7350
|
1268, 2731
|
2747, 2801
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,699
| 161,807
|
28641+57602
|
Discharge summary
|
report+addendum
|
Admission Date: [**2176-7-6**] Discharge Date:
Service: VSU
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: This is an 85 year-old gentleman
who was initially hospitalized here on [**2176-6-23**] to [**2176-6-24**] for
a diagnostic CT angiogram determination of aortic aneurysm
repair. Patient has a known abdominal aortic aneurysm for 4
years. It is difficult to assess by interview and follow-up.
Although the most recent ultrasound showed an aneurysm of 5
to 7 cm. Patient is asymptomatic. Because of his renal
insufficiency, he was admitted for rehydration and
arteriogram. Completed the study without difficulty and was
discharged to home to follow-up with Dr. [**Last Name (STitle) 1391**]. He had an
elective surgical date for aortic repair on [**2176-7-8**]. In the
interim, the patient was hospitalized at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36688**] Hospital
for complete heart block which required a pacemaker
implantation and a gastrointestinal bleed requiring
transfusion. The patient required intubation during this
period of time. He was extubated on [**2176-7-6**] and transferred to
our institution for anticipated repair. Since the interval
being seen, he denies any chest pain, shortness of breath,
abdominal pain, back pain, melena, hematemesis or weakness.
ALLERGIES: No known drug allergies.
MEDICATIONS: Lovastatin 10 mg daily. Plavix 75 mg daily.
Tamsulosin .4 mg capsules daily. Cortisone .1 mg daily.
Ipromium bromide inhalations daily. Disopyramide 150 mg
sustained tablets q. 12 hours. Paroxetine 12.5 mg sustained
released. Ciprofloxacin 500 mg q. 24 hours for 3 doses for
urinary tract infection.
MEDICATIONS ON TRANSFER: Coreg 3.125 mg daily. Cleocin 600
mg IV q. 8 hours. Rocephin 1 gram q. 24 hours. Norpace.
Plavix and Protonix at home.
PAST MEDICAL HISTORY: Chronic renal insufficiency with a
baseline creatinine of 2.2. history of transient ischemic
attacks, manifested by left upper arm hemiparesis. Status
post right CEA [**2170**] at [**Hospital3 **]. No further
symptomatology. History of peptic ulcer disease at the age
of 38 to 39 with a gastrointestinal bleed. Asymptomatic since
except for recent gastrointestinal bleed. History of CAD.
History of congestive heart failure in [**7-7**]. History of
complete heart block in [**7-7**] requiring a permanent pacemaker.
Coronary artery stenting in [**2174**] x3. Previous coronary artery
bypass grafting x3 in [**2165**]. History of cardiac arrhythmias
on Norpace. History of colon cancer, status post AP
resection with colostomy.
SOCIAL HISTORY: The patient is retired, 72, is the former
vice president of a company. He lives with his wife
and ambulates independently. Habit wise, he is a former
smoker and has not smoked for 20 years. Prior to that, it
was a pack per day. He started at the age of 16. He admits to
occasional beer, maybe 6 a year.
PHYSICAL EXAMINATION: Vital signs 96.6; 76, 22, blood
pressure 149/66. Oxygen saturation of 97% on 2 liters.
General appearance: Alert and oriented x3 in no acute
distress. Skin exam was without rashes, ecchymosis or
jaundice. HEENT: Unremarkable. Carotids are palpable
without bruit. The lungs are diminished at the bases. There
was no adventitial sounds. Excursion is equal. Heart is
regular rate and rhythm without rub. Abdomen: Soft,
reducible ventral hernia. No abdominal bruits. No palpable
masses. Colostomy stoma is pink. There is a right groin
mass which is mobile. Pulse exam shows carotids are palpable
bilaterally 1+, radials are palpable 2+, femorals are
palpable 2+, popliteals are palpable 2+. DP and PT are
palpable and 1+.
HOSPITAL COURSE: The patient was admitted to the ICU.
Gastric lavage was negative. He was continued on the
Protonix. EP was requested to see the patient and interrogate
the pacemaker. Nasogastric was placed to suction. He was
given maintenance fluids. He remained in the VICU. On
hospital day number 2, there were no overnight events. His
admitting hematocrit was 30.3; BUN 29; creatinine 1.8;
albumin 3.0; coags INR of 1.7. The nasogastric tube was
discontinued. He was continued on his Protonix and
subcutaneous heparin was started. Patient's urine culture
was negative and attempt for a sputum culture was of no
avail. Culture sent was consistent with upper respiratory
secretions.
Chest x-ray after IJ placement showed moderate cardiomegaly
which is chronic mild pulmonary vasculature engorgement which
is stable. There is no pulmonary edema or pleural effusion.
The nasogastric tube ended in the upper stomach and the tip
of the right subclavicular central venous line projected over
the right atrium. The right ventricular transvenous pacer
lines and new left pectoral pacemaker projects over the
cavity of the right ventricle rather than the floor. There is
no pneumothorax or appreciable pleura.
The gastrointestinal service was consulted because of the
hematemesis and anemia to determine whether there may be a
gastrointestinal source of bleeding or AV fistulization from
his aneurysm. The patient underwent an upper endoscopy on
[**2176-7-7**]. A small hiatal hernia was noted. There was partially
digested food in the body and fundus of the stomach. There
was diffuse continuous erythema. The mucosa was not bleeding
in the whole stomach, greater in the antrum. Findings were
compatible with mild gastritis. Duodenum had continuous
erythematous mucosa with no bleeding noted in the duodenal
bulb, compatible with duodenitis. Second portion of the
duodenum was clean without evidence of fresh or old blood. No
obvious source was identified for the patient's reported
hematemesis although this may have been due to his
esophagitis and gastritis.
Recommendations were to continue a PPI twice daily for a
total of 30 days and there were no contraindications for
anticoagulation if indicated at surgery. The patient
underwent on [**2176-7-8**], an open abdominal aortic repair with an
aorta bifemoral graft, a ventral hernia repair and lysis of
abdominal adhesions. The patient tolerated the procedure
well. He was transferred to the PACU in stable condition,
intubated. He received 4 units of packed red blood cells
intraoperatively and 1000 cc of red blood cells from the cell
[**Doctor Last Name 10105**]. He also received 4.5 liters of ringers lactate.
Postoperatively, hematocrit remained stable with 30.7, BUN
24; creatinine 1.2. CE was negative. His blood gas was 7.33,
46, 170, 25. Patient could not be extubated, therefore, he
was transferred to the ICU for respiratory support. He was
seen by EP who interrogated his pacemaker and found it be
working appropriately. Postoperative day number 2, he
continued to be n.p.o. Nasogastric tube remained in place
until the patient's respiratory status improved and he was
extubated. His hematocrit remained stable. Postoperative day
three, there were no overnight events. The patient was
extubated. He remained n.p.o. and continued with respiratory
pulmonary toiletry. He was stable on Carvedilol and he had
good response to the Lasix. Aldactone 25 mg daily was
instituted. His hematocrit remained stable. He was
considered for transfer to the VICU or floor on postoperative
day number 3. He was evaluated by physical therapy.
Recommended that the patient be discharged to rehab to
address impairment and progress patient's mobility.
Postoperative day number 5, the patient received a unit of
packed cells for a hematocrit of 27.6. A KUB was obtained
and that was negative for any obstructive pattern and sips
were instituted. Ambulation to chair was begun. The patient
remained in the VICU. The patient was transferred to the
regular nursing floor on postoperative day number #[**Serial Number **].
Physical therapy continued to work with him. The patient
still had intermittent episodes of confusion, mostly at night
but did not require a sitter. Diet was advanced as tolerated.
Patient was known to have candidiasis of the perineal area
and his urinalysis showed a yeast infection. Fluconazole was
instituted for 3 days. Patient had a right groin lymphocele
drainage and a colostomy bag was placed over that to collect
the fluid. The patient returned to surgery on [**2176-7-16**] for a
lymphatic fistula ligation and right inguinal exploration. [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain was placed for continued drainage. The
remaining hospital course was unremarkable. Determination on
antibiotic therapy would be made by the intraoperative
cultures. He continued on Vancomycin. Rehab screening was
instituted. Patient will be discharged when medically stable
on appropriate antibiotics, if indicated if the cultures
intraoperatively are positive.
DISCHARGE INSTRUCTION: The patient should follow-up with Dr.
[**Last Name (STitle) 1391**] in 2 to 3 weeks after discharge from rehab.
Should continue his Protonix 40 mg b.i.d. for a total of 30
days from [**2176-7-7**].
DISCHARGE DIAGNOSES:
1. Double aortic aneurysm. Initial repair was in [**2156**] with
increasing size to 6.5 cm.
2. History of peptic ulcer disease with bleed at the age of
38-39 with a gastrointestinal bleed in [**7-7**].
3. History of transient ischemic attacks in [**2170**], manifested
by left upper extremity hemiparesis, resolved, status
post right cerebrovascular accident.
4. History of coronary artery disease, status post coronary
artery bypass graft x 3 in [**2165**]; status post coronary
artery stenting x3 in [**2174**].
5. History of chronic renal insufficiency. Baseline
creatinine was 2.1, now 1.7.
6. History of congestive heart failure, [**7-7**], compensated.
7. History of complete heart block, status post VVI
pacemaker, [**2176-7-6**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 36688**] Hospital.
8. History of small bowel obstruction [**5-7**].
9. Postoperative blood loss anemia, transfused.
10. Postoperative delirium, improved.
11. Postoperative urinary tract infection, treated with
fluconazole.
12. Postoperative perineal candidiasis, treated, improved.
13. Postoperative right groin seroma, drained.
MAJOR SURGICAL PROCEDURES: Abdominal aortic repair with
aorta bifemoral bypass, hiatal hernia repair.
Lysis of abdominal adhesions on [**2176-7-8**].
Upper endoscopy on [**2176-7-16**].
Right groin exploration with ligation of lymphatic fistula on
[**2176-7-16**].
DISCHARGE MEDICATIONS:
1. Plavix 75 mg daily.
2. Lovastatin 10 mg daily.
3. Albuterol sulfate inhalation q. 4 hours as needed.
4. Ipromium bromide inhalation q. 6 hours as needed.
5. Spironolactone 25 mg daily.
6. Aspirin 325 mg daily.
7. Lopressor 25 mg b.i.d.
8. Protonix 40 mg sustained release q. 24 hours.
9.Tamsulosin .4 mg capsules q. 24 hours.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2176-7-17**] 15:10:16
T: [**2176-7-17**] 16:11:04
Job#: [**Job Number 69308**]
Name: [**Known lastname **],[**Known firstname 33**] Unit No: [**Numeric Identifier 11825**]
Admission Date: [**2176-7-6**] Discharge Date: [**2176-7-25**]
Date of Birth: [**2091-2-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
[**2176-7-17**] episdoe x2 VT,nonsustained. cardiac enzymes negative
[**2176-7-18**] Geratric consulted for persistan postop confusion.
Dementia labs ordered. rt. groin drain remains inplace until 24
hr drainage < 50cc. Will continue augmantin until drain removed.
await transfer to rehab. pending geratric input.delerium with
multifocal causes in a complicated hospital course. started on
risperidol @ HS and prn for agitation. repeat urinalysisand c/s
since completed fluconazole course. Encourage ambulation and day
chair. Will continue the protonix [**Hospital1 **] x 1 month.secondary to
recent GI bleed and stress of recent surgeries.Will plan
transfer to rehab when medically stable and bed avaible.
Vit B12 663 (nl), folate 6.2(nl)TSH 11, T3,T4,T3up were normal
and thyroid supplementation was discontinued.
[**7-24**]//06 JP drained and pressure dressing applied to site which
should be continued until seen in followup.Continue Augmentin
until seen in followup with Dr. [**Last Name (STitle) **].
[**2176-7-25**] transfered to Rehab stable. rt. groin site clean dry and
intact no swelling.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 4415**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2176-7-25**]
|
[
"V45.81",
"553.20",
"496",
"V45.82",
"V45.01",
"535.51",
"788.20",
"998.2",
"458.29",
"593.9",
"V15.82",
"V10.05",
"112.89",
"V44.3",
"293.0",
"998.6",
"428.0",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.05",
"46.73",
"53.59",
"38.44",
"45.13",
"38.86",
"39.25",
"99.04",
"40.9"
] |
icd9pcs
|
[
[
[]
]
] |
12595, 12826
|
9013, 10455
|
10478, 12572
|
3697, 8992
|
2951, 3679
|
90, 118
|
147, 1700
|
1726, 1848
|
1871, 2605
|
2622, 2928
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,683
| 192,101
|
22642
|
Discharge summary
|
report
|
Admission Date: [**2162-3-22**] Discharge Date: [**2162-4-19**]
Date of Birth: [**2097-1-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Keflex / Ketamine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Fluid retention with increased fatigue and dyspnea on exertion.
Major Surgical or Invasive Procedure:
Redo sternotomy, PVR, TV repair, ventricular outflow tract patch
[**2162-3-24**].
History of Present Illness:
Mr. [**Known lastname **] is a 65 yo male with history of tetrology of fallot
and dextrocardia. He is s/p tetrology of fallot repair in [**2148**].
He reports that in [**3-19**] he again began to feel unwell. He was
found to be in atrial fibrillation and was cardioverted. In
[**12-19**] he was in the hospital for colonoscopy and was found to be
in right heart failure. Cath in [**1-20**] with ongoing right heart
failure with tricuspid regurgitation adn pulmonic regurgitation.
He had been admitted in [**2-20**] with plans for surgery but was
found to have an asymptomatic UTI with E. coli. Chronic
indwelling foley catheter in place secondary to BPH. He was
instead sent home with abx. On [**3-23**] a urinalysis and culture at
his primary MDs office was negative.
He was thus admitted [**3-23**] pre-op for surgery.
Past Medical History:
CHF.
Tetrology of fallot.
Dextrocardia.
Ascites.
Glaucoma.
Anxiety.
Hypothyroid.
Hiatal hernia.
Atrial fibrillation.
Barrett's esophagus.
Sleep apnea.
Chronic renal insuffiency.
BPH.
Colon polyps.
Social History:
Lives with wife in [**Name (NI) **], [**Name (NI) **]. Works as math professor.
Tob: quit pipe 15 years ago.
ETOH: rare.
Family History:
Father deceased at 64 with aortic aneurysm.
Pertinent Results:
[**2162-4-19**] 04:03AM BLOOD WBC-11.5* RBC-3.22* Hgb-9.2* Hct-29.5*
MCV-92 MCH-28.7 MCHC-31.3 RDW-15.3 Plt Ct-323
[**2162-4-10**] 02:56AM BLOOD Neuts-91.8* Lymphs-4.7* Monos-2.8 Eos-0.4
Baso-0.3
[**2162-4-19**] 04:03AM BLOOD PT-15.7* PTT-59.6* INR(PT)-1.5
[**2162-4-19**] 04:03AM BLOOD Plt Ct-323
[**2162-4-19**] 04:03AM BLOOD Glucose-90 UreaN-14 Creat-0.7 Na-133
K-4.8 Cl-93* HCO3-37* AnGap-8
[**2162-4-19**] 04:03AM BLOOD Amylase-290*
[**2162-4-16**] 05:58AM BLOOD ALT-27 AST-39 AlkPhos-227* Amylase-389*
TotBili-0.9
[**2162-4-19**] 04:03AM BLOOD Lipase-547*
[**2162-4-17**] 07:20PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2162-4-17**] 07:20PM URINE RBC-0 WBC-0-2 Bacteri-FEW Yeast-MOD Epi-0
Brief Hospital Course:
Mr. [**Known lastname **] was admitted [**3-23**] following a negative urinalysis at
his PCP's office. An ID consult was initiated and a repeat
complete ua and culture was negative. He was therefore cleared
for surgery by ID.
On [**2162-3-24**] he proceede dto teh OR and underwent a redo
sternotomy, PVR, TV repair, ventricular outflow tract patch.
Please see op note for full details.
He had a tough post-op course with initial VTah off bypass and
vent arrythmia post-op. he was also found to have hemiparesis
when first weening from sedation. A neuro consult was obtained
with recs for head CT when stable.
On POD two a head CT demonstrated no infarct.
On POD three he was febrile and an ID consult was obtained while
he was continued on vanco, levo, and astreonam.
PODs [**3-22**] were significant for ongoing hemodynamic management in
the CSRU. ID, neurology, and EP continued to follow pt. Some
improvement in left sided weakness.
On POD 8 he proceeded to the cath lab for pacer placement.
On POD ten he was successfully weened and extubated.
On POD 15 Mr. [**Known lastname **] continued to be febrile with rising WBC.
ID continued to follow pt with recs for checking blood cultures,
checking for C.diff., us bilateral legs, and restart
levofloxacin, aztreonam, and vanco.
POD 16 was significant for ongoing LE cellulitis for which a
derm consult was obtained. They recommended increased dose of
topical steroids, [**Male First Name (un) **] stockings, leg elevation, and diuresis
with ongoing abx per ID and follow-up appointment outpatient.
The avscular surgery servoce was also consulted with very
similar recommendations.
POD 18 his amylase and lipase were found to be elevated and a
general surgery consult was obtained without much concern for
acute surgical issues. Over the next several days his amylase
and lipase continued to trend upwards. On POD 23, his
amiodarone, lipitor, and levo were discontinued -- general
surgery still had little concern for surgery with asymptomatic
pancreatitis. On POD 25-26, his lipase/amylase were
significantly lower.
On POD 19 he proceeded to the cath lab for planned elective PCI
to the LAD.
On POD 21 it was felt that pt was stable for transfer out of the
ICU and onto the inpatient telemetry floor.
On POD 28 it was decided that Mr. [**Known lastname **] was safe for discharge
to a rehabilitation facility for ongoing management and
treatment with increased physical therapy.
Medications on Admission:
Finasteride 5 daily.
Aldactone 50 daily.
Synthroid 100 daily.
Protonix 40 daily.
Flomax 0.4 daily.
Aloprazolam 0.25 hs PRN.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day).
5. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Papain-Urea 830,000-10 unit-% Spray, Non-Aerosol Sig: One (1)
Appl Topical DAILY (Daily).
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
11. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
12. Warfarin Sodium 1 mg Tablet Sig: 7.5 mg Tablets PO once
[**2162-4-19**]: Dose dailyper INR.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
14. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
16. Foradil 12 mcg Capsule, w/Inhalation Device Sig: One (1) 12
mcg inhalation Inhalation [**Hospital1 **] ().
17. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) 1250 units Intravenous ASDIR (AS DIRECTED). 1250
units
18. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 17921**] Center - [**Location (un) 5450**], NH
Discharge Diagnosis:
Severe pulmonic regurgitation.
Moderate tricuspid valve regurgitation with prolapse.
Atrial fibrillation.
