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11,346
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8614
|
Discharge summary
|
report
|
Admission Date: [**2167-9-25**] Discharge Date: [**2167-9-27**]
Date of Birth: [**2108-4-9**] Sex: M
Service: MEDICINE
Allergies:
Iron Dextran Complex / Bupropion
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
syncope/ hypotension
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
For full details please see full admission note from MICU. in
brief, the patient is a 59 year old male with history of ESRD on
HD< DM, CAD who was in his USOH until [**2167-9-25**] when he
experienced dizziness and lightheadedness with standing with
some resolution by the next morning. When walking the next day
he experienced some dyspnea and chest pressure. On arrival to
[**Last Name (un) **] that day for a planned appointment he syncopized in the
lobby. At that time the patient was found to he hypotensive to
70/30 for which he was taken to the E.D. immediately. There is
no report of aura prior to this episode, seizure, or post-ictal
state.
.
On arrival to the ED the patient was with following vitals:
T97.0, HR55, BP 84/53, O2 95%RA with ECG revealing a junctional
rhythm. IJ was placed and cardiology consulted with impression
that this was secondary to nodal effect of both Toprol and Dilt,
recommendation to monitor overnight holding BB and CCB. In the
ICU the patient regained sinus rhythm and pressure improved to
104/70 without other intervention. CXR unremarkable and lactate
WNL. The patient was monitored overnight and has remained
hemodynamically stable, had HD today. The patient had Metoprolol
Tartrate 37.5 PO tid started today and tolerating well thus far.
The patient is now transferred to the medical floor for ongoing
care.
.
On arrival to floor the patient feels well. He denies currently
chest pain, dyspnea, dizziness. He reports stable symptoms of
chest pressure with exertion, particularly climbing stairs, that
have stable over 1 year.
Past Medical History:
# ESRD - on HD (since '[**64**]) Tu/Th/Sat; failed kidney [**Year (2 digits) **]
attempted [**Year (2 digits) **] [**4-20**] from Hep C positive donor but aborted
[**1-16**] hypoxia. c/b wound dehiscence.
# Diabetes - followed by [**Last Name (un) **]
# Hep C - genotype 1 c hepatitis C viral load of 18,400,000 I.U.
Followed by Dr. [**Last Name (STitle) 497**]
# Diastolic CHF - last ECHO [**4-20**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RA
moderately dilated; LVEF>55%
# GERD
# Former Substance Abuse - alcohol, cocaine, heroine; clean
since '[**64**], 1 relapse with cocaine in '[**65**]; attends [**Hospital1 **] and NA
# Renal cell carcinoma s/p removal [**2162**] followed w/o recurrence
# Pericardial effusion [**2165**], presumed viral; required
pericardiocentesis for tamponade physiology
# Depression- no suicide attempts, +passive thoughts about
suicide with no plan
# Barrett's Esophagus (from OMR)c/b Anemia
# Carpal Tunnel Syndrome - used wrist splints
# Sleep Apnea
Social History:
Mr. [**Known lastname 30197**] previously worked at Sheraton Hotel, retired in
[**2164**]. Currently lives with his sister
[**Name (NI) 1139**]: 80 pack-year history, quit [**2165-5-15**]
ETOH: history of 1 pint per week, quit [**2165-5-15**]
Illicits: Previous crack cocaine use, quit [**2165-5-15**].
Previous heroin use, quite 5-6 years ago. Member of NA, in
therapy for substance abuse.
Family History:
Father-died at age 52 from stroke
Mother-died in her 50s from cirrhosis
[**Name (NI) 12408**] DM
[**Name (NI) 30204**] addict
[**Name (NI) 30205**] at unknown age, due to problems with kidney and
pancreas
Physical Exam:
Vitals: T- 98.9 lying: BP- 140/60 HR- 80 standing: BP 120/60 HR
80 RR-18 O2- 97% on RA
.
General: Patient is a well appearing African American Male,
pleasant, in NAD
HEENT: NCAT, EOMI, sclera muddy brown, conjunctiva WNL. OP: MMM,
no lesions
Neck: Obese, JVP difficult to assess [**1-16**] body habitus
Chest: Relatively clear to auscultation anterior and posterior,
few end expiratory course wheezes
Cor: RRR, normal S1/S2. No murmurs appreciated. + S4
Abdomen: Obese, mod distended. Soft, non-tender. + well healed
RLQ surgical scar
Ext: Trace lower extremity edema
Pertinent Results:
Trop: .02 - .03
WBC: 12.1
Imaging:
[**2167-9-25**] CXR - no acute process, line in place
Micro:
[**2167-9-25**] Blood - PENDING UPON DISCHARGE
[**2167-9-25**] Urine - PENDING UPON DISCHARGE
Catheter TIP culture: PENDING UPON DISCHARGE
ECG: Sinus Brady, LAD. Qs III, aVF. no acute ST/TW changes
[**2167-9-25**] 03:13PM LACTATE-1.4
[**2167-9-25**] 12:45PM K+-4.5
[**2167-9-25**] 12:35PM GLUCOSE-100 UREA N-44* CREAT-8.3*# SODIUM-139
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-27 ANION GAP-20
[**2167-9-25**] 12:35PM CK(CPK)-119
[**2167-9-25**] 12:35PM cTropnT-0.02*
[**2167-9-25**] 12:35PM CK-MB-3
[**2167-9-25**] 12:35PM WBC-11.6* RBC-3.99* HGB-11.2* HCT-35.6*
MCV-89 MCH-28.0 MCHC-31.5 RDW-20.7*
[**2167-9-25**] 12:35PM NEUTS-58 BANDS-0 LYMPHS-23 MONOS-12* EOS-5*
BASOS-1 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-2*
[**2167-9-25**] 12:35PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-OCCASIONAL
POLYCHROM-1+ TEARDROP-OCCASIONAL
[**2167-9-25**] 12:35PM PLT SMR-NORMAL PLT COUNT-374
Brief Hospital Course:
Bradycardia / Hypotension - Likely related to bradycardia with
possible contribution from volume depletion. No evidence by labs
or exam for infectious etiology. Patient was on dilt 360mg po
daily and Toprol 100mg po daily. His EKG showed marked sinus
bradycardia with a rate in the 20s and a junctional escape
rhythm with a rate in the high 50s. He was hypotensive and
fluid resuscitated, his hypotension resolved and his rhythm
returned to sinus. His medications were adjusted to Toprol 50mg
daily. Diltiazem was discontinued. EP was consulted and helped
direct the plan. The patient's primary cardiologist was
notified of the changes.
Diabetes - blood glucoses well controlled as inpatient.
ESRD- on HD, rec'd HD as inpatient on Saturday [**9-26**].
Hep C - no active issues. Outpatient follow up.
Medications on Admission:
ASA 81mg daily
Citalopram 20mg daily
Dilt SR 360 daily
Valsartan 320 daily (patient not taking)
Gabapentin 100mg TID
Lantus 30 units
Reglan 10mg daily
Prilosec 20 mg daily
Vit B
Vit C
Folic acid
Cinacalcet 30mg daily
Toprol XL 100 daily
Allopurinol 100 daily
Calcium acetate
sevelamer 800 TID with meals
Mirapex 0.25 QHS
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
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. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
11. Insulin Glargine Subcutaneous
12. Toprol XL 50 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*
13. Neurontin 100 mg Capsule Sig: Three (3) Capsule PO as
directed: take 3 pills after dialysis sessions.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Syncope
Sinus Bradycardia with junctional escape rhythm
Secondary Diagnosis:
ESRD on HD
HTN
DM II
Discharge Condition:
sinus rhythm, not symptomatically orthostatic, stable
Discharge Instructions:
You were admitted for a fall probably related to your
medications. Please note the following medication changes:
PLEASE STOP TAKING YOUR DILTIAZEM. ALSO, DECREASE YOUR TOPROL
XL DOSE TO 50MG DAILY.
Please call your doctor or go to the emergency room if you fall,
if you have lightheadedness, shortness of breath, chest pain, or
any other symptoms that concern you.
Followup Instructions:
Please follow up with your primary care physician and your
kidney doctors [**Name5 (PTitle) 176**] 4 weeks of your discharge.
You have the following appointments:
1. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-10-5**]
5:00
2. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8753**], MD Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2167-10-7**] 8:00
3. [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2167-10-14**] 9:30
|
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"E942.4",
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icd9cm
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[
[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,514
| 138,477
|
35428
|
Discharge summary
|
report
|
Admission Date: [**2114-5-13**] Discharge Date: [**2114-5-23**]
Date of Birth: [**2060-10-20**] Sex: F
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Transferred while intubated to [**Hospital1 18**] from [**Hospital 37477**] Hospital (ME)
for possible thrombectomy in setting of PE.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53F transferred from [**Hospital 37477**] Hospital intubated w/respiratory
distress for possible thrombectomy in setting of PE. The pt is
s/p LAR for rectal mass (tubulovillous adenoma w/high grade
dyplasia) on [**4-26**] at Bridgton w/stapled anastomosis who was
discharged on [**4-30**] but returned on [**5-6**] with fevers, chills and
severe dysuria found to have an anastomotic leak with pelvis
abscesses s/p abdominal washout and diverting loop colostomy on
[**5-7**], placed on Unasyn.
On [**5-13**] the patient got up to the bathroom and developed the
sudden onset of sharp left-sided episode of pleuritic chest pain
and was found to have a large LLL PE. She was readmitted to
Bridgton, had at CT the revealed at PE, was started on a heparin
gtt, but unfortunately developed another episode of shortness of
breath and tachypnea that required intubation. Her ABGs were as
follows:
8:52am not intubated 7.27/60/75.3/27.4/-.7
9:34 100% vent 7.13/87/249/28/-3.1
10:45 100%vent 7.25/61/446/26/-2.2
The patient was transferred to [**Hospital1 18**] for ? thrombectomy given
that the patient could not receive thrombolysis in the setting
of recent surgery. She was transferred on dopamine and a
heparin gtt.
Past Medical History:
PMH: Hyperlipidemia, COPD, depression
PSH: ganglionic excision, s/p TAHBSO, s/p appendectomy, s/p umbo
hernia repair
Social History:
Works as a housekeeper at [**Hospital 37477**] Hospital. Married, from
Europe, has sister in [**Country 74323**], is a former smoker, quit 1mo, 20
pk yr smoking hx, no ETOH
Family History:
N/C
Physical Exam:
Upon discharge
A and O NAD, though pale
VSS
EOMi, anicteric, no JVD
RRR no m/r/g
CTAB
Soft NT/ND, no HSM, colostomy with gas and stool; midline lower
abd incision c/d/i with steristrips and retention sutures in
place, no erythema/edema
no c/c/e (UE and LE)
Neuro and Pysch grossly intact
Pertinent Results:
[**2114-5-21**] 11:19PM BLOOD WBC-7.6 RBC-4.19* Hgb-12.9 Hct-39.9
MCV-95 MCH-30.8 MCHC-32.4 RDW-15.0 Plt Ct-726*#
[**2114-5-17**] 07:25AM BLOOD WBC-9.2 RBC-4.60# Hgb-14.0 Hct-42.5#
MCV-92 MCH-30.4 MCHC-32.9 RDW-15.1 Plt Ct-477*#
[**2114-5-15**] 03:16AM BLOOD WBC-10.2 RBC-3.57* Hgb-11.3* Hct-33.2*
MCV-93 MCH-31.7 MCHC-34.1 RDW-15.0 Plt Ct-193
[**2114-5-14**] 02:24AM BLOOD WBC-8.6 RBC-3.59* Hgb-11.7* Hct-33.1*
MCV-92 MCH-32.5* MCHC-35.2* RDW-15.0 Plt Ct-152
[**2114-5-13**] 06:02PM BLOOD WBC-9.1 RBC-3.78* Hgb-12.3 Hct-35.3*
MCV-93 MCH-32.5* MCHC-34.8 RDW-15.2 Plt Ct-144*
[**2114-5-13**] 01:10PM BLOOD WBC-10.3 RBC-3.74* Hgb-12.1 Hct-34.9*
MCV-93 MCH-32.3* MCHC-34.7 RDW-15.0 Plt Ct-111*
[**2114-5-17**] 07:25AM BLOOD Neuts-71.4* Lymphs-20.1 Monos-7.1 Eos-1.0
Baso-0.4
[**2114-5-22**] 12:50PM BLOOD PT-35.3* PTT-69.8* INR(PT)-3.7*
[**2114-5-22**] 07:00AM BLOOD PT-33.9* PTT-79.0* INR(PT)-3.6*
[**2114-5-21**] 11:19PM BLOOD PT-33.1* PTT-64.9* INR(PT)-3.5*
[**2114-5-19**] 03:05PM BLOOD PTT-66.7*
[**2114-5-19**] 08:45AM BLOOD PT-27.5* PTT-57.7* INR(PT)-2.8*
[**2114-5-19**] 07:30AM BLOOD PT-23.8* PTT-48.7* INR(PT)-2.3*
[**2114-5-19**] 12:02AM BLOOD PT-29.1* PTT-58.5* INR(PT)-3.0*
[**2114-5-18**] 04:05PM BLOOD PT-24.4* PTT-57.8* INR(PT)-2.4*
[**2114-5-18**] 07:50AM BLOOD PTT-60.4*
[**2114-5-17**] 11:30PM BLOOD PT-21.8* PTT-53.9* INR(PT)-2.1*
[**2114-5-17**] 07:25AM BLOOD Plt Ct-477*#
[**2114-5-17**] 12:50AM BLOOD PT-20.9* PTT-49.4* INR(PT)-2.0*
[**2114-5-16**] 10:24AM BLOOD PTT-58.3*
[**2114-5-15**] 07:15PM BLOOD PT-21.6* PTT-49.7* INR(PT)-2.0*
[**2114-5-15**] 03:16AM BLOOD PT-22.6* PTT-65.1* INR(PT)-2.2*
[**2114-5-13**] 01:10PM BLOOD PT-15.9* PTT-95.6* INR(PT)-1.4*
[**2114-5-13**] 01:10PM BLOOD Plt Ct-111*
[**2114-5-13**] 01:10PM BLOOD Fibrino-517*
[**2114-5-14**] 09:14AM BLOOD ProtCFn-88 ProtSFn-58
[**2114-5-21**] 11:19PM BLOOD Glucose-131* UreaN-11 Creat-0.7 Na-140
K-4.4 Cl-105 HCO3-24 AnGap-15
[**2114-5-13**] 05:22PM BLOOD Glucose-99 UreaN-3* Creat-0.5 Na-140
K-3.2* Cl-108 HCO3-23 AnGap-12
[**2114-5-22**] 06:55AM BLOOD CK(CPK)-15*
[**2114-5-13**] 05:22PM BLOOD ALT-25 AST-20 CK(CPK)-46 AlkPhos-98
TotBili-0.5
[**2114-5-13**] 05:22PM BLOOD Albumin-2.7* Calcium-7.7* Phos-2.7 Mg-1.9
[**2114-5-14**] 07:53AM BLOOD Type-ART pO2-74* pCO2-43 pH-7.45
calTCO2-31* Base XS-4
[**2114-5-13**] 05:27PM BLOOD Type-ART pO2-222* pCO2-41 pH-7.40
calTCO2-26 Base XS-0
[**2114-5-14**] 09:14AM BLOOD :
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES Positive
COMMENT: Positive for Heparin PF4 Antibody Test by [**Doctor First Name **].
Result reported to [**Last Name (LF) **], [**First Name3 (LF) **] [**2114-5-14**] at 7:00PM
Complete report on file in the laboratory.
Comment: Source: Line-arterial
Imaging:
[**5-13**]
CTA OF THE CHEST: The endotracheal tube terminates above the
carina.
Pulmonary artery embolus involves the left pulmonary artery, and
extends into the upper lobe, lower lobe and lingular branches.
No right pulmonary embolus is identified. There is no definite
evidence of right heart strain. The thoracic aorta is normal in
caliber, and opacifies normally.
There is a small left pleural effusion. There is no pericardial
effusion.
Airspace opacity at the left lung base, and adjacent atelectasis
are
progressive in comparison to CT from the outside hospital,
likely represent a combination of atelectasis and infarct. Right
basilar atelectasis is similar to the prior study.
The airways are patent to the subsegmental level. A prominent
pretracheal
lymph node measures 8 mm in short axis. No enlarged hilar or
axillary lymph nodes are identified.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: Delayed images demonstrate
heterogeneous perfusion of the left lobe of the liver. The
gallbladder is
mildly distended, with a trace amount of pericholecystic fluid.
The spleen is normal in size. The kidneys enhance normally and
symmetrically. The pancreas enhances normally. Pancreatic duct
measures approximately 2 mm. There is no intra- or extra-hepatic
ductal dilation. The stomach, duodenum and small bowel are
normal in caliber. There are skin staples along the abdomen. No
enlarged mesenteric or retroperitoneal lymph nodes are
identified.
A colostomy is present within the right hemiabdomen, with a
fat-containing
parastomal hernia. Oral contrast is present within colon
proximal and distal to the ostomy. The distal colon contains
dense barium, and is patent and relatively smaller in caliber.
The left portal vein and branches are occluded by thrombus
(3B:136). Thrombus also involves the inferior mesenteric vein
(3b:165 - 170). The main and right portal vein, splenic and
superior mesenteric veins are patent. The aorta is normal in
caliber. The proximal celiac, superior mesenteric and inferior
mesenteric arteries are patent. The inferior vena cava opacifies
normally.
CT PELVIS WITH INTRAVENOUS CONTRAST: There is a Foley catheter
within the
urinary bladder. Air in the non-dependent portion of the urinary
bladder may be due to instrumentation. The colonic anastamotic
site is patent. An irregularly shaped rim-enhancing collection
extends along the right pelvis superiorly to the level of the
sacrum. The largest component, in the presacral area measures
4.0 cm (TRV) x 1.2 cm (AP) (3B:234) and contains small foci of
gas (3B:234). The uterus appears surgically absent. The left
common femoral vein is expanded, with hypoattenuation
anteriorly, and a rim of enhancement (3B:269) consistent with
thrombus. The right common femoral vei and iliac veins opacify
normaly. Bone windows demonstrate no lesions suspicious for
malignancy.
IMPRESSION:
1. Pulmonary embolism of the left main pulmonary artery
extending into the
left upper lobe, lower lobe and lingular branches, unchanged in
comparison to the CT eight hours prior.
2. Small layering left pleural effusion and a combination of
atelectasis and infarct at the left lung base.
3. Thrombosis of the left portal vein with heterogeneous
perfusion of the
left lobe of the liver.
4. Thrombosis of the inferior mesenteric vein.
5. DVT of the left common femoral vein.
6. Small, irregularly shaped rim-enhancing collection within the
pelvis,
containing small foci of air, concerning for infection. This
collection is
not amenable to image-guided drainage.
7. Post-operative changes of the pelvis and colon.
Fat-containing parastomal hernia.
[**5-13**]
1.There was no clot seen in the main pulmonary artery and the
proximal portion of the right pulmonary artery. Left pulmonary
artery was not visualized.
2. No atrial septal defect is seen by 2D or color Doppler.
3.Overall left ventricular systolic function is low normal (LVEF
50-55%).
4.The right ventricular cavity is mildly dilated with focal
hypokinesis of the apical free wall.
5.There are simple atheroma in the descending thoracic aorta.
6. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
7.Mild to moderate ([**2-9**]+) mitral regurgitation is seen.
[**5-14**]
BILATERAL UPPER EXTREMITY ULTRASOUND: [**Doctor Last Name **]-scale and color
Doppler
son[**Name (NI) 493**] images demonstrate wall-to-wall flow in the
bilateral internal
jugular veins, with normal response to respiration. Bilateral
internal
jugular, subclavian, axillary, and both brachial veins
demonstrate normal
compressibility and wall-to-wall flow with normal responses to
augmentation.
The cephalic veins are demonstrated on each side.
Brief Hospital Course:
OPERATIONS DURING ADMISSION
None
CONSULTATIONS DURING ADMISSION
Hematology
Social Work
Physical Therapy
BRIEF HOSPITAL COURSE
[**5-13**] admitted while intubated to ICU. Underwent TEE that
revealed a mildly dilated right ventricular cavity with focal
hypokinesis of the apical free wall. No clot was seen in the
PA.
The patient also underwent a CTA chest and CT abd/pelvis that
revealed:
-embolus in the left pulmonary artery, extending into the upper
lobe, lower lobe and lingular branches.
-thrombosis of the left portal vein
-thrombosis of the inferior mesenteric vein
-DVT of the left common femoral vein
Her hemodynamics were stablized, her pressors were discontined.
The patient was continued on zosyn (started in setting of
anastomotic leak)
The patient received a hematology consult, who was concerned
about HIT-T given the massive thrombosis in the setting of
likely perioperative SQH and heparin gtt following development
of PE with worsening of sx following heparin gtt. The following
day the patient was extubated. Her HIT Ab was STRONGLY
POSITIVE, and so she was started on argatroban for
anticoagulation.
The remainder of the hospital course is by day events:
[**5-15**] tx to floor, reg diet, coumadin 2 mg dose 1. For HIT-T the
patient needed to be on 5-days overlap of coumadin with
argatroban given the initial hypercoagulable state with
beginning coumadin. Unasyn continued in setting of leak
[**5-16**] social work consult, PT c/s, coumadin 2mg dose 2,
argatroban, started gabapentin for pain concerns, given inhalers
in setting of recent PE and weaned off O2.
[**5-17**] staples remvoed but retention sutures kept in; colostomy
putting out gas and stool. Pt remained subtherapeutic on
argatroban (PTT < 60), got coumadin 4 mg, PT recs home
[**5-18**] ostomy nsg came, received colostomy consult for colostomy
care, got OOB
[**5-19**] Her PTT was finally therapeutic, still given coumadin 4,
PTT regular checks
[**5-20**] Continued to dose coumadin. Pt upset w/care here, frequent
breakdowns, still getting SW consults, hematology visits
[**5-21**] completed 2 wk course Unasyn (for anastomotic leak)
[**5-22**] started 5 coumadin, PTT therapeutic
[**5-23**] transfer back to Bridgton per patient request
At the time of dictation the patient is being transferred to
another acute-care facility for titration of her coumadin,
continuation of her argatroban drip until therapeutic levels are
reached. She is presently stable: voiding independtly,
ambulating, tolerating PO intake, with good output from her
colostomy, afebrile with vital sign stable, though still
subtherapeutic INR while on coumadin and argatroban. She will
need titration of the above as outlined in the discharge
instructions.
Medications on Admission:
[**Last Name (un) 1724**]: none
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours).
2. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
5. Argatroban 100 mg/mL Solution Sig: One (1) Intravenous
INFUSION (continuous infusion): Dose presently at 3.5
mcg/kg/min; has been stable PTT 65-75 for > 24h.
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1
doses: Dose titrated daily for INR [**5-13**] on argatroban, INR [**3-13**]
off argatroban.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
-Heparin Induced Thrombocytopenia Thrombosis
-Pulmonary Embolus of Left PA extending into upper lobe, lower
lobe and lingular branches.
-Thrombosis of the left portal vein
-Thrombosis of the inferior mesenteric vein
-DVT of the left common femoral vein
PMH: Hyperlipidemia, COPD, depression
PSH: ganglionic excision, s/p TAHBSO, s/p appendectomy, s/p umbo
hernia repair, s/p LAR for rectal mass on [**2114-4-26**] c/b leak s/p
washout, transverse colostomy [**2114-5-7**] (rectal mass:
tubulovillous adenoma w/high grade dysplasia)
Discharge Condition:
stable, good
Discharge Instructions:
1. Directions for anticoagulation in patients with HIT-T:
-With Heparin Induced Thrombocytopenia Thrombosis (HIT-T), the
patient must be anticoagulated for six months after thrombotic
events.
-The ultimate goal INR in HIT-T is [**3-13**], but the patient must be
transition on argatroban drip.
-While on argatroban, the goal INR is [**5-13**], because the
argatroban "falsely" elevates the INR.
-The goal PTT on argatroban is 60-80; the PTT should be checked
q6h. The patient's PTT has been therapeutic for > 24 hours
while on 3.5 mcg/kg/min. If the PTT on argatroban is
subtherapeutic, then titrate up the argatroban by 0.25 mcg, and
recheck PTT is 6h. (see attached)
-Dose the coumadin daily for goal INR on argatroban [**5-13**]; the
patient should receive 5 mg coumadin today at 1600. (Her last
INR was 3.9 at 6:30am on [**2114-5-23**])
-Once the INR on argatroban is > [**5-13**] for 48hours, stop the
argatroban.
-Recheck the INR in 4h after the drip is stopped. The goal INR
then is [**3-13**]. If the INR is < 2, restart the argatroban and
continue to titrate up the coumadin. If the INR is therapeutic,
then stop the argatroban, and the patient may be discharged on
the final dose of coumadin with outpatient follow-up of her INR.
-Finally, encourage mobility e.g. walking etc to prevent
thrombotic events
-NO HEPARIN PRODUCTS (HEPARIN SHOULD BE CONSIDERED AN ALLERGY)
-Education and teaching on dietary modifications for coumadin
2. Colostomy care: see attached sheets
Followup Instructions:
1. Follow up with your surgeon to have your retention sutures
removed and to be scheduled for colostomy reversal
2. Colostomy care per VNA in Bridgton
3. Follow up with hematology/your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 7038**]t of your INR.
Completed by:[**2114-5-23**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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409, 415
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1827, 2003
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,015
| 119,375
|
34178
|
Discharge summary
|
report
|
Admission Date: [**2163-10-21**] Discharge Date: [**2163-10-25**]
Date of Birth: [**2095-10-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
68 yo M with hx of COPD on 3L O2, CAD s/p cardiac arrest, lung
CA s/p RUL resection/chemo/radiation, trachemalacia s/p tracheal
stent replacement last week, presents from OSH with 2d worsening
SOB with R shoulder pain. At OSH pt received 3 neb treatments,
steroids and magnesium.
.
On arrival to [**Hospital1 18**], vitals were T98.6 HR86 BP106/78 O289. Pt
denied chest pain, palpitations, trauma, F/C, N/V/D. R shoulder
full PROM, limited abduction on active ROM. Labs were
significant for leukocytosis to 11.8 without bandemia, anemia to
30, elevated bicarbonate 41, Trop 0.05 with flat CKs. EKG was
unremarkable. Pt desatted to low 80s from baseline 88-89 and was
labored.
CXR showed subtle LUL opacity and pt received CTX and
azithromycin. Blood cultures were sent and ABG 7.25 pCO2 102 pO2
98. BiPAP was attempted but pt did not tolerate. He was given
some ativan and became more lethargic with relatively unchanged
ABG. IP was contact[**Name (NI) **] in the [**Name (NI) **] and confirmed that stent is size
16, can fit 7.5 ETT if necessary. Pt was then intubated in the
ED. CXR confirmed placement.
Past Medical History:
PMHx:
* Squamous cell cancer of lung with possible recurrence: s/p RUL
lobectomy ([**2158**]), s/p Cyberknife
* Coronary Artery Disease s/p cardiac arrest and stent
* COPD/emphysema
* Tracheobronchomalacia s/p Y-stent
* OSA (noncompliant with nocturnal CPAP)
* Hypertension
* Hypercholesterolemia
* Hypothyroidism
* Gout
Social History:
Single, retired from telephone company.
Drinks 3-4 beers/night. Was 100+ pack year smoker - 5
cigarettes/day. No known asbestos exposure. He has two
daughters,
[**Name (NI) 698**] and [**Name (NI) **] who are supportive.
Family History:
Brother with TB and coronary artery disease
Physical Exam:
On admission:
GENERAL: Intubated, sedate male, appears comfortable
HEENT: No scleral icterus. Round face.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Prolonged expiratory phase with exp wheezing and diffuse
rales.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, strong distal pulses
SKIN: No rashes/lesions, ecchymoses.
NEURO: Does not respond to voice.
On discharge:
GENERAL: Comfortable, communicative, NAD.
HEENT: No scleral icterus.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No MRG
LUNGS: Decreased BS, prolongued expiratory phase, no crackles,
rhonchi or rales
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, strong distal pulses.
Unable to abduct against gravity. Not painful.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Appropriate. A+A x3
Pertinent Results:
[**2163-10-20**]
WBC-11.8* RBC-3.97* Hgb-9.0* Hct-30.6* Plt Ct-425
Neuts-89.9* Lymphs-6.4* Monos-2.5 Eos-0.7 Baso-0.3
Glucose-104 UreaN-13 Creat-0.7 Na-132* K-4.8 Cl-87* HCO3-41*
AnGap-9
Calcium-8.0* Phos-2.9 Mg-2.2
.
[**2163-10-21**] 12:34AM
ART pO2-98 pCO2-102* pH-7.25* calTCO2-47* Base XS-12 Non
rebreather
.
[**2163-10-21**] 01:34AM
ART pO2-80* pCO2-97* pH-7.26* calTCO2-46* Base XS-12 BIPAP
.
[**2163-10-21**] 04:56AM
ART pO2-78* pCO2-75* pH-7.33* calTCO2-41* Base XS-9 -Intubated
.
[**2163-10-22**] 11:29AM
ART pO2-94 pCO2-65* pH-7.39 calTCO2-41* Base XS-10 - Extubated
.
[**2163-10-22**] 05:29PM
ART pO2-63* pCO2-49* pH-7.44 calTCO2-34* Base XS-7 - Extubated
.
CXR [**10-20**]
Subtle opacity in the left upper lung, concerning for early
consolidation.
.
Shoulder XRay [**10-24**]
No fracture or dislocation is detected involving the right
shoulder.
Degenerative narrowing and spurring of the AC joint is noted.
There is
probable diffuse osteopenia. No periarticular calcification is
identified.
.
Shoulder MRI: Final read pending, prelim read showed
tenosynovitis, trace fluid in joint.
.
Labs on DC:
.
[**2163-10-25**] 07:48AM BLOOD WBC-9.6 RBC-3.65* Hgb-8.3* Hct-26.7*
MCV-73* MCH-22.7* MCHC-31.1 RDW-18.5* Plt Ct-327
.
[**2163-10-25**] 07:48AM BLOOD Glucose-77 UreaN-13 Creat-0.6 Na-140
K-4.2 Cl-97 HCO3-37* AnGap-10
Brief Hospital Course:
Mr [**Known lastname 17926**] is a 68 yo M with hx of COPD on 3L O2, CAD s/p
cardiac arrest, lung CA s/p RUL resection/chemo/radiation,
trachemalacia s/p tracheal stent replacement last week,
presented from OSH for several days SOB. Found to be in
hypercapneic respiratory failure thought secondary to COPD
exacerbation.
.
# Respiratory Distress: CXR concerning for left upper pneumonia,
and lung exam also with evidence of COPD exacerbation. He was
intubated and started on Vancomycin in addition to CTX and
Azithro given by the ED. He received standing inhalers and high
dose steroids for treatment of acute COPD exacerbation. On [**10-22**]
he was extubated, tolerated extubation without difficulty. He
was monitored for 24 hrs without further intervention and
transferred to the floor for further care. His abx were
narrowed to ciprofloxacin given his sputum grew cipro-sensitive
pseudomonas. He continued to improve on the floor with O2 sats
in the 90s on 3 L at rest, dropping to high 89 with ambulation
on 3L which is his home O2 requirement. He was discharged on a
prednisone taper and course of cipro (5 days left on discharge).
He was also treated with bactrim prophylaxis and vit D/Calcium
given his chronic steroid use.
.
# Hypertension: BP meds were initially held given
peri-intubation MAPs 60s, however restarted as pressures and HR
stabilized on transfer to the floor. He was discharged on his
home doses of metoprolol tartrate, quinapril and HCTZ.
.
# Squamous cell cancer of lung: pt will f/u with Dr [**Last Name (STitle) 2036**].
There was some concern for metastatic disease causing his RUE
weakness. MRI was obtained of the shoulder and showed no
evidence of rotator cuff tear, some fluid in the joint and
tenosynovitis, however no clear cause of his weakness. He will
f/u with MRI of the brachial plexus for further evaluation of
his weakness, will also f/u with PCP.
.
#. Shoulder weakness: Patient has had increasing right-sided
shoulder weakness over the last couple of [**Last Name (un) 26512**] which has been
increasingly limiting his ability to care for himself. The
isolated weakness on adduction suggests a deltoid process with
preserved rotator cuff. Preliminary MRI read showed no rotator
cuff injury, but tenosynovitis and fluid accumulation in the
joint. As stated above, there was concern for axilla nerve
injury. PCP was notified of this issue and further imaging of
the brachial plexus and follow-up will be managed by his PCP on
an outpatient basis.
.
# Metabolic alkalosis: thought to be consempatory in the context
of a respiratory acidosis from COPD. Sats were maintained in
the low 90s to prevent suppression of his respiratory drive.
Bicarb improved somewhat from admission with treatment of his
COPD.
.
# Coronary Artery Disease s/p cardiac arrest and stent. His
aspirin and statin were continued in the hospital
.
# Hyperlipidemia: Continued on simvastatin
.
# Hypothyroidism: Continued on levothyroxine
.
# Chronic lower back: Continued on Naproxen and Fentanyl patch.
There was some concern that his fentanyl patch may be causing
his shoulder pain, therefore it was recommended that he change
the location of the patch when it is replaced.
.
# Gout: Stable. Continued on Allopurinol
.
# Anemia: At baseline Hct 30, concerning for iron deficiency.
No evidence of bleed during this hospitalization. Recommend
outpatient colonoscopy.
Medications on Admission:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Inhalation [**Hospital1 **]
2. Allopurinol 100 mg PO DAILY
3. Fentanyl 50 mcg/hr Patch q72 hr
4. Levothyroxine 88 mcg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Naproxen 500 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Quinapril 20 mg PO DAILY
10. Simvastatin 40 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Multivitamin PO DAILY
13. Albuterol Sulfate q8h prn
14. Acetylcysteine 20 % 1-10 MLs Q 8H
15. Guaifenesin 600 mg PO BID
16. Spiriva 18 mcg inhalation once a day.
17. Trimethoprim-Sulfamethoxazole 160-800 mg PO DAILY for PCP
[**Name9 (PRE) **] while on Prednisone, Last Day: [**2072-10-23**]. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: [**10-18**]-22. One (1) Tablet PO every other day for 3
days: 5 mg on [**2079-10-20**], 27 None on [**2080-10-20**], 28
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): Please avoid placing on right
shoulder and change location when you replace the patch.
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Naproxen 500 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
8. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
16. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q8H (every 8 hours).
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-31**] Inhalation every eight (8) hours as
needed for wheezing.
18. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: Two (2) Capsule PO once a day.
19. Prednisone 10 mg Tablet Sig: as directed by taper Tablet PO
twice a day: Starting on [**10-26**], take 4 pills (40 mg) once a day
for 3 days. On [**10-29**] take 3 pills once a day for 3 days, on
[**11-1**], take 2 pills once a day for 3 days. After this, please
contact Dr. [**First Name (STitle) **] for further instructions on tapering your
prednisone.
Disp:*30 Tablet(s)* Refills:*0*
20. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 doses: Please take first dose on the
night of discharge and finish all of the pills.
Disp:*10 Tablet(s)* Refills:*0*
21. Outpatient Physical Therapy
Pulmonary rehabilitation for COPD, eval and treat.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: chronic obstructive pulmonary disease exacerbation
SECONDARY: Hypertension, R shoulder weakness.
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital for an exacerbation of your
chronic obstructive pulmonary disease. You were treated in the
ICU with steroids and antibiotics. You were eventually
transfered to the medical floor and showed improvement in your
respiratory status. Additionally, you were evaluated for new
weakness in your right upper extremity. An MRI was performed of
your shoulder and did not show any rotator cuff tear but you
will require further evaluation for the cause of your new
weakness.
You will need to get another MRI in a few days of your brachial
plexus (nerves in your shoulder) and will need to follow up with
your primary care physician in the next week. You will be
discharged on a steroid taper for treatment of your COPD.
You should return to the hospital if you experience worsening
shortness of breath, chest pain, fever, or any other symptoms
that are concerning to you.
MEDICATIONS
-Prednisone: Starting on [**10-26**], take 4 pills (40 mg) once a day
for 3 days. On [**10-29**] take 3 pills once a day for 3 days, on
[**11-1**], take 2 pills once a day for 3 days. After this, please
contact Dr. [**First Name (STitle) **] for further instructions on tapering your
prednisone.
-Ciprofloxacin: please take 500 mg every 12 hours when you leave
the hospital for 10 more doses
-You should also start taking calcium and vitamin D. You can
get these over the counter and should take 2 600 mg-400 unit
tabs every day.
Followup Instructions:
Please follow up with your PCP, [**Name10 (NameIs) **] [**First Name (STitle) **] at 11:30 on Friday
[**10-28**].
Dr [**First Name (STitle) **] will schedule an MRI of your brachial plexus (should
nerves) at [**Hospital6 4287**]. They will call you to tell you
when this is scheduled.
Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 7769**]) spoke with you about follow up with
your cancer and will help you arrange an appointment with Dr
[**Last Name (STitle) 2036**]. If you are not called regarding the scheduling of this
appointment in 1 week, please call the number above to schedule.
Please call to schedule pulmonary rehab at the number provided
to you by the physical therapists. You will be provided with a
prescription for this.
|
[
"V45.82",
"518.81",
"724.2",
"401.9",
"327.23",
"276.2",
"280.9",
"726.12",
"482.1",
"491.21",
"414.01",
"274.9",
"244.9",
"272.4",
"V58.65",
"519.19",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.71",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
11132, 11138
|
4397, 7796
|
337, 349
|
11288, 11297
|
3045, 4374
|
12790, 13539
|
2091, 2136
|
8721, 11109
|
11159, 11267
|
7822, 8698
|
11321, 12767
|
2151, 2151
|
2608, 3026
|
277, 299
|
377, 1491
|
2165, 2594
|
1513, 1836
|
1852, 2075
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,248
| 162,105
|
38120
|
Discharge summary
|
report
|
Admission Date: [**2106-7-27**] Discharge Date: [**2106-8-8**]
Date of Birth: [**2069-5-26**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Bicycle struck by motor vehicle.
Major Surgical or Invasive Procedure:
[**2106-7-27**]
-Tracheostomy
-Open reduction internal fixation of thyroid cartilage fracture
with mini plate
[**2106-7-31**]
-Open reduction and internal fixation of [**Last Name (un) **]-orbital ethmoid
fracture.
-Open reduction and internal fixation of maxillary fracture via
multiple approaches for frontozygomatic plating as well as
orbital rim plating.
[**2106-7-31**]
-Closed reduction with maxillomandibular fixation of the
mandible fractures including the left condylar head fracture,
the right parasymphysis fracture, and the right ramus mandible
fractures.
-Manipulation and attempt to reseat the left condyle.
-Insertion of custom splint.
[**2106-8-5**]
-Open reduction internal fixation of right mandibular [**Last Name (un) 85067**]
fracture.
-Open reduction internal fixation of right mandibular
parasymphysis fracture.
-Open reduction without fixation of left mandibular condyle
followed by repositioning of the dislocated condyle in the
fossa.
-Open reduction internal fixation of maxillary fractures.
-Placement of maxillary mandibular fixation.
History of Present Illness:
37 F bicyclist struck by a motor vehicle. The patient was
transported on a long spine board and collar and arrived at
[**Hospital1 18**] as a basic trauma activation. Upon
evaluation, the patient was seen to have multiple facial
injuries. Notably she was seen to have a displaced mandible
fracture, multiple tooth fractures and bleeding from the oral
cavity. She was able to maintain airway spontaneously and
room air SPO2 was 100%.
Past Medical History:
PMH- none
PSH- none
Social History:
NC
Family History:
NC
Physical Exam:
On Admission, In trauma bay:
HR:66 BP:144/94 Resp:17 O(2)Sat:100 and normal
Constitutional: Alert and oriented x3, awake and conversant
HEENT: Pupils 3 mm to 2 mm bilaterally, equal and reactive,
right periorbital ecchymosis, multiple broken/missing upper
teeth, full-thickness laceration under the lower lip
C-collar
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, negative FAST
Pelvic: Stable pelvis
GU/Flank: No costovertebral angle tenderness, no vertebral
tenderness
Extr/Back: Skin is warm and well perfused, abrasions noted
on the right fingers, tenderness to palpation of the left
thumb
Skin: Warm and dry
Neuro: Speech fluent, follows commands, 5 over 5 strength,
normal sensation bilaterally gait not tested
Psych: Normal mentation
Pertinent Results:
CT CAP - RUL Ground glass opacity, Pneumomediastinum c/w
tracheal laceration
CT CSpine - Hyoid fracture, laryngeal laceration at level of
hyoid fracture.
CT Sinus -
1. Displaced mandibular arch, bilateral rami, left condylar
fractures.
2. Bilateral pterygoid plate fractures.
3. Medial, Lateral, Posterior maxillary wall fractures.
4. Maxillary arch fracture.
5. Nasal bone fractures.
CT Head - No intracranial injury, facial fractures as above.
Brief Hospital Course:
Imaging revealed multiple complex facial fractures, bilateral
mandibular condyle fracture, a fracture through the symphysis of
the mandible with displacement. Upon further evaluation, the
patient was also seen to have a hyoid bone fracture as well as
thyroid cartilage fracture. Orthopedic surgery was consulted for
L thumb fx anbd R scaphoid fracture and they recommended
elevation and NWB b/l UE. The patient was admitted to the
trauma ICU for airway observation. The patient became
progressively more hoarse, therefore, the decision was made to
proceed to the operating room for examination, intubation and
tracheostomy which was performed on [**2106-7-27**]. At the same
setting, the plastic surgery service repaired complex facial
lacerations and ENT was consulted for repair of the thyroid
cartilage. Following this, the patient was extubated without
difficulty and was transferred out of the ICU to the floor for
further management.
Pt was stable on floor and followed primarily by General Surgery
with the Neurosurgery, Plastics, and OMFS services consulting.
On [**2106-7-30**], Neurosurgery identified no emergent or urgent
management issues and signed-off. On [**2016-7-30**] Plastic surgery
brought the patient to the OR for reduction of the zygomatic,
nasal, and right mandibular fractures including fixation when
indicated. Intermaximallary fixation was also achieved at this
time. Pt was returned to floor after uneventful stay in PACU
with adequate pain control, excellent respiratory status and
airway control via the existing tracheostomy. Patient had an
uneventful interval course on the floor leading up to [**2106-8-5**]
when she was taken back to the OR by OMFS for plating of her R
mandibular fractures and reduction of her L condylar fracture.