Tetrology of fallot.
Dextrocardia.
S/P repair of tetrology of fallot in [**2148**].
Redo sternotomy, PVR, TV repair, ventricular outflow tract patch
[**2162-3-24**].
Discharge Condition:
Stable.
Discharge Instructions:
Shower daily and wash incisions with soap and water. Rinse
well. Do not apply any creams, lotions, powders, or ointments.
No lifting greater than 10pounds.
No driving.
Schedule follow-up appointments as directed.
Followup Instructions:
Follow-up with Dr [**Last Name (STitle) **] in 4 weeks.
Follow-up with Dr. [**Last Name (STitle) 37217**] in [**2-19**] weeks.
Follow-up with Dr. [**Last Name (STitle) 32622**] in [**2-19**] weeks.
FOllow-up with dermatologist; [**Telephone/Fax (1) 1971**].
Completed by:[**2162-4-19**]
|
[
"V15.1",
"682.6",
"427.1",
"E878.9",
"996.09",
"414.01",
"427.31",
"746.09",
"V13.69",
"746.89",
"429.4",
"746.87",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"36.07",
"88.72",
"35.25",
"35.95",
"35.39",
"35.33",
"39.61",
"88.56",
"36.01",
"37.94",
"33.24",
"37.22",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6862, 6948
|
2516, 4959
|
348, 432
|
7264, 7273
|
1731, 2493
|
7536, 7825
|
1667, 1712
|
5134, 6839
|
6969, 7243
|
4985, 5111
|
7297, 7513
|
245, 310
|
460, 1291
|
1313, 1512
|
1528, 1651
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,589
| 156,344
|
49519
|
Discharge summary
|
report
|
Admission Date: [**2103-12-8**] Discharge Date: [**2103-12-18**]
Date of Birth: [**2029-12-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1977**]
Chief Complaint:
Left Flank Pain, Nausea, Vomiting
Major Surgical or Invasive Procedure:
Left Percutaneous Nephrostomy Tube Placement ([**2103-12-8**])by IR
History of Present Illness:
73 year old woman with history of DMII and urolithiasis who had
presented from the ED on [**2103-12-8**] with complaint of L flank pain
x 2 days, with temp of 101.4; labs revealed elevated Cr to 2.7
from baseline 1.0 --> found to have L sided 7mm proximal stone
with mild hydronephrosis. BP in 90s-low 100s. Given 2L NS in ED
and Percocet then Morphine IV for pain. [**Date Range 159**] was consulted in
ED and recommended stenting in AM. On floor, patient given 1g
Ceftriaxone. At 9 PM, patient developed tachycardia and
hypotension to systolic 76; had received 300cc of 1 L NS bolus
at that time, in addition to 2L given in ED. Re-checked manually
5 mins later and systolic increased to 90s, then re-checked 5
mins later and systolics in high 80s-low 90s. Transferred to
MICU for closer monitoring, concern for early sepsis. Patient
was taken directly to IR for percutaneous nephrostomy tube prior
to MICU. On arrival, patient in mild distress secondary to pain
in left flank.
.
ROS was otherwise negative. No N/V/breathing difficulties (had
N/V 3 days PTA, which improved), no chest pain, shortness of
breath, or arthralgias.
Past Medical History:
Type II DM
Asthma
HTN
Hyperlipidemia
Social History:
Lives alone in a senior [**Hospital3 **] center, widowed, used to
work in the distribution center at [**University/College **] Law School. Has 2
daughters in NC, 3 sons in town who she is close to. Used to
drink "a drink at weddings," no EtOH since she was diagnosed
with DM. No tobacco, no illicits. Ambulatory and indeendent of
ADL's at the [**Hospital3 **] housing.
Family History:
Brother who died of Prostate CA, sister who died of Ovarian CA
Physical Exam:
VS: T 99.2; HR 102; BP 104/67; RR 25; 95% RA
GENERAL: Obese, African-American female in mild distress
secondary to pain
HEENT: NCAT, sclera anicteric, wears glasses
NECK: supple, FROM. No JVD.
HEART: S1S2 RRR. No MRG
LUNGS: CTA B/L
ABDOMEN: Percutaneous nephrostomy tube present on L draining
serosanguinous fluid. Otherwise soft, NT/ND. +BS
EXT: symmetric DPs. No CCE
Pertinent Results:
ADMISSION LABS:
[**2103-12-8**] 10:50AM BLOOD WBC-18.6* RBC-4.52 Hgb-11.4* Hct-33.7*
MCV-75* MCH-25.1* MCHC-33.6 RDW-14.9 Plt Ct-202
[**2103-12-8**] 10:50AM BLOOD Neuts-93.2* Bands-0 Lymphs-4.6*
Monos-1.7* Eos-0.2 Baso-0.3
[**2103-12-8**] 10:50AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-NORMAL
[**2103-12-9**] 03:33AM BLOOD PT-13.7* PTT-22.5 INR(PT)-1.2*
[**2103-12-8**] 10:50AM BLOOD Glucose-170* UreaN-38* Creat-2.7*# Na-136
K-4.4 Cl-102 HCO3-21* AnGap-17
[**2103-12-8**] 10:50AM BLOOD ALT-12 AST-28 AlkPhos-70 Amylase-40
TotBili-0.4
[**2103-12-8**] 10:50AM BLOOD Lipase-21
[**2103-12-8**] 10:50AM BLOOD Albumin-3.6
[**2103-12-9**] 03:33AM BLOOD Calcium-7.5* Phos-3.3 Mg-1.7
[**2103-12-8**] 06:58PM BLOOD Lactate-1.7
[**2103-12-9**] 05:15AM BLOOD Lactate-2.5*
.
CT PELVIS/ABD W&W/O C; CT PELVIS W&W/O C
BONE WINDOWS: No suspicious lytic or blastic lesions are
identified.
IMPRESSION:
1. 7 x 4 mm stone seen within the left proximal ureter, with
obstruction of the left kidney.
2. Cholelithiasis.
.
MRI of abdomen:
IMPRESSION:
1. Left-sided nephrostomy catheter in place. Location of the
distal catheter is not weel assess with MRI. Edematous and
enlarged left kidney without evidence for hydronephrosis.
Obstructing stone is still visualized in the proximal UPJ.
2. No evidence for hydronephrosis or retroperitoneal hemorrhage.
3. Layering gallstones seen within the gallbladder. Bilateral
layering pleural effusions.
.
Echocardiogram:
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
a trivial/physiologic pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with
preserved global and regional systolic function.
.
MICROBIOLOGY:
Blood culture
ESCHERICHIA COLI
AMPICILLIN------------ <=2 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
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
73 F with DM, HTN, h/o nephrolithiasis, admitted with left
proximal ureteral stone/hydronephrosis, transferred to the MICU
for sepsis, s/p urgent left nephrostomy tube placement, with
gram negative sepsis.
.
1. GRAM NEGATIVE SEPSIS: Growing E.Coli in [**3-10**] bottles from
[**2103-12-8**]. Likely due to urinary pathogen from nephrolithiasis and
pyelonephritis (E. coli in urine). S/P nephrostomy tube
placement and drainage with purulent fluid. Received zosyn for
broad spectum until sensitivities returned and patient changed
to ciprofloxacin. Will complete 14 day course. She remained
afebrile on the floor.
.
2. NEPHROLITHIASIS: Patient with history of kidney stones, will
need to assess dietary intake and review prior work-up to assess
for underlying causes. S/P percutaneous nephrostomy tube
placement [**2103-12-8**] by IR. [**Month/Day/Year 159**] following and recommend [**Month/Day/Year **]
f/u as outpt in [**3-9**] weeks, once infection has clears, for
removal of nephrostomy tube and possible stent vs lithotripsy.
.
3. SVT: Developed tachycardia, found to have Aflutter and MAT on
EKG. Difficult to control on 120 diltiazem QID so changed to
metoprolol and loaded with digoxin. Achieved better rate
control on this regimen. Cardiology following. Anticoagulation
decision not clear in patient with Aflutter but MICU team
elected not to anticoagulate as patient will be having
procedures (nephrostomy tube removal, possible stent) in near
future. The patient converted to normal sinus rhythm during
admission, and was discharged on metoprolol for rate control.
.
4. DIABETES: Poorly controlled, last Hgb A1C 9.7%. Treated with
RISS, FS QID. On Lantus at home. Will need metformin restarted
at home dose of 1000mg [**Hospital1 **] once resovered.
.
5. ACUTE RENAL FAILURE: Likely pre-renal from dehydration from
poor PO intake and IV contrast. Creatinine slowly trended down
with fluids and time. Urine output remained adequate.
.
6. HTN: Held BP meds in setting of hypotension, was on
amlodipine 10 and lisiniopril 40. Was left only on metoprolol
for blood pressure control on discharge.
.
7. Dispo: In good condition, with nephrostomy tube in place,
with follow up with nephrology and primary care doctor.
Medications on Admission:
Atorvastatin 20mg Po Qday
Amlodipine 10mg po Qday
ASA 81 mg po daily
Humalog Sliding Scale
Lantus - 50Units @ bedtime
Lisinopril 40mg Daily
Metformin 1000mg po BID
Triamcinolone 4 puffs po BID
Albuterol PRN
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
7. Lantus 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
Gram negative sepsis
Atrial flutter
.
Secondary diagnosis:
Type II DM
Asthma
HTN
Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted for sepsis from a kidney stone, and developed
atrial flutter during your hospitalization, which resolved
before you were discharged.
.
You will be discharged with a nephrostomy tube in place (in your
kidney), which will be removed by the urologist. You have an
appointment to see him in [**Month (only) 1096**]. You should contact your
primary care doctor if you are having any fevers, chills,
abdominal pain, flank pain, blood in your stool or urine.
.
You will have a home health nurse come to your home to help
teach you how to do dressing changes, and someone to help teach
you about cleaning your tube and signs of infection.
.
You were started on Metoprolol (to help control your heart rate)
and on Aspirin, which you should take daily for heart
protection. You have 3 days left of your antibiotic for your
kidney infection (cipro). Please complete the course of the
antibiotic, it is very important to your recovery.
Followup Instructions:
You have an appointment to see [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 3748**], MD [**First Name (Titles) 767**] [**Last Name (Titles) 159**]
on [**1-4**] @ 11am, [**Hospital Ward Name 23**] [**Location (un) 470**]: If you need to change
this appointment, please call ([**Telephone/Fax (1) 8791**].
.
You have the following appointments already made:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5629**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2104-1-15**] 12:20
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2104-4-15**] 11:00
|
[
"493.90",
"428.0",
"288.60",
"427.32",
"995.92",
"272.0",
"285.9",
"401.9",
"V16.41",
"584.8",
"590.80",
"041.4",
"729.89",
"038.42",
"357.2",
"250.60",
"592.1",
"591",
"V16.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
8581, 8638
|
5258, 7491
|
351, 421
|
8797, 8804
|
2513, 2513
|
9798, 10501
|
2044, 2108
|
7749, 8558
|
8659, 8659
|
7517, 7726
|
8828, 9775
|
2123, 2494
|
278, 313
|
449, 1580
|
8737, 8776
|
2529, 5235
|
8678, 8716
|
1602, 1641
|
1657, 2028
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,839
| 152,908
|
43924+58671
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-5-15**] Discharge Date: [**2190-5-25**]
Service: MEDICINE
Allergies:
Quinine
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Thrombectomy
Transesophageal Echocardiography
Progressive Renal Insuffiency
History of Present Illness:
82 y/o male with hx ischemic DCM (EF 50%, 2+MR/AR), CAD s/p
single vessel CABG SVG -->LAD with St.[**Male First Name (un) 1525**] MVR for severe MR,
hx AMI, htn, chronic AF, CVA in [**2179**], DM, CRI, who has been off
coumadin X 5 days in preperation for days for vitreous
aspiration surgery (endophthalmitis) yest ([**5-14**]). Last night,
noted severe RUE pain and found to have a R brachial artery clot
with decreased pulses then went to ED where he was also found to
have some component of CHF. Taken to OR for thrombectomy which
was successful after lasix 80mg IV X 1. After surgery, BP's
elevated to ~200's and nitro gtt started. Currently, no SOB or
CP or RUE pain.
Past Medical History:
CAD s/p one V CABG
St. [**Male First Name (un) 1525**] MVR
CRI
HTN
Atrial Fibrillation
Benign Prostatic Hypertrophy
Diabetes mellitus
Hypercholesterolemia
Cardiomyopathy - Echo [**9-5**] - EF 55%, Stress Echo [**8-31**] EF30%
hypokinesis (unclear why discrepancy)
Social History:
Retired Russian literature professor. Lives with wife in
[**Name (NI) 583**], quit tobacco 50 years ago. 20 pack year. No ETOH,
IVDA.
Family History:
Non Contributory.
Physical Exam:
Gen: NAD, lying at 30 degrees
Heent: R eye EOMI and reactive. Left with dressing.
Neck: No JVD.
Heart: Irregular. No S3. Soft holosystolic murmur.
Lungs: Few crackles at bases. Poor air movement in general.
Abd: Soft, nt/nd. NABS
Ext: 2+ L>R. Good pulses. Hard hematoma and edema in RUE.
Right hand warm and dopplerable with 1+ radial pulse.
Neuro: Non-focal
Pertinent Results:
[**2190-5-22**] 08:00AM BLOOD WBC-12.7* RBC-3.22* Hgb-9.0* Hct-27.3*
MCV-85 MCH-28.0 MCHC-33.1 RDW-15.0 Plt Ct-252
[**2190-5-21**] 06:30AM BLOOD WBC-11.1* RBC-3.55* Hgb-10.0* Hct-30.4*
MCV-86 MCH-28.1 MCHC-32.8 RDW-14.8 Plt Ct-240
[**2190-5-15**] 08:40AM BLOOD Neuts-94.1* Bands-0 Lymphs-2.9* Monos-2.9
Eos-0.1 Baso-0
[**2190-5-22**] 08:00AM BLOOD Plt Ct-252
[**2190-5-22**] 08:00AM BLOOD PT-19.5* PTT-70.8* INR(PT)-2.5
[**2190-5-15**] 04:14PM BLOOD Fibrino-411*
[**2190-5-17**] 06:16PM BLOOD Ret Aut-1.8
[**2190-5-22**] 08:00AM BLOOD Glucose-150* UreaN-83* Creat-3.6* Na-135
K-4.5 Cl-99 HCO3-23 AnGap-18
[**2190-5-19**] 05:24AM BLOOD Glucose-162* UreaN-79* Creat-4.2* Na-141
K-3.9 Cl-104 HCO3-24 AnGap-17
[**2190-5-15**] 08:40AM BLOOD Glucose-316* UreaN-42* Creat-2.2* Na-142
K-4.4 Cl-104 HCO3-20* AnGap-22*
[**2190-5-21**] 06:30AM BLOOD LD(LDH)-346*
[**2190-5-20**] 10:30AM BLOOD TotBili-0.8 DirBili-0.3 IndBili-0.5
[**2190-5-16**] 04:23AM BLOOD CK(CPK)-342*
[**2190-5-16**] 12:36AM BLOOD CK(CPK)-378*
[**2190-5-15**] 04:14PM BLOOD CK(CPK)-331*
[**2190-5-16**] 04:23AM BLOOD CK-MB-21* MB Indx-6.1* cTropnT-1.30*
[**2190-5-16**] 12:36AM BLOOD CK-MB-26* MB Indx-6.9* cTropnT-1.14*
[**2190-5-15**] 04:14PM BLOOD CK-MB-29* MB Indx-8.8* cTropnT-0.64*
[**2190-5-15**] 08:40AM BLOOD CK-MB-9 cTropnT-0.15* proBNP-[**Numeric Identifier **]*
[**2190-5-22**] 08:00AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
[**2190-5-19**] 05:24AM BLOOD calTIBC-215* Hapto-<20* Ferritn-122
TRF-165*
[**2190-5-16**] 12:43AM BLOOD Lactate-1.5
Renal U/S: :
The right kidney measures 10.4 cm. The left kidney measures
10.1
cm. A 3.7 x 3.4 x 3.1 cm anechoic cyst is again demonstrated in
the upper
pole of the right kidney, unchanged. A nonobstructing calculus
is again
identified in the lower pole of the right kidney. The kidneys
are unchanged in appearance with no hydronephrosis. The bladder
is unremarkable.
RUE Duplex:
Duplex evaluation was performed of the right upper extremity
arterial system. The brachial, radial and ulnar arteries are
all patent with triphasic waveforms. There is a sizable
hematoma in the right upper forearm. There is no evidence of AV
fistula.
TEE:
The left atrium is moderately dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium and
moderate/severe SEC in the left atrial appendage. No
mass/thrombus is seen in the left atrium or left atrial
appendage. There are complex (>4mm, non-mobile) atheroma in the
ascending aorta, in the aortic arch, and in the descending
thoracic aorta. The aortic valve leaflets are mildly thickened.
No masses or vegetations are seen on the aortic valve. Mild
(1+) aortic regurgitation is seen. A bileaflet prosthesis is
seen in the mitral position with normal disc motion. No mass or
vegetation is seen on the mitral valve. A small paravalvular
leak is probably present. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is no pericardial effusion.
TTE:
The left ventricular cavity size is normal. Left ventricular
systolic function is probably grossly preserved but views are
technically suboptimal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis. Moderate (2+) aortic regurgitation is
seen. A bileaflet mitral valve prosthesis is present. The
transmitral gradient is normal for this prosthesis. Mitral
regurgitation is present but cannot be quantified. There is no
pericardial effusion.
CT TOrso:
CT OF THE CHEST WITHOUT CONTRAST: No mediastinal hematoma is
identified. The thoracic aorta is of normal contour with
evidence of atherosclerotic disease. There is prominent
mediastinal fat as well as prominence of the
brachiocephalic vessels, which could explain the mediastinal
widening seen on the prior chest radiograph. Small bilateral
pleural effusions are present with possible loculated components
along the major fissures bilaterally. Associated atelectasis is
seen within the dependent portions of both lungs. There is no
evidence of failure. The airways are patent to the level of the
segmental bronchi bilaterally. No pneumothorax is seen. There
are calcifications within the coronary arteries as well as
evidence of prior mitral valve replacement.
CT OF THE ABDOMEN WITH CONTRAST: A simple cyst measuring 4.7 cm
is present at the upper pole of the right kidney.
Nonobstructing stone is seen within the lower pole of the right
kidney measuring 11 mm. There is no evidence of hydronephrosis.
The adrenal glands, spleen, atrophic pancreas, and liver are
within normal limits. There is a gallstone within the
gallbladder with no pericholecystic inflammatory change. No
dilatation or wall thickening is seen within large or small
bowel. The appendix is normal in appearance. The abdominal
aorta is of normal caliber. No periaortic stranding seen. No
free fluid or free air is seen within the abdomen.