She was returned to the floor after an uneventful recovery in
the PACU at which time she complained of increased
post-procedural pain. Her IV pain regimen was titrated to
control her pain with good result while maintaining excellent
respiratory status.
On [**2106-8-5**] patient returned to the OR with OMFS. She
underwent open reduction internal fixation of right mandibular
[**Last Name (un) 85067**] fracture, open reduction internal fixation of right
mandibular parasymphysis fracture, open reduction without
fixation of left mandibular condyle followed by repositioning of
the dislocated condyle in the fossa, open reduction internal
fixation of maxillary fractures, and placement of maxillary
mandibular fixation. Patient post operative course was
uneventful. Patient returned to a regular nursing floor.
Patient's diet was advanced to clears and fulls. At the time of
discharge on [**2106-8-8**], the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a full
liquid diet, ambulating, 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:
none
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane every twelve (12) hours.
Disp:*900 ML(s)* Refills:*2*
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: Two (2)
Drop Ophthalmic QID (4 times a day).
3. Hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical QID (4
times a day) as needed for rash.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) ml PO BID (2
times a day).
Disp:*300 ml* Refills:*2*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Disp:*20 Suppository(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
Disp:*800 ML(s)* Refills:*0*
8. Augmentin 250-62.5 mg/5 mL Suspension for Reconstitution Sig:
Ten (10) ml PO twice a day for 7 days.
Disp:*140 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
-Pedestrian struck by vehicle
-Pan fascial midface fracture including LaFort 3 levelfractures.
-Left condylar head fracture along with dislocation of the
condyle lateral over the zygomatic arch.
-Compounded right parasymphysis fracture of the mandible.
-Comminuted right mandibular [**Last Name (un) 85067**] fracture.
-Malocclusion.
-Pain.
-Mastoid dysfunction.
-Multiple mandible fractures including displaced right
parasymphysis mandible fracture, right comminuted ramus mandible
fracture, left displaced condylar head mandible fracture.
-Other facial fractures include a nasal fracture,maxillary
fracture, which is a left LeFort II, left zygomaticomaxillary
complex fracture.
-Pain, malocclusion, and lateral displacement of the left
condyle.
-Laryngeal and hyoid bone fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient is to continue Augmentin for one week total
Patient should rinse mouth with peridex twice a day
Patient should continue a full liquid diet
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-24**] 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:
Follow up in one week with OMFS - Dr. [**Last Name (STitle) **] - call [**Telephone/Fax (1) 28910**]
([**Doctor First Name 2127**]) to make appt
Follow up in [**2-17**] weeks with ENT- Dr. [**First Name (STitle) 34209**] call ([**Telephone/Fax (1) 7767**]
Please follow up in Hand Clinic: ([**Telephone/Fax (1) 32269**] Please call to
make an appointment
Please follow up in plastic surgery clinic for non-emergent
surgery
Plastic Surgery Clinic: ([**Telephone/Fax (1) 7138**]
Acute Care Surgery Clinic, call ([**Telephone/Fax (1) 2537**] to schedule appt.
|
[
"802.0",
"802.39",
"807.6",
"E849.5",
"801.01",
"802.6",
"815.01",
"958.7",
"E813.6",
"802.5",
"814.11",
"873.63",
"802.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"76.79",
"86.59",
"76.75",
"31.64",
"21.72",
"31.1",
"76.74",
"76.73",
"76.92",
"76.78"
] |
icd9pcs
|
[
[
[]
]
] |
7326, 7388
|
3275, 6282
|
324, 1390
|
8214, 8214
|
2802, 3252
|
10505, 11073
|
1932, 1936
|
6337, 7303
|
7409, 8193
|
6308, 6314
|
8365, 9973
|
9989, 10482
|
1951, 2783
|
251, 286
|
1418, 1853
|
8229, 8341
|
1875, 1896
|
1912, 1916
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,010
| 168,101
|
32275
|
Discharge summary
|
report
|
Admission Date: [**2194-11-11**] Discharge Date: [**2194-11-19**]
Date of Birth: [**2115-8-14**] Sex: M
Service: MEDICINE
Allergies:
Macrolide Antibiotics
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Agitation, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79yo man with laryngeal SCC s/p trach/PEG tx. with chemo and
radiation, recently diagnosed lung adenoma in [**Month (only) **]., COPD, CAD,
with shortness of breath, hypoxia, increased agitation and
increased trach secretions from [**Hospital3 **]. He was recently
hospitalized at [**Hospital1 336**], where he has received all his medical
care, in [**8-29**] with Pseudomonas pna, treated initially with
zosyn X 10d, then when repeat cx. showed pseudomonas, he was
started on meropenem and transitioned to cipro after
sensitivities returned. At that admission also had CT-guided
bx. diagnosing adenoCa. Of note also was treated during this
hospitalization with keflex for PEG tube superficial infection
and flagyl presumptively for c. Diff. despite negative C. Diff
tests. He has recently completed his radiation treatments and
was transferred ~10d ago to [**Hospital3 **] from [**Hospital1 **].
.
In ED, T 98, tachy to 110s, BP 140s/60s, 14, 98% 10L TM, with
thick tan sputum suctioned from trach. EKG w/ no [**Hospital1 65**] ST/T
changes. CXR with what was thought to be LUL, had ABG of
7.37/58/116/35 on 10L TM, and admitted to MICU for closer
monitoring and trach suctioning.
Past Medical History:
TB, treated in [**2145**], [**2146**]
s/p CVA [**2189**] with R hemiparesis
Hypertension
COPD on home O2
CAD
h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**2187**]
Unclear history of dementia
Chronic kidney disease BL Cr 1.4-1.6
Rectal bleeding at last hospitalization, [**Last Name (un) **] nl 3 yrs ago.
Depression
Anemia
Laryngeal SCC s/p trach/PEG
Adenocarcinoma of lung
Social History:
Had lived with daughter in past, was at [**Hospital3 2558**] prior to
admit.
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
.
Vitals: temp 98.6 , BP 130/48 HR 69, RR 31-->23, SaO2 98% on
15L Trach mask
General: well appearing man in NAD, with trach, coughing up
sputum productively
HEENT: anicteric sclera, trach in place, tongue automations.
CV: distant HS, RRR, nls1s2, no murmurs, JVP flat
Pulm: rhonchi bilaterally on post. exam. + wheezes throughout
all lung fields
Abdomen: soft, nondistended, non-reproducible TTP in LLQ.
G-tube in place, no erythema, warmth, bleeding
Ext: no edema, 2+ DPs
Neuro: AA&Ox1, knows he's in "america", CN III-XII intact, good
cough.4+/5 strength in RUE, [**3-27**] in LUE. nl strength elsewhere,
pill-rolling tremor on left.
Skin: multiple ecchymoses on forearms bilaterally.
Pertinent Results:
[**2194-11-11**] GLUCOSE-140* UREA N-35* CREAT-1.2 SODIUM-137
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-31 ANION GAP-11
.
[**2194-11-11**] ALBUMIN-3.0* CALCIUM-8.4 PHOSPHATE-4.3 MAGNESIUM-2.3
.
[**2194-11-11**] ALT(SGPT)-30 AST(SGOT)-23 CK(CPK)-33* ALK PHOS-96
AMYLASE-28 TOT BILI-0.3 LIPASE-14
.
[**2194-11-11**] WBC-6.4 RBC-3.77* HGB-10.6* HCT-32.9* MCV-87 MCH-28.2
MCHC-32.4 RDW-17.9*
.
[**2194-11-11**] LACTATE-1.0
.
[**2194-11-11**] TYPE-ART RATES-/14 PO2-32* PCO2-59* PH-7.38 TOTAL
CO2-36*
.
[**2194-11-11**] URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
.
CXR [**11-11**]
AP PORTABLE UPRIGHT CHEST: No prior studies available for
comparison. There is a tracheostomy tube in place. Right-sided
subclavian central line with its tip in the mid SVC. Although
this radiograph is somewhat difficult to interpret due to
patient positioning and low position of the left
scapula/clavicle, there is a left apical airspace opacity with
volume loss and traction bronchiectasis, likely chronic.
Remainder of the lungs are clear. There may be a component of
underlying emphysema.
IMPRESSION: Left apical opacity with volume loss and traction
bronchiectasis, likely chronic. (Is there a history of
malignancy, prior radiation, or tuberculosis?) In the correct
clinical setting, this could represent acute pneumonia, but this
is thought less likely. Correlation with prior studies would be
helpful and follow up to resolution if warranted.
.
CXR [**11-13**]:IMPRESSION:
1. New left basilar ill-defined opacity may reflect an evolving
pneumonia.
2. Stable left apical opacity, unclear if this is a chronic or
an acute on chronic process, prior examinations would be useful.
Recommend a follow up to resolution.
.
EKG:Sinus tachycardia. Normal tracing, except for rate. No
previous tracing available for comparison.
.
Brief Hospital Course:
Mr. [**Known lastname 75448**] is 79 year-old man with laryngeal cancer s/p
trach/PEG tx. with chemo and radiation, recent diagnosis of lung
adenoca in [**Month (only) **]., COPD, CAD, p/w shortness of breath, hypoxia,
increased agitation and increased trach secretions found to have
pneumonia.
.
# Respiratory distress: At presentation this seemed to be more
consistent with a COPD exacerbation and likely had mucus plug
that has cleared in ED with aggressive suctioning. He was
continued on supplemental oxygen via trach mask. He was started
on a short course prednisone 60mg for 4 days as well as
vancomycin and zosyn for COPD exacerbation, dosed per CrCl (day
1 [**11-11**]). Vancomycin stopped on [**11-16**], zosyn stopped [**11-18**]. PT
completed 7 day course. Repeat CXR suggested PNA. A sputum
culture was sent, mucinex given to loosen secretions. He was
started on chest PT and continued on his home regimen of
spiriva, albuterol/atrovent nebulizer treatment. Respiratory
care followed the patient daily. He was placed on 35% TM for
humidity to help with secretions.
.
# Abdominal pain: Initially had some left lower quadrant
tenderness on exam. Serial exams were performed and no further
abdominal pain was elicited. Peg tube site, C/D/I without
discharge.
.
# Laryngeal squamous cell carcinoma/adenocarcinoma of the lung
with chronic pain: He was continued on his fentanyl patch and
PRN magic mouthwash. He has a trach and PEG for feeding as he is
unable to tolerate PO as per swallowing evaluation.
.
# palliative care consult for discussion regarding further care
of SCC and lung adenocarcinoma. A family meeting was held on
[**11-18**] to discuss goals of care and code status. Family decided
that they wanted the patient to return to [**Hospital3 2558**] for
rehab with the hopes that he may be able to return home one day
with services. Pt's family declined palliative/hospice care at
this time and decided that pt would see his oncologist next week
otherwise he has an appointment on [**2194-12-13**].
.
# Anemia: He was continued on supplemental iron. Aranesp was
held as this medication is non-formulary. Hct was trended and
remained stable.
.
# Depression/Psych: He was continued on his home dose celexa,
risperdal. He received several doses of haldol for agitation.
Olanzapine given prn.
.
# CAD: He was continued on his statin and started on low dose
aspirin.
.
# FEN: Jevity 1.2 TFs as prior to admit.
# Access: Portacath (not accessed) and 2 PIVs
# DVT prophylaxis: Heparin SC
.
# Code status: FULL CODE
.
# Contact: daughter, HCP [**Name (NI) **] [**Telephone/Fax (1) 75449**](h) [**Telephone/Fax (1) 75450**]
(cell)
Medications on Admission:
Atorvastatin 20 qdaily
celexa 20mg qdaily
hep SC
aranesp 150SC qmonday
cardura 4mg qdaily
fentanyl patch 50mcg q 72h
FeSo4 350mg qhs
advair q12h
prevacid 30mg daily
metoprolol 50bid
nilstat 10,000 qid
bicarb qdaily
spiriva 18mcg qdaily
mucomyst 10% q4h PRN
risperdal 0.25qhs
.
albuterol nebs q4h PRN
colace 100mg [**Hospital1 **] PRN
atrovent nebs PRN
magic mouthwash q4hPRN
imodium PRN
maalox 30ml [**Hospital1 **] PRN
MOM 30mol qod PRN
zofran 4mg q8hPRN
tylenol PRN
ativan 0.5 po bid PRN
Jevity 1.2 285ccq4h
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) mL
Injection three times a day.
2. Atorvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Doxazosin 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime).
5. Fentanyl 50 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
8. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day) as needed.
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]:
One (1) Cap Inhalation DAILY (Daily).
10. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6
hours).
11. Risperidone 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
neb treatment Inhalation Q6H (every 6 hours) as needed.
13. Ondansetron 4 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
14. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
15. aranesp
150mg SC qmonday
16. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
17. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
1.) Chronic obstructive pulmonary disease flare
Secondary:
2.) Laryngeal squamous cell carcinoma
3.) adenocarcinoma lung
4.) pneumonia
5.) CAD
6.) HTN
7.) depression
Discharge Condition:
stable, afebrile
Discharge Instructions:
You were admitted to the hospital because of low oxygen
saturation and respiratory distress. This was treated with
aggressive suctioning, oxygen, antibiotics and steroids, with
significant improvement. Additionally, you were seen by a
swallowing specialist who recommended no food or drink by mouth
due to excess secretions. This could be reevaluated in the
future.
.
If you develop fever, chills, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, please contact your doctor or
go to the emergency room.
.
Please take your medications as prescribed and follow up with
the appointments below.
Followup Instructions:
Follow-up with primary care provider per rehab/nursing home
physicians
Oncologist as already scheduled.
|
[
"585.9",
"162.8",
"V44.0",
"403.90",
"414.01",
"285.22",
"584.9",
"V44.1",
"482.1",
"491.21",
"438.20",
"338.3",
"V10.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9773, 9843
|
4730, 7386
|
315, 322
|
10062, 10081
|
2837, 4707
|
10740, 10847
|
2065, 2083
|
7947, 9750
|
9864, 10041
|
7412, 7924
|
10105, 10717
|
2098, 2112
|
245, 277
|
350, 1536
|
2126, 2818
|
1558, 1955
|
1971, 2049
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,964
| 105,873
|
31349
|
Discharge summary
|
report
|
Admission Date: [**2108-6-18**] Discharge Date: [**2108-6-21**]
Date of Birth: [**2032-11-19**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
ARF, Hyperkalemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
75 y.o. Spanish-speaking female c/ PMHx CHF (EF 20-25%), CAD,
CRI who presented to the ED after routine labs revealed ARF w/
creat. to 3.8 and K of 6.
.
In early [**Name (NI) **], pt. was restarted on Lisinopril, a medication
which has been held in the past because of hypotension and acute
renal failure. Labs drawn after initiating a second trial of
Lisinopril revealed the aforementioned renal compromise with
associated hyperkalemia. On discovering the hyperkalemia, the
lab called the patient at home and instructed the pt. to come to
the ED when the lab recognized the abnormalities. Pt admits to
some light-headedness before coming-in to hospital.
.
In the ED, patient was hypotensive to SBP 70s, but asymptomatic.
Persistently elevated creatinine and potassium were noted.
Hyperkalemia was treated [**Last Name (un) 22121**] Kayexalate, Insulin, glucose and
calcium. Pt. additionally received small IVF boluses with
improvement in SBP to her baseline of high 90s, low 100s.
Patient was then triaged to the ICU for closer overnight
monitoring while treating for ARF and hyperkalemia.
.
Patient's hypotension improved to systolic 90's in the MICU,
which is thought to be her baseline. She was tranferred to the
service for continued treatment of renal failure and associated
electrolyte changes in the setting of prior history of CHF.
.
On admission to the floor, patient denies poor PO intake or
increased ostomy output, denies nausea/vomiting, dysuria,
hematuria, SOB, CP, lightheadedness. She does note decreased
urine output over the last two weeks.
.
OUTPATIENT MEDICATIONS:
Baby ASA
Lisinopril ("for past two months")
MV
.
ROS negative for h/o stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. She
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
.
MEDICAL DECISION MAKING
[**2108-6-19**]: CXR No acute cardiopulmonary process.
ECG [**2108-1-9**]: Sinus rhythm
Ventricular premature complex
Nonspecific ST-T abnormalities
Since previous tracing of [**2108-1-2**], ventricular ectopy present
and ST-T wave changes appear slightly less prominent
Stress: TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 55
INTERPRETATION: 74 yo woman (severe cardiomyopathy with LVEF ~
20%)
was referred for a CAD evaluation. The patient was administered
0.142
mg/kg/min of persantine over 4 minutes. No chest, back, neck or
arm
discomforts were reported by the patient during the procedure.
In the
presence of baseline ST-T wave abnls, no additional ECG changes
were
noted during the procedure. The rhythm was sinus with occasional
vea;
occasional isolated VPDs, rare ventricular couplets. In
addition, rare isolated APDs were noted. The hemodynamic
response to the persantine infusion was appropriate. Three min
post-MIBI, the patient received 125 mg aminophylline IV.
IMPRESSION: No anginal symptoms or ECG changes from baseline.
Nuclear
report sent separately.
2D-ECHOCARDIOGRAM performed on [**2107-7-1**] demonstrated:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated with severe global hypokinesis. [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] . No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size is mildly increased with free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Left ventricular cavity enlargement with severe
global hypokinesis. Moderate mitral regurgitation. Pulmonary
artery systolic hypertension. Right ventricular free wall
hypokinesis.
CLINICAL IMPLICATIONS:
Based on [**2106**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
LABORATORY DATA:
See below.
.
INITIAL ASSESSMENT AND PLAN: 75yo fem c/ PMH of HTN, CRI
presenting with hyperkalemia and hypotension likely secondary to
exacerbation of renal failure due to Lisinopril.
.
#. A on CRF: Recent baseline creatinine around 1.2, currently
at 3-4. DDX includes ACE-I induced ARF esp. given reported prior
history. There is no clear h/o decreased PO intake or decreased
volume, and Feena <1. There is likewise no hx suggestive for
post-renal obstruction. Intrinsic causes include her recently
started ACE-I or simple hypotension. U/A not suggestive of ATN.
-We have D/C'd the ACE-I and expect improving renal function.
-Support BP with gentle NS boluses if SBP < 85 and symptomatic
-QD potassium and creatinine
-QD lytes in setting of metabolic acidosis
-strict I/O's
-Renal u/s --> renal consult
-Avoid nephrotoxins (ie, contrast/NSAIDS)
.
#. Pump: CHF not an active issue, but EF = 20-25% ([**12-2**])
limits [**Female First Name (un) **] of fluid resuscitation for kidneys.
-strict I/O's
-If exacerbation of CHF, gentle diuresis with non-K sparing
diuretic only.
.
#. Hyperkalemia: Likely 2dary to ARF as discussed above. K =
5.6 this AM --> 4.4 this pm, trending down s/p Kayexalate,
Insulin, glucose and Ca yesterday. Expect further resolution as
kidneys recover function s/p Ace-I d/c.
-Replicate hyperkalemic regimen if K > 6 (Kayexalate, Insulin,
Glucose, Ca).
-Continue tele
.
#
CAD: Non-contributory to complaint.
-con't ASA
-Atorvastatin 10 mg PO DAILY
-check lipid profile
.
#Hypotension: Likely 2dary to new ACE-I. There are no signs/sx's
of evolving infection. In setting of impaired renal function,
adequate BP is necessary for adequate renal perfusion.
Currently stable without evidence of evolving HTN s/p Ace-I d/c.
-small (250-500) NS bolus for low BP
.
#Non-gap Acidosis: Pt has bicarb of 16 on transfer. Likely
represents metabolic acidosis secondary to ARF as above. Expect
resolution as compromise resolves. Other possibilities include
diarrhea from Kayexalate, or dilutional effect from boluses of
NS.
#Anemia: Baseline crit = 28-32, currently at 28.5. Pt. appears
to be within baseline range, but will f/u with iron studies.
-f/u iron studies, B-12, Folate
.
#. FEN: Follow and replete electrolytes. Cardiac diet. No IVF at
present.
.
#. Access: PIV
.
#. PPx: PO diet.
.
#. Code: Full
.
#. Dispo: Pending good BP control off Ace-I and resolved
creatinine. Hope for d/c in [**12-28**] days.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 44432**] PGY1
Past Medical History:
1) CHF: EF 20-25%, presumably ischemic
2) CRI: baseline creatinine of 1.1 - 1.7 recently in 1/'[**07**], now
at 3 on transfer
3) CAD (Persantine MIBI 8/'[**06**]): Large reversible defect
involving the LAD, fixed defects in the PDA with hypokinesis of
the anteroseptal, distal anterior, distal septal,distal inferior
and apical walls. Patient deferred cardiac catheterization
4) Colon Cancer - s/p subtotal colectomy and ileostomy on 7/'[**06**]
5) Relative Hypotension - baseline SBPs in 90 - 100s
.
Cardiac Risk Factors: Dyslipidemia, HTN
.
Cardiac History: CHF, CAD and hypotension as above
Percutaneous coronary intervention: not applicable
Pacemaker/ICD: not applicable
.