CT OF THE PELVIS WITH CONTRAST: The urinary bladder, prostate
gland, and
rectum are within normal limits. There is sigmoid diverticuli
with no fat
stranding or wall thickening to suggest diverticulitis.
CT head: : No definite evidence for acute intracranial
pathology including signs of hemorrhage or infarction.
Equivocal region of hypodensity within the left frontal lobe,
which may be artifactual. Given that this patient has multiple
old areas of infarction and obvious areas of atherosclerosis
within the cerebral vasculature, an MRI with diffusion would be
a more sensitive test to evaluate for acute infarction.
Brief Hospital Course:
A/P: 82 y/o male with ischemic DCM, MVR who p/w acute brachial
arterial thromoboembolic event and CHF in setting of stopping
anticoagulation.
*. CHF: Multifactorial. Likely [**2-3**] diastolic dysfunction,
valvular dysfunction and NSTEMI. Diuresed on day one for goal
I/O -1L per 24 hour. ACE readded on day 2 based on Cr. Started
isordil/hydral for afterload inhibition in setting of renal
failure. Had 24 hours of nesiritide, but d/c'd [**2-3**] renal
failure. By time of discharge, pt was euvolemic and will
continue on BB/afterload inhibitors
* HTN: Pt had continued high BP's with systolics in the 190's.
Started BB slowly (history bradycardia), but by time of
discharge max'd on carvedilol at 25mg [**Hospital1 **]. Also continued
clonidine 0.1mg [**Hospital1 **] and isordil/hydral. No standing lasix.
* MVR: No evidence of clot by TEE. Continued hep gtt until INR
theraputic. D/C'd on coumadin 13mg nightly for goal INR
2.5-3.5.
*. CAD: Mild troponin leak. Likely [**2-3**] demand ischemia. Cont
asa/statin. . Very high risk for future events. [**Month (only) 116**] need
outpt cath once GFR improves to baseline. Will f/u with
Dr.[**First Name (STitle) 2031**] for this problem. [**Name (NI) **] was d'c'd on asa/statin/BB.
*. Rhythm: Chronic AF. Anticoagulated. Rate well controlled
on coreg.
*. RUE clot: Likely embolic from heart or aortic arch clot.
Underwent thrombectomy in OR successfully. [**Name (NI) **] pt has large
hematoma and decreased, but palpable pulses. HCT dropped and
pulses weakened, worrisome for bleeding into his wound, so
vascular placed JP drain, which drained ~70 cc blood. ACE
bandage placed and on day of discharge, JP drained removed.
* ANEMIA: Restart Epogen, also iron deficiency. Pt needs outpt
w/u that may include colonoscopy.
*. A on CRI: Pt's creatinine increased from baseline ~2.0 to
4.1. Renal was consulted. Likely the pt had pre-renal azotemia
from forward failure, overaggressive diuresis with lasix and
neseritide. GFR improving, but may have new baseline. No
evidence of renal infarction. Pt did not require inpt dialysis.
Will f/u with [**Last Name (un) **] nephrologist.
*. S/P Endophthalmitis: Continued renal dosed vancomycin and
levaquin X 7 days per ID recc's. No visual problems while in
house.
*. DM: Followed at [**Last Name (un) **]. Continued RISS while in house.
Medications on Admission:
asa
clonidine
coumadin
lipitor
lisinopril
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR ([**Last Name (un) 766**] -Wednesday-Friday).
Disp:*qs * Refills:*2*
3. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
4. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Warfarin Sodium 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
Disp:*30 Tablet(s)* Refills:*2*
8. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Congestive Heart Failure
Acute Renal Failure
Right Brachial Artery Embolectomy
Anemia
Discharge Condition:
Fair
Discharge Instructions:
Continue taking your medications as directed. If you have these
symptoms, call your physician or go to the ED:
- chest pain
- shortness of breath
- palpitations
- dizziness, visual changes
- increased leg swelling
- weight increase by 3 pounds
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 3670**]: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time:[**2190-5-25**] 2:00
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 3512**] Date/Time: Thursday, [**6-17**] at 3:30
3. Dr.[**Last Name (STitle) 1391**]: [**Doctor First Name **], suite 5c, [**Last Name (LF) 94288**], [**6-2**] at 2:30.
4. Dr.[**Last Name (STitle) 7626**]: [**Last Name (LF) 766**], [**6-14**] at 9am.
Completed by:[**2190-5-25**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 14929**]
Admission Date: [**2190-5-15**] Discharge Date: [**2190-5-25**]
Date of Birth: [**2107-12-15**] Sex: M
Service: MEDICINE
Allergies:
Quinine
Attending:[**First Name3 (LF) 1090**]
Addendum:
Please note change in d/c meds. Pt discharged on warfarin 10mg
qHS.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs * Refills:*2*
3. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
4. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Warfarin Sodium 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydralazine HCl 50 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours).
Disp:*30 Tablet(s)* Refills:*2*
8. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 313**], [**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1094**] MD [**MD Number(1) 1095**]
Completed by:[**2190-5-25**]
|
[
"V45.81",
"410.71",
"428.31",
"250.40",
"584.9",
"360.01",
"998.12",
"444.21",
"280.9",
"V43.3",
"403.91",
"427.31",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"38.03",
"86.04",
"99.04",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
13742, 13973
|
7544, 9931
|
235, 313
|
11342, 11348
|
1900, 7099
|
11642, 12714
|
1477, 1497
|
12737, 13719
|
11233, 11321
|
9957, 10000
|
11372, 11619
|
1512, 1881
|
176, 197
|
341, 1021
|
7110, 7521
|
1043, 1309
|
1325, 1461
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,200
| 131,171
|
8489
|
Discharge summary
|
report
|
Admission Date: [**2126-6-10**] Discharge Date: [**2126-6-21**]
Date of Birth: [**2060-9-21**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Rabies Immune Globulin
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
Anterior fusion L3-S1
Posterior fusion L2-S1
History of Present Illness:
65-year-old gentleman with multiple medical issues including
HCV, RA, T2DM, history of lumbar post-laminectomy syndrome,
history of arachnoiditis with lumbar spinal stenosis and lumbar
facet arthropathy with lumbar radiculopathy
Past Medical History:
1. Diabetes. Excellent A1c. Up to date on screening. Of note,
EMG
did not show diabetic neuropathy.
2. Hypertension.
3. Hypothyroidism.
4. Chronic pain-lumbar polyradiculopathy followed by pain
clinic.
Recent EMG reviewed.
5. Atypical chest pain/left upper extremity paresthesias and
weakness-EMG reveals C5-T1 radiculopathy. ETT/echo negative.
6. Rheumatoid arthritis. Followed by Dr.[**Last Name (STitle) **], [**Hospital1 112**]. On
prednisone,
recently started on remicaid for uveitis.
7. Hepatitis C, elevated LFTs.
8. Colon polyps-adenoma [**2113**], normal colonoscopy [**2118**].
9. Foot pain-now followed by Dr. [**Last Name (STitle) **] for multiple issues
including tendon rupture
10. Sleep disorder-uses trazodone for zolpidem.
11. History of positive PPD.
12.? osteoporosis. On alendronate, prescribed by his
rheumatologist. He does not recall a recent bone density study.
Social History:
Pt has been a member of [**Location (un) 86**] Chambala center since [**2084**]. As
part of its teachings he has been living in solitary retreat for
the last four years for meditation and for "realization of the
true nature of his mind.". He admits to former tobacco use - he
smoked 1-2 packs/day for 25 years but reports he quit in '[**98**]. He
also admits to alcohol use - 6-12 beers/day for 25 years but
slowed down since '[**97**] where he is now drinking only a couple of
beers since his return from [**Location (un) 27138**]. He denies any illicit
drug use ever.
Family History:
1. Father: CAD s/p stent, chronic angina, 1st MI at age 70s
2. Mother: deceased from natural causes
3. Sister: DM
4. Brother: emphysema + tobacco
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2126-6-18**] 10:36AM BLOOD WBC-6.5 RBC-3.15* Hgb-9.7* Hct-28.8*
MCV-91 MCH-30.8 MCHC-33.7 RDW-14.9 Plt Ct-148*
[**2126-6-17**] 07:46AM BLOOD WBC-5.6 RBC-2.83* Hgb-9.0* Hct-25.9*
MCV-91 MCH-31.8 MCHC-34.8 RDW-14.7 Plt Ct-103*
[**2126-6-16**] 11:11PM BLOOD WBC-5.6 RBC-2.71* Hgb-8.4* Hct-24.7*
MCV-91 MCH-31.0 MCHC-33.9 RDW-14.8 Plt Ct-100*
[**2126-6-16**] 04:07AM BLOOD WBC-7.5 RBC-2.71* Hgb-8.6* Hct-24.7*
MCV-91 MCH-31.7 MCHC-34.8 RDW-14.9 Plt Ct-102*
[**2126-6-15**] 02:30AM BLOOD WBC-4.7 RBC-3.29* Hgb-10.3* Hct-28.7*
MCV-87 MCH-31.2 MCHC-35.8* RDW-14.5 Plt Ct-96*
[**2126-6-17**] 07:46AM BLOOD Glucose-91 UreaN-8 Creat-1.1 Na-135 K-3.6
Cl-103 HCO3-24 AnGap-12
[**2126-6-15**] 02:46PM BLOOD Glucose-95 UreaN-7 Creat-1.0 Na-139 K-4.2
Cl-108 HCO3-26 AnGap-9
[**2126-6-14**] 05:00PM BLOOD Glucose-101* UreaN-8 Creat-0.8 Na-141
K-3.8 Cl-109* HCO3-25 AnGap-11
[**2126-6-10**] 06:45PM BLOOD Glucose-142* UreaN-18 Creat-1.2 Na-131*
K-4.2 Cl-97 HCO3-26 AnGap-12
[**2126-6-17**] 07:46AM BLOOD Calcium-7.6* Phos-3.3 Mg-1.3*
[**2126-6-16**] 04:07AM BLOOD Calcium-7.7* Phos-4.1 Mg-1.5*
[**2126-6-14**] 05:00PM BLOOD Calcium-8.1* Phos-2.8 Mg-1.4*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2126-6-10**] and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the ICU
due to large EBL. TEDs/pnemoboots were used for postoperative
DVT prophylaxis. Intravenous antibiotics were given per standard
protocol. Initial postop pain was controlled with a PCA. On HD#2
he returned to the operating room for a scheduled L2-S1
decompression with PSIF as part of a staged 2-part procedure.
Please refer to the dictated operative note for further details.
The second surgery was also without complication and the patient
was transferred to the PACU in a stable condition. Postoperative
HCT was low and he was transfused multiple units of PRBCs. A
bupivicaine epidural pain catheter placed at the time of the
posterior surgery remained in place until postop day one. He was
kept NPO until bowel function returned then diet was advanced as
tolerated. The patient was transitioned to oral pain medication
when tolerating PO diet. Foley remained in place and will be
discontinued at rehab. He was fitted with a lumbar warm-n-form
brace for comfort.
He experienced wound break down posteriorly and a VAC dressing
was placed. This will stay in place for 10 days with q48 hour
dressing changes. Physical therapy was consulted for
mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
ALENDRONATE - (Prescribed by Other Provider) - 70 mg Tablet - 1
Tablet(s) by mouth once weekly
BRIMONIDINE - (Prescribed by Other Provider) - Dosage uncertain
ECONAZOLE - (Prescribed by Other Provider) - 1 % Cream - aaa
twice a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day
LEVOTHYROXINE - 75 mcg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) -
No Substitution
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth three
times a day
NYSTATIN - 100,000 unit/gram Cream - apply to areas twice a day
as needed
OXYCODONE - (Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - 15 mg
Tablet - 1 Tablet(s) by mouth qid prn pain
POTASSIUM CITRATE - 5 mEq (540 mg) Tablet Extended Release - one
Tablet(s) by mouth twice a day
PREDNISONE - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth once a day
PREGABALIN [LYRICA] - 150 mg Capsule - one Capsule(s) by mouth
three times a day
TOCILIZUMAB - (Prescribed by Other Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] - Dosage
uncertain
TRAZODONE - 100 mg Tablet - [**11-26**] - 1 Tablet(s) by mouth qhs prn
sleep
ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, HA, temp > 101
2. Alendronate Sodium 70 mg PO 1X/WEEK (TU)
3. Amlodipine 10 mg PO DAILY
4. Amoxicillin 500 mg PO Q12H Duration: 10 Days
5. Bisacodyl 10 mg PR [**Hospital1 **]:PRN constipation
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q 12H
7. Calcium Carbonate 1000 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Hydrochlorothiazide 25 mg PO DAILY
10. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
12. Levothyroxine Sodium 75 mcg PO DAILY
13. Lisinopril 20 mg PO DAILY
14. Metoprolol Tartrate 25 mg PO TID
15. OxycoDONE (Immediate Release) 15-45 mg PO Q3H:PRN pain
RX *oxycodone 15 mg [**11-27**] tablet(s) by mouth Q3H Disp #*100 Tablet
Refills:*0
16. PredniSONE 5 mg PO DAILY
17. Pregabalin 150 mg PO TID
18. Senna 1 TAB PO BID
19. Zolpidem Tartrate 5-10 mg PO HS
20. econazole *NF* 1 % Topical as needed
21. Nystatin Cream 1 Appl TP [**Hospital1 **]
22. Pantoprazole 40 mg PO Q24H
23. traZODONE 50-100 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Lumbar spondylosis and stenosis
Acute post-op blood loss anemia
Wound break down
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity: Activity as tolerated
LSO when OOB
Treatments Frequency:
Please continue to change the dressing daily
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2126-6-20**]
|
[
"E878.1",
"E878.8",
"585.2",
"V15.82",
"721.3",
"722.52",
"250.60",
"357.2",
"285.1",
"714.0",
"070.54",
"560.1",
"518.0",
"722.83",
"564.00",
"608.86",
"403.10",
"268.9",
"244.9",
"998.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"81.06",
"81.07",
"80.51",
"81.63",
"84.52",
"77.79",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
8108, 8178
|
3965, 5663
|
297, 344
|
8303, 8310
|
2801, 3942
|
10446, 10526
|
2115, 2266
|
7023, 8085
|
8199, 8282
|
5689, 6998
|
8334, 8433
|
2281, 2782
|
10295, 10355
|
10377, 10423
|
8469, 8662
|
248, 259
|
8698, 9165
|
9177, 10277
|
372, 602
|
624, 1512
|
1528, 2099
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,619
| 112,030
|
45071
|
Discharge summary
|
report
|
Admission Date: [**2127-4-17**] Discharge Date: [**2127-4-21**]
Date of Birth: [**2048-3-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79M with metastatic cholangiocarcinoma s/p metal biliary stent
placement [**11-8**], who presents with fever x 1 day following
repeat ERCP. Pt is a very poor historian, so most of the history
is obtained through chart review and ED providers. The patient
stated that he had the ERCP done, returned home, felt really
fatigued and unable to walk ([**3-7**] leg pain and weakness). His
wife called 911 and he was taken to [**Hospital1 18**] ED. Denied any chest
pain, abd pain, nausea, vomiting. +fevers to 104 at home, +
chills. No headaches. No LOC, no h/o syncope.
.
Patient had second, outpatient ERCP by Dr. [**Last Name (STitle) **] the day
prior to admission due to increasing pruritis and a CT at [**Hospital1 **] that suggesting tumor ingrowth into the stent. He was
pretreated with ampicillin 2gm IV, and gentamicin 80mg IV. ERCP
demonstrated a malignant-appearing biliary stricture affecting
the hilumand right and left ducts. There was debris visible with
in the stent at early cholangiogram. Occulsion cholangiograqm
revealed extensive stricturing of both left and right
intrahepatic ducts. Although a small left intrahepatic radical
opacified, it was not possible to advance the balloon catheter
in this direction. For this reason, no stent could be
introduced. Balloon sweeps were performed from just above the
stent and down through the stent, and a moderate amount of
debris was removed. Even after multiple sweeps, there was some
filling defect left in the upperprotion of the stent, consistent
with a degree of tumor ingrowth. Sticture not amenable to ERCP,
and suggested PTCA as next intervention if futher obstructive
symptoms occur. He was NOT discharged on any anti-biotic ppx.
.
Today pt presents with fever to 103.8, no [**Last Name (un) 103**] pain. no
nausea/no vomiting. c/o fatigue, with reported fevers at home of
103.8--pt took tylenol. In ED, hemodynamically stable.
clinically appears well. wcc is 20. pt was pancultured and
started on levo and flagyl per ercp fellow who review pt in am
for consideration of ir guided drainage if abscess present. ct
in er was equivocal regards to this. pt was therefore admitted
for iv rehydration, iv abx and possible ir procedure. Apparently
had an episode of unresponsiveness in the ED + incontinence.
Stat Head CT ordered--negative. Dr. [**Last Name (STitle) 3271**] requested a neuro
consult on the floor.
.
In the ED, initial VS were T98.8; HR 63; BP 107/57; rr 16, O2
sat 96%. No nausea/vomting reported. No abdominal pain. Blood cx
sent. IVF given, levo, flagyl given as well. Pt was schdeduled
to go to the regular floor but at 2305; pt was found to be
unresponsive, diaphoretic and incontinent of stool. T 102.0(R);
hr 57; BP 104/45; rr 21 O2 sat 97%2L. BS 246 at the time. Per
nsg report, got up to go to the bathroom, felt off, ? syncopal
event; got back into bed, was found by nurse to be unresponsive
and was incontinent of stool. Pt woke up after sternal rub,
alert and oriented x 3. CT scan was ordered in the ED--negative.
Of note, but had a recent 40-50lbs weight loss over last year.
.
Upon arrival to the [**Hospital Unit Name 153**], the patient's complaint was fatigue
and leg pain. Vital signs were stable. No abdominal pain, no
nausea, no vomiting.
Past Medical History:
1) Metastatic cholangiocarcinoma, diagnosed [**11-8**], s/p metal
stent placement.
2) Glucose intolerance
3) CAD, s/p old inferior MI, s/p cath [**2121**] demonstrating 60% LCx
lesion, no intervention . EF 45%.
4) PVD
5) hyperlipidemia
6) s/p pacemaker placement for bradycardia 4 yrs ago--[**Company 1543**]
Sigma 300 SDR. placed for sx bradycardia. programmed DDD with
max rate 80.
PSH:
7) intussusception repair as a child
8) herniorraphy
Social History:
The patient has been married for 47 years, has four children and
11 grandchildren. He does not smoke though he did in the remote
past having quit 20 years ago.
Family History:
[**Name (NI) **] father died of heart disease at age
88. [**Name (NI) **] mother had [**Name (NI) 4522**] disease, and apparently died of
complications of that in her late 60's. Two of the patient's
children are physicians.
.
Physical Exam:
PE: Temp: 99.5; HR 100; BP 106/63; RR 17; O2 sat 98%ra
HEENT: very dry mucus membranes. no thyromegaly. no scleral
icterus appreciated.
CV: regular S1 and S2. No murmurs, rubs or gallops appreciated.
LUNG: CTAB. no wheezes, rales, rhonchi
ABD: scar from previous surgery. +BS. soft, non-tender,
non-distended, no organomegaly appreciated. no RUQ tenderness
EXT: WWP, good palpable pulses.
NEUR: a and o x 3. responds to questions appropriately, but at
times tangential and a poor historian
SKIN: no rashes
Pertinent Results:
[**2127-4-16**] 10:00AM WBC-8.4 RBC-4.43* HGB-13.6* HCT-41.6 MCV-94
MCH-30.7 MCHC-32.7 RDW-14.2
[**2127-4-16**] 10:00AM NEUTS-78.9* LYMPHS-13.8* MONOS-5.1 EOS-0.8
BASOS-1.3
[**2127-4-16**] 10:00AM PLT COUNT-224
[**2127-4-16**] 10:00AM PT-15.2* INR(PT)-1.4*
[**2127-4-16**] 10:00AM ALBUMIN-3.8
[**2127-4-16**] 10:00AM ALT(SGPT)-99* AST(SGOT)-101* ALK PHOS-516*
TOT BILI-1.8* DIR BILI-0.4* INDIR BIL-1.4
[**2127-4-16**] 10:00AM UREA N-18 CREAT-1.1 SODIUM-138 POTASSIUM-6.0*
CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
[**2127-4-16**] 11:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2127-4-16**] 11:00AM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
troponin 0.04->0.02
ck-mb 7->3
.
AEROBIC BOTTLE (Final [**2127-4-20**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2127-4-18**] 11AM.
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2127-4-20**]):
ENTEROBACTER CLOACAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
.
surveillance blood cx from [**4-19**] and [**4-20**]: no growth to date
.
EKG:
Sinus rhythm with atrial sensing and ventricular pacing. No
previous tracing available for comparison.
.
CT OF THE ABDOMEN WITH IV CONTRAST: There are mild dependent
changes at the lung bases. A biliary stent is noted in the
common duct. Moderate intrahepatic biliary ductal dilatation is
noted. Near the porta hepatis and adjacent to the proximal end
of the biliary stent is an approximately 5.7 x 3.7-cm area of
hypodensity of the hepatic parenchyma with ill-defined borders.
Multiple smaller satellite low-attenuation hepatic foci with
similar ill- defined appearance are noted. There is associated
moderate intrahepatic biliary ductal dilatation. There is no
defined fluid collection and no subcapsular or perihepatic
fluid. There is no ascites or intraperitoneal focal fluid
collection or abscess. The pancreas, spleen, adrenal glands,
stomach and bowel are unremarkable. At the upper pole of the
right kidney is a 3.1-cm exophytic lesion which measures 28
Hounsfield units, higher than expected for a simple cyst.
Smaller bilateral parapelvic cysts are noted. There are
bilateral extrarenal pelves. There is no pathologic mesenteric
or retroperitoneal lymphadenopathy.
CT OF THE PELVIS WITH IV CONTRAST: The rectum, urinary bladder
and pelvic loops of bowel are unremarkable. The prostate is
mildly enlarged. There is no free pelvic fluid or
lymphadenopathy.
BONE WINDOWS: No suspicious osteoblastic or osteolytic lesions
are identified.
IMPRESSION:
1. 5.7 x 3.7 cm region of low attenuation of the hepatic
parenchyma near the porta hepatis with ill-defined borders and
multiple smaller satellite hypodense foci. These findings are
thought more likely to represent primary cholangiocarcinoma with
intrahepatic metastases. The possibility of superinfection
cannot be definitively excluded. Evaluation with ultrasound
could be helpful to determine if there is a fluid component. If
so, this could be aspirated for diagnostic purposes.
2. Bilateral parapelvic renal cysts.
3. 3.1-cm exophytic lesion of the right kidney measures greater
density than expected for a simple cyst. Ultrasound is suggested
to determine if this is a cyst or possibly a solid lesion.
.
RUQ ULTRASOUND:
FINDINGS: There is mild edema within the gallbladder wall which
may be seen with liver disease. The gallbladder is relaxed and
no pericholecystic fluid is identified to suggest cholecystitis.
As noted on prior CT, there is intrahepatic biliary ductal
dilatation. Upper pole cyst is identified on the right kidney
measuring 3.1 cm x 3 cm x 2.1 cm. No fluid collections around
the liver or gallbladder are identified.
IMPRESSION:
1. No fluid collections identified in or around the liver or
gallbladder.
2. Intrahepatic biliary ductal dilatation also noted on CT one
day previous.
3. Edema within the gallbladder wall which may be seen with
liver disease. No evidence of acute cholecystitis identified.
.
AP CXR:
Heart size top normal. Lungs clear. No edema or pleural
effusion. Fullness in the mediastinum at the thoracic inlet to
the right of midline could be due to goiter or tortuous head and
neck vessels. Transvenous right atrial and right ventricular
pacer leads in standard placements. No pneumothorax or pleural
effusion.
.
HEAD CT W/O CONTRAST:
FINDINGS: No definite evidence of acute intracranial hemorrhage.
There is no shift of normally midline structures or
hydrocephalus. [**Doctor Last Name **]-white matter differentiation appears grossly
preserved. Several areas of relative [**Name (NI) 33214**] is seen
within vessels, including the MCAs and vertebrals, possibly
secondary to recent contrast administration. Visualized
paranasal sinuses appear normally aerated.
IMPRESSION: No evidence of acute intracranial hemorrhage. MRI
with diffusion-weighted images is more sensitive in the
evaluation for acute ischemia/infarct and for vascular detail.
Brief Hospital Course:
1) Gram negative septicemia due to cholangitis: Bacteremia may
have been secondary to manipulation during ERCP. RUQ ultrasound
showed no evidence of cholecystitis. Culture grew enterobacter.
Patient received ampicillin and gentamicin while in house and
was discharged on po cipro. Surveillance blood cultures remain
negative. Plan for total of 14 days of antibiotics. Patient is
hemodynamically stable. LFTs are steadily improving.
Percutaneous biliary drain was discussed but was not necessary
given bili trending down with the cleaning of the stent done on
initial ERCP.
.
2) Cholangiocarcinoma/locally metastatic, growing into the
stent, obstructing bile ducts: Patient is currently under
hospice care.
.
3) Syncope: Pacer was interrogated. Episode of ? VT noted but
did not temporally correlate with patient's episode. More
likely this was due to transient hypotension in the setting of
his sepsis. However, could certainly consider AICD once
bacteremia completely treated given concurrent low EF (EF
20-30%). However, patient is in hospice and likely would
refuse. This was not discussed during his inhospital course.
Neuro exam was normal and head CT was negative. Orthostatics
were negative. No significant arrhythmias on tele other than a
transient tachycardia EP believes was possibly afib/flutter,
ventricularly paced.
.
4) Renal cyst: Incidental finding on CT. Consider follow-up
ultrasound to better characterize, as recommended, if patient
agreeable.
.
5) h/o CAD: Patient is on an aspirin and a beta blocker. He
denied any chest pain. His statin was held due to bump in LFTs.
Could consider restarting at follow-up but likely little
benefit given overall prognosis and patient will continue to be
at risk of recurrent transaminitis.
.
6) h/o colitis: Patient was continued on his home Asacol,
Anaspaz
.
7) ARF: Resolved with IVF. Likely prerenal. Please resume
diovan at follow-up visit if creatinine and blood pressure
remain stable.
.
8) Coagulopathy: Resolved with vitamin K. Inr 1.9 on admit, now
1.4.
.
9) Dispo: discharged home with prior hospice services
.
10) Code status: DNR/DNI
Medications on Admission:
Meds from records--need to confirm with wife in AM
ASACOL 400MG--2 tabs three times a day per dr [**Last Name (STitle) 96328**]
ASPIRIN 81MG--One tablet twice a day
DIOVAN 80MG--One tablet by mouth every day
HYOSCYAMINE SULFATE 0.375MG--One tablet twice a day
METOPROLOL TARTRATE 25MG--One tablet twice a day
PRAVACHOL 20MG--One tablet at bedtime
TIMOLOL 0.25%--One gtt twice a day
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
3. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Disp:*120 Tablet, Sublingual(s)* Refills:*0*
4. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO twice a
day for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
primary:
enterobacter septicemia due to cholangitis
secondary:
cholangiocarcinoma
syncope
Discharge Condition:
good: hemodynamically stable, afebrile, LFTs improved
Discharge Instructions:
Please call your doctor or go to the emergency room for
temperature > 100.5, worsening abdominal pain or fullness, or
other concerning symptoms.
Please take the antibiotics, as prescribed, until they are gone.
Please note you have been started on a new blood pressure
medication, which also helps with controlling the rate of your
heart. Please take, as prescribed.
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6164**], on Monday, [**2127-4-28**] at 4:30 PM to follow-up this
hospital admission. Phone: [**Telephone/Fax (1) 4475**]
You can call to schedule follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **], only
as needed. Phone: ([**Telephone/Fax (1) 10532**]
|
[
"414.01",
"197.8",
"V58.66",
"576.1",
"V45.01",
"753.10",
"443.9",
"997.5",
"365.9",
"401.9",
"E947.8",
"V15.82",
"584.9",
"995.91",
"412",
"155.1",
"286.9",
"272.4",
"038.49",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
14151, 14209
|
11067, 13194
|
320, 327
|
14344, 14400
|
5026, 11044
|
14817, 15204
|
4254, 4483
|
13627, 14128
|
14230, 14323
|
13220, 13604
|
14424, 14794
|
4498, 5007
|
275, 282
|
355, 3595
|
3617, 4061
|
4077, 4238
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,914
| 111,378
|
44394
|
Discharge summary
|
report
|
Admission Date: [**2152-12-3**] Discharge Date: [**2152-12-5**]
Date of Birth: [**2078-6-20**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 74-year-old man with a
history of hypertension and an atrophic right kidney who
presents for rehydration for renal artery angiography and
stenting. He has a baseline creatinine of 2.6. An MR
angiogram on [**10-5**] showed bilateral high grade renal artery
stenosis with near complete occlusion of the right renal
artery and an atrophic poorly functional right kidney. He
also had a focal segment of high grade stenosis in the
proximal left renal artery.
Mr. [**Known lastname 3794**] [**Last Name (Titles) **] headache, fever, chills, nausea, vomiting,
diarrhea, chest pain, shortness of breath, orthopnea, PND,
dysuria, bright red blood per rectum, melena, or abdominal
pain. He notes muscle pain since switching from Zocor to
Lipitor.
PAST MEDICAL HISTORY: Hypertension for 14 years,
hypercholesterolemia, gout, diverticulosis with a flare in
[**2150**], bilateral renal artery stenosis with an atrophic right
kidney and an 11.4 cm left kidney. His baseline creatinine
is 2.6. Arthritis. Status post transurethral resection of
the prostate in [**2140**]. Cardiac catheterization in [**2150-4-28**]
with no coronary artery disease and an EF of 63%.
MEDICATIONS: Lipitor 10 mg q day, Allopurinol 300 mg q day,
Cardizem CD 240 mg q day, Amiloride/HCTZ [**3-/2101**] one tablet q
day, Coreg 12.5 mg q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **]
uses no tobacco or intravenous drugs. He has social alcohol
use. He is a former firefighter and football coach. He is
independent with no restrictions on his activity at home.
PHYSICAL EXAMINATION: This is an elderly gentleman in no
acute distress who is afebrile with a blood pressure of
143/64, a pulse of 64 and oxygen saturation of 99% on room
air. He weighs 83.9 kg. His HEENT exam was unremarkable.
He has no jugulovenous distension or carotid bruits. His
lungs are clear to auscultation bilaterally, and his heart is
regular rate and rhythm with no murmurs. His abdomen is
benign. His extremities are without edema and with 2+
dorsalis pedis and posterior tibial pulses bilaterally. He
has no groin bruits. His neuro exam is grossly intact.
LABORATORY DATA: Reveal a white count of 7.5, hematocrit
39.7 and platelet count of 178,000. His Chem 7 is within
normal limits except for a BUN of 61 and creatinine of 2.9.
His coagulations are within normal limits. His calcium is
9.3, magnesium 2.2 and phosphorus 3.3. His CK is 58. Repeat
CKs after his procedure were 50 and 42. These CKs are
suggestive of his muscle aches not being from side effects
from his Lipitor. His baseline creatinine is 2.6.
HOSPITAL COURSE: Mr. [**Known lastname 3794**] was admitted and hydrated with
normal saline and received Mucomyst prior to catheterization.
The procedure revealed a proximal total occlusion of his
right renal artery which was his known atrophic kidney. He
had a 90% proximal tubular lesion of his left renal artery
that was angioplastied and stented with 0% residual stenosis
and normal flow. He was then admitted to the CCU for
observation due to complications in the cath suite. He was
noted initially to be bradycardic with a heart rate in the
40's but normotensive with a blood pressure of 107/51 at the
start of the case. He required 0.6 mg of Atropine at three
separate times during the procedure for his low heart rate.
His case was also complicated by hypotension during injection
of the left renal artery and during angioplasty of that
artery. His blood pressure dropped as low as 79/48. For
this reason, Dopamine was started and titrated up to 10 mcg
per kg per minute. After left renal artery stent placement,
the Dopamine was successfully weaned off with a systolic
blood pressure in the 90's to 100's before the case was
concluded. At this time he complained of chest pain and some
ST depressions were noted. Coronary angiography was
performed at that time that revealed no evidence of
significant coronary disease. He had a normal left main, LAD
and left circumflex arteries. He had a 30% mid right
coronary artery stenosis with normal flow.
In the CCU, he was bradycardic with a heart rate in the 40's
and on the low end of normotensive with a blood pressure in
the 100's/50's. His antihypertensives were held with an
increase in his heart rate and blood pressure over the next
12 hours to a heart rate in the 80's and a blood pressure in
the 130's/60's by the morning. He suffered no further
complications of his procedure. His hematocrit remained
stable at around 37-38. His creatinine returned to its
baseline of 2.6 after catheterization.
He was discharged home on Aspirin for life and Plavix for
thirty days for his stent. A new antihypertensive regimen
was discussed with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who
follows him for blood pressure control as he did not appear
to be tolerating two AV nodal blocking agents well as
evidenced by his bradycardia. His Cardizem was stopped and
replaced by Norvasc. He will follow-up with Dr. [**First Name (STitle) **] who
performed the procedure in [**3-3**] weeks and follow-up with Dr.
[**Last Name (STitle) **] regarding his blood pressure in one week. He will also
have a follow-up creatinine checked in two days with the
results faxed to Dr.[**Name (NI) 29343**] office.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home to follow-up with Dr. [**Last Name (STitle) 95174**] in
[**3-3**] weeks and to follow-up with Dr. [**Last Name (STitle) **] in one week.
DISCHARGE DIAGNOSIS:
1. Hypertension.
2. Bilateral renal artery stenosis, status post left renal
artery stent placement.
3. Hypercholesterolemia.
4. Gout.
5. Diverticulosis.
6. Arthritis.
7. Status post transurethral resection of the prostate.
DISCHARGE MEDICATIONS: Lipitor 10 mg q day, Allopurinol 300
mg q day, Amiloride/HCTZ [**3-/2101**] one tab q day, Coreg 12.5 mg q
day, Norvasc 5 mg q day, Aspirin 325 mg q day, Plavix 75 mg
for 30 days.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2152-12-5**] 18:15
T: [**2152-12-8**] 09:51
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern1) 95175**]
|
[
"274.9",
"427.89",
"440.1",
"458.2",
"272.0",
"403.90",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"39.50",
"89.68",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
6008, 6502
|
5753, 5984
|
2838, 5533
|
1799, 2820
|
156, 909
|
932, 1522
|
1539, 1776
|
5558, 5732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,477
| 127,598
|
44730
|
Discharge summary
|
report
|
Admission Date: [**2147-8-17**] Discharge Date: [**2147-8-29**]
Date of Birth: [**2071-2-2**] Sex: M
Service: SURGERY
Allergies:
Ativan
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain & weight loss.
Major Surgical or Invasive Procedure:
[**2147-8-17**]:
1. Exploratory laparotomy.
2. Double bypass consisting of Roux-en-Y
choledochojejunostomy and gastroenterostomy.
3. Celiac lymph node biopsy for staging.
4. Placement of CyberKnife gold fiducial seeds.
5. Extended adhesiolysis.
History of Present Illness:
This 76-year-old Russian-speaking gentleman recently presented
with chronic abdominal pain which was progressive over the last
2 months. He had lost weight from this. He had a general failure
to thrive over this period time. He was not
yet jaundiced. He was worked up and found to have a pancreatic
head mass. This furthermore was biopsied through endoscopic
means and found to be an adenocarcinoma. He presented to Dr.
[**First Name (STitle) **] from Medical Oncology for consideration of chemotherapy
and radiation therapy given the large size of this mass. Dr.
[**First Name (STitle) **] requested an opinion regarding potential resectability.
Mr. [**Known lastname **] was admitted for surgical intervention, probable
Whipple pancreaticoduodenectomy versus palliative bypass surgery
depending on the resectability of the tumor.
Past Medical History:
PMHx: Type II DM, HTN, hypercholesterolemia, GERD, BPH, CAD with
h/o MI.
.
PSHx: Vocal cord cancer diagnosed [**2140**] (SCC) s/p surgery,
partial colectomy [**2129**], CAD with h/o MI s/p CABG, s/p appy, s/p
laparoscopic cholecytectomy.
Social History:
Primary language is Russian. Lives in [**Location 2312**] with his wife.
[**Name (NI) 3003**] tobacco -100 pack-years. No ETOH. Retired barber in
[**Country 532**].
Family History:
Denies CAD or lung cancer.
Physical Exam:
[**2147-8-11**] Pre-Admission Physical:
On physical exam, his abdomen is soft, moderately distended, but
nontender. There is no mass effect to be appreciated. There is
no evidence of hernias or infections in his incisions, which
include a median sternotomy incision as well as a right
paramedian incision. His inguinal and genital region shows no
evidence of any masses or any hernias. His rectal exam was
deferred today. The remainder of his physical exam is entirely
normal.
.
At Discharge:
VS: AVSS
GEN: Thin male in NAD.
HEENT: Sclerae clear. O-P clear.
NECK: Supple.
LUNGS: CTA(B).
COR: RRR
ABD: Midline incision with steri-strips c/d/i. 2 small areas of
wound breakdown packed with wet-to-dry dressing. No erythema or
induration, no purulence from wound. Prior (R)LQ JP drain
(discontinued) site healing with DSD. Appropriately tender to
palpation along incision, otherwise soft/NT/ND.