Social History:
No TOB. EtOH limited to a "sip" of beer very occasionally. There
is no family history MI.
Family History:
+ for Ca, no h/o CHF, HTN, MI or SCD
Physical Exam:
PHYSICAL EXAMINATION:
VS 98.4, 97/65, 90R, 18, 100%2L
Gen: Well-appearing, [**Last Name (un) 1425**], supine in bed. 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, JVP not able to be assessed.
CV: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Minimal crackles RLL.
No wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits. There is a empty colectomy bag
with clear/dry/intact origin.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 3 PT 2+
Left: Carotid 2+ 2+ DP 2+ PT 2+
Pertinent Results:
[**2108-6-19**]: CXR No acute cardiopulmonary process.
[**2108-6-18**] 10:41PM K+-4.4
[**2108-6-18**] 08:18PM cTropnT-<0.01
[**2108-6-18**] 08:18PM cTropnT-<0.01
[**2108-6-18**] 08:13PM WBC-6.0 RBC-3.61*# HGB-11.1*# HCT-32.1*
MCV-89 MCH-30.9 MCHC-34.7 RDW-13.7
[**2108-6-18**] 08:13PM PLT COUNT-329
[**2108-6-18**] 08:13PM PT-11.8 PTT-21.9* INR(PT)-1.0
[**2108-6-18**] 10:00AM UREA N-91* CREAT-3.8*# SODIUM-129*
POTASSIUM-6.8* CHLORIDE-99 TOTAL CO2-17* ANION GAP-20
[**2108-6-18**] 08:13PM CK(CPK)-86
[**2108-6-18**] 08:13PM CK-MB-NotDone
Brief Hospital Course:
The patient presented to the ED with hypotension to the systolic
70's and acute renal and briefly was admitted to the MICU for
evaluation, observation and management. The patient's active
issues quickly resolved as below and the patient was transferred
to the [**Hospital1 1516**] service for a final 36 hours of monitoring before
discharge.
#Renal Failure: On admission, the patient was found to have
creatinine = 3.8 up from baseline .8. The patient's moderate
metabolic metabolic acidosis was thought secondary to this
failure. It was noted that the patient had recently re-stated
Lisinopril, which had previously been noted to induce
hypotension and renal failure in this patient. The patient's
creatinine quickly corrected and returned to near baseline with
fluids and discontinuation of Lisinopril, such that creatinine
was trending down to 1.8 on discharge.
#Hyperkalemia: On admission, the patient was found to have K =
6. Calcium Gluconate, Dextrose, Insulin, Kayexealae 30gm were
given. EKG showed no peaked T waves. Potassium quickly improved
to WNL without any arrhythmias as monitored on telemetry.
#Hypotension: In the ED, the patient was fond to have BP =
70's/52. It was noted that the patient had recently re-stated
Lisinopril, which had previously been noted to induce
hypotension and renal failure in this patient. There was no
evidence of infection as a driver for septic hypotension. Home
anti-hypertensives were held. Her pressures responded quickly to
fluid boluses and cessation of her anti-hypertensives, including
Lisinopril. Pressures were nted to be 100-120 systolic before
discharge.
#CHF: The patient has known EF = 20-25%. No evidence of heart
failure on exam.
#CAD: Patient has known CAD. Given concern for demand ischemia
from hypotension, the patient's enzymes were cycled and she
ruled out for MI. ASA was continued but BB was held given
hypotention, with plan to re-start if possible after discharge
in conjunction with the patient's PCP. [**Name Initial (NameIs) **] statin was added to the
patient's treatment regimen and prescribed at time of discharge.
Lipid studies are pending and will need to be followed-up as
outpatient.
#Proph: The patient was maintained on Heparin SQ throughout the
hospitalization. Physical therapy worked with the patient at the
end of the hospitalization and cleared the patient for
discharge. The patient was discharged in good condition.
Medications on Admission:
Aspirin 81mg QD
Lisinopril 2.5mg QD
Toprol XL 25mg QD
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute Renal Failure
Hyperkalemia
Secondary:
CHF
CAD
Heart Failure
Anemia
Discharge Condition:
Stable.
Discharge Instructions:
You were found to have a problem with your kidneys that was
likely caused by Lisinopril. We believe the Lisinopril caused
your body to retain a higher than normal amount of potassium.
Because high potassium can damage the heart, we treated you with
medications to lower the amount of potassium in your body,
including Kayexelate. The amount of potassium in your body
decreased and is now normal. The function of your kidneys is
improving.
During your hospitalization, we stopped the following
medications:
Lisinopril
Toprol XL (please discuss resuming this medication with your PCP
[**Name Initial (PRE) 503**]).
We began the following medications:
Atorvastatin 10mg daily
Please keep all follow-up appointments. They are listed below.
Please return to the ED or call Dr. [**Last Name (STitle) 31**] ([**Telephone/Fax (1) 2130**])
for shortness of breath, chest pain, dizziness, "fainting", or
any other concerning symptom.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 31**], your PCP, [**Name10 (NameIs) 503**] at
11:20 at [**University/College 70860**]. Please bring this paperwork with
you to the appointment. Please ask Dr. [**Last Name (STitle) 31**] to discuss 1.
the management of your blood pressure, and 2. the addition of
Atorvastatin to your medication regimen, and 3. the addition of
a beta blocker as your blood pressure and HR permit.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2108-12-10**]
|
[
"276.2",
"276.51",
"276.7",
"V10.05",
"585.3",
"428.0",
"428.22",
"584.9",
"V44.2",
"285.21",
"414.01",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12500, 12506
|
9776, 12190
|
334, 342
|
12633, 12643
|
9195, 9753
|
13619, 14171
|
8259, 8297
|
12294, 12477
|
12527, 12612
|
12216, 12271
|
12667, 13596
|
8312, 8312
|
4659, 7429
|
1956, 4636
|
8334, 9176
|
277, 296
|
370, 1932
|
7452, 8132
|
8148, 8243
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,611
| 151,997
|
29181
|
Discharge summary
|
report
|
Admission Date: [**2122-9-24**] Discharge Date: [**2122-10-1**]
Date of Birth: [**2056-4-30**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Ceftriaxone
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
hypophosphatemia and hypoglycemia
Major Surgical or Invasive Procedure:
HD
History of Present Illness:
66 y.o. woman with MMP including SLE, ESRD on HD, PVD, chronic
atypical chest pain, and CVA sent in by her nephrologist for
hypophosphatemia down to 0.4. On route to ED, she developed 30
mins of CP in ambulance, was treated with ASA and nitro, and
resolved prior to arrival in the ED. EKG showed NSR at 95bpm,
LAD, TW inversion inferolaterally with no ST changes ->
unchanged from prior EKGs.
.
ED course: She was found to have a phos of 0.4 and was treated
with 6 packets of neutraphos and 45 mmol of sodium phos, with
improvement in her phos to 2.0. She was also noted to
hypoglycemic down to 20 which resolved with and amp of D50 to
200. She had a CXR which was negative. However, BS again
dropped to 12 (per report) prior to transfer to the floor so pt.
sent to the MICU for closer monitoring.
.
Past Medical History:
.s/ p CVA ([**5-3**], with left facial drop)
.HIT Ab + ([**2120**], s/p treatment with argatroban and Coumadin,
PF4+ in [**4-4**]))
.TTP (s/p plasmapheresis *10)
.ESRD on HD (first HD, [**2121-9-5**], HD three days/week), s/p
.VRE septic thrombophlebitis in IJ ([**1-4**]) s/p linezolid)
.C. difficile colitis with h/o failed flagyl
.SLE (diagnosed [**2119**])
.HTN
.ACD (baseline Hct from [**Date range (1) 70208**], 26---37)
.Bowel and bladder incontinence
.Peripheral vascular disease
.Diverticulosis
.Peptic ulcer disease
.s/p Billroth II gastrectomy ([**2118**])
.Gout
.ETOH abuse
.Depression
.s/p hysterectomy
Social History:
She lives in a nursing home. Prior to going to the nursing home
she was living alone. Her husband died 3 years ago. she has a
son and [**Name2 (NI) **]. Her son lives locally with his wife. they are
supportive. used to work as [**Name8 (MD) **] RN. Smoked for 8 years about [**1-31**]
cig a day. quit about 40 years ago. Alcohol states quit 1 year
ago, previous heavy use. Her daughter is her HCP
Family History:
Unknown
Physical Exam:
VS: Temp: 98.7 BP: 129 / 94 HR: 90 RR: 10 O2sat: 95%
general: pleasant, comfortable, NAD, complaining of being cold
HEENT: PERLLA, EOMI, anicteric, no scleral icterus, no sinus
tenderness
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: no cyanosis or edema
skin/nails: no rashes/no jaundice/no splinters
neuro: AAOx2. persistant left side weakness -> residual from
stroke. Otherwise able to MAE
Pertinent Results:
[**2122-9-23**] 08:22PM PHOSPHATE-0.4*
[**2122-9-24**] 12:15AM WBC-2.8*# RBC-2.68* HGB-8.6* HCT-29.0*
MCV-108* MCH-32.1* MCHC-29.6* RDW-22.9*
[**2122-9-24**] 12:15AM GLUCOSE-80 NA+-137 K+-3.5 CL--97* TCO2-32*
[**2122-9-24**] 12:15AM CALCIUM-7.2* PHOSPHATE-0.4* MAGNESIUM-1.3*
[**2122-9-24**] 12:15AM CK-MB-NotDone
[**2122-9-24**] 12:15AM cTropnT-0.19*
[**2122-9-24**] 12:15AM CK(CPK)-16*
[**2122-9-24**] 05:43AM CK-MB-NotDone
[**2122-9-24**] 05:43AM cTropnT-0.22*
[**2122-9-24**] 05:43AM CK(CPK)-7*
[**2122-9-24**] 03:15PM CK-MB-NotDone cTropnT-0.18*
[**2122-9-24**] 03:15PM CK(CPK)-20*
CXR [**9-24**]-Small-to-moderate right-sided pleural effusion, which
appears
larger than on the prior study, tracking into the fissure.
Likely associated
atelectasis. No left- sided abnormality is noted.
ECG [**9-25**]-Normal sinus rhythm, rate 84. Left axis deviation.
Non-specific
anterolateral repolarization changes consistent with ischemia.
Compared
with tracing of [**2122-8-26**] sinus tachycardia has given way to
normal sinus rhythm. Also, repolarization changes are more
pronounced in the lateral precordial leads and less pronounced
in the mid precordial leads.
LUE U/S [**9-27**]-Left upper extremity deep venous thrombosis
extending from the internal jugular vein through the basilic
veins.
Head CT w/o contrast [**9-29**]-There is no evidence of acute
hemorrhage or mass. There is no shift of normally midline
structures. The ventricles and sulci are prominent, consistent
with age-appropriate involutional changes. There is normal
[**Doctor Last Name 352**]- white matter differentiation. There are periventricular
hypodensities, consistent with chronic microocclusive small
vessel disease. A small area of subinsular hypodensity is
unchanged in appearance since previous exam and likely
represents an old lacunar infarct. The visualized paranasal
sinuses are unremarkable. There are degenerative changes of the
bilateral temporomandibular joints noted.
IMPRESSION: 1. No evidence of acute intracranial process.
Chronic small vessel microocclusive disease as described above.
Chest X ray portable [**9-30**]-Little overall change.
Brief Hospital Course:
66 y.o. woman with MMP including SLE, ESRD on HD, PVD, chronic
atypical chest pain, and CVA who presented with hypophosphatemia
and hypoglycemia.
.
Initially she was in the MICU where her phosphate was repleted,
and her electrolytes were monitored. She had episodes of
hypoglycemia when her phosphate was corrected. When her
electrolytes improved she was transferred to the floor, where
she was tachypneic. An ABG showed a pH 7.7, pCO2 18, and a
bicarb was 22. She was thought to have primary respiratory
alkalosis and was transferred to the MICU. Her tachypnea was
not severe there and multiple attempts at access were made with
no success. A LUE U/S was done because of concern about LUE
edema, which showed a DVT in the brachial vein, subclavian vein
and possible extending into the IJ. She was started on
argatroban as she has history of HIT Ab + ([**4-4**]). She had a
femoral line placed. Coumadin therapy was initiated and she was
transferred to the floor. On the floor she had a head CT to
investigate cause of tachypnea, which was negative. CT for PE
could not be done, as contrast cannot be injected through a
femoral line. She had an episode of tachypnea with low oxygen
saturation readings, which resolved, and an ABG on room air
showed respiratory alkalosis but good oxygenation (pO2 100). PE
was determined to be unlikely as she was on coumadin with a
therapeutic coagulation parameters. As there was prior imaging
that showed her DVT in the subclavian vein as far back as [**2120**],
anticoagulation was felt to be unnecessary. Her phosphate was
stable, as was her glucose. She was felt to be stable for
discharge to [**Location (un) **] Elders Home [**10-1**].
Please see discussion below for more detals.
.
# Hypophos: She was sent in by her nephrologist who noted a low
phosphate. On admission her phos was 0.4 and was treated with 6
packets of neutraphos and 45 mmol of sodium phos, with
improvement in her phos to 2.0. Initial DDx includes: Internal
redistribution, Increased insulin secretion, particularly during
refeeding, Acute respiratory alkalosis, Hungry bone syndrome,
Decreased intestinal absorption
Inadequate intake, Antacids containing aluminum or magnesium,
Steatorrhea and chronic diarrhea, Vitamin D deficiency or
resistance, Increased urinary excretion, Primary and secondary
hyperparathyroidism, Vitamin D deficiency.
Initially thought to be likely related to refeeding in this
patient as she has had very poor intake over past year since
moving into the [**Hospital3 **] facility and her daughter has
been cooking for the pt. [**First Name9 (NamePattern2) **] [**Last Name (un) **] the past week and corroborated
the story of the pt. eating more -> gaining about 8 lbs in last
week. Her electrolytes were checked and repleted prn. After
her electrolytes improved, she was transferred to the floor,
where she was tachypneic. An ABG was done that showed
respiratory alkalosis and she was sent back to the MICU. See
below. In the setting her of respiratory alkalosis, it was
determined that the hypophosphatemia is likely due to
transcellular shift (secondary to upregulation of
phosphofructokinase in the setting of alkalosis, resulting in
phosphorylation and intracellular phosphate shift). Prior to
discharge her phosphate had stablilized at a value near 2.
.
#Respiratory alkalosis-The patient was found to be tachypneic
with a primary respiratory alkalosis when transferred to the
floor on [**9-26**]. She was transferred to the MICU where she was
less tachypneic. The etiology of her tachypnea is unclear. When
transferred to the floor again ([**9-29**]), CT head to r/o central
cause of tachypnea was done, which was negative. CTA to r/o PE
was considered, but could not be done because she has no access
(several attempts were made to obtain access, however, due to
the HD line and DVT-see below, could not be done). PE was also
considered somewhat unlikely as she was on coumadin for
treatment of her DVT of the LUE. On [**9-30**], she had an episode of
tachypnea and low readings of oxygen saturation on a monitor.
An ABG showed respiratory alkalosis and a pO2 of 100. The
tachypnea is likely due to anxiety as per family she has done
this once before while in transport to NH by ambulance. As
there was prior imaging in [**2120**](neck CT) that showed left
subclavian DVT, it was felt that she did not need to be treated
for this DVT.
.
#DVT in left brachial vein and subclavian vein-A LUE U/S was
done on [**9-27**] for concern about her left arm edema. It showed a
subclavian and brachial DVT that possibly extends to the IJ. As
there was evidence of clot as far back as [**2120**] (on a neck CT),
it was felt that it did not need to be treated.
.
# Hypoglycemia: Thought to be most likely related to refeeding.
She has no h/o insulin use; insulinoma rare, though possible.
She had decreases in her blood sugar when phosphate was repleted
but her finger sticks were stable in the low 100's upon
discharge. Her diet was supplemented with Boost drinks.
.
# Hyponatremia: She was hyponatremic initially, potentially
related to dehydration and poor po intake. This resolved after
hydration and better po intake.
.
# Renal failure: She has known chronic renal failure secondary
to SLE, on HD M/W/F with the renal service following her.
Medications were dosed renally and her Creatinine was stable.
.
# FEN: She was on a regular diet with boost at each meal, as
per nurtrition consult.
.
# PPx: Heparin was held given h/o HIT positivity; pneumoboots
bowel regimen
.
# Acccess: tunneled HD catheter
.
# Code: full - daughter [**Name (NI) 18945**] HCP
.
# Communication: daughter [**Name (NI) 18945**] [**Name (NI) **] [**Telephone/Fax (1) 70209**](home);
[**Telephone/Fax (1) 70210**](husband cell)
.
Medications on Admission:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Vancomycin 500 mg Recon Soln Sig: One (1) Intravenous
3x/week at hemodialysis for 6 days.
.
ALL: HIT +
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. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for prn constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): please take every six hours for the next 4 days, then
take twice a day for one week, then take once a day for one
week, then take every other day for one week, then take every
third day for two weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
respiratory alkalosis secondary to tachypnea
hypophosphatemia secondary to respiratory alkalosis
DVT of left subclavian vein
s/p CVA ([**5-3**], with left facial drop) w/ cog impairement
HIT Ab + ([**2120**], s/p treatment with argatroban and Coumadin)
TTP (s/p plasmapheresis *10)
ESRD on HD (first HD, [**2121-9-5**], HD three days/week), s/p
VRE septic thrombophlebitis in IJ ([**1-4**]) s/p linezolid)
SLE (diagnosed [**2119**])
HTN
ACD (baseline Hct from [**Date range (1) 70208**], 26---37)
Bowel and bladder incontinence
Peripheral vascular disease
Diverticulosis
Peptic ulcer disease
s/p Billroth II gastrectomy ([**2118**])
Gout
Rheumatoid arthritis
ETOH abuse
Vitamin B12 deficiency
Depression
Discharge Condition:
stable, afebrile, good po intake
Discharge Instructions:
You were admitted with a low phosphate and low blood sugar, you
received phosphate and your labs were monitored. You were
treated in the medical ICU. You also had a deep vein thrombosis
(blood clot) in the veins of your left neck and shoulder area.
You are being treated for that. You had some episodes of fast
breathing. A head CT scan was done that was negative.
You should continue to take your medication as prescribed. You
will take coumadin and have your blood tested at dialysis to
determine the appropriate dose.
You should follow up as outlined below.
Please call your doctor if you have any difficulty breathing,
chest pain, lightheadedness, weakness or any other concerning
symptoms.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) 1356**] [**Last Name (NamePattern1) **] at [**Company 191**] [**10-16**], 1:30pm
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
Completed by:[**2122-10-1**]
|
[
"710.0",
"438.83",
"585.6",
"443.9",
"276.3",
"276.1",
"008.45",
"582.81",
"274.9",
"285.21",
"275.3",
"403.91",
"287.5",
"453.8",
"276.51",
"251.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12392, 12462
|
5015, 10792
|
323, 327
|
13210, 13245
|
2821, 4992
|
13993, 14268
|
2235, 2244
|
11422, 12369
|
12483, 13189
|
10818, 11399
|
13269, 13970
|
2259, 2802
|
250, 285
|
355, 1163
|
1185, 1803
|
1819, 2219
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,402
| 171,805
|
16923
|
Discharge summary
|
report
|
Admission Date: [**2164-5-3**] Discharge Date: [**2164-5-7**]
Date of Birth: [**2087-6-21**] Sex: F
Service: MEDICINE
Allergies:
Valium
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
ICD misfiring
Major Surgical or Invasive Procedure:
ICD extraction
History of Present Illness:
76 year old woman with HCM, s/p ICD implant in [**2160**], moderate
MR, hypertension, now with ICD lead fracture requiring
extraction. Her device has not caused her any problems up until
[**4-29**], when her ICD spontaneously fired 3-4 times while eating
lunch. She felt well before and after these shocks.
.
She presented to OSH. While in the ED, she had repeated ICD
shocks while in NSR. The device was deactivated. Her device was
interrogated at the OSH. She was transferred to [**Hospital1 18**] for lead
extraction.
.
She is without chest pain, palpitations, shortness of breath, or
lightheadedness. At baseline, she gets short of breath with 1-2
flights of stiars. No PND. No LE edema at baseline.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: [**2163-5-26**] [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] 2 V243 dual chamber ICD
3. OTHER PAST MEDICAL HISTORY:
HOCM
Moderate MR
H/o benign pulmonary nodules
H/o appendectomy, hysterectomy and oopherectomy
Social History:
Lives alone in a seniors apartment.
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
Family History:
Father died of heart attack at age 80. Maternal uncle died in
his teens of heart condition (unknown).