GU: Foley d/c'ed prior to discharge and patient voiding without
difficulty. Negative CVAT.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal.
Pertinent Results:
On Admission:
[**2147-8-17**] 04:24PM POTASSIUM-4.1
[**2147-8-17**] 04:24PM CK(CPK)-103
[**2147-8-17**] 04:24PM CK-MB-4 cTropnT-<0.01
[**2147-8-17**] 04:24PM MAGNESIUM-1.6
[**2147-8-17**] 04:24PM HCT-35.2*
[**2147-8-17**] 12:39PM TYPE-ART PO2-268* PCO2-48* PH-7.34* TOTAL
CO2-27 BASE XS-0
[**2147-8-17**] 12:39PM GLUCOSE-148* LACTATE-0.8 NA+-137 K+-3.8
CL--101
[**2147-8-17**] 12:39PM HGB-12.1* calcHCT-36
[**2147-8-17**] 12:39PM freeCa-1.15
.
Prior to Discharge:
[**2147-8-21**] 11:09AM BLOOD WBC-8.4 RBC-3.36* Hgb-10.4* Hct-30.3*
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.4 Plt Ct-193
[**2147-8-21**] 11:09AM BLOOD Plt Ct-193
[**2147-8-21**] 11:09AM BLOOD Glucose-112* UreaN-8 Creat-0.7 Na-138
K-4.0 Cl-102 HCO3-30 AnGap-10
[**2147-8-18**] 04:07AM BLOOD CK(CPK)-484*
[**2147-8-21**] 10:16PM BLOOD Calcium-7.7* Phos-3.5# Mg-1.9
.
[**2147-8-17**] Pathology:
SPECIMEN SUBMITTED: NODE OF IMPORTANCE.
DIAGNOSIS: Metastatic mucin-producing adenocarcinoma involving
lymph node and fibroadipose tissue, consistent with
pancreatico-biliary origin.
Clinical: Pancreatic cancer, node of importance.
Gross:
The specimen is received fresh from the OR for frozen section
diagnosis labeled with the patient's name, "[**Known lastname **], [**Known firstname 95696**]" the
medical record number and additionally "node of importance."
The diagnosis per Dr. [**Last Name (STitle) **] is " Adenocarcinoma; no lymph nodal
tissue clearly identified". The specimen consists of piece of
fatty tissue measuring 3 x 2 x 1 cm. Upon examining it for
lymph nodes, two have been identified. One lymph node is
separate from the rest of the specimen and will be designated
lymph node 1. The other lymph node is attached to the fatty
tissue and will be designated lymph node 2. Both lymph nodes
are represented on the frozen section. The specimen is entirely
submitted as follows: A = frozen section remnant containing
lymph nodes 1 and 2, B = remainder of lymph node 1, C-E =
remaining fatty tissue.
.
[**2147-8-17**] ECG:
Sinus rhythm. Non-diagnostic inferior Q waves. Diffuse ST-T
waves. Compared to the previous tracing of [**2147-8-11**] ST-T wave
changes are new.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
80 124 88 [**Telephone/Fax (3) 95697**]1 147
.
[**2147-8-17**] CXR:
IMPRESSION: No acute cardiopulmonary process.
[**2147-8-26**] CXR:
Impression: mild [**Hospital1 **]-basilar atelectasis
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation of the aforementioned problem. On [**2147-8-17**], the
patient underwent exploratory laparotomy, double bypass
consisting of Roux-en-Y, choledochojejunostomy and
gastroenterostomy, celiac lymph node biopsy for staging,
placement of CyberKnife gold fiducial seeds, extended
adhesiolysis, which went well without complication (reader
referred to the Operative Note for details). In the PACU, the
patient experienced tachycardia, low urine output, and
hypotesion, for which he received a total of 1 liter in fluid
boluses and albumin with good response. Cardiac enzymes were
negative. EKG without ectopy or arrythmia. Later, the patient
was transferred to the floor NPO with an NG tube, on IV fluids,
with a foley catheter and a JP drain in place. He received a
single dose of intra-thecal morphine prior to surgery with good
pain control on POD#0. The patient was hemodynamically stable.
.
Post-operative pain was initially well controlled with the
intra-thecal morphine on POD#0 and then a Dilaudid PCA
thereafter, which was converted to oral pain medication when
tolerating clear liquids. The NG tube and foley catheter were
discontinued on POD#4. Unfortunately, the patient was unable to
void and the foley catheter was replaced. The patient has a
history of BPH. Home dose of Flomax was restarted. On POD#6, the
foley was again discontinued, again the patient was unable to
void, and the foley was replaced. Urology was consulted. As per
their recommendations, the foley was maintained in place until
POD 11, when the patient was again having urinary tract pain. A
U/A was sent and negative for infection and at the patient's
request the catheter again d/c'ed for a voiding trial. He was
again unable to pass urine and the catheter re-inserted, he was
sent home on his BPH meds with urology follow up as an
outpatient. The patient was started on sips of clears on POD#5,
which was progressively advanced as tolerated to a regular diet
by POD#6. The JP was discontinued on POD#7.
.
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. 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. When tolerating clears, he was
restarted on his home hypoglycemic medications, with the
exception of Januvia, which is not formulary.
.
Overnight on POD#3, the patient became agitated and exhibited
sundowning behavior. His experienced similar symptoms for the
next few nights. The Psychiatric Clinical Nurse Specialist and
Socail Worker were consulted. He received Haldol PRN and
re-orientation. As his recovery progressed, this behavior
improved.
.
On POD 7 the patient was noted to have 2 small areas of wound
breakdown around the incision line, in these areas the staples
were removed and small pieces of saline soaked gauze was used to
pack them sterily. A wound culture grew MSSA and he was started
on levoquin. The areas were packed for the remainder of his stay
and he was discharged on 5 days of levoquin with VNA for wet-to
dry packing changes.
.
At the time of discharge on POD 12, the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
regular diet, although with poor appetite, ambulating, and pain
was well controlled. The foley catheter was in place and patent.
He was discharged to an extended care facility. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Colace 100mg 1 cap PO BID
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. ASA 81mg 1 tab PO daily
13. Nitroglygerin 0.4mg SL Q15minutes x3 PRN for chest pain
14. Insulin Regular Human 100 unit/mL Solution Sig: 2-12 units
Injection As directed per Regular Insulin SlidingScale.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(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).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed for SOB/cough/wheeze.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain: Rx in Russian please.
Disp:*50 Tablet(s)* Refills:*0*
14. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
15. Insulin Regular Human 100 unit/mL Solution Sig: 2-12 units
Injection As directed per Regular Insulin SlidingScale.
16. Dronabinol 2.5 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 2 weeks.
Disp:*42 Capsule(s)* Refills:*0*
17. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] house
Discharge Diagnosis:
1. Pancreatic cancer.
2. Obstruction of the bile duct.
3. Gastric outlet obstruction.
4. Dense intraoperative adhesions.
5. Urinary retention
6. Type II DM
Discharge Condition:
Good
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 is 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.
You will be discharged with a foley catheter in place and a leg
bag - you were instructed in its use by nursing staff - you will
follow up with urology as an outpatient in [**11-18**] weeks. Please
call their office for an appointment.
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 [**3-26**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
- You will have wet-to-dry packing changes of the incision site
on your abdomen, as have been done in the hospital. A visiting
nurse will help you with this. It is important to keep this area
clean and change the dressing 2x/day.
*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 Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Surgery). Phone: ([**Telephone/Fax (1) 2828**].
Date/Time: [**2147-9-8**] at 9:15am. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
You will need to follow up with Urology as an outpatient at
8:45am [**9-6**], this is with Dr [**Last Name (STitle) 986**]. This is located on
[**Hospital Ward Name 23**] 3 on the [**Hospital Ward Name **].
.
You have an appointment with Radiation oncology at 9:30am on
[**8-31**] (THURSDAY). This is in the [**Hospital Ward Name 516**] [**Hospital Ward Name **]
building at [**Location (un) **] in the basement. You can call
[**Telephone/Fax (1) 9710**] with any questions.
.
Please call ([**Telephone/Fax (1) 1921**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 13959**] (PCP) in [**12-20**] weeks.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2147-9-13**]
9:00
Completed by:[**2147-8-29**]
|
[
"272.0",
"998.32",
"576.2",
"788.29",
"401.9",
"157.0",
"537.0",
"V45.81",
"998.59",
"412",
"041.11",
"250.00",
"783.7",
"568.0",
"600.01",
"E878.2",
"414.00",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.36",
"44.39",
"40.11",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
12014, 12067
|
5379, 9132
|
294, 544
|
12267, 12274
|
2959, 2959
|
14746, 15785
|
1865, 1893
|
10286, 11991
|
12088, 12246
|
9158, 10263
|
12298, 13989
|
14004, 14723
|
1908, 2392
|
2406, 2940
|
225, 256
|
572, 1405
|
2974, 5356
|
1427, 1666
|
1682, 1849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,571
| 123,832
|
28839
|
Discharge summary
|
report
|
Admission Date: [**2154-7-31**] Discharge Date: [**2154-8-4**]
Date of Birth: [**2131-5-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Motor vehicle accident.
Major Surgical or Invasive Procedure:
None on this admission.
History of Present Illness:
Pt is 29 y/o man with no psychiatric
hx who presents from [**Hospital 1474**] Hospital, where he had been
admitted following MVA. Per pt's father, pt had been driving
home
from the gym at around 10-11pm Tuesday night to go out with
friends prior to the accident. Pt's truck apparently struck a
guardrail and rolled over; pt was unrestrained and was likely
either thrown through the passenger side window or through the
windshield on the passenger side. He had loss of consciousness,
and EMS brought him to [**Hospital1 1474**]. Head imaging was negative;
spine
imaging was notable for a T6 compression fracture. BAL
reportedly
165, Utox reportedly otherwise negative. Pt was intermittently
agitated and combative. He was intubated and transferred to
[**Hospital1 18**]. At [**Hospital1 18**] his BAL was 58; Utox positive for benzos
(possibly received at [**Hospital1 1474**]). He was extubated, and he
remained intermittently agitated.
Past Medical History:
None
Family History:
Noncontributory.
Pertinent Results:
[**2154-8-3**] 12:50PM BLOOD WBC-11.9* RBC-4.59* Hgb-15.0 Hct-41.1
MCV-90 MCH-32.6* MCHC-36.4* RDW-13.0 Plt Ct-289#
[**2154-8-2**] 09:15AM BLOOD WBC-8.7 RBC-4.29* Hgb-14.0 Hct-39.1*
MCV-91 MCH-32.7* MCHC-35.9* RDW-13.3 Plt Ct-174
[**2154-8-1**] 02:35AM BLOOD WBC-12.3* RBC-4.70 Hgb-14.9 Hct-41.2
MCV-88 MCH-31.7 MCHC-36.2* RDW-13.0 Plt Ct-284
[**2154-7-31**] 04:04PM BLOOD WBC-12.1* RBC-4.67 Hgb-15.0 Hct-41.5
MCV-89 MCH-32.2* MCHC-36.3* RDW-13.2 Plt Ct-265
[**2154-8-3**] 12:50PM BLOOD Plt Ct-289#
[**2154-8-2**] 09:15AM BLOOD Plt Ct-174
[**2154-7-31**] 05:10AM BLOOD Fibrino-231
[**2154-8-4**] 05:50AM BLOOD Glucose-87 UreaN-13 Creat-1.1 Na-143
K-3.7 Cl-105 HCO3-26 AnGap-16
[**2154-8-3**] 12:50PM BLOOD Glucose-112* UreaN-13 Creat-1.0 Na-145
K-3.9 Cl-110* HCO3-22 AnGap-17
[**2154-8-4**] 05:50AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.2
[**2154-8-3**] 12:50PM BLOOD Calcium-9.2 Phos-4.6* Mg-2.5
[**2154-7-31**] 05:10AM BLOOD ASA-NEG Ethanol-58* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2154-7-31**] 05:18AM BLOOD Glucose-165* Lactate-6.3* Na-145 K-3.6
Cl-102 calHCO3-20*
.
.
URINE
[**2154-7-31**] 05:10AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2154-7-31**] 05:10AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-100 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2154-7-31**] 05:10AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2154-7-31**] 05:10AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
[**2154-8-1**] 2:27 am URINE Source: Catheter.
**FINAL REPORT [**2154-8-2**]**
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
[**2154-8-2**]): Negative for Chlamydia trachomatis by PCR.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final [**2154-8-2**]): Negative for Neisseria Gonorrhoeae by
PCR.
.
.
CT T-SPINE W/O CONTRAST; CT L-SPINE W/O CONTRAST
FINDINGS: C7 through S1 were evaluated in this study. There is
an NG tube extending below the diaphragm into the stomach. There
is an ET tube which appears to be in appropriate position with
the tip approximately 2 cm above the carina.
There is mild compression of the vertebral body of T6 which
appears to be decreased in height, slightly more evident
posteriorly. No definite cortical break can be identified in
this study. This likely represents a compression fracture of
unknown age. There is no evidence of spinal canal stenosis at
this level or retropulsed fragment at this level. No other
fractures were identified. The alignment of the facet joints is
within normal limits. The curvature of the spine is normal.
Dependent atelectasis in the lungs is seen. No other paraspinal
abnormality is noted.
IMPRESSION: Mild (approximately 25%) compression of the
vertebral body of T6. This likely represents a compression
fracture of unknown age. There is no evidence of central spinal
canal narrowing or retropulsed fragment at this level.
.
.
CT T-SPINE W/O CONTRAST [**2154-7-31**] 1:04 PM
FINDINGS: C7 through S1 were evaluated in this study. There is
an NG tube extending below the diaphragm into the stomach. There
is an ET tube which appears to be in appropriate position with
the tip approximately 2 cm above the carina.
There is mild compression of the vertebral body of T6 which
appears to be decreased in height, slightly more evident
posteriorly. No definite cortical break can be identified in
this study. This likely represents a compression fracture of
unknown age. There is no evidence of spinal canal stenosis at
this level or retropulsed fragment at this level. No other
fractures were identified. The alignment of the facet joints is
within normal limits. The curvature of the spine is normal.
Dependent atelectasis in the lungs is seen. No other paraspinal
abnormality is noted.
IMPRESSION: Mild (approximately 25%) compression of the
vertebral body of T6. This likely represents a compression
fracture of unknown age. There is no evidence of central spinal
canal narrowing or retropulsed fragment at this level.
.
Brief Hospital Course:
This patient was admitted as a transfer trauma patient status
post motor vehicle accident. He had a GCS of 8 at the referring
hospital, for which he was intubated and brought over here to
[**Hospital1 18**]. At [**Hospital1 18**], he was stable, and re-scanned as necessary. He
had no obvious injuries and was taken to the ICU for
observation. He was agitated and was difficult to awaken while
in the unit; he was later extubated but remained agitated and
did not always communicate with members of housestaff. He was
transfered to the floor, where a Code Purple was immediately
called. The Code Purple was called for pt's shouting and
combativeness. Upon the arrival of psychiatry, pt hadalready
been placed in 4-pt restraints. He cried out periodically,
shouted obscenities, and at one point yelled, "Get off of me;"
security was present in the room at that time, but no one was on
the patient at the time of the comment. He was given Haldol and
Ativan, which temporarily helped to calm him down. Overnight, he
remained agitated and aggressive, and was given various
combinations of Cogentin, Haldol, Morphone and Ativan. The
following morning, he was more calm, although still in
restraints. Throughout the remaining duration of his stay at
[**Hospital1 18**], he continued to improve and become more alert and less
agitated. He remained slightly confused. His Foley catheter was
eventually removed, and he had daily EKG's to monitor his QTc.
This patient was discharged in a stable condition.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for prn pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Benztropine 1 mg/mL Solution Sig: One (1) Injection Q4 () as
needed.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
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. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
Q4H (every 4 hours) as needed for aggitation.
Discharge Disposition:
Home
Discharge Diagnosis:
Motor vehicle accident.
Discharge Condition:
Stable.
Discharge Instructions:
Please call/return to [**Hospital1 18**] if you have persistent fevers, pain,
shortness of breath, decreased/pain with urination, fatigue,
bleeding and/or infection.
Followup Instructions:
Please arrange for a follow-up appointment with your primary
care physician in one week's time (please ask your PCP to do [**Name Initial (PRE) **]
repeat EKG and assess neurological function, both central and
peripheral). Your PCP may arrange an appointment for you to see
a psychiatrist, if he/she feels it is necessary.
You may also arrange a follow-up appointment at the Trauma
Clinic as necessary, or if you experience furthur symptoms/have
furthur questions. The number is [**Telephone/Fax (1) 12786**].
Completed by:[**2154-8-6**]
|
[
"780.09",
"293.9",
"V71.4",
"E815.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7628, 7634
|
5515, 7014
|
337, 362
|
7701, 7710
|
1409, 5492
|
7925, 8465
|
1372, 1390
|
7037, 7605
|
7655, 7680
|
7734, 7902
|
274, 299
|
390, 1328
|
1350, 1356
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,991
| 152,515
|
21622
|
Discharge summary
|
report
|
Admission Date: [**2184-3-3**] Discharge Date: [**2184-3-16**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
cystoscopy
History of Present Illness:
This is a 89 yo F with a PMHx of recently diagnosed bladder mass
suspicious for TCC, dementia (possibly [**Last Name (un) 56911**] body), DMII, h/o
CVA and possibly seizures who p/f [**Hospital3 **] with complaints
of worsening hematuria.
.
The patient got her labs drawn at [**Last Name (un) **] hosue and her Hct was
found to be down to 25.3 from 29.3 . She was also reported to
be complaining of worsening weakness, dizziness and decreased po
intake. She was sent to the [**Hospital1 18**] ED.
.
There her VS were stable and a 3 way foley was placed. Urology
saw the patient and advised continued flushing and medicine
admission. The patient was recently seen by Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] a
cystoscopy was done on [**2184-1-16**] which showed an anterolateral and
posterior wall tumor. Urine cytology was suspicious for
urotherlial dysplasia. A CT was also done as part of that work
up which revealed two bladder masses concerning for TCC. The
patient was admitted for w/u for her ARF and hematuria.
.
On the floor, the patient c/o constipation. Otherwise she
denies complaints.
.
12 points ROS is otherwise negative
.