Physical Exam:
VS: T=98.4 BP=155/79 HR=82 RR=18 O2 sat= 97% on RA
GENERAL: WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of at clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Harsh [**2-24**] early peaking systolic murmur
loudest at LUSB. Blowing 4/6 systolic murmur at apex.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm well perfused. No edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2164-5-3**] 07:14PM BLOOD WBC-11.4* RBC-3.83* Hgb-11.2* Hct-33.3*
MCV-87 MCH-29.2 MCHC-33.6 RDW-13.6 Plt Ct-219
[**2164-5-4**] 05:25AM BLOOD WBC-8.7 RBC-3.75* Hgb-10.8* Hct-32.7*
MCV-87 MCH-28.7 MCHC-32.9 RDW-13.5 Plt Ct-212
[**2164-5-4**] 05:25AM BLOOD PT-12.9 PTT-25.6 INR(PT)-1.1
[**2164-5-4**] 05:25AM BLOOD Plt Ct-212
[**2164-5-3**] 07:14PM BLOOD Glucose-190* UreaN-26* Creat-0.8 Na-141
K-3.6 Cl-106 HCO3-25 AnGap-14
[**2164-5-4**] 05:25AM BLOOD Glucose-86 UreaN-22* Creat-0.6 Na-142
K-4.3 Cl-110* HCO3-23 AnGap-13
[**2164-5-3**] 07:14PM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2
[**2164-5-4**] 05:25AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
[**5-3**] CXR
FINDINGS: Consistent with the given history, a dual-chamber
pacemaker/AICD is
noted in standard position from a left subclavian approach.
Please note there
is suggestion of more proximal migration of the defibrillator
leads. Lungs
are clear without consolidation or edema. There is a small
hiatal hernia. No
effusion or pneumothorax is noted. Mild degeneration is noted
throughout the
thoracic spine. There is atheromatous disease of the aorta. The
cardiac
silhouette is borderline enlarged.
IMPRESSION: No acute pulmonary process. Incidental findings as
above.
[**2164-5-5**] 05:03AM BLOOD WBC-12.4* RBC-2.92* Hgb-8.7* Hct-25.3*
MCV-87 MCH-29.8 MCHC-34.4 RDW-13.6 Plt Ct-208
[**2164-5-6**] 04:14AM BLOOD WBC-9.5 RBC-3.44* Hgb-10.2* Hct-30.2*
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.1 Plt Ct-176
[**2164-5-7**] 06:15AM BLOOD WBC-9.1 RBC-3.45* Hgb-10.1* Hct-30.6*
MCV-89 MCH-29.2 MCHC-33.0 RDW-14.2 Plt Ct-212
[**2164-5-7**] 06:15AM BLOOD PT-13.0 PTT-29.5 INR(PT)-1.1
[**2164-5-7**] 06:15AM BLOOD Plt Ct-212
[**2164-5-6**] 04:14AM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-141
K-3.5 Cl-111* HCO3-23 AnGap-11
[**2164-5-7**] 06:15AM BLOOD Glucose-91 UreaN-10 Creat-0.5 Na-143
K-3.8 Cl-111* HCO3-24 AnGap-12
[**2164-5-7**] 06:15AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.1
[**2164-5-4**] 05:38PM BLOOD Glucose-92 Lactate-1.2 Na-137 K-3.8
Cl-106
[**5-5**] Echo
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
valvular [**Male First Name (un) **] with a severe resting left ventricular outflow
tract obstruction (>64mmHg). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (?#)
appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen.The mitral valve leaflets are
mildly thickened. There is systolic anterior motion of the
mitral valve leaflets. At least moderate (2+) mitral
regurgitation is seen. There is an anterior space which most
likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Hypertrophic obstructive
cardiomyopathy. At least moderate mitral regurgitation.
[**5-6**] CXR
The heart size is top normal. Mediastinal position, contour and
width are
unremarkable. The pacemaker leads terminate in right atrium and
right
ventricle, unchanged in appearance since the prior study. Within
the
limitations of this study technique, no break within the leads
was
demonstrated. Lungs are essentially clear except for right
basilar opacities
that might represent an area of atelectasis, although attention
to this area
should be paid to exclude developing infection. Left basal
linear atelectasis
is new.
Brief Hospital Course:
76 yo F with h/o HOCM, s/p ICD placement in [**2160**], now with ICD
misfiring, transferred for lead extraction.
Pt was transferred to CCU on [**5-4**] after lead extraction. She was
extubated after lead extraction without complication and was
admitted to the CCU brief post-op monitoring. CXR showed no
evidence of hemo/pneumothorax. TTE to assess for pericardial
effusion s/p pacer lead removal showed mild symmetric LVH,
severe resting LVOT obstruction (>64mmHg), 2+ MR. [**First Name (Titles) 47652**] [**Last Name (Titles) 47653**]d from 33.3 to 25.3 to 23.8 and then trended up after 2 U
PRBC to 29.3 and then 30.2. Patient developed eccymosis of the
LEFT breast that was stable prior to transfer back the
cardiology floor. Patient was started on po keflex for planned 7
day course. Plan for follow up with Dr. [**Last Name (STitle) **] in 1 week in
device clinic.
Medications on Admission:
Omeprazole 10mg po bid
ASA 81mg po daily
Verapamil 240mg po daily
[**Doctor First Name **] 60mg po bid
Crestor 10mg po daily
Evista 50mg po daily
Quinapril 10mg po bid
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO daily ().
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for allergies.
6. Rosuvastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Quinapril 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days: Final dose on Friday [**5-11**].
Disp:*20 Capsule(s)* Refills:*0*
9. Outpatient Lab Work
Please have your HCT checked on [**5-9**].
10. Device check
Please have your device checked on Friday [**5-11**]
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary diagnosis:
1. ICD malfunction
Secondary diagnosis:
Hypertrophic obstructive cardiomyopathy
Hypertension
Discharge Condition:
Hemodynamically stable. HCT 30.6
Discharge Instructions:
You were admitted after your ICD misfired. You had a lead
extraction performed by electrophysiology. The procedure was
uncomplicated. We started you on Keflex antibiotics after this
procedure. The final day of antibiotics will be Friday [**5-11**].
We did not make any other changes to your medications.
If you have palpitations, chest pain, shortness of breath, or
your ICD fires again, please call your cardiologist or go to the
emergency department.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 47654**] in [**12-23**] weeks.
You will need to have your device checked on Friday [**5-11**].
Please call your Cardiologist for this.
Completed by:[**2164-5-7**]
|
[
"401.9",
"425.1",
"424.0",
"996.72",
"996.04",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7951, 8012
|
5956, 6830
|
278, 295
|
8168, 8203
|
2564, 5933
|
8708, 8922
|
1563, 1667
|
7049, 7928
|
8033, 8033
|
6856, 7026
|
8227, 8685
|
1682, 2545
|
1141, 1309
|
225, 240
|
323, 1031
|
8092, 8147
|
8052, 8071
|
1340, 1436
|
1053, 1121
|
1453, 1547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,410
| 114,394
|
50165
|
Discharge summary
|
report
|
Admission Date: [**2162-12-23**] Discharge Date: [**2162-12-25**]
Date of Birth: [**2109-8-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53m healthy male presents with 3 days CP. CP radiates to left
neck, improves with sitting up. Was getting worse this morning
and so came into ED. Describes pain starting all of a sudden 3
days ago. Dull, pressure. Worse laying down. Some mild
associated dyspnea, no orthpnea. Able to climb stairs. Never
happened before. No trauma, no sick contacts. Did have URI sx ~
5 days ago. Tried tylenol without improvement. Pain continued to
worsen, presented to ED. In ED, there was initial concern for ST
elevations in V2-V5 and so code STEMI was called. Received asa,
integrillin, hep bolus, and plavix. On review by cards, looked
like more diffuse st elevations and so was felt to be more
consistent with pericarditis. CXR showed widened mediastinum but
CTA was negative for dissection (did show small defect in one of
the arteries going to the lingula but looks old, per rads).
Received morphine and nitro for CP--> BP dropped to 60s,
improved with IVF and trendelenburg, got 2+ L NS. Otherwise
vitals stable. Also got dilaudid and toradol for CP which worked
better. CP [**2-1**] prior to transfer to floor. Of note, also has
chronic neck and back pain (on percocet). TTE in the ED showed
no effusion.
First set enzymes neg.
.
On arrival to CCU, pt reports being comfortable, pain [**2163-11-26**].
Otherwise on review of systems, he denies HA, fevers, chills,
heart burn, palpitations, abd pain, n/v/diarrhea/constipation,
dysuria, joint pain. No recent skin infections, IVDU. + chronic
LBP and neck pain. No syncope, LE edema.
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:
Back pain
HTN
Seasonal Allergies
Obesity
Social History:
Pt unemployed on disability for LBP, formerly carpet cleaner at
[**Hospital3 **]. In monogamous relationship with GF.
-Tobacco history: Quit smoking: Never smoked
-ETOH: Never
-Illicit drugs:Former cocaine use, last use 3 years ago. Denies
h/o IVDU
Family History:
Father with DM and ? of CAD
Physical Exam:
GENERAL: Overweight middle aged AA gentleman, resting
comfortably.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Engorged neck veins, JVP to angle of jaw.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachycardic, regular. Nl S1, S2, rub ascultated 2nd
intercostal space, L of sternum with breath held.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Mild
tachypnea. Crackles b/l at bases.
ABDOMEN: Obese, soft, NT. Hypoactive BS.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
LABS ON ADMISSION:
.
[**2162-12-23**] 03:50PM BLOOD WBC-14.6*# RBC-6.39* Hgb-14.9 Hct-45.4
MCV-71* MCH-23.2* MCHC-32.7 RDW-15.4 Plt Ct-235
[**2162-12-23**] 03:50PM BLOOD Neuts-84.9* Lymphs-8.4* Monos-5.8 Eos-0.7
Baso-0.4
[**2162-12-23**] 03:50PM BLOOD PT-14.1* PTT-27.5 INR(PT)-1.2*
[**2162-12-23**] 03:50PM BLOOD Glucose-112* UreaN-11 Creat-1.1 Na-136
K-5.2* Cl-98 HCO3-28 AnGap-15
.
[**2162-12-23**] 06:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2162-12-23**] 06:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.049*
.
Discharge labs-
[**2162-12-25**] 06:23AM BLOOD WBC-9.3 RBC-5.67 Hgb-13.0* Hct-39.5*
MCV-70* MCH-22.9* MCHC-32.9 RDW-15.1 Plt Ct-213
[**2162-12-25**] 06:23AM BLOOD Plt Ct-213
[**2162-12-25**] 06:23AM BLOOD Glucose-135* UreaN-14 Creat-1.0 Na-140
K-3.4 Cl-98 HCO3-29 AnGap-16
[**2162-12-25**] 06:23AM BLOOD CK(CPK)-82
[**2162-12-25**] 06:23AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2162-12-24**] 04:10AM BLOOD Mg-1.9
.
Studies-
echo [**2162-12-23**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: No pericardial effusion. Mild symmetric left
ventricular hypertrophy with normal global/regional
biventricular systolic function. Mild pulmonary hypertension.
CTA chest [**2162-12-23**]
IMPRESSION.
1. No aortic dissection.
2. No central pulmonary embolus.
3. Questionable small filling defect at the bifurcation of the
inferior
lingula branch pulmonary artery that may represent a small
pulmonary embolus of uncertain chronicity. If real, this would
represent a very small thrombus burden of doubtful clinical
consequence. This was discused with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on
[**2162-12-22**] by Dr. [**Last Name (STitle) 20059**].
4. Bibasilar airspace opacities. Volume loss favors atelectasis
(versus
consoldation or aspiration).
CXR [**2162-12-23**]
IMPRESSION: Mild pulmonary edema with small-to-moderate sized
bilateral
pleural effusions. Bibasilar atelectasis.
Brief Hospital Course:
In summary, Mr [**Known lastname 104684**] is a 53M with hx of HTN, who was admitted
with history of three days of chest pain, likely caused by a
viral pericarditis.
# Pericarditis: Chest pain was most consistent with viral
pericarditis given story of recent URI, rub initial exam, and
ECG findings of diffuse ST elevations and PR depressions, with
PR elevation in avr. Patient's symptoms were also
characteristic. His urine tox screen was negative for cocaine.
No evidence of effusion on TTE. Pt was ruled out for a ACS with
three sets of cardiac biomarkers. There was initially a question
of PE on CTA, although per radiology this looked more chronic.
Also pt was not hypoxic and no risk factors for PE. Thus PE was
considered unlikely and he was not anticoagulated. He was
treated with TID ibuprofen with PPI for gastric mucosal
protection, and then changed to indomethacin 50mg [**Hospital1 **] for better
pain control. He was discharged on a 2 week course, however,
this may need to be extended depending on his symptoms. He was
instructed to have his renal function checked at his PCPs office
in seven days and to have PCP follow up.
# PUMP: TTE in ED showed LVH c/w chronic hypertensive disease.
On admission he had slight evidence of fluid overload on exam
with crackles and elevated JVP, in setting of rapid fluid bolus
in ED while hypertensive. He developed mild shortness of breath
and was given 10 mg IV Lasix with good response. He had no
shortness of breath on day of discharge.
# Blood pressure - Patient had a history of HTN, TTE c/w chronic
hypertensive changes. BP low-normal on arrival to floor, had
been hypotensive in ED after receiving nitro for possible STEMI.
Blood pressure improved with IV fluids. He was restarted on HCTZ
when BP was stable and was increase to SBP of 140 on day of
discharge. His BP will need to be re-evaluated at his f/u
appointment.
Medications on Admission:
prn Percocet
prn Certrizine
(used to take HCTZ for BP)
Discharge Medications:
1. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-26**] Sprays Nasal
QID (4 times a day) as needed: for nasal congestion.
Disp:*1 bottle* Refills:*3*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO In the morning, before
breakfast: take while on indomethacin.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
4. Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day) for 2 weeks: for pericarditis, take with food.
Disp:*56 Capsule(s)* Refills:*0*
5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): for blood pressure.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary-
Pericarditis
Secondary-
Hypertension
Mild Left ventrical hypertrophy
Discharge Condition:
Hemodynamically stable, afebrile, pain free
Discharge Instructions:
You were admitted to the hospital due to chest pain, you were
diagnosed with pericarditis. This is likely secondary to a viral
illness. You were treated with medication to decrease the
inflammation. You also had an echocardiogram to evaluate your
heart function.
You will need to call you PCP [**Name9 (PRE) 104685**] for [**Name Initial (PRE) **] follow up appointment.
You were started on new medications, please take them as
instructed. Stop taking the indomethacin if you have difficulty
urinating or notice blood in your stool.
- Indomethacin 50mg twice a day with food, for your pericarditis
- omeprazole 20mg in the morning 30 minutes before eating to
protect your stomach while on the indomethacin
- hydrocholrothiazide- was restarted for your blood pressure
You will need to have lab work done on Friday to check your
kidney function. You can have this done at your primary care
clinic.
If you have shortness of breath, worsening chest pain,
difficulty urinating, blood in your stool, severe stomach pain,
or other concerning symptoms please seek medical attention or go
to the ER.
Followup Instructions:
Please call to schedule a follow up appointment for 7-10 days
with your Primary care doctor, [**Doctor Last Name **],[**Doctor Last Name **] A.
[**Telephone/Fax (1) 7976**]
Please have lab work done this Friday to check your kidney
function.
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2162-12-29**] 1:50
Provider: [**Name10 (NameIs) 8741**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2162-12-29**]
2:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2162-12-25**]
|
[
"723.1",
"420.91",
"276.6",
"402.10",
"E942.4",
"724.2",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8511, 8517
|
5740, 7627
|
327, 333
|
8640, 8686
|
3122, 3127
|
9830, 10479
|
2430, 2459
|
7733, 8488
|
8538, 8619
|
7653, 7710
|
8710, 9807
|
2474, 3103
|
2000, 2073
|
277, 289
|
361, 1889
|
3141, 5717
|
2104, 2147
|
1911, 1980
|
2163, 2414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,389
| 150,309
|
24042
|
Discharge summary
|
report
|
Admission Date: [**2151-3-25**] Discharge Date: [**2151-3-27**]
Date of Birth: [**2088-9-14**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer from OSH w/overwhelming sepsis, MRSA bacteremia with
multiorgan failure
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
HPI: 62yo male w/hx of CAD s/p MI (EF50%), COPD, OSA, Chronic
Myelosuppresion, and CVA who was admitted to [**Hospital3 26615**]
Hospital on [**2151-3-9**] for SOB. He was thought to be having a COPD
exacerbation and was initially treated w/solumedrol and
erythromyocin. The timing of subsequent events is not completely
clear from the medical records that were provided, but he did
have the following pertinent events documented:
-AFlutter w/LBBB s/p cardioversion
-CT Neck w/contrast on [**3-22**] showing no mass or fluid collection
-CT Head on [**3-22**] showing low attenuation area in Left parietal
white matter consitent with infarction, as well as right
maxillary sinus fluid collection.
-Chest CT w/o contrast on [**3-22**] showing consolidation/collapse of
RLL and LLL consolidation. Right pleural effusion, and a
questionable blockage of the bronchus intermedius due to a mucus
plug.
-MIBI on [**3-18**] very small anteroseptal defect at apex w/mild
decrease in systolic function.
-LENI Left and Right leg on [**3-11**] showing no DVT.
-TEE showed no [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]. No AS/AR. Trival MR. Elevated right
sided pressures.
Over the course of his stay he continued to deteriorate and
developed worsening renal failure and CHF. It seems that he was
intubated at 4/4 and that dialysis was initiated on [**3-24**] through
a temporary right femoral line. His hypoxia continued to worsen
on the ventillator despite increasing FiO2's and pressures. At
this time he was transferred to [**Hospital1 18**] for further evaluation and
managment.
Past Medical History:
CAD s/p MI [**2140**], Nonobstructive CAD on cath [**4-21**] w/EF 50%
Pancytopenia s/p 2 marrow biopsies, felt to be secondary to
liver disease and hypersplenism
COPD/emphysema
Asbestosis
OSA
h/o CVA
s/p 2 knee replacements on right
CHF
DMII
CRI w/baseline creatinine of 1.5-1.9
h/o of negative EGDs/Colonoscopies
Social History:
Unknown
Family History:
Noncontributory
Physical Exam:
T103 P90 BP 105/54(on levophed) RR28 02sats 89-92% on AC
Morbidly obese, sedated, warm extremities
Pupils [**3-20**] bilat, intubated
CV w/RRR and SEM
Lungs w/course breath sounds anteriorly
Abdomen obese/w ? distention, echymossis anteriorly
Sacral decub w/break down of skin in gluteal cleft
right groin line, +2 edema in LE, chronic venous stasis changes
in extremities, echymosis/mottling of right foot.
Neuro/sedated, pupils minimillay reactive
Pertinent Results:
[**2151-3-25**] 04:18PM PT-15.5* PTT-40.0* INR(PT)-1.5
[**2151-3-25**] 04:18PM PLT COUNT-51*
[**2151-3-25**] 04:18PM WBC-10.5 RBC-3.30* HGB-10.1* HCT-31.6* MCV-96
MCH-30.6 MCHC-32.1 RDW-16.3*
[**2151-3-25**] 04:18PM PHENYTOIN-6.6*
[**2151-3-25**] 04:18PM VANCO-17.1*
[**2151-3-25**] 04:18PM CORTISOL-93.8*
[**2151-3-25**] 04:18PM ALBUMIN-2.9* CALCIUM-7.8* PHOSPHATE-4.9*
MAGNESIUM-1.9
[**2151-3-25**] 04:18PM CK-MB-3 cTropnT-0.08*
[**2151-3-25**] 04:18PM ALT(SGPT)-104* AST(SGOT)-161* CK(CPK)-609*
ALK PHOS-125* TOT BILI-1.1
[**2151-3-25**] 04:18PM GLUCOSE-240* UREA N-50* CREAT-3.7* SODIUM-139
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-22 ANION GAP-18
[**2151-3-25**] 04:30PM freeCa-1.10*
[**2151-3-25**] 04:30PM HGB-10.2* calcHCT-31 O2 SAT-88
[**2151-3-25**] 04:30PM GLUCOSE-233* LACTATE-4.2* K+-4.8
[**2151-3-25**] 04:30PM TYPE-ART TEMP-40.6 RATES-20/0 TIDAL VOL-600
PEEP-15 O2-80 PO2-74* PCO2-60* PH-7.18* TOTAL CO2-24 BASE XS--6
AADO2-446 REQ O2-75 INTUBATED-INTUBATED VENT-CONTROLLED
COMMENTS-AXILLARY T
[**2151-3-25**] 06:03PM PLT COUNT-52*
[**2151-3-25**] 06:03PM WBC-13.5* RBC-3.45* HGB-10.5* HCT-33.4*
MCV-97 MCH-30.3 MCHC-31.3 RDW-15.9*
[**2151-3-25**] 06:38PM O2 SAT-92
[**2151-3-25**] 06:38PM GLUCOSE-245* LACTATE-4.1*
[**2151-3-25**] 06:38PM TYPE-ART TEMP-40.1 RATES-20/0 TIDAL VOL-534
PEEP-15 O2-80 PO2-87 PCO2-71* PH-7.09* TOTAL CO2-23 BASE XS--9
AADO2-422 REQ O2-72 INTUBATED-INTUBATED VENT-CONTROLLED
[**2151-3-25**] 06:44PM O2 SAT-77
[**2151-3-25**] 06:44PM TYPE-MIX TEMP-40.1 PO2-62* PCO2-76* PH-7.07*
TOTAL CO2-23 BASE XS--9
[**2151-3-25**] 08:10PM HCT-34.5*
[**2151-3-25**] 08:17PM freeCa-1.11*
[**2151-3-25**] 08:17PM LACTATE-3.8*
[**2151-3-25**] 08:17PM TYPE-ART TEMP-39.3 TIDAL VOL-500 PEEP-15
O2-100 PO2-79* PCO2-73* PH-7.14* TOTAL CO2-26 BASE XS--5
AADO2-573 REQ O2-93 -ASSIST/CON INTUBATED-INTUBATED
[**2151-3-25**] 10:02PM LACTATE-4.0*
[**2151-3-25**] 10:02PM TYPE-ART TEMP-39.2 RATES-30/0 TIDAL VOL-500
PEEP-15 O2-100 PO2-78* PCO2-71* PH-7.14* TOTAL CO2-26 BASE XS--6
AADO2-576 REQ O2-93 -ASSIST/CON INTUBATED-INTUBATED
[**2151-3-25**] 11:24PM TYPE-ART TEMP-39.2 RATES-30/ TIDAL VOL-600
PEEP-15 O2-100 PO2-81* PCO2-62* PH-7.18* TOTAL CO2-24 BASE XS--6
AADO2-582 REQ O2-94 -ASSIST/CON INTUBATED-INTUBATED
[**2151-3-25**] CXR: FINDINGS: This is a technically limited study due
to portable technique. There is an endotracheal tube present
with the tip probably terminating satisfactorily in the trachea
at the level of the thoracic inlet. A NG tube is present,
probably in the esophagus with the tip not well seen. There is
also a left internal jugular catheter with the tip probably in
the SVC. There is evidence for failure with cardiomegaly, upper
zone redistribution, and prominence of the central vascularity.
There are bilateral pleural effusions. There is retrocardiac
atelectasis or consolidation and patchy bibasilar opacities.
[**2151-3-26**]: ECHO Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function cannot be reliably assessed. 2. The aortic
valve leaflets are mildly thickened.
3. The mitral valve leaflets are mildly thickened.
4. The valves are not well seen, but there is no obvious
vegetation seen.
Brief Hospital Course:
[**2151-3-25**]: Transferred from OSH in overwhelming sepsis. Redosed
vanco. Added ceftaz for pseudomonal coverage. Pressors changed
to Levophed. Transfuse for goal Hct>30. Re-site central venous
access from IJ. Scheduled HD, made renal aware. Started insulin
gtt for tighter glycemic control. Consulted plastics for eval of
decub ulcer. Serial Hcts secondary to coffee ground from OG tube
suction. Vitamin K given for elevated INR and hx of liver dz.
Supplement w/steroids for septic shock. Maxamized ventilatory
support w/increased PEEP given morbid obesity.
[**2151-3-26**]: Renal planning for CVVHDF. Lactate continuing to trend
higher, now 6.5, despite resuc efforts. WBC trending from 10.5
to 23.8. Adding gent given these lab findings while on Vanco.
Esophageal balloon study to set PEEP. ? of PFO causing continued
hypoxia on ABGs.
[**2151-3-27**]: Episode of rapid Afibb w/LBBB, bolused w/amiodarone and
started gtt. Unsucessfull balloon study. Right subclavian
placed. Sacral decub ulcer growing GPC. CXR w/evid of resolving
failure. TTE w/o evidence of vegitations. Lactate now 19.1.
Noted to have multiple ischemic/cool digits on right foot while
on pressors. Vascular consulted and recs implimented w/heparin
gtt. Family meeting w/directions for team to make patient
CMO/patient's wishes per family not to be ventilated more than a
few days. Patient declared dead at 4:15pm by Dr. [**Last Name (STitle) **]
Medications on Admission:
Lantus / Iron / Dilantin / Solumedrol / Lasix / Amiodarone /
Propofol / Dopamine / Reglan / Levaquin / Vancomyocin / Diflucan
/ Ceftaz
Discharge Medications:
NONE
Discharge Disposition:
Expired
Facility:
MICU at [**Hospital1 18**]
Discharge Diagnosis:
Sepsis
Discharge Condition:
Deceased
Discharge Instructions:
NONE
Followup Instructions:
NONE
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"785.52",
"482.41",
"995.92",
"250.00",
"276.2",
"584.9",
"518.81",
"501",
"707.03",
"038.11",
"427.31",
"492.8",
"284.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7772, 7819
|
6137, 7558
|
358, 364
|
7869, 7879
|
2865, 6114
|
7932, 8075
|
2362, 2379
|
7743, 7749
|
7840, 7848
|
7584, 7720
|
7903, 7909
|
2394, 2846
|
237, 320
|
392, 1983
|
2005, 2321
|
2337, 2346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,238
| 108,880
|
18361
|
Discharge summary
|
report
|
Admission Date: [**2192-10-24**] Discharge Date: [**2192-10-26**]
Date of Birth: [**2142-5-23**] Sex: F
Service: NEUROSURGERY
Allergies:
NSAIDS
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Left Frontal Craniotomy for resection of meningioma
History of Present Illness:
50yo woman who presented on [**2192-9-11**] after experiencing the
worst h/a of her life. CT scan was negative for SAH but LP was
not successfully obtained. A CTA was performed which was
negative
for vascular malformation but did reveal a left frontal lesion.
It was recommended that she return in 1 month with an MRI.
Since her discharge she denies h/a's, visual disturbances,
weakness, change in personality or memory. She did note rare
episodic numbness/tingling of her tongue.
Past Medical History:
-Bipolar d/o
-s/p gastric bupass
-s/p LOA
-s/p cholecystectomy
-s/p abdominal panniculectomy [**2192-8-23**]
Social History:
-Married, lives w/ husband
-denies tobacco
-infrequent ETOH
Family History:
-no family history of brain cancer
Physical Exam:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: no adventicious sounds
Cardiac: RRR
Abd: Soft, NT
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-26**] throughout. No pronator drift
Sensation: Intact to light touch, propioception
Coordination: normal on finger-nose-finger, rapid alternating
movements
PHYSICAL EXAM UPON DISCHARGE:
NF
staples intact
Pertinent Results:
[**10-24**] MRI Brain CONCLUSION: No change in the left frontal
enhancing extra-axial mass,
apparently dural-based, most likely a meningioma.
[**10-24**] CT Head: IMPRESSION: Status post left frontal extra-axial
mass resection with expected post-operative changes and no
concerning acute intracranial process
[**10-25**] MRI Brain: PENDING
Brief Hospital Course:
Mrs. [**Known lastname 12130**] was admitted for elective craniotomy for resection
of meningioma. She underwent left-sided frontal craniotomy for
resection of the tumor on [**2192-10-24**]. Please see operative note for
details. She tolerated the procedure well and was taken to
Neuro-ICU in stable condition. In the PACU she became slightly
hypotensive with SBP in the 90-100 mmHg range which improved
after IVF replacement. On POD#1 she was transferred to the
floor. She resumed PO intake on POD#1, was ambulating
independently. She complained of nausea which responded well to
antiemetics.
On POD#2 She was neurologically intact and without complaint.
She is tolerating PO, ambulating, voiding and pain is well
controlled. She is cleared for discharge home and she is in
agreement with this plan.
Medications on Admission:
LAMOTRIGINE 275 mg daily
SERTRALINE 100 mg Daily
CALCIUM CITRATE 1200 mg daily
CHOLECALCIFEROL (VITAMIN D3) 1 tab daily
CYANOCOBALAMIN (VITAMIN B-12) 1 tab daily
FERROUS SULFATE - Dosage uncertain
MULTIVITAMIN 1 tab daily
THIAMINE HCL 1 tab daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, T>38.5.
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*15 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. lamotrigine 25 mg Tablet Extended Rel 24 hr Sig: Eleven (11)
Tablet Extended Rel 24 hr PO DAILY (Daily).
6. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: 2 and
1/2 Tablets PO DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper: 4mg
Q8hrs on [**10-26**], 3mg Q8hrs on [**10-27**], 2mg Q8hrs on [**10-28**]
2mg Q12hrs on [**10-29**]
1mg Qday on [**10-30**] then d/c.
Disp:*qs Tablet(s)* Refills:*0*
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
15. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Left Frontal Meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery do not
resume these until after being cleared by your surgeon.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring. Please note that we increased
your dose after your surgery.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**7-1**] days (from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**11-12**] at
930am with Dr [**Last Name (STitle) 6570**]. The Brain [**Hospital 341**] Clinic is located on the
[**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their
phone number is [**Telephone/Fax (1) 1844**]. Please call if you need to change
your appointment, or require additional directions.
Completed by:[**2192-10-26**]
|
[
"V45.86",
"225.2",
"296.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51"
] |
icd9pcs
|
[
[
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]
] |
5346, 5365
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2680, 3481
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282, 336
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5433, 5433
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2314, 2469
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7402, 8245
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1073, 1110
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3780, 5323
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5386, 5412
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234, 244
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364, 846
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15,301
| 189,615
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51720
|
Discharge summary
|
report
|
Admission Date: [**2135-5-16**] Discharge Date: [**2135-5-20**]
Date of Birth: [**2060-1-15**] Sex: M
Service: MEDICINE
Allergies:
Protamine Sulfate / Ambien
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
PICC placement (removed prior to discharge)
History of Present Illness:
Mr. [**Known lastname 20741**] is a 75 year old male with h/o DM, COPD, CRF, AAA,
OSA who presented to [**Hospital1 18**] with complaints of hematuria and
continued rib pain after sustaining a fall last week which was
thought to be a rib contusion. He was seen in [**Company 191**] and referred
to ED for further evaluation.
.
In the emergency department, initial vitals: 17:11 8 97.4 72
150/61 22 93. He received Levo 750 mg IV and flagyl 500 mg IV
after CT chest revealed LLL consolidation as well as multiple
new rib fractures on left (4th-7th). In the ED, his BS were
repeatedly low in 50's, but improved with food and D50.
.
On arrival to MICU, he states that he was sitting eating
breakfast on Wednesday when he suddenly found himself on the
floor. No prodrome but he believes that he lost consciousness.
He has had episodes like this in the past that have been
worked-up w/o an etiology found. He was evaluated at the OSH and
was discharged on pain medications. He has been sleeping in his
chair [**1-31**] pain. He has continued to take his diuretics despite
decreased po intake. He also notes no BM X 5 days as it hurts to
valsalva. + severe L rib pain on inspiration.
.
It was felt that his fall may have been precipitated by
hypoglycemic episode. The patient's family notes that the
patient is frequently very somnolent due to severe OSA and he
falls asleep frequently which may also have contributed to his
fall.
.
Upon evaluation by floor, he reports feeling somewhat better
than when he first came in. His rib pain is still [**7-8**], but
somewhat controlled with dilaudid PCA. his major complaint is
severe constipation and some nausea, which he attributes to
constipation. ROS negative for chest pain, palpiatations,
fever,chills, cough. He also reports some tenderness in his R
thigh as well as RLE calf.
.
Review of systems:
(+) Per HPI, cough productive of whitish sputum X 2 weeks. +
Mild nausea. Does endorse occasional low blood sugars.
(-) Denies fever, chills, night sweats, recent weight loss or
gain (dry weight 305). Denies headache, sinus tenderness,
rhinorrhea or congestion. Denied shortness of breath. Denied
chest pain or tightness, palpitations. Denied diarrhea,
abdominal pain. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Chronic renal failure, Stage IV
Hyperlipidemia
DM2
HTN
CAD
Osteoarthritis
Peripheral neuropathy [**1-31**] spinal stenosis
AAA
MGUS
Thrombocytopenia
COPD
Diastolic CHF w/ LVH
Morbid obesity
Social History:
Former history of tobacco use, [**4-3**] ppd x 40-50 years, stopped in
'[**16**]. Heavy alcohol use, though decreasing in recent months, last
drink was over a week ago. No history of withdrawal. Denies
illicit drug use.
Family History:
father died at 96. mother died at 93. Diabetes
Physical Exam:
VITAL SIGNS: T 95.5 BP 141/80 HR 71 RR 24 O2 97% on 4L NC
GENERAL: Pleasant, alert, good historian, yelling in pain w/
movement but comfortable at rest
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. dry. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP not able to be assessed
LUNGS: CTAB but difficult exam given pain w/ deep inspiration.
ABDOMEN: NABS. Soft, obese, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, non-palp pedal pulses.
SKIN: ecchymoses on upper arms bilaterally.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. + asterixis
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Labs on Admission:
[**2135-5-16**] 07:10PM BLOOD WBC-8.7 RBC-3.60* Hgb-10.8* Hct-32.2*
MCV-90 MCH-30.1 MCHC-33.6 RDW-14.4 Plt Ct-131*
[**2135-5-17**] 04:15AM BLOOD PT-14.1* PTT-27.2 INR(PT)-1.2*
[**2135-5-16**] 05:30PM BLOOD Glucose-35* UreaN-107* Creat-5.5*# Na-137
K-5.4* Cl-99 HCO3-21* AnGap-22*
[**2135-5-16**] 07:10PM BLOOD ALT-27 AST-69* CK(CPK)-3428* AlkPhos-120*
TotBili-0.3
[**2135-5-16**] 07:10PM BLOOD Albumin-4.0 Calcium-8.9 Phos-5.7* Mg-3.1*
[**2135-5-17**] 12:28AM BLOOD Lactate-1.3
.
Creatinine and Lytes trend during hospital stay:
[**2135-5-16**] 05:30PM BLOOD Glucose-35* UreaN-107* Creat-5.5*# Na-137
K-5.4* Cl-99 HCO3-21* AnGap-22*
[**2135-5-16**] 07:10PM BLOOD Glucose-29* UreaN-108* Creat-5.5* Na-138
K-4.9 Cl-98 HCO3-23 AnGap-22*
[**2135-5-17**] 04:15AM BLOOD Glucose-135* UreaN-101* Creat-4.8* Na-142
K-4.8 Cl-101 HCO3-28 AnGap-18
[**2135-5-18**] 05:14AM BLOOD Glucose-156* UreaN-106* Creat-6.1*#
Na-139 K-5.6* Cl-101 HCO3-28 AnGap-16
[**2135-5-18**] 01:46PM BLOOD Glucose-198* UreaN-103* Creat-5.6* Na-140
K-5.2* Cl-102 HCO3-27 AnGap-16
[**2135-5-19**] 05:25AM BLOOD Glucose-201* UreaN-80* Creat-4.1* Na-145
K-4.2 Cl-107 HCO3-25 AnGap-17
[**2135-5-19**] 01:37PM BLOOD Glucose-207* UreaN-72* Creat-3.7* Na-144
K-3.8 Cl-107 HCO3-23 AnGap-18
[**2135-5-20**] 06:00AM BLOOD Glucose-204* UreaN-57* Creat-2.8* Na-148*
K-3.5 Cl-111* HCO3-25 AnGap-16
.
Labs on Discharge:
[**2135-5-20**] 06:00AM BLOOD WBC-6.2 RBC-3.07* Hgb-9.1* Hct-27.2*
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.5 Plt Ct-109*
[**2135-5-20**] 06:00AM BLOOD Plt Ct-109*
[**2135-5-20**] 06:00AM BLOOD Glucose-204* UreaN-57* Creat-2.8* Na-148*
K-3.5 Cl-111* HCO3-25 AnGap-16
[**2135-5-20**] 06:00AM BLOOD CK(CPK)-431*
[**2135-5-20**] 06:00AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.2
.
Imaging:
CT HEAD W/O CONTRAST Study Date of [**2135-5-16**]: No evidence of
acute intracranial hemorrhage, edema, mass effect,
hydrocephalus, or a large vascular territory infarction is seen.
Periventricular and subcortical white matter hypodensities are
suggestive of chronic microvascular ischemic disease. Old
lacunar infarct or prominent perivascular space in the left
basal ganglia as was previously seen. The soft tissues and
orbits appear intact. No fracture is seen in the skull. Rounded
lucency at the vertex measures 11 mm which is little change and
likely represents a venous [**Doctor Last Name **]. Minimal mucosal thickening is
noted in the ethmoid air cells. Otherwise, the visualized
paranasal sinuses and mastoid air cells
are well aerated. Vascular calcifications are noted along the
cavernous
carotid arteries. IMPRESSION: No evidence of acute traumatic
injury seen.
.
[**5-16**] PA/Lat CXR: The lungs are of low volume. There is
atelectasis present at the left lung base. There is irregularity
of the left fourth and fifth rib posteriorly, this may represent
minimally displaced fractures. The heart remains enlarged. The
right lung is clear. There are multilevel degenerative changes
present in the spine. CONCLUSION: Question minimally displaced
fractures of the posterior left 4th and 5th ribs. There is no
pneumothorax.
.
CT CHEST W/O CONTRAST Study Date of [**2135-5-16**]:
1. Multiple new rib fractures on the left. Small left
non-hemorrhagic
pleural effusion. Dependent atelectasis. Left lower lobe
consolidation
possibly likely atelectasis, less likely aspiration.
2. No intra-abdominal injury seen.
.
Ultrasound [**2135-5-18**] IMPRESSION: No evidence of DVT of the right
lower extremity.
.
Microbiology:
Blood culture: no growth.
Brief Hospital Course:
MICU COURSE:
75 M w/ pmh of obesity, OSA, stage IV CKD, DM2 p/w pain from rib
fractures and hypoglycemia. In the MICU, his blood sugars ranged
from 120-150's. His NPH was held. Pain service was consulted
regarding his severe rib fracture pain and recommended epidural,
which the patient refused. He was then placed on a dilaudid PCA
started on [**5-17**]. In addition, he was noted to have LLL
consolidation c/w pneumonia versus atelectasis. Antibiotics were
not continued as he had no fever or leukocytosis. Patient was
transferred to the floor for further management.
.
General Medicine Course:
.
75 M w/ PMH of obesity, OSA, stage IV CKD, DM2 p/w pain from rib
fractures and hypoglycemia. Labs demonstrated acute on chronic
renal failure. Floor course according to active problem list.
.
# Acute on Chronic renal failure: Creatinine increased to 6.1
(baseline [**2-1**]). Renal was consulted. Urine demonstrated non
dysmorphic RBCs, no casts to suggest ATN. Following two days of
aggressive hydration creatinine improved to baseline 2.8.
Etiology of acute failure felt to be prerenal secondary to
decreased po intake and recent NSAID use. There may be an
underlying component of obstruction secondary to BPH (when foley
was placed patient diuresed 400 cc of urine). Consequently,
patient was discharged with a foley, started on Flomax and
Urology outpatient follow-up was arranged.
- SPEP result pending at time of discharge
- Re-started Lisinopril at 10 mg - recommend increasing to
outpatient dose of 20 mg once creatinine stable at baseline 2.8
- 3.7.
- Held Lasix - can be re-started once creatinine stablized at
baseline 2.8-3.7
- Monitor creatinine and electrolytes twice weekly for 2 weeks,
then weekly (especially K for hyperkalemia). Recommend next lab
check [**2135-5-22**] or [**2135-5-23**].
- Sodium was mildly elevated on discharge (148) - patient
encouraged to drink free water. Recommend next lab check [**2135-5-22**]
or [**2135-5-23**].
.
#. Pain control/Rib fractures: Continues to have [**4-8**] pain.
Patient refused dilaudid and epidural. Discharged on standing
tylenol with prn percocet. No more than 4 gm Tylenol a day.
.
#. Anemia: Stable at 27 HCT (some dilutional effect secondary to
PICC line draw). Chronic normocytic anemia secondary to anemia
of chronic disease and renal disease.
.
#. Diabetes: On admission hypoglycemia secondary to increased
insulin effect in setting of acute renal failure and decreased
po intake. At time of discharge BS ranging from 200-228.
- Continue QID FSBS with humolog sliding scale
- Continue to hold fixed insulin dose due to poor po intake
- encourage PO intake, re-start fixed dose insulin 70/30 once
adequate po intake
.
#. Hypoxia: Stable 94% 4 L. Known COPD although not on home O2.
Current hypoxia related to poor inspiration secondary to
splinting from rib fractures.
- pain control
- continue albuterol, ipratropium, flovent
- IS 10X/hour
- Wean NC O2 as possible
.
# Decreased mental status: Mental status returned to baseline
once dilaudid PCA was stopped. Appears to have been narcotic
side effect vs. uremia now resolved.
.
#. Syncope? vs fall: Family feels he fell asleep (severe OSA)
and fell out of chair. Based on presenting hypoglycemia,
hypoglycemia also on differential as etiology (see treatment as
above). No abnormalities other than PACs on tele.
.
# OSA: Patient used home CPAP while in house.
#. Thrombocytopenia: During admission at baseline (range
88-117).
#. HTN: Patient re-started on Metoprolol 50 mg [**Hospital1 **] outpatient
dose prior to discharge.
- Re-started Lisinopril at 10 mg - increase to outpatient dose
20 mg once creatinine stable at baseline 2.8 - 3.7.
#. Hyperlipidemia: Held Gemfibrosil and statin during admission
due to elevated CK. Re-started prior to discharge with decreased
CK.
#. Peripheral neuropathy from spinal stenosis: Continued
amitriptyline. Decreased gabapentin to renal dose).