Past Medical History:
1. Seizure
2. DMII with multiple admissions for hypoglycemia
3. Dementia (possibly [**Last Name (un) 56911**] body with reported occasional
hallucinations)
4. CVA
5. TIA
6. Hypertension
7. Diverticulosis
8. GERD
9. stage I cervical cancer
10. h/o Zoster of the upper lip
11. osteoporosis
Social History:
Former EtOH, quit smoking 50 years ago, now lives at [**Location 5346**]
Family History:
Noncontributory
Physical Exam:
Admission PE
97.8 144/62 75 18 99 RA BG 197
General: AAOX1 (only knows name, unsure of location or date) in
NAD, speaks in difficult to comprehend speech
HEENT: MM somewhat dry, OP reveals white film on tongue,
partially removable
Neck: no lad, no obvious thryoid masses
CV: slightly irregular rate, no rmg
Lungs: CTAB no wrr
Abdomen: active BS X4, TTP in epigastrum, mild, no HSM
Extremities: WWP, pulses +1 and equal, ble edema 1+
Neuro: CN wnl, MS per above, strength and sensation wnl
Psyc: somewhat tangential, difficult to understand
.
Pt expired
Pertinent Results:
ADMISSION LABS:
[**2184-3-3**] 11:45PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2184-3-3**] 11:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
[**2184-3-3**] 11:45PM URINE RBC->182* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-3
[**2184-3-3**] 11:45PM URINE MUCOUS-RARE
[**2184-3-3**] 10:45PM WBC-5.1 RBC-3.06* HGB-8.3* HCT-27.6* MCV-90
MCH-27.1 MCHC-30.0* RDW-13.7
[**2184-3-3**] 10:45PM NEUTS-74.7* LYMPHS-16.9* MONOS-6.9 EOS-1.2
BASOS-0.3
[**2184-3-3**] 10:45PM PLT COUNT-300
[**2184-3-3**] 07:11PM LACTATE-0.9
[**2184-3-3**] 07:01PM GLUCOSE-161* UREA N-48* CREAT-1.4* SODIUM-135
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-19* ANION GAP-16
[**2184-3-3**] 07:01PM estGFR-Using this
[**2184-3-3**] 07:01PM CALCIUM-8.6 PHOSPHATE-2.6* MAGNESIUM-2.5
[**2184-3-3**] 07:01PM WBC-5.1# RBC-3.14* HGB-8.6* HCT-28.1* MCV-90
MCH-27.3 MCHC-30.5* RDW-13.5
[**2184-3-3**] 07:01PM NEUTS-72.9* LYMPHS-19.4 MONOS-6.5 EOS-1.0
BASOS-0.2
[**2184-3-3**] 07:01PM PLT COUNT-297#
[**2184-3-3**] 07:01PM PT-10.9 PTT-27.7 INR(PT)-1.0
[**2184-3-3**] 06:50PM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020
[**2184-3-3**] 06:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN->300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-9.0*
LEUK-LG
[**2184-3-3**] 06:50PM URINE RBC->182* WBC-31* BACTERIA-MOD
YEAST-NONE EPI-17
.
OTHER LABS OF HOSPITAL COURSE, prior to death:
[**2184-3-15**] 04:49AM BLOOD WBC-10.8 RBC-2.58* Hgb-7.2* Hct-23.7*
MCV-92 MCH-28.0 MCHC-30.5* RDW-14.2 Plt Ct-254
[**2184-3-7**] 06:25AM BLOOD Neuts-72.5* Lymphs-18.3 Monos-7.7 Eos-1.4
Baso-0.2
[**2184-3-15**] 04:49AM BLOOD Plt Ct-254
[**2184-3-15**] 02:50PM BLOOD Fibrino-621*
[**2184-3-15**] 02:50PM BLOOD FDP-10-40*
[**2184-3-15**] 02:32AM BLOOD Glucose-144* UreaN-32* Creat-1.9* Na-144
K-4.0 Cl-111* HCO3-25 AnGap-12
[**2184-3-13**] 04:24AM BLOOD ALT-35 AST-41* LD(LDH)-404* AlkPhos-78
TotBili-0.4
[**2184-3-11**] 09:34AM BLOOD CK-MB-4 cTropnT-0.03*
[**2184-3-11**] 02:56PM BLOOD CK-MB-5 cTropnT-0.03*
[**2184-3-12**] 04:03AM BLOOD CK-MB-5 cTropnT-0.07*
[**2184-3-7**] 06:25AM BLOOD Hapto-486*
[**2184-3-14**] 03:52AM BLOOD Phenyto-1.6*
[**2184-3-14**] 03:15PM BLOOD Phenyto-1.8*
[**2184-3-15**] 02:39AM BLOOD freeCa-1.16
.
IMAGING:
[**2184-3-6**] CT
Multidetector CT imaging of the chest was performed without
intravenous contrast. Sagittal and coronal reformats were
generated and
reviewed.
CT OF THE CHEST WITHOUT INTRAVENOUS CONTRAST: The major airways
are patent to subsegmental levels bilaterally. Multiple round
soft tissue nodules are seen in both lungs, the largest at the
junction of the left lower lobe and lingula measuring 2.3 x 2.0
cm. The pleural-based mass in the right upper lobe measures 1.6
x 0.9 cm (3:21). There is moderate-sized simple right pleural
effusion with compressive atelectasis of a major portion of the
right lower lobe. There is no left pleural effusion. Few
enlarged lymph nodes are seen in the paratracheal, prevascular,
subcarinal and hilar regions, with the largest lymph node in the
prevascular region measuring 13 mm (2:17). Few of thesenodes are
calcified, suggestive of prior granulomatous disease.
The imaged portion of the heart is unremarkable, except for
extensive coronary arterial calcification. There is no
pericardial effusion. No significant mediastinal, hilar, or
axillary adenopathy is seen. The main and lobar pulmonary
arteries are dilated, with the main pulmonary artery measuring
3.2 cm, consistent with pulmonary arterial hypertension. The
thoracic aorta has moderate atherosclerotic calcification
without aneurysmal dilation. This study is not tailored for
evaluation of the subdiaphragmatic organs, within this
limitation, imaged portion of the liver and spleen are
unremarkable.
BONES AND SOFT TISSUES: No bone lesions suspicious for infection
or
malignancy are detected. Mild degenerative changes are seen in
the thoracic
spine.
IMPRESSION:
1. In this patient with clinical concern for bladder cancer,
multiple
pulmonary nodules are concerning for metastatic disease. Few
mostly calcified
mediastinal lymph nodes relate to prior granulomatous disease.
2. Pulmonary arterial hypertension.
3. Moderate-sized simple right pleural effusion.
Portable TTE (Complete) Done [**2184-3-11**] at 11:32:35 AM FINAL
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is considerable beat-to-beat variability of
the left ventricular ejection fraction due to an irregular
rhythm/premature beats. The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
borderline normal free wall function. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] 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. Moderate to severe [3+] tricuspid
regurgitation is seen (may be underestimated due to the
technically suboptimal nature of this study). There is severe
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
IMPRESSION: severe, chronic or acute-on-chronic right
ventricular afterload excess
CHEST PORT. LINE PLACEMENT Study Date of [**2184-3-11**] 5:14 AM
FINDINGS: As compared to the previous radiograph, the patient
has been
intubated. The tip of the endotracheal tube projects 4.6 cm
above the carina.
The size of the cardiac silhouette in the left lung is
unchanged. On the
right, however, is a relatively extensive pleural effusion,
combined to an
area of perihilar atelectasis. These could reflect mucus
plugging or acute
lung disease such as aspiration or blleding.
The lung disease.
BILAT LOWER EXT VEINS Study Date of [**2184-3-11**] 1:16 PM
IMPRESSION: No evidence of right lower extremity deep vein
thrombosis.
CHEST (PORTABLE AP) Study Date of [**2184-3-11**] 2:52 PM
Right internal jugular line is in place with its tip at the
level of mid SVC.
There is substantial interval increase in the right pleural
effusion,
questionable intervention should be of concern. Cardiomegaly is
substantial.
There is evidence of interval development of minimal pulmonary
edema. No
pneumothorax is seen.
UNILAT LOWER EXT VEINS LEFT Study Date of [**2184-3-12**] 10:13 AM
IMPRESSION: No evidence of left lower extremity deep vein
thrombosis.
CHEST (PORTABLE AP) Study Date of [**2184-3-14**] 5:25 AM
FINDINGS: In comparison with the study of [**3-12**], there is little
overall
change. Continued mild to large layering pleural effusion on the
right with compressive atelectasis. Similar opacification at the
left base consistent with atelectasis and small pleural
effusion. In the appropriate clinical setting, supervening
pneumonia would have to be considered.
Known bilateral pulmonary nodules are seen in better detail on
the recent CT scan.
Brief Hospital Course:
This is a 89 yo F with a PMHx of recently diagnosed bladder
masses suspicious for TCC, dementia, DM II who p/w ARF,
persistent hematuria and fatigue and decreased po intake.
.
Pt was initially admitted to the medical service for evaluation
and treatment of her anemia which was presumably due to
microscopic/macroscopic hematuria. She was seen by urology for
evaluation for suspected bladder cancer. She underwent a
cystoscopy which showed bladder masses that were biopsied. These
were presumed metastatic disease.
On the morning of [**2184-3-10**] the patient was noted to be
unresponsive after being turned upon having a bowel movement.
She had no pulse during this arrest and a Code blue was called
for PEA arrest with return of pulse after 2 cycles chest
compressions and 1mg epi x2 and 1amp bicarb. She was intubated
and transferred to the [**Hospital Unit Name 153**]. Femoral line was attempted
peri-code but was arterial and removed. Pt was intubated during
the code. CXR in the unit showed white out of the entire right
lung suggesting layering of her known pleural effusion (likely
malignancy related, see below). CXR also suggested some new
widening of the mediastinum. Right IJ was placed. Later that day
she was extubated. She did not exhibit much neurologic function;
would respond to painful stimuli but no other responses. EKG
showed Right axis deviation. TTE showed pulmonary hypertension
and evidence of RV strain. Out of c/f PE heparin was started
empirically. Vanc/Zosyn also started for c/f possible pneumonia.
The pt continued to not improve neurologically and was not
responding to pain. Neurology was consulted and found her to
have positive brainstem reflexes but little evidence of cortical
function. After several days of no improvement her family
decided to make the pt [**Name (NI) 3225**]. IVF, heparin and antibiotics were
stopped and the patient passed away peacefully that evening. The
family was made aware and was present at the bedside. The family
refused autopsy and the medical examiner refused the case.
Medications on Admission:
alendronate 70 Q week
ASA 325 QD
atenolol 200 QD
ferrous sulfate 325 QD
HCTZ 50 QD
lisinopril 40 QD
MVI
nifedipine 60 ER QD
latanoprost .005 1 drop to right eye QD
docusate 100 [**Hospital1 **]
minoxidil 1.25 [**Hospital1 **]
pantroprazole 40 [**Hospital1 **]
erythromycin opth apply to left eye
risperidone .75 QHS
ultram 50 TID
aepe 650 Q6H prn
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"599.71",
"564.00",
"401.1",
"780.39",
"785.6",
"331.82",
"486",
"250.00",
"511.81",
"197.0",
"294.10",
"188.8",
"733.00",
"415.19",
"491.21",
"438.89",
"518.81",
"584.9",
"285.1",
"427.5",
"785.51",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"57.49",
"57.33",
"38.97",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12394, 12403
|
9909, 11957
|
267, 279
|
12462, 12479
|
2491, 2491
|
12543, 12697
|
1885, 1902
|
12354, 12371
|
12424, 12441
|
11983, 12331
|
12503, 12520
|
1917, 2472
|
218, 229
|
307, 1468
|
2507, 9886
|
1490, 1779
|
1795, 1869
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,275
| 120,414
|
53891
|
Discharge summary
|
report
|
Admission Date: [**2112-10-25**] Discharge Date: [**2112-11-16**]
Service: MEDICINE
Allergies:
Sulfonamides / Morphine / Ultram
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hypotension, AFib
Major Surgical or Invasive Procedure:
PICC line placement, INTUBATION, bronchoscopy
History of Present Illness:
Ms. [**Known firstname 110553**] [**Known lastname **] is a [**Age over 90 **] year old Persian speaking woman with a
history of CLL and non-Hodkins lymphoma s/p chemotherapy and
recent recurrence of herpes zoster with subsequent postherpetic
neuralgia.
Pt states that 2 weeks ago while staying at her families house
for [**Hospital1 **] holidays she slipped while getting out of the shower.
She hit her head in a glancing fashion on the wall and fell on
her backside. She did not lose conciousness or bleed. A
bruise/bump developed on her head. She was not brought to the
hospital or to a doctor's office initially because the family
wanted to watch her and see if she got better. Initially she had
some pain in her lower back, sacrum, and bilateral legs but was
still able to ambulate with a cane as she does at home baseline.
However, as days went by the pain in her buttocks and bilateral
extermities has worsened to the point that for the past 4-5 days
she has been unable to ambulate with her cane. Because of these
worsening symptoms she finally came to the hospital. She states
In ED initial vital signs were T 98.2 HR 90 RR 16 BP 134/70 SpO2
97% RA. She underwent CXR, bilateral hip x-ray, CT abd/pelvis,
CT head, MRI C-T-L Spine. Labs were significant for WBC of 11.3,
negative cardiac enzymes, chem 7 within normal limits, and UA
with moderate blood. Neurology team was consulted and examined
pt. They reported normal rectal tone with an essentially normal
neuro exam except for slightly decreased muscle bulk. No UMN
signs. They did not walk pt. They recommended C-spine and
L-spine MRI and admission for pain control. Patient received
dilaudid IV and zofran prior to her transfer to the Medicine
Service.
Upon arrival at the medical floor pt was immediately given IV
dilaudid for pain. Persian interpreter was called and came to
interpreter had to leave after a pre-set amount of time and not
all desired information was able to be gathered while she was
there, but all of the above information was gathered through the
interpreter.
Updated info per grandson [**Name (NI) **]: Pt fell 1-2 weeks ago and was
okay post fall. Hit head and landed on buttocks but was able to
ambulate around normally the next day and had been doing
fine/improving until yesterday at when she suddenly developed
pain in lower back, buttocks, and bilateral lower extermities
that became excruciating later in the day. This pain did not
feel like her zoster pain. Pt was unable to move legs and had to
be carried out to the car and [**Last Name (un) 4662**] to the hospital. Pt had one
episode of uninary incontinence after acute pain onset. No stool
incontinence. Pt has been drinking plenty of fluid and making
uring over the last week.
Pt contracted shingles 1 month ago and was receiving gabapentin
and fentanyl patch for shingles pain - these helped although
somewhat loopy with fentanyl. Shingles seemed to be improving
recently and rash had scabbed over but had been down entire left
leg starting at hip. Otherwise she has been very healthy with
reports of only CLL and some respiratory problems with a few bad
PNAs per the grandson. At baseline he says she is very active
and dose much of the cooking and laundry in the house.
On the morning of [**10-28**], she went into atrial fibrillation with
RVR with HRs in the 160s - 180s; she developed a rate related
LBBB at this time and was not otherwise symptomatic. Her blood
pressure at this time dipped to 80s-100s systolic. She received
1.5 L of IVF with no significant improvement in her blood
pressure. 2.5 mg of IV diltiazem was given with restoration of
sinus rhythm almost immediately. Her BP however failed to
improve despite sinus rhythm with BPs continuing to be 80s-100s.
Her O2 sats were holding 90s-95 % on 2 L. Given her new onset
atrial fibrillation, especially in setting of recent bedrest and
fracture, a CTA was ordered but has not yet been performed.
Given her persistent hypotension with no improvement in BP
following fluids, she was transferred to MICU for further
monitoring.
Past Medical History:
1. Brain meningioma.
2. CLL in [**2094**], transformed to NHL, status post CHOP and [**Hospital1 **].
3. Hypogammaglobulinemia with recurrent sinopulmonary
infections, improved with IVIG replacement therapy. Last IVIG
infusion [**2103-9-18**]. ([**2107-12-27**]: IgG 1245, IgA 183, IgM 55)
4. Colon cancer status post hemicolectomy (Stage 3, T3N1M0).
5. Motor vehicle accident, status post splenectomy.
6. SVC clot in [**2104**] in setting of indwelling central line.
7. Pneumonia complicated by adult respiratory distress
syndrome in [**1-31**]. Pneumonia with prolonged intubation [**4-30**]
8. Ejection fraction greater than 60%, mild mitral
regurgitation and mild pulmonary hypertension on an
echocardiogram from [**2105-1-28**].
9. Chronic low back pain
10. Interstitial Lung Disease; PFTs [**8-31**]: FEV1 1.17 (108%pred),
FVC 1.63 (94%pred), FEV1/FVC 72 (116% pred)
Social History:
The patient is a nonsmoker, nondrinker. She lives alone but
near daughter. Farsi speaking, originally from [**Country **].
Family History:
Non-contributory
Physical Exam:
VS HR 87, BP 100/52, 100% O2 sat, RR 10
Gen: Well appearing female in no apparent distress
HEENT: Anicteric, dry mucous membranes
Cardiac: irregular rhythm, no appreciable murmurs
Pulm: clear bilaterally
Abd: very soft and nontender
Ext: no edema noted
.
Pertinent Results:
ADMISSION LABS:
[**2112-10-25**] 12:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2112-10-25**] 12:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2112-10-25**] 12:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2112-10-25**] 12:30AM URINE RBC-[**4-1**]* WBC-0 BACTERIA-OCC YEAST-NONE
EPI-0
[**2112-10-25**] 12:10AM GLUCOSE-101* UREA N-10 CREAT-0.5 SODIUM-139
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2112-10-25**] 12:10AM CK(CPK)-84
[**2112-10-25**] 12:10AM cTropnT-<0.01
[**2112-10-25**] 12:10AM WBC-11.3* RBC-4.29 HGB-12.2 HCT-36.3 MCV-85
MCH-28.5 MCHC-33.7 RDW-15.8*
[**2112-10-25**] 12:10AM NEUTS-73.8* LYMPHS-18.1 MONOS-6.2 EOS-1.0
BASOS-0.8
[**2112-10-25**] 12:10AM PLT COUNT-401
[**2112-10-25**] 12:10AM PT-12.3 PTT-26.1 INR(PT)-1.0
MICRO:
[**10-28**] UCx:
ESCHERICHIA COLI
| ENTEROBACTER AEROGENES
| |
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
CTA:IMPRESSION: 1. No evidence of PE. 2. Severe fibrotic
interstitial lung disease, similar in appearance. No evidence of
superimposed consolidation.
3. Minimal interval increase in right upper lobe nodule now
measuring 6 mm. ******This should be reevaluated in three
months' time with a high-resolution CT so that the interstitial
lung disease can also be adequately evaluated **********
DISCHARGE LABS:
[**2112-11-16**] 03:30AM BLOOD WBC-10.6 RBC-3.30* Hgb-9.6* Hct-30.0*
MCV-91 MCH-29.2 MCHC-32.2 RDW-17.7* Plt Ct-520*
[**2112-11-16**] 03:30AM BLOOD Glucose-88 UreaN-14 Creat-0.3* Na-140
K-3.7 Cl-92* HCO3-46* AnGap-6*
[**2112-11-16**] 03:30AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.7
Brief Hospital Course:
[**Age over 90 **] year old female with history of CLL s/p IVIG with recent
history of zoster, now presenting with fall at home with small
displaced sacral fracture, who developed hypotension in setting
of atrial fibrillation with RVR unresponsive to IVFs and was
transferred to the ICU.
# Hypotension: Initially in setting of receiving IV diltiazem.
Received fluids. Started on vasopressors. Remained hypotensive
despite fluid resuscitation - started pressors. With antibiotics
treating for UTI and possible pneumonia. When intubated,
pressures worsened, better with pressors. Random cortisol level
was normal. Pressors were weaned. On discharge patient had
sustained SBPs in 90s. Patient was making adequate urine output
and was mentating well.
# Hypoxemic Respiratory failure: Patient was intubated for
respiratory failure/altered mental status on [**2112-11-4**]. She was
bronched and a mucus plug was pulled from her left lung, with
adequate reexpansion. She continued to be hypotensive and had
trouble weaning for several days. She was started on tube feeds
and completed a course of PNA antibiotics. She was diuresed >10L
of fluid. She was extubated successfuly once her pulmonary edema
improved on [**2112-11-13**] and was started on a Kosher Diet. Patient
was also treated with Vanco and Cefepime for possible
aspiration/health-care associated pneumonia for 8 days.
Patient's oxygenation improved with therapeutic bronchoscopy and
antibiotics were discontinued. Pt was diuresed with Lasix
20-40mg IV prn for goal net negative 500-1000cc/day. Would
recommend titrating Lasix dosing for the same I/O goal.
# Afib with RVR - Started on [**10-28**]. Converted to sinus rhythm
after receiving diltiazem, however blood pressures dropped. On
[**11-9**], afib with RVR recurred. Patient was started on digoxin.
Patient is now on a maintenance dose of 0.125mg every other day.
Dose is titrated to rate control. Anticoagulation was not
addressed, as the patient is currently back in sinus rhythm.
HR/rhythm should be monitored and risks/benefits should be
addressed as an outpatient. HR in 70-80s on discharge.
#. Sacral fracture: Patient sustained a sacral fracture on day
of admission. Orthopedics was consulted however did not
recommend any interventions. Pain was controlled with tylenol
and lidocaine patch. Opioids/narcotics should be avoided as
patient becomes quite sedated with minimal doses. Also, would
recommend avoiding NSAIDs - patient developed decreased UOP and
eos in urine, suggestive of possible AIN.
# UTI: Patient was diagnosed with UTI and treated with
ciprofloxacin. Patient was asymptomatic on discharge.
# Zoster: Recent reactivation of herpes zoster on her left thigh
(started around [**2112-9-16**]) and rash started to scab and heal
around [**2112-9-27**]. The rash had started to heal by the time she
went to her physician and he diagnosed her with Zoster. It was
thought to be too late to consider any treatment, and she was
started on gabapentin for post-herpetic neuralgia. Gabapentin
was held during admission because of concern for sedative
properties. No further complaints of thigh pain.
# Eosinophilia: Throughout the hospital stay the patient had
intermittent eosinophilia. Originally it was thought to be a
drug reaction to cefepime, which improved with switching abx to
meropenem. However the eos count again rose. On [**2112-11-4**] she had
15% eos with a WBC of 9.7. An eosinophilic lung process was
considered unlikely even her clinical improvement without
steroids. Recommend ongonig trend of eos count and surveying for
signs of allergic reaction.
#. Osteoporosis: Long standing issue and was being treated with
calcitonin, aledronate, and vitamin D as an outpatient.
Medications was held on admission given fracture and acuity of
illness. Patient should be reassessed as an outpatient prior to
restarting medications.
Medications on Admission:
ALENDRONATE 70 mg tablet qweek
CALCITONIN one spray in nostril every other day
ERGOCALCIFEROL VITAMIN D2 50,000 units 1 capsule every other
week
GABAPENTIN 300 mg po tid (recently increased [**2112-10-12**])
MELOXICAM 7.5 mg po daily prn pain
ACETAMINOPHEN - 650 mg Tablet 1 Tablet(s) by mouth q6h
CALCIUM CITRATE-VITAMIN D3 315 mg-200 unit daily
CHOLECALCIFEROL (VITAMIN D3) 1,000 unit daily
Discharge Medications:
1. digoxin 125 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. acetaminophen 325 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q6H (every
6 hours).
3. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
5. 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.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
One (1) Puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
7. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
1-2 Puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. furosemide 10 mg/mL Solution [**Last Name (STitle) **]: 20-40 mg Injection as
needed: please titrate Lasix boluses to goal net negative
500-1000mL/day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Sacral Fracture
Atrial Fibrillation
Hypotension
Urinary Tract Infection
Pneumonia
Pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **]:
You were admitted because you had a tailbone fracture. The bone
doctors saw [**Name5 (PTitle) **] but you did not require any operations to help
fix the fracture. While you were in the hospital you developed a
very fast heart rate and low blood pressure. You were
transferred to the ICU for further care. While in the ICU you
required a breathing tube to help you breath. After some time,
you were able come off of the ventilator. Many changes were made
to the medications. Please see attached list.
Followup Instructions:
Please keep the following appointment
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2113-1-3**] 10:30
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2112-11-16**]
|
[
"599.0",
"416.8",
"275.3",
"348.30",
"276.69",
"V12.51",
"V10.05",
"788.30",
"733.13",
"518.81",
"518.0",
"427.31",
"486",
"515",
"V10.79",
"E915",
"276.0",
"E849.7",
"053.19",
"276.4",
"934.1",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"96.04",
"33.29"
] |
icd9pcs
|
[
[
[]
]
] |
13595, 13666
|
8099, 11971
|
267, 314
|
13808, 13808
|
5765, 5765
|
14541, 14870
|
5457, 5475
|
12415, 13572
|
13687, 13787
|
11997, 12392
|
13984, 14518
|
7798, 8076
|
5490, 5746
|
210, 229
|
343, 4401
|
5781, 7781
|
13823, 13960
|
4423, 5299
|
5315, 5441
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,249
| 190,386
|
22448
|
Discharge summary
|
report
|
Admission Date: [**2154-9-22**] Discharge Date: [**2154-10-2**]
Date of Birth: [**2100-10-9**] Sex: M
Service: CSU
CHIEF COMPLAINT: Chest pressure and shortness of breath.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 58326**] is a 53-year-old
man who was admitted to the [**Hospital 1474**] Hospital in [**2153-11-22**], where he ruled in for an MI. A subsequent cath showed
50 to 70 percent LAD and 90 percent D1 with an LVEDP of 30.
Cardiac echo done at that time showed mild AS with a peak
gradient of 21, mild MR and an EF of 55 percent.
PAST MEDICAL HISTORY: Significant for hypertension,
hypercholesterolemia, peripheral vascular disease, abdominal
aortic aneurysm 4.5 cm, per patient report, adrenal mass on
the left, bilateral renal artery stenosis, right axillary to
bifemoral bypass in [**2140**], complicated by an occlusion for
which the patient has been on Coumadin since that time and
PTSD.
MEDICATIONS PRIOR TO ADMISSION:
1. Imdur 120 every day.
2. Lipitor 80 every day.
3. Zetia 10 mg every day.
4. Lasix 20 every day.
5. Coumadin 12 every day.
6. Aspirin 81 every day.
7. Zantac 150 b.i.d.
8. Atenolol 50 every day.
9. Nifedipine SR 60 every day.
10. Ferrous sulfate 325 every day.
11. Sublingual nitroglycerin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is a retired grounds keeper. He lives
with his wife and his granddaughter. [**Name (NI) **] has CAD on both
sides of his parents as well as several aunts and uncles. [**Name (NI) **]
denies alcohol use. Tobacco: One pack per day.
PHYSICAL EXAMINATION: Vital signs 98.4; 67 sinus rhythm;
140/58, respiratory rate 18, oxygen saturation 96 percent on
room air. General: 53 year old man, in no acute distress.
Skin: Unremarkable. HEENT: Pupils equally round and
reactive to light. Extraocular movements intact. Neck is
supple. Mucous membranes moist. No thyromegaly. No JVD.
Lungs: Clear to auscultation bilaterally. Cardiac: Regular
rate and rhythm, S1-S2 with no murmur. Abdomen: Soft,
nontender, nondistended with normoactive bowel sounds.
Extremities: Warm and well perfused with no edema and no
varicosities. Neurologic is grossly intact. Nonfocal exam.
Pulses: Femoral two plus bilaterally. Dorsalis pedis non
palpable. Posterior tibial one plus bilaterally and radial
two plus bilaterally.
LABORATORY DATA: White count 8.3, hematocrit 39.7, platelets
293, PT 12.7, PTT 27.7, INR 1.0, sodium 142; potassium 4.5,
chloride 106, CO2 25, BUN 14, creatinine 1.0, glucose 97, ALT
55, AST 23, alkaline phos 86, total bili 0.5, albumin 4.7.
EKG sinus rhythm at 57 beats per minute. Nonspecific ST
changes. UA is negative. Chest x-ray with no acute
cardiopulmonary processes.
HOSPITAL COURSE: As stated previously, the patient had a
past medical history of CAD and was admitted one day prior to
coronary artery bypass grafting. On [**9-23**], the
patient was brought to the operating room. Please see the OR
report for full details. In summary, he had a coronary
artery bypass graft times two with LIMA to the diagonal and
saphenous vein graft to the posterior descending artery. His
bypass time was 63 minutes with a cross clamp time of 50
minutes. He tolerated the operation well and was transferred
from the operating room to the cardiothoracic intensive care
unit. At the time of transfer, the patient was in sinus
rhythm at 98 beats per minute with a CVP of 10 and a PAD of
16. He had phenylephrine at 0.5 mcg/kilogram per minute and
propofol at 20 mcg per kilogram per minute. The patient did
well in the immediate postoperative period. His anesthesia
was reversed. He was weaned from the ventilator and
successfully extubated. Throughout the operative day, the
patient remained hemodynamically stable. On postoperative
day one, the patient continued to do well. He continued to
be hemodynamically stable. His Swan-Ganz catheter and
central line were discontinued. Diuretics were begun and he
was transferred to the floor for continuing postoperative
care and cardiac rehabilitation. On postoperative day number
two, the patient continued to be hemodynamically stable. His
chest tubes were removed. His activity level was advanced
with the assistance of the physical therapy department. On
postoperative day three, the patient again remained
hemodynamically stable. His temporary pacing wires were
removed and he was begun on Coumadin, given his preoperative
occlusion of his axillary bifemoral bypass. Over the next
several days, the patient had an uneventful hospital course.
His activity level was increased with the assistance of the
Physical Therapy staff as well as nursing staff. The
patient's Coumadin dose was adjusted, awaiting the patient to
have a therapeutic INR. He remained on heparin infusion
during that period of time and on postoperative day nine, it
was decided that the patient was stable and ready to be
discharged to home.
PHYSICAL EXAMINATION: At the time of this dictation, the
patient's physical exam is as follows. Temperature 98.6,
heart rate 77 sinus rhythm, blood pressure 130/60,
respiratory rate 20, O2 sat 94 percent on room air.
LABORATORY DATA: Potassium 3.9, BUN 15, creatinine 1.1, PT
16.6, PTT 66.5, INR 1.7.
On physical examination, the patient was in no acute
distress. Neurologic: Alert and oriented times three. Moves
all extremities. Follows commands. Nonfocal exam.
Pulmonary: Expiratory wheezes bilaterally. Cardiac:
Regular rate and rhythm, S1-S2 with no murmur. Sternum is
stable. Incision with no drainage or erythema. Abdomen is
soft, nontender, nondistended with normoactive bowel sounds.
Extremities: Warm and well-perfused with 2 plus edema.
Small amount of serous drainage on the right saphenous vein
graft harvest site.
The patient's condition at the time of discharge is good. He
is to be discharged to home with VNA. He is to have follow-
up with [**First Name11 (Name Pattern1) 518**] [**Last Name (NamePattern4) 58327**], M.D. in two to three weeks.
He is also to have his INR checked on Friday the 12th and
Monday, the 15th, with results called into Dr. [**Last Name (STitle) **]
office. He is also to have follow-up with Dr. [**Last Name (STitle) 70**] in
six weeks and follow-up with Dr. [**Last Name (STitle) 7047**] in two to three
weeks.
DISCHARGE DIAGNOSES:
1. CAD status post coronary artery bypass grafting times two
with LIMA to the diagonal; saphenous vein graft to the
PDA.
2. Peripheral vascular disease, status post right axillary
bifemoral bypass, complicated by occlusion.
3. Hypertension.
4. Hypercholesterolemia.
5. Abdominal aortic aneurysm.
6. PTSD.
DISCHARGE MEDICATIONS:
1. Potassium chloride 20 meq twice a day times two weeks and
then 20 mEq every day.
2. Colace 100 mg b.i.d.
3. Aspirin 81 mg every day
4. Oxycodone 40 mg sustained release, one tablet every 12
hours times 10 days.
5. Oxycodone 5 mg tablets, one to two tablets every four to
six hours prn as needed for pain.
6. Ezetimibe 10 mg every day.
7. Ferrous sulfate 325 mg every day.
8. Multi-vitamin, one tablet every day.
9. Ascorbic acid 400 mg twice a day.
10. Nicotine patch 14 mg, one patch for 24 hours times 2
weeks.
11. Combivent one to two puffs every six hours.
12. Metoprolol 100 mg b.i.d.
13. Amlodipine 10 mg every day.
14. Lasix 40 mg twice a day times 14 days and then every
day.
15. Warfarin as directed, to meet a target INR of 2.5.
The patient has received 12.5 mg every day for the last 3
days.
16.
Lipitor 80 mg every day.
17. Zantac 150 mg b.i.d.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2154-10-2**] 16:31:31
T: [**2154-10-2**] 19:07:07
Job#: [**Job Number 58328**]
|
[
"401.9",
"414.01",
"440.21",
"441.4",
"070.70",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6332, 6648
|
6671, 7847
|
2752, 4935
|
970, 1312
|
4958, 6311
|
154, 195
|
224, 573
|
596, 938
|
1329, 1568
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,865
| 176,110
|
39533
|
Discharge summary
|
report
|
Admission Date: [**2146-12-6**] Discharge Date: [**2146-12-10**]
Date of Birth: [**2068-9-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Cardiogenic shock
Major Surgical or Invasive Procedure:
-proctocolectomy
-Tracheal intubation
-cardiac catheterization [**2146-12-6**]: thrombotic LAD stent with no
flow, and thrombotic Cx stent with TIMI 3 flow. Received Export
to LAD and CX and POBA to both. RFA Perclose
History of Present Illness:
Mr. [**Known lastname **] is a 78 year-old man with CAD s/p PCI w/ BMS to LAD
and LCx on [**2146-11-4**] with a recent diagnosis of colorectal
cancer with plan for bowel resection today. However, he
developed cardiac arrest during surgery requiring defibrillation
and subsequently found to have ST elevations on EKG. Patient had
apparently stopped both plavix and aspirin on [**11-30**] prior to his
surgery today. Per report, patient became hypotensive on
pressors with MAP in 40s and tachycardic to 120s after prone
jackknife positioning. Rhythm was identified as ventricular
tachycardia. He was flipped back supine and got CPR for ~10
minutes, including Epi, Vasopressin, Atropine, a shock for
transient VF, and a femoral CVL, with return of pulse and
pressure. ABG immediately after was 7.24/36/391/16 w/lactate
7.2. He was transferred to [**Hospital Unit Name 153**] where TEE showed global LV
hypokinesis and a normal RV, while the rhythm strip showed large
ST elevations anteriorly. Troponins were greater than
recordable. He was put on a heparin gtt and amiodarone bolus and
was brought to the cath lab emergently on afternoon of [**2146-12-6**].
.
In cath lab was found to have thrombotic LAD stent with no flow,
and thrombotic Cx stent with TIMI 3 flow. Received Export to LAD
and CX and POBA to both. RFA Perclose. He received a Heparin
bolus and Plavix load in the cath lab and a Swan-Ganz was
placed. His heparin ggt was turned off and he returned to the OR
to complete proctocoletomy with open perineum and diverting
ileostomy. He was transferred to the trauma SICU
post-operatively and was cooled via Artic Sun protocol, and has
since been rewarmed. Also has received 2 units PRCs on [**2146-12-7**]
for HCT of 29, and 1 dose of vanc/zosyn for post-op ppx.
.
Today he was noted to be dropping his pressures, so returned to
cath lab to have balloon pump placed and angiogram which
confirmed patency of vessels. Upon transfer to ICU, he is on
levophed ggt, neo ggt, milrinone and vasopressin ggt. He is also
on fentanyl/versed ggt's for sedation. He is anuric with a Cr of
2.7 (baseline 0.9). Renal is following.
Past Medical History:
1. CARDIAC RISK FACTORS: Hyperlipidemia
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS:
-[**2146-11-4**]: Cath revealing two vessel coronary artery disease.
With successful PTCA/stenting of the mid LAD with BMS and the
proximal LCx with BMS
-[**2146-12-6**]: Cath revealing thrombosis of both stents s/p export
with POBA
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-GERD
-Colorectal Cancer- s/p chemo Xrt in [**2146-7-20**]
Social History:
He lives in [**Location 620**] with is partner who is [**Name8 (MD) **] RN. He is a former
smoker and smoked one pack per week for approximately [**9-7**]
years. This calculates out to a four-pack-year smoking history.
He has formerly drunk a few cocktails a day but has cut back to
one
glass of wine at night. He is independent in his activities of
daily living and has no difficulties with walking. He formerly
owned a small construction business and retired within the last
year.
Family History:
He has three brothers and a sister, all of whom are healthy. His
brother is status post a CABG.
Physical Exam:
GENERAL: Intubated/sedated. Responding to command by squeezing
fingers
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, JVP elevated to ear lobe lying flat
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: On vent, coarse BS anteriorly
ABDOMEN: Soft, Laparoscopic incisions c/d/i. Bowel in ostomy
looks brown today. No output right now. No tenderness
illicited Abd aorta not enlarged by palpation. No abdominial
bruits.
EXTREMITIES: Cool extremeties. 1+ DP/PT pulses. Right groin
catheter site c/d/i
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
.
[**2146-12-6**] 12:52PM BLOOD WBC-10.8# RBC-3.23* Hgb-10.9* Hct-33.3*
MCV-103* MCH-33.9* MCHC-32.8 RDW-13.3 Plt Ct-199
[**2146-12-6**] 06:40PM BLOOD PT-14.9* PTT-77.0* INR(PT)-1.3*
[**2146-12-6**] 12:52PM BLOOD Glucose-261* UreaN-18 Creat-1.4* Na-138
K-5.1 Cl-105 HCO3-19* AnGap-19
[**2146-12-7**] 03:19PM BLOOD ALT-3942* AST-5276* LD(LDH)-5784*
CK(CPK)-7255* AlkPhos-46 TotBili-1.5
[**2146-12-6**] 12:52PM BLOOD Calcium-8.4 Phos-6.7* Mg-2.4
.