# Constipation: Aggressive bowel regiman.
# ACCESS: PICC placed, removed prior to discharge.
# CODE STATUS: Throughout admission DNR/DNI
Medications on Admission:
Active Medication list as of [**2135-5-17**]: (reviewed w/ patient)
Medications - Prescription
ALBUTEROL SULFATE - 0.083 % (0.83 mg/mL) Solution for
Nebulization - one ampule inhaled every 6-8 hours as needed for
as needed for shortness of breath Use with nebulizer machine -
No Substitution
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2 puffs by mouth every four (4) to six (6) hours as needed
for cough/wheezing
AMITRIPTYLINE - 150 mg Tablet - 1 (One) Tablet(s) by mouth hs
CALCITRIOL - 0.5 mcg Capsule - 1 Capsule(s) by mouth once a day
DEPTH SHOES AND INSERTS - - wear daily for patient with
diabetes and neuropathy
DIABETIC STOCKINGS - - use daily
DOXYCYCLINE HYCLATE - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) -
50 mg Capsule - 1 Capsule(s) by mouth twice a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
inhales twice a day
FUROSEMIDE [LASIX] - 40 mg Tablet - 3 Tablet(s) by mouth once a
day
GABAPENTIN [NEURONTIN] - 600 mg Tablet - 1 Tablet(s) by mouth
twice daily
GEMFIBROZIL - 600 mg Tablet - [**12-31**] Tablet(s) by mouth twice a day
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - use with
meals as directed twice daily by sliding scale
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -
2 puffs inhaled four times a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METOLAZONE [ZAROXOLYN] - 2.5 mg Tablet - 1 (One) Tablet(s) by
mouth once a day as needed for weight greater than 305 pounds
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a day
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth every six (6)
hours as needed for pain
PRAVASTATIN - 20 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - (Prescribed by Other
Provider; OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet
by mouth day
GERIATRIC MULTIVITAMINS-MIN [MULTI-VIT 55 PLUS] - (Prescribed
by Other Provider) - Tablet - 1 Tablet(s) by mouth day
INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL
(70-30) Suspension - 78 units in the morning and 90 units before
supper
INSULIN SYRINGE-NEEDLE U-100 - 31 gauge X [**5-14**]" Syringe - use
twice a day as directed
--------------- --------------- --------------- ---------------
Discharge Medications:
1. Amitriptyline 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours): No more than 4 gm tylenol a day. .
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation: Hold for loose stool. .
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain: No more than 4 gram
tylenol a day. .
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
14. Atrovent HFA 17 mcg/Actuation Aerosol Sig: [**12-31**] Inhalation
four times a day.
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
16. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-31**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
18. Insulin sliding scale
Please follow print out. Adjust as needed.
19. Outpatient Lab Work
Lab work: Creatinine and electrolytes. Twice a week for 2 weeks,
then weekly.
20. Doxycycline Hyclate 50 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
21. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Acute on chronic renal failure
Rib fracture
Acute pain
Atelectasis
Hypoglycemia
Hypoxia
Anemia
Discharge Condition:
Good, requires rehab
Discharge Instructions:
You were admitted for low blood sugar and severe pain. You were
observed in the Intensive Care Unit until your blood sugar
increased. You were found to have 4 rib fractures secondary to
your recent fall and started on pain medication. You developed
worsened kidney failure which improved with aggressive IV fluid
hydration. Your worsened kidney failure was secondary to
dehydration and motrin use. In addition, you most likely have a
condition called Benign Prostatic Hypertrophy (BPH) which can
obstruct your urine output. Consequently, you are being
discharged with a foley, a new medication called Flomax
(Tamsulosin) and urology follow-up (BPH specialists).
.
Medications:
HELD Lasix, Zaroxolyn. Can re-start once renal function stable.
HELD Fixed insulin 70/30. Can re-start once adequate po intake.
DECREASED Lisinopril, Gabapentin. Increase Lisinopril to 20 mg
once a day when renal function stable. Gabapentin decreased to
renal dose.
STARTED Bowel regimen for constipation, Flomax for urinary
retention
STARTED Standing tylenol, prn percocet for pain
STARTED Calcium Carbonate for low calcium
.
Follow-up:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]
Specialty: urology
Date and time: Thursday, [**6-2**] 9:30am
Location: [**Location (un) **], [**Location (un) 86**] [**Hospital Ward Name 23**] Bldg, [**Location (un) 470**]
Phone number: [**Telephone/Fax (1) 164**]
Special instructions if applicable: Dr. [**Last Name (STitle) 770**] will be very
busy this day. Expect to have a bit of a wait for this
appointment, but please arrive on time.
.
Primary Care Appointment #2:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2135-5-26**] 11:40
.
Renal Appointment #3:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2135-5-26**]
2:00
.
Call your doctor if you experience fever, chills, nausea,
vomiting, diarrhea, shortness of breath, chest pain or any other
concerning symptoms.
Followup Instructions:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]
Specialty: urology
Date and time: Thursday, [**6-2**] 9:30am
Location: [**Location (un) **], [**Location (un) 86**] [**Hospital Ward Name 23**] Bldg, [**Location (un) 470**]
Phone number: [**Telephone/Fax (1) 164**]
Special instructions if applicable: Dr. [**Last Name (STitle) 770**] will be very
busy this day. Expect to have a bit of a wait for this
appointment, but please arrive on time.
.
Primary Care Appointment #2:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2135-5-26**] 11:40
.
Renal Appointment #3:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2135-5-26**]
2:00
Completed by:[**2135-5-26**]
|
[
"600.00",
"V58.67",
"278.01",
"272.4",
"807.04",
"414.01",
"403.90",
"585.4",
"428.0",
"356.9",
"799.02",
"518.0",
"496",
"707.22",
"287.4",
"707.03",
"584.9",
"250.80",
"E884.2",
"564.09",
"327.23",
"285.21",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15788, 15860
|
7445, 10396
|
300, 346
|
15999, 16022
|
3908, 3913
|
18202, 19104
|
3100, 3148
|
13824, 15765
|
15881, 15978
|
11515, 13801
|
16046, 18179
|
3163, 3889
|
2217, 2634
|
248, 262
|
5296, 7422
|
374, 2198
|
3927, 5277
|
10411, 11489
|
2656, 2847
|
2863, 3084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,488
| 179,144
|
2891
|
Discharge summary
|
report
|
Admission Date: [**2160-11-17**] Discharge Date: [**2160-12-4**]
Date of Birth: [**2118-3-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Neurontin / Wellbutrin
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
pain with eating
Major Surgical or Invasive Procedure:
S/p L thoracotomy, LOA, and repair of diaphragmatic hernia on
[**2160-11-18**]. (Paraesophageal diaphragmatic hernia found
incidentally on CXR, elective surgery scheduled).
History of Present Illness:
42-year-old gentleman with a [**Known lastname **]
complicated upper gastrointestinal history. He presented over
10 years ago with nutcracker esophagus and underwent a [**Known lastname **]
esophageal myotomy with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13989**] fundoplication. This was
complicated by severe erosive esophagitis and eventually an
undilatable stricture requiring transhiatal esophagectomy.
This was subsequently complicated by severe and unrelenting
bile reflux and was treated with biliary diversion and a Roux-
en-Y gastrojejunostomy. Approximately 10 months ago, he
underwent a procedure to revise the gastrojejunostomy which
was stenotic. He has continued to have inability to aliment
himself orally with a postprandial severe pain. Radiographic
and endoscopic examinations revealed an incarcerated portion
of bowel in the chest to the level the main pulmonary artery.
There appears to be a bezoar in the small bowel component of
this and I am concerned that this is an incarcerated hernia
involving part of the colon but also part of the Roux-en-Y
limb. I recommended reduction of this hernia and the
possible need to revise again the gastrojejunostomy. This was
planned as a joint procedure between myself, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 957**]. The patient agreed to the treatment plan.
Past Medical History:
s/p Ex-lap with lysis of adhesions, gastrojejunostomy and
feeding jejunostomy [**12-12**]
Erosive esophagitis
Nutcracker esophagus
s/p Myotomy [**2151**]
s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13989**] procedure [**2151**]
s/p Esophagectomy [**2152**]
s/p Roux-en-y gastrojejunostomy
s/p J tube placement [**6-11**]
Asthma
s/p EGD showing large bezoar proximal to the previous surgical
anastamosis
Social History:
Pt is disabled, former truck driver. He has been living in a
rehab facility since [**6-11**]; he reprots a 20 pack year smoking
history and currently smokes one pack/day. He denies etoh and
illicit drug use.
Family History:
Denies knowledge of significant family illnesses
Physical Exam:
General- Ill appearing middle age male
HEENT- PERRLA, dentition-poor,
REsp-CTA bilat
Cor-RRR
Abd- soft, NT, ND. J- tube in place
Ext-no edema
Skin- j-tube site- redness, tx local anti fungal
Neuro- grossly intact, pain control adequate at present
Pertinent Results:
[**2160-11-17**] 04:20PM PLT COUNT-313
[**2160-11-17**] 04:20PM WBC-12.1*# RBC-5.37 HGB-13.9* HCT-42.0
MCV-78* MCH-25.8* MCHC-33.0 RDW-21.9*
[**2160-11-17**] 04:20PM CALCIUM-9.6 PHOSPHATE-4.7* MAGNESIUM-2.0
[**2160-11-17**] 04:20PM GLUCOSE-98 UREA N-7 CREAT-0.8 SODIUM-136
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
[**2160-11-17**] 09:18PM PT-12.3 PTT-26.3 INR(PT)-1.0
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2160-12-3**] 05:35AM 30.5*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2160-12-2**] 03:53AM 276
[**2160-12-2**] 03:53AM 12.7 30.3 1.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2160-12-3**] 05:35AM 101 15 0.6 136 4.61 98 292 14
SLIGHT HEMOLYSIS
1 HEMOLYSIS FALSELY INCREASES THIS RESULT
2 NOTE UPDATED REFERENCE RANGE AS OF [**2160-8-8**]
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2160-12-3**] 05:35AM 8.7 4.2 2.01
SLIGHT HEMOLYSIS
1 HEMOLYSIS FALSELY INCREASES THIS RESULT
ANTIBIOTICS Vanco
[**2160-12-1**] 07:28AM 15.2*
@Trough
RADIOLOGY Final Report
CTA CHEST W&W/O C &RECONS [**2160-11-24**] 5:05 PM
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: spiral Chest Ct to r/o pulmonary embolism- plaese obtain
sca
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with diaphragmatic hernia repair- POD 6- now w/
desat requiring high fio2
REASON FOR THIS EXAMINATION:
spiral Chest Ct to r/o pulmonary embolism- plaese obtain scan at
4pm
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Diaphragmatic hernia repair, postop day 6 with
desaturation, evaluate for pulmonary embolus.
COMPARISON: [**2159-12-5**].
TECHNIQUE: Axial MDCT images were obtained through the chest
prior to and following the administration of 100 cc of
intravenous Optiray in the pulmonary arterial phase. Additional
coronal and sagittal reformations are provided.
CONTRAST: Intravenous nonionic contrast was administered due to
the rapid rate of bolus injection required for this examination.
CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: There is
marked enlargement of the main and right and left main pulmonary
arteries consistent with pulmonary arterial hypertension. The
left main pulmonary artery measures 5.2 cm in diameter
(prevously 4.8 cm) and the main pulmonary artery has increased
from 3.4 cm to 4.1 cm in diameter at the level of the carina.
No definite filling defects are identified within the pulmonary
arteries to suggest pulmonary embolus.
The patient is status post esophagectomy with a large portion of
the stomach located within the thorax. Surgical clips are seen
within the mediastinum consistent with postoperative change. The
central airways appear patent. There are bilateral pleural
effusions of moderate size which appear partially loculated and
contain multiple air-fluid levels, and atelectasis of the left
lower lobe. There is additional atelectasis within the lingula.
Multifocal patchy ground- glass opacity and interlobular septal
thickening is seen in a geographic distribution involving
primarily the right upper and lower lobes and left upper lobe.
There is additional patchy airspace consolidation within the
lung apices. The heart and pericardium appear unremarkable.
There are numerous subcentimeter mediastinal, hilar, and
axillary lymph nodes not individually meeting criteria for
pathologic enlargement. An additional right hilar lymph node
measures 2.4 x 1.6 cm.
Limited images of the upper abdomen, including limited images of
the liver and spleen, appear unremarkable.
BONE WINDOWS: Bone windows demonstrate no evidence of suspicious
lytic or sclerotic osseous lesions.
MULTIPLANAR REFORMATS: Coronal and sagittal reformations
demonstrate marked enlargement of the pulmonary arteries without
evidence of filling defects to suggest pulmonary embolus.
IMPRESSION:
1. No pulmonary embolus.
2. Marked enlargement of the pulmonary arteries, consistent with
pulmonary arterial hypertension.
3. Bilateral pleural effusions and ground- glass opacity and
interlobular septal thickening suggests pulmonary edema which
may be cardiogenic or noncardiogenic.
4. Loculated bilateral pleural effusions with air-fluid levels
on the left. Bibasilar atelectasis.
RADIOLOGY Final Report
BAS/UGI W/KUB [**2160-12-2**] 1:47 PM
BAS/UGI W/KUB
Reason: eval for esophogeal leak
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with please use water soluble contrast to r/o
leak, 42 year old man with extensive esophogeal surgery, s/p
roux-en-y g/j ostomoy, j-tube placement [**6-11**], s/p diaphramatic
hernia repair [**11-24**].
REASON FOR THIS EXAMINATION:
eval for esophogeal leak
STUDY: Barium esophagram.
COMPARISON: None.
INDICATION: 42-year-old man with distal esophagectomy and
diaphragmatic hernia repair. Please evaluate for esophageal
leak.
BARIUM ESOPHAGRAM: Nonionic(Optiray) contrast assed freely
through the esophagus with no evidence for extraluminal
extravasation. The patient was then administered barium orally.
Barium flowed freely through the esophagus with no evidence for
destruction detected. No hiatus hernia or GE reflux was
demonstrated. No extraluminal extravasation was demonstrated.
There was moderate retention of barium within the esophagus
without evidence for obstruction.
IMPRESSION: NO evidence for obstruction or extravasation.
RADIOLOGY Preliminary Report
ABDOMEN (SUPINE & ERECT) [**2160-12-3**] 3:07 PM
ABDOMEN (SUPINE & ERECT)
Reason: leak and passage of barium from barium swallow done
previous
[**Hospital 93**] MEDICAL CONDITION:
42 year old man with J-tube replaced, unable to visualize on
prior x-ray.
REASON FOR THIS EXAMINATION:
leak and passage of barium from barium swallow done previously.
INDICATION: 42-year-old man with J tube replaced. Evaluate for
passage of barium from barium swallow done previously.
ABDOMEN, SUPINE AND ERECT: There is opacification of the large
bowel. Contrast extending into the rectum. Sigmoid diverticuli
are visualized. There is no free air. The osseous structures are
unremarkable.
Brief Hospital Course:
Admitted [**2160-11-17**] for diaphramatic hernia repair. Pt tolerated
procedure well, transferred to PACU in stable condition,
extubated with pain control of ketamine PCA iv gtt,dilaudid PCA,
bupivicaine epidural, and toradol IV. Pt remained in PACU until
POD#2 due to pain rx requirments, then transferred to floor late
POD#2.
Post-op course significant for:
Pain management: Acute pain service managed pt on above regimen
until bupivicain epidural, and ketamine PCA d/c on [**2160-11-24**], at
time of chest tube removal. Maintained on dilaudid PCA until
[**12-3**], when transitioned to dilaudid 5mg sq q3-4 hours w/
adequate objective pain management. Fentanyl patch briefly
POD#[**6-14**] when d/c in ICU to assist w/ pulmonary toilet
participation
Pneumonia-POD#6 [**2160-11-24**] pt limited IS&activity developed LLL
pneumonia. Bronch [**11-24**]> thick mucous/ moderate secretions, BAL
of LLL. O2 Sats 88-90% on 6L, 85% RA; post bronch 100% NRB w/
sat 90% sat. CXRAY and Chest CT done. Pt transferred to ICU for
close monitoring.
ICU course ([**2160-11-24**]): O2 support w/ O2 and BIPAP; antibiotic of
Vancomycin course (d/c [**2160-12-4**]), and ciprofloxacin for GNR in
BAL results; pulmonary toilet, periodic bronchoscopy prn. O2
gradually decreased w/ antibx therapy, gentle diuresis. Pain
regimen of Dil PCA cont w/ fentanyl patch x2 days, removed d/t
sedation. Patient stable for transfer to floor on [**11-29**], but
unable until [**12-2**] due to bed availability w/ stable oxygenation
of 4-5L nc w/ sat 92-93%.
GI- Impact with Fiber tube feedings via J- tube started post op
and gradually increased to goal of 65cc and tolerated well. NPO
x2 weeks. Clear liquids started [**12-2**] pm after normal barium
swallow and KUB. Pt instructed repeatedly that diet is clear
liquids only, full tube feedings until f/u appointment w/ Dr.
[**Last Name (STitle) **] in 2weeks after discharge.
On floor [**12-2**]- Pt maintained on pain regimen of dilaudid PCA,
transitioned to dilaudid sq 10/26pm, tube feedings at goal,
clear liquid diet. Ambulation independent. ADL's independent.
Patient transferred to facility in stable condition
Medications on Admission:
[**Last Name (un) 1724**]: amitryptyline 25', quetiapine 100hs, clonazepam 0.5'',
oxcarbazine 300'', levothyroxine 100mcg', oxazepam 10hs prn,
FeSO4 300/5 ml, zolpidem 5-10pm, hydromorphone 4q4,
hydromorphone sc 4 q6hrs, metoclopramide 5/5ml q6, colace 100'',
venlafaxine 75'', lorazepam 1 q8, morphine conc. 20mg/ml q4prn,
mirtazapine 15hs.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
7. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
8. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: Fifteen (15) cc PO
BID (2 times a day).
10. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Ten
(10) cc PO DAILY (Daily).
15. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
16. Hydromorphone 1 mg/mL Solution Sig: Five (5) mg Injection
q3-4hrs: SQ.
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 13990**] [**Location (un) 5110**]
Discharge Diagnosis:
Pneumonia, nutcracker esophagus, asthma, intravenous drug use
PSH: esophageal myotomy [**2151**]; [**Last Name (un) 13989**] procedure [**2151**];
esophagectomy [**2152**]; Roux-en-Y gastrojej; ex-lap, LOA, gastrojej,
feed jej [**12-12**]
Discharge Condition:
good
Discharge Instructions:
Call Thoracic Surgery [**Telephone/Fax (1) 170**] for: fever, shortness of
breath, chest pain, nausea, or vomiting.
Clear liquids and full strength tube feeding for 2 weeks
-ABSOLUTELY NO SOLIDS until cleared by Dr. [**Last Name (STitle) **]. Follow-up
appointment with Dr. [**Last Name (STitle) **] for further diet decisions.
Followup Instructions:
Call Thoracic Surgery office for appointment with Dr. [**Last Name (STitle) **] in
2 weeks; [**Telephone/Fax (1) 170**].
Completed by:[**2160-12-4**]
|
[
"482.9",
"568.0",
"724.2",
"552.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"53.80",
"93.90",
"33.23",
"45.11",
"38.91",
"33.24",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
12951, 13024
|
9049, 11195
|
307, 482
|
13307, 13314
|
2897, 4231
|
13691, 13843
|
2565, 2615
|
11587, 12928
|
8533, 8607
|
13045, 13286
|
11221, 11564
|
13338, 13668
|
2630, 2878
|
251, 269
|
8636, 9026
|
510, 1878
|
1900, 2321
|
2337, 2549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,933
| 117,669
|
8356
|
Discharge summary
|
report
|
Admission Date: [**2110-12-25**] Discharge Date: [**2111-1-28**]
Date of Birth: [**2055-3-2**] Sex: F
Service: MEDICINE
Allergies:
Cipro / Doxycycline / Paxil / Quinine / Compazine / Levaquin /
Lithium / Cefepime
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
[**12-25**] Exploratory laparotomy with lysis of adhesions, bowel
decompression and SB enterotomy
EGD
History of Present Illness:
The patient is a 55 yo female w/ hx multiple small bowel
obstructions, likely secondary to previous intraabdominal
surgery who was admitted to [**Hospital1 18**] on [**12-25**] with concerns for
small bowel obstruction, given her symptoms of nausea, vomiting,
and abdominal pain.
(Per surgery admission note)
Past Medical History:
# Hepatic sarcoidosis and regenerative hyperplasia
- s/p TIPS [**12-19**] placed d/t GI bleeding from varices and portal
gastropathy
- TIPS re-do with angioplasty and portal vein embolectomy
- severe portal hypertensive gastropathy
- Grade II varices
- grade 3 esophagitis
# multiple SBOs, most recent [**5-20**]
# Idiopathic cardiomyopathy:
-ECHO demonstrating an EF of 15-20% (no report, ?OSH) and a
p-mibi that confirmed an EF of 23% with no ischemic changes-->
improving [**6-17**] to EF 40-45%, mild-to-moderate global left
ventricular hypokinesis
-Cardiac cath [**2-16**]: no angiographically apparent flow-limiting
lesions, mild mitral regurgitation, and severe systolic
ventricular dysfunction with a left ventricular ejection
fraction of 20%.
-Right heart cath: [**2109-2-18**]: Normal right sided filling
pressures. Mild pulmonary artery hypertension. Preserved cardiac
index.