CARDIAC ENZYMES
.
[**2146-12-7**] 03:19PM BLOOD CK-MB-GREATER TH cTropnT-GREATER TH
[**2146-12-8**] 05:47AM BLOOD CK-MB-305* MB Indx-7.6* cTropnT-GREATER
TH
[**2146-12-8**] 10:52AM BLOOD CK-MB-184* MB Indx-5.5
[**2146-12-8**] 03:55PM BLOOD CK-MB-137* MB Indx-5.3
[**2146-12-9**] 04:53AM BLOOD CK-MB-58* MB Indx-4.9
[**2146-12-10**] 05:00AM BLOOD CK-MB-17* MB Indx-3.7 cTropnT-GREATER TH
.
STUDIES:
.
CARDIAC CATH [**12-6**]:
COMMENTS:
1. Stent thrombosis of CX and LAD stents.
2. Successful 2 vessel thrombectomy and balloon only
angioplasty.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Primary angioplasty to LAD and Cx.
.
ECHO [**12-6**]:
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Severely depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic
function. Cannot assess regional RV systolic function.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Aortic valve not well seen.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed with near global LV severe hypokinesis/akinesis; the
basal septum and basal lateral wall have relatively preserved
function (overall LVEF= ~15-20 %). Right ventricular chamber
size is normal with grossly normal free wall contractility. The
mitral valve leaflets are mildly thickened. The aortic valve is
not well visualized.
EKG [**12-6**]:
Probable sinus rhythm at upper limits of normal rate. P-R
interval
prolongation. Fusion of the P wave with the prior T wave. There
is a
single wide complex beat, probably ventricular. Low limb lead
voltage.
There is an intraventricular conduction delay of left
bundle-branch block type with prominent inferior and lateral ST
segment elevation. Since the previous tracing of [**2146-11-5**] the
rate is faster. The axis is more vertical. QRS complex is
wider. ST-T wave abnormalities are new. Clinical correlation is
suggested.
.
ECHO [**12-8**]:
Overall left ventricular systolic function is severely depressed
(LVEF= 20 %). There is focal hypokinesis of the apical free wall
of the right ventricle. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is no pericardial effusion
Brief Hospital Course:
78 yo male with CAD s/p LAD/LCx BMS in [**10/2146**] presenting with
STEMI in setting of stopping asa/plavix prior to colorectal
surgery, s/p cardiac arrest on table, on IABP, pressors, CVVH.
Of note, the patient had no meaningful improvement and serial
family meetings were held. Aware of the poor prognosis and
believing that the current maximal supportive care including
pressors, mechanical intubation, and IABP would not meet the
patient's wishes, family decided to withdraw support and pt was
taken of pressors, balloon pump, and was extubated. He expired
shortly there after at 16:03 on [**12-10**]
.
# STEMI: Pt initially presenting for elective proctocolectomy
for locally invasive colorectal cancer. Pt noted to go into
Vtach on the operating table and subsequently found to have
STEMI. Of note, pt undwerwent successful PTCA/stenting of the
mid LAD with BMS and the proximal LCx with BMS in [**2146-11-4**], now
presenting with thrombosis of the stents likely in the setting
of stopping his asa/plavix prior to colorectal surgery.
Underwent successful 2 vessel thrombectomy and balloon only
angioplasty. Echo showing EF 15-20% with severely depressed LV
function. IABP placed to augment coronary filling. ECG showing
q waves and low voltages indicating extensive non-recoverable
myocardial injury. He was maintained on asa, plavix and heparin
ggt which was changed to argatroban for conern of HIT. Despite
interventions, pt continued to be cardiogenic shock as below.
.
# Shock: Pt with echo showing severely depressed LV systolic
function with EF 15-20% in setting of STEMI. Pt initially on
milrinone, neo, levophed, and vasopressin. He was weaned off
levophed, but continued on milrinone, neosynephrine, and
vasopressin throughout admission. He was also started on
vanc/zosyn for possible septic component. He was in multiorgan
failure with LFTs in the 5000s and Cr peaking at 5.1. He was
started on CVVH, but pt was unable to be weaned successfuly from
pressors or the balloon pump, and prognosis was discussed with
family who understood that recovery was unlikely. The decision
was eventually made to wean the pressors, d/c the balloon pump,
and extubate on [**12-10**]. Pt expired shortly after at 16:03.
.
# Ectopy: Pt noted to have frequent multifocal PVCs on tele
overnight [**12-6**] and was subsequently started on amio ggt.
Continued to have ectopy throughout admission and was continued
on amio until support was weaned
.
# [**Last Name (un) **]: Cr peaking at 5.1 and actually improved to 3.4 in setting
of CVVH. However continued to be in multiorgan failure unable
to wean from pressors. Likely [**Last Name (un) **] from cardiogenic shock
# Transaminitis: LFTs peaking in the 3000-5000 range, likely
shock liver. They started to downtrend throughout admission.
.
# Anemia: Pt received a total of 7 U PRBC over admission
including intraoperatively with a goal ~30. He continued to
ooze from his perineum surgical site likely explaining his
anemia. DIC was considered but ruled out with fibrinogen and
FDPs.
.
# S/p Colectomy for colorectal surgery: Pt s/p proctocolectomy
with open perineum and diverting ileostomy. Standard post-op
care was maintained. Of note, pt with significant oozing from
open perineum likely contributing to anemia
Medications on Admission:
Ferrous sulfate 325 mg p.o. b.i.d.
Plavix 75mg
Ranitidine 300mg
Nitroglycerin 0.4mg
Simvastatin 20mg
Aspirin
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
EXPIRED
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"785.51",
"570",
"E878.8",
"154.1",
"428.21",
"427.41",
"428.0",
"410.71",
"584.5",
"E878.1",
"414.01",
"V45.82",
"997.1",
"285.9",
"272.4",
"427.5",
"287.5",
"530.81",
"995.94",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.51",
"37.61",
"99.60",
"39.95",
"00.66",
"37.22",
"99.62",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
11086, 11095
|
7604, 10894
|
323, 543
|
11146, 11155
|
4557, 4557
|
11211, 11314
|
3696, 3793
|
11054, 11063
|
11116, 11125
|
10920, 11031
|
5582, 7581
|
11179, 11188
|
3808, 4538
|
2782, 3086
|
266, 285
|
571, 2700
|
4573, 5565
|
3117, 3178
|
2722, 2762
|
3194, 3680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,297
| 182,410
|
52364
|
Discharge summary
|
report
|
Admission Date: [**2164-4-11**] Discharge Date: [**2164-5-2**]
Date of Birth: [**2098-8-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**4-12**] Cardiac catherization
[**2164-4-18**] Coronary artery bypass grafting x3 with a left internal
mammary artery to left anterior descending artery and reverse
saphenous vein graft to the right coronary artery and the obtuse
marginal artery
[**2164-4-27**] [**Company 1543**] DDD pacer placement
History of Present Illness:
65 year old female with known CAD s/p DES to Lcx on [**9-19**] on ASA
and Plavix, h/o PE on coumadin with subtherapeutic INR, and
pulmonary fibrosis in the setting of radiation to treat hodgkins
disease. She has been c/o doe for the last week and a half.
.
Claims to have SOB at baseline from pulmonary fibrosis. For
last month, patient has noticed worsening SOB with exertion.
Could only walk a few steps before becoming acutely SOB. Also,
had episodes of SOB at rest, sitting up in bed, or laying in
bed. Complete rest with little exertion helped resolved
sympotms. Denied pain during this time. Five nights prior to
presenation, patient awoke in the middle of the night with
severe crushing chest pain like "an elephant sitting on her
chest". Did not take an asprin, did not call 911, did not alert
husband. [**Name (NI) 1194**] resolved in 20-30 minutes. Followed up at
doctor's office per husband's wishes.
.
The patient presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office today c/o above
symptoms. Endorsed 2-3lb weight gain, PND. Vitals in Dr. [**Name (NI) 108233**] office were 110/60 90 16 RR 100% RA at rest. With
activity, vitals changed to HR of 110 RR: 30 90-92% on RA
visibly dyspneic after 2 laps. In office EKG after ambulation
showed new ST depressions in lateral leads.
.
In the ED, initial vitals were 96.4 89 123/43 16 100%. A
hemolyzed specimen was sent. She was started on heparin gtt and
admitted to [**Hospital Unit Name 196**]. EKG showed ST depressions in II, III, and
aVF V5 V6. Seen by Cards who agreed with heparin drip.
Past Medical History:
Diffuse carotid disease
Hodgkin's disease stage 2 in '[**22**] treated with total body
radiation
Reactive airways disease/Pulmonary Fibrosis
Multiple PNAs, most recently in [**2163-6-11**] requiring ICU care for
sepsis/hypotension
Functional Asplenism s/p radiation treatment
Radiation induced ovarian failure s/p total hysterectomy and
Estradiol therapy
Hypothyroidism
Supraventricular tachycardia (Presumably Afib)
Gastroesophageal
Pulmonary emoblism (VTE) in '[**54**] on longterm low-dose coumadin
Right chest lentigo
[**Female First Name (un) 564**]/HSV esophagitis in setting of being on steroids
s/p Staging laparotomy [**2122**]
Social History:
Patient is married and lives in [**Location 1514**], MA with her husband.
She is a retired school administrator. She is independent and
performs ADLs without limitation. Physically, she has difficulty
climbing stairs and hills. No tob or drugs. Occasional EtoH, but
rarely.
Family History:
No family history of lung or cardiac diseases. NC for CAD, SCD
or arrhythmia.
Mother: [**Name (NI) 2481**]
Maternal GM: Uterine cancer
Physical Exam:
VS: T=afebrile BP=132/46 HR=106 RR=20 O2 sat=100%
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 of 2 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachycardic. Normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: Prominent vertebral column. No chest wall deformities,
Resp were unlabored, no accessory muscle use. Dry crackles
diffusely, but without wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace edema. No signs of vascular dermatitis or
arterial insufficiency changes
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2164-4-12**] Cardiac Catherization: 1. Selective coronary angiography
of this right dominant system three vessel coronary artery
disease. The LMCA was found ot have no flow limiting stenosis.
The LAD had an ostial 80% narrowing. The Lcx had a 90%
mid-stent restenosis. The RCA had an ostial 60-70% lesion. 2.
Resting hemodynamics revealed elevated left and right sided
filling pressures, with an RVEDP of 21 mmHg and a mean PCWP of
20mmHg. There was moderatl severe pulmonary hypertension, with
a PASP of 55mmHg. Moderate systemic hypertension was noted, wth
a cental aortic pressure of 166/67 mmHg.
[**2164-5-2**] 06:04AM BLOOD WBC-11.4* RBC-3.65* Hgb-10.7* Hct-32.9*
MCV-90 MCH-29.4 MCHC-32.6 RDW-15.9* Plt Ct-544*
[**2164-5-2**] 06:04AM BLOOD PT-15.7* PTT-22.8 INR(PT)-1.4*
[**2164-5-2**] 06:04AM BLOOD Glucose-145* UreaN-51* Creat-1.0 Na-143
K-4.6 Cl-102 HCO3-33* AnGap-13
Radiology Report CHEST (PORTABLE AP) Study Date of [**2164-4-30**] 1:53
PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2164-4-30**] 1:53 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 108234**]
Reason: assess rt ptx
Final Report
INDICATION: Coronary artery bypass grafting, permanent
pacemaker, assess for
right pneumothorax.
COMPARISON: Radiographs dating back to [**2164-4-11**] and most recently
[**2164-4-30**].
FINDINGS: Persistent right middle, right lower, and left lower
lobe
atelectasis are unchanged. A moderately large left pleural
effusion is
stable. The right pneumothorax is moderate in size, relatively
unchanged
since [**2164-4-30**], a right hydropneumothorax, best seen on the
lateral projection
on yesterday's radiograph appears loculated and persists on the
current study. The tip of the right upper extremity peripherally
inserted central venous catheter is projected over the expected
location of the lower superior vena cava. The permanent
pacemaker wires terminate over the right atrium and ventricle.
The nasogastric tube and median sternotomy wires are unchanged
in satisfactory position.Extensive subcutaneous emphysema has
slightly decreased in severity.
IMPRESSION:
1. Persistent right middle and lower lobe and left lower lobe
collapse.
2. Moderate left pleural effusion.
3. Right-sided loculated hydropneumothorax, stable since
[**2164-4-30**].
Cardiac echo: [**2164-4-23**]
Conclusions
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild to moderate regional left ventricular
systolic dysfunction with septal akinesis to dyskinesis (the
apex is not well seen). No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. There
is no pericardial effusion.
Brief Hospital Course:
The pt. was admitted and underwent cardiac cath [**2164-4-12**] and had
80% LAD, 90% LCX with mid stent restenosis, and an ostial 60-70%
RCA lesion. Dr. [**Last Name (STitle) **] was consulted for cardiac surgery. Preop
carotid studies showed a 50-99% right carotid stenosis and a
stable 40-50% stenosis on the left. She was seen by vascular
surgery who did not recommend intervention. She continued
having chest pain with EKG changes at rest and was waiting for a
plavix washout. On [**2164-4-18**] she underwent CABGx3(LIMA->LAD,
SVG->OM, dRCA). She tolerated the procedure well and was
transferred to the CVICU on Epi, Propofol, and Neo. She was
slow to wake from anesthesia and was extubated early in the
morning of POD#1. She had been weaned off Epi but then she had
a decreased cardiac output. An echo revealed dysynchrony of the
septum and she was restarted on Epi and Milrinone was added.
She was weaned off the epi and continued on Milrinone for a few
days. Her cardiac function improved and she was weaned off the
Milrinone.
on [**4-20**] she developed atrial fibrillation at a rapid rate which
was alternating with a junctional rhythm. Cardiology was
consulted and recommended intermittent pacing.
EP was also consulted and observed her and thought she may need
a pacer in the future. She also developed a right pneumothorax
and had a chest tube placed. The lung did not completely
reexpand. She developed subcutaneous emphysema over the next
day which eventually required intubation. Another chest tube
was placed and the pneumothorax got smaller and the subcutaneous
emphysema improved. Throughout this time she remained on low
dose milrinone and had an intermittent junctional rhythm. She
was extubated on post op day #6 and her chest tube was
discontinued after thoracic surgery was consulted.
She had a swallowing evaluation and did not tolerate any solids
or liquids. She continued to require tubefeedings. On POD#8
she was transferred to the floor and her strength was improving.
She continued to be anticoagulated with coumadin.
The following morning she had a 15 second pause after she had a
run of rapid AF and was transferred back to the ICU. She
continued to have pauses and had a [**Company 1543**] DDD pacemaker
placed. She tolerated the procedure well and was transferred
back to the floor the following day.
She continued to progress and was advanced to a puree and nectar
thick diet. She has tubefeedings at night. She was transferred
to [**Hospital1 **] [**Hospital1 8**] on POD#14 in stable condition.
Medications on Admission:
AMOXICILLIN-POT CLAVULANATE - 875 mg-125 mg Tablet - TAKE ONE
TABLET ONLY IF YOU HAVE A TEMP 100.4 OR ABOVE. CALL YOUR DOCTOR
RIGHT AWAY.
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth DAILY
(Daily)
LEVOTHYROXINE [LEVOTHROID] - 100 mcg Tablet - 1 (One) Tablet(s)
by mouth Monday through Friday
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice a day
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth at bedtime
SPACER - - use daily with inhalers
WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - take
up to 1 Tablet(s) by mouth daily or as directed by coumadin
clinic
WARFARIN - 2.5 mg Tablet - Take up to 2 Tablet(s) by mouth Daily
or as directed by coumadin clinic
Medications - OTC
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth DAILY (Daily)
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (OTC) - 500 mg
(1,250 mg)-400 unit Tablet - 1 Tablet(s) by mouth twice a day
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth DAILY (Daily)
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 + D] - (OTC) - 500 mg
(1,250 mg)-400 unit Tablet - 1 Tablet(s) by mouth twice a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO DAILY (Daily).
7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours).
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
10. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): swish and spit.
11. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
MD to dose daily for goal INR [**3-15**], dx: a-fib, PE.
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
13. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO DAILY (Daily) for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Diffuse carotid disease
Hodgkin's disease stage 2 in '[**22**] treated with total body
radiation
Reactive airways disease/Pulmonary Fibrosis
Multiple PNAs, most recently in [**2163-6-11**] requiring ICU care for
sepsis/hypotension
Functional Asplenism s/p radiation treatment
Radiation induced ovarian failure s/p total hysterectomy and
Estradiol therapy
Hypothyroidism
Supraventricular tachycardia (Presumably Afib)
Gastroesophageal
Pulmonary emoblism (VTE) in '[**54**] on longterm low-dose coumadin
Right chest lentigo
[**Female First Name (un) 564**]/HSV esophagitis in setting of being on steroids
s/p Staging laparotomy [**2122**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**2164-5-23**] 1:45
Cardiologist: Dr.[**Doctor Last Name 3733**] on Friday [**2164-5-18**] at 2:00 PM
Echocariogram on Friday [**2164-5-18**] at 1 PM in [**Location (un) 8661**] [**Location (un) **]
Primary Care Dr. [**Last Name (STitle) 665**] Wednesday [**2164-6-27**] at 11:40 AM
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Afib, h/o DVT
Goal INR [**3-15**]
First draw [**2164-5-3**]
Department: [**Hospital3 249**]
When: FRIDAY [**2164-4-20**] at 11:10 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*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.
Completed by:[**2164-5-2**]
|
[
"424.0",
"998.81",
"458.29",
"427.31",
"E934.2",
"530.81",
"244.9",
"428.43",
"401.9",
"433.10",
"790.92",
"201.90",
"511.89",
"414.01",
"E878.2",
"V12.51",
"411.1",
"530.19",
"272.4",
"584.9",
"427.89",
"E879.2",
"428.0",
"440.20",
"V70.7",
"493.90",
"427.81",
"416.8",
"V58.65",
"709.09",
"508.1",
"112.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.12",
"37.83",
"36.15",
"39.61",
"96.04",
"96.71",
"37.72",
"34.06",
"38.93",
"37.78",
"88.56",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12568, 12639
|
7574, 10130
|
293, 597
|
13403, 13614
|
4195, 7551
|
14537, 15813
|
3198, 3335
|
11345, 12545
|
12660, 12722
|
10156, 11322
|
13638, 14514
|
3350, 4176
|
234, 255
|
625, 2231
|
12744, 13382
|
2907, 3182
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.