# COPD, followed by [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **], PFTs WNL
# Hx of SAH [**2101**] s/p coiling, 2 new aneurysms seen on angio
[**2108-6-21**]
# Colonic AVM and diverticulum
# Evidence of CVA/TIA
# Hypothyroidism
# Anemia
# s/p hysterectomy
# s/p cholecystecomy
# s/p appendectomy
# Reflex Sympathetic Dystrophy s/p fall, on disability, now
resolved
# Raynauds
Social History:
Married, lives in [**Hospital1 **], has 2 sons and 5 grandchildren, 36
pack-year smoking hx quit 2.5 years ago, does not drink EtOH and
denies former abuse, no h/o illicits or IVDU, does not work [**3-15**]
disability for RSD.
Family History:
[**Name (NI) 29555**] MI, [**Name (NI) 29556**]
Physical Exam:
Physical exam on transfer from MICU to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] wards.
Initial PE not available
VS: Tc 98, Tm98.4, HR 98 (90-100s), 130/64 (100-140/50/80), 19
HEENT: EEG leads in place, sclerae anicteric, PERRL, OP Clear
Neck: Supple, no lymphadenopathy
Cor: rrr, no murmurs appreciated
Pulm: clear anteriorly
Abd: midline laparotomy scar wellhealed, voluntary guarding with
palpation of abdomen diffusely, normoactive bowel sounds, no
rebound
Extrem: no peripheral edema
Neuro: responds to voice, oriented to self & place, states "i'm
worried about him [her husband]. He's always been here for me,"
after being asked if her husband has been in to see her today.
No twitching. Difficulty engaging pt in exam. Moves all ext's
spontaneously
Pertinent Results:
Admission labs
[**2110-12-24**] WBC-6.6# RBC-3.69* Hgb-11.2* Hct-32.9* MCV-89 MCH-30.3
MCHC-34.0 RDW-16.5* Plt Ct-64*
[**2110-12-24**] Neuts-89.5* Lymphs-5.1* Monos-3.4 Eos-1.6 Baso-0.4
[**2110-12-24**] PT-12.9 PTT-30.8 INR(PT)-1.1
[**2110-12-24**] Glucose-95 UreaN-25* Creat-1.1 Na-140 K-4.9 Cl-105
HCO3-24 AnGap-16
[**2110-12-24**] ALT-27 AST-33 AlkPhos-197* TotBili-0.9
[**2110-12-24**] Mg-1.6
[**2110-12-26**] calTIBC-178* Ferritn-418* TRF-137*
[**2110-12-25**] Ammonia-60*
[**2110-12-24**] URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2110-12-24**] URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Miscellaneous Lab Data
[**2111-1-15**] 02:37AM BLOOD WBC-6.3 RBC-3.39* Hgb-9.7* Hct-30.1*
MCV-89 MCH-28.6 MCHC-32.3 RDW-15.2 Plt Ct-74*
[**2111-1-6**] 10:12AM BLOOD WBC-7.0 RBC-3.09* Hgb-9.1* Hct-26.7*
MCV-86 MCH-29.4 MCHC-34.1 RDW-16.8* Plt Ct-106*
[**2110-12-26**] 12:20PM BLOOD WBC-7.2 RBC-3.31* Hgb-10.2* Hct-28.7*
MCV-87 MCH-30.9 MCHC-35.6* RDW-16.5* Plt Ct-60*
[**2110-12-27**] 08:57PM BLOOD Fibrino-598*
[**2111-1-10**] 04:22AM BLOOD Glucose-97 UreaN-41* Creat-1.0 Na-137
K-4.3 Cl-108 HCO3-23 AnGap-10
[**2111-1-13**] 05:30AM BLOOD Glucose-214* UreaN-57* Creat-1.8* Na-148*
K-4.1 Cl-116* HCO3-21* AnGap-15
[**2111-1-14**] 10:45AM BLOOD Glucose-295* UreaN-63* Creat-1.4* Na-150*
K-4.3 Cl-120* HCO3-19* AnGap-15
[**2111-1-19**] 06:58AM BLOOD Glucose-125* UreaN-91* Creat-2.1* Na-136
K-4.6 Cl-109* HCO3-14* AnGap-18
[**2111-1-20**] 06:30AM BLOOD Glucose-119* UreaN-97* Creat-2.6* Na-137
K-4.9 Cl-111* HCO3-11* AnGap-20
[**2111-1-22**] 02:19PM BLOOD Glucose-134* UreaN-93* Creat-3.1* Na-145
K-4.0 Cl-118* HCO3-14* AnGap-17
[**2111-1-26**] 05:00AM BLOOD Glucose-86 UreaN-57* Creat-2.5* Na-138
K-3.9 Cl-108 HCO3-20* AnGap-14
[**2111-1-27**] 05:37AM BLOOD Glucose-82 UreaN-49* Creat-2.2* Na-139
K-3.5 Cl-109* HCO3-20* AnGap-14
[**2111-1-19**] 06:58AM BLOOD ALT-13 AST-17 LD(LDH)-173 CK(CPK)-14*
AlkPhos-177* TotBili-0.4
[**2111-1-1**] 05:20AM BLOOD Triglyc-206* HDL-51 CHOL/HD-2.8
LDLcalc-51
[**2111-1-13**] 04:48PM BLOOD Ammonia-6*
[**2111-1-20**] 11:06AM BLOOD Ammonia-49*
[**2111-1-14**] 01:47AM BLOOD TSH-0.37
[**2111-1-20**] 05:43PM BLOOD Phenyto-18.0
[**2111-1-22**] 02:19PM BLOOD Phenyto-21.2*
[**2111-1-28**] 05:03AM BLOOD Phenyto-12.0
Discharge Labs
[**2111-1-28**] 05:03AM BLOOD WBC-3.7* RBC-3.29* Hgb-9.9* Hct-28.6*
MCV-87 MCH-30.1 MCHC-34.6 RDW-16.0* Plt Ct-90*
[**2111-1-28**] 05:03AM BLOOD Plt Ct-90*
[**2111-1-28**] 05:03AM BLOOD Glucose-92 UreaN-44* Creat-2.0* Na-140
K-3.9 Cl-111* HCO3-20* AnGap-13
[**2111-1-28**] 05:03AM BLOOD ALT-12 AST-18 LD(LDH)-218 AlkPhos-232*
TotBili-0.4
[**2111-1-28**] 05:03AM BLOOD Albumin-3.4 Calcium-8.1* Phos-3.3 Mg-2.2
[**2111-1-28**] 05:03AM BLOOD Phenyto-12.0
.
Imaging: [**12-10**] Abdominal US: No significant abdominal ascites
and no tapable fluid collection. Cirrhotic liver with portal HTN
including splenomegaly. Probable SBO, incompletely visualized on
examination.
[**12-10**] CT A/P: SBO with transition point in RLQ. No bowel wall
thickening or pneumatosis. Also c/w cirrhosis and portal HTN.
TIPS shunt occluded.
[**12-25**] CT A/P: same transition pt in RLQ pelvis with fecalization
of SB proximal to this pt, ? anther transition pt at proximal SB
but contrast passes thru; no pneumatosis
[**12-28**] EGD: 3 nonbleeding grade 2 varices in distal esophagus;
portal hypertension gastritis w small blood clot in stomach; no
active bleeding.
[**1-1**] KUB: persistent small-bowel obstruction or postop ileus
[**1-5**] CT Abd: Persistent dilation of multiple loops of small
bowel with wall thickening and mesenteric edema without a
definitive transition point. Although there is a relative
[**Name (NI) 29563**] point in the terminal ileum, these findings suggest
the possibility of mixed mechanical and functional obstruction;
Cirrhotic liver with TIPS and portal hypertension, such as
splenomegaly; Diverticulosis without evidence of diverticulitis.
[**1-13**] Abd U/S and duplex: scant ascites, patent vasculature, no
biliary dilatation
[**1-15**] CT abd:
There is increased ascites compared to prior study. There is no
focal fluid collection to suggest abscess formation. There is
diffuse anasarca and mesenteric edema. Small bowel is mildly
dilated with mild bowel wall
thickening, decreased since prior study. There is no pneumatosis
or free air.
.
Micro:
[**1-5**] Abd JP: Klebsiella oxytoca and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**]
[**1-6**] Abd JP: Klebsiella oxytoca
[**1-19**]: ascites fluid gram stain with gram negative rods
[**1-21**] bld cx pending
[**2111-1-26**] 06:15AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2111-1-26**] 06:15AM URINE RBC-5* WBC-12* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
[**2111-1-19**] 10:40AM URINE Eos-NEGATIVE
[**2111-1-20**] 03:32PM URINE Hours-RANDOM Na-88 K-30 Cl-93
[**2111-1-19**] 10:40AM URINE Hours-RANDOM Creat-39 Na-48
[**2111-1-18**] 03:45PM CEREBROSPINAL FLUID (CSF)
WBC-0 RBC-93* Polys-20 Lymphs-60 Monos- WBC-0 RBC-[**Numeric Identifier 29564**]*
Polys-33 Bands-7 Lymphs-33 Monos-27
TotProt-32 Glucose-53 LD(LDH)-34
ANGIOTENSIN 1 CONVERTING ENZYME-Test
HERPES SIMPLEX VIRUS PCR-Test Name
Ascites Studies
[**2111-1-5**] 07:44PM ASCITES WBC-7400* RBC-250* Polys-88* Lymphs-4*
Monos-0 Mesothe-3* Macroph-5*
[**2111-1-6**] 06:17PM ASCITES WBC-5250* RBC-200* Polys-93* Lymphs-4*
Monos-3*
[**2111-1-19**] 03:03PM ASCITES WBC-1025* RBC-[**Numeric Identifier 7438**]* Polys-66*
Lymphs-13* Monos-0 Eos-1* Macroph-20*
[**2111-1-27**] 10:00AM ASCITES WBC-125* RBC-5175* Polys-38* Lymphs-46*
Monos-0 Eos-1* Mesothe-2* Macroph-13*
[**2111-1-6**] 06:17PM ASCITES TotPro-0.8 Glucose-157 Amylase-36
TotBili-0.2 Albumin-<1.0
[**2111-1-19**] 03:03PM ASCITES TotPro-1.8 Glucose-118 LD(LDH)-78
Amylase-25 Albumin-1.1
Brief Hospital Course:
HOSPITAL COURSE AS SUMMARIZED BY SURGICAL AND MEDICAL SERVICES
Mrs. [**Known lastname **] is a 55 yo female with with history of ELSD from
hepatic sarcoid who initially presented on [**2110-12-25**] w/ small
bowel obstruction and had hospital course complicated by ARF,
status epilepticus, secondary bacterial peritonitis, and hepatic
encephalopathy.
BRIEF HOSPITAL COURSE BY PROBLEM
Small Bowel Obstruction
The patient was admitted to [**Hospital1 18**] with nausea, abdominal pain,
and diarrhea. Given her history of hepatic sarcoidsis, the
patient underwent CT of abd/pelvis revealing a transition point
in RLQ pelvis with fecalization of SB proximal to this pt. Of
note, prior CT on [**12-10**] had revealed cirrhosis and portal HTN
with TIPS shunt occluded. The patient was thus taken to the OR
on [**12-25**] where she underwent exploratory laparotomy with
enterotomy and lysis of adhesions. Intraoperatively she was
found to have some adhesions with dilated loops of bowel but no
transition point; the small bowel was dilated to the extent that
an enterotomy was required in order to decompress the bowel and
close the abdomen. She also had a CVL placed in the OR.
She was kept intubated overnight and brought to the ICU. She
was weaned to extubated in the am. She received perioperative
antibiotics and stress dose steroids postoperatively.
Esophageal Varices/Anemia/Portal Gastropathy
She also had an EGD on [**12-28**] that revealed 3 nonbleeding grade 2
varices in distal esophagus and portal hypertension gastritis w
small blood clot in stomach; no active bleeding. She had a
relatively stable anemia that trended down around [**1-20**] that was
thought to be morst likely secondary to slow ooze from portal
gastropathy. She was transfused 2 units PRBC [**1-20**], 1 unit [**1-21**]
with subsequent stabilization of HCT. Varices were banded on day
of discharge and she was started on sucralfate for 10 days.
Postoperative Ileus
On [**12-28**] she was transferred to the floor, her NGT was
discontinued, and she was started on sips, which she tolerated
well. On [**1-1**] she was noticed to be increasingly tender
without bowel movements; KUB revealed persistent dilated
small-bowel loops with multiple air-fluid levels concerning for
persistent small-bowel obstruction or post-operative ileus. Her
NGT was replaced. She was started empirically on unasyn.
Acute Renal Failure
While on surgical service, the patient was also noted to have
an increase in her creatinine from 1.3 to 2.2; this was thought
secondary to large fluid losses from her JP drain in her
abdomen; she was started on replacements 1/2 cc/cc with
improvement in her creatinine to 1.2 on [**1-1**]. She had a PICC
placed on [**1-2**] and was started on TPN.
She again developed a rise in her creatinine on [**1-18**]. She was
given albumin 62.5g on [**1-19**] and bicarb and blood on [**1-20**] for
volume rescusitation. Urine microscopy showed granular and
hyaline cast. Urine lytes were not consistent with pre-renal but
renal felt this was a pre-renal/evolving ATN picture. She has a
mixed non-gap and gap acidosis. The gap is likely from the renal
failure and the non-gap from her diarrhea. The bicarb has
improved her acid-base status and lactulose was stopped to slow
down the diarrhea. Creatinine trended down prior to discharge.
Diuretics were held.
Hepatic Encephalopathy
On the floor the patient was noticed to be increasingly less
talkative with a dull affect, thought to be consistent with past
episodes of hepatic encephalopathy. She was given high dose
lactulose PR with initial improvement in her mental status.
Secondary Bacterial Peritonitis
The patient had been improving, and so her NGT was
discontinued. Unfortunately, she then developed increasing
abdominal pain; on [**1-5**] she underwent repeat CT scan of
abd/pelvis that revealed persistent dilation of multiple loops
of small bowel with wall thickening and mesenteric edema without
a definitive transition point concerning for a mixed mechanical
and functional obstruction, a cirrhotic liver with TIPS and
portal hypertension, such as splenomegaly, and diverticulosis
without evidence of diverticulitis.
The JP drain fluid was sent for analysis; Klebsiella oxytoca
and [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] grew out from the fluid both on [**1-5**] and
[**1-6**]. Infectious disease was consulted; the patient was
started on zosyn for the Klebsiella and [**Month/Year (2) 29565**] for the
[**Female First Name (un) 564**]. The zosyn was eventually changed to cefepime on [**1-9**]
given the sensitivities. Cefepime was later changed to
Meropenem due to concern for precipitating seizure. Her home
gabapentin and amitriptyline were held given their potential
muscarinic effects on peristalsis. The patient had been having
low-grade fevers in the setting of steroids but no mental status
changes at the time. She was thought to have infected
peritoneal fluid possibly secondary to the enterotomy, though
the etiology is not completely clear. Serial paracenteses were
performed until pt no longer had evidence of bacterial
peritonitis with <250 polys in ascitic fluid. She was continued
on antibiotics for two week course after JP pulled to complete
[**2111-2-1**].
The patient's abdominal exam gradually improved, her NGT was
discontinued on [**1-8**], and she was started on a regular diet
given that she was passing gas and having bowel movements. That
said, the patient continued to have low-grade fevers throughout
even though she was still on steroids (tapered to her home dose
from admission) and multiple antibiotics.
Because of her improved exam, decreased output from her JP
and the thought that her fluid status could be better managed
with the drain out, her JP drain was removed. She did have some
tenederness on abdominal exam on [**1-15**], and so she underwent
another CT scan that revealed increased ascites compared to
prior study but no focal fluid collection to suggest abscess
formation. The patient did have diffuse anasarca and mesenteric
edema; the small bowel was mildly dilated with mild bowel wall
thickening, decreased since prior study, and there was no
pneumatosis or free air.
Hypernatremia
The patient also became hypernatremic to a high of 154 on
[**1-14**](she was started on free water replacements), likely
intravascularly depleted given her high BUN, and hyperchloremic
with a low bicarbonate; the later two likely secondary to
previous normal saline/TPN loads.
Given her stable vital signs, she was transferred to the floor
on [**1-15**], though she still remains with altered mental status
further discuused below.
Altered mental status
On [**1-13**] the patient was noted to be increasingly abulic, though
paranoid appearing. She was transferred to the SICU. She
underwent an abd U/S on [**1-13**] that revealed scant ascites, patent
vasculature, and biliary dilatation. Given the results the
patient did not undergo paracentesis even though this was one
possible etiology for her AMS. Both psychiatry (who had
previously been following the patient for depression) and
neurology were consulted. Her mental status waxed and waned
with occasional episodes of increased awareness and pronouncing
her name.
Her altered mental status was initially thought to be due to
toxic metabolic encephalopathy [**3-15**] liver disease, infection, and
underlying brain disease. Her EEG on [**1-15**] was consistent with
this and negative for seizure per neurology although there was a
questionable focus in the frontal lobe. LP and MRI/A were
performed and were both negative on [**1-18**]. NG tube was pulled out
on [**1-17**] and put back in [**1-18**] and patient was treated with
lactulose with stool outputs of a liter per day. Patient had
paracentesis [**1-19**] with reduction in white cells but persistent
bacterial peritonitis and gram negative rods on gram stain. On
[**1-20**], per ID, metronidazole was added to cover anerobes. Patient
had been on cefepime for klebsiella and [**Month/Day (4) 29565**] for [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 563**] since her initial tap. She completed 2 week course
(after JP pulled) with change of antibiotics to Meropenem (then
ertapenem at discharge for once daily dosing) and Caspo.
Status Epilepticus
On the morning of [**1-20**] she was noted to be "twitching". Her
glucose and electrolytes were wnl. Neurology was contact[**Name (NI) **] and
initially did not think this was seizure activity but EEG was
ordered to r/o myoclonic seizure. EEG demonstrated status
epilepticus. She was given 2 mg IV ativan and this resolved. She
was loaded with fosphenytoin and continued on fosphenytoin with
daily monitoring of levels. It was unclear what precipitaed
seizures but may have been form underlying brain disease (h/o
CVA), hepatic encephalopathy, or med effect. Flagyl was
discontinued and Cefeoime changed to [**Last Name (un) **]. She was transferred
to MICU fo closer monitoring. EKG and cxr were wnl during this
episode. When her mental status remained altered after being on
therapeutic dilantin, she was started on Keppra in addition to
Dilantin. Mental status subsequently continued to improve and
she became awake, oriented and conversant. She was started on a
regular diet and started working with physical therapy and was
discharged to home with services.
Hypothyroidism
Continued on levothroxine. TSH WNL.
Code
Full
Medications on Admission:
Albuterol 90 mcg 1 puff INH q4-6h prn, amitriptyline 50 qhs,
cyanocobalamin 1000 mcg/mL qmonth, folic acid 1', Lasix 20',
gabapentin 300'', hydroxyzine 25''', lactulose 10g/15mL soln 2
teaspoons daily, levothyroxine 88', omeprazole 80'', prednisone
10', aldactone 50', sucralfatre 1 QID, ursodiol 600 qAM 300 qPM,
ambien 10 qhs, ferrous sulfate 325'', vit B1 100'
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. [**Last Name (un) **] 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ursodiol 300 mg Capsule Sig: as directed Capsule PO twice a
day: Take 2 tabs in am and 1 tab at night.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. [**Last Name (un) **] 70 mg Recon Soln Sig: 35 mg Recon Solns
Intravenous Q24H (every 24 hours) for 4 doses.
Disp:*2 Recon Soln(s)* Refills:*0*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Titrate to 4 BMs per day.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
9. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection
Injection once a month.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Ertapenem 1 gram Recon Soln Sig: 0.5 grams Intravenous once
a day for 4 days.
Disp:*2 grams* Refills:*0*
12. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for 2 weeks.
Disp:*1 bottle* Refills:*0*
14. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day.
Disp:*90 Capsule(s)* Refills:*2*
15. Keppra 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
16. Sucralfate 100 mg/mL Suspension Sig: One (1) gram PO twice a
day for 10 days: Do not take within 2 hours of taking dilantin
(phenytoin).
Disp:*200 grams* Refills:*0*
17. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
18. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a
day.
19. Outpatient Lab Work
Please check cbc, chem-10, LFTs on Friday [**1-30**]. Please
have results faxed to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 4409**]
20. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection four
times a day: 10 cc sash and prn.
Disp:*16 flushes* Refills:*0*
21. Heparin Flush 10 unit/mL Kit Sig: One (1) flush Intravenous
once a day: 3 cc sash and prn.
Disp:*10 flushes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] vna
Discharge Diagnosis:
Primary Diagnosis
Small Bowel Obstruction s/p Lysis of Adhesions
Acute Renal Failure
Status epilepticus
Secondary bacterial peritonitis
Secondary Diagnosis
Hepatic sarcoidosis listed for transplant
Esophageal varices grade II
Severe portal hypertensive gastropathy
Esophagitis
Multiple admissions for hepatic encephalopathy
Multiple prior SBO's (treated non-operatively)
COPD
h/o CVA/TIA's
hypothyroidism
Raynaud's syndrome
cerebral aneurysms s/p coiling after SAH
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You were
found to have a small bowel obstruction which required surgery
to lyse adhesions in your abdomen. You later developed an
infection in your abdomen and were started on antibiotics. A
repeat paracentesis on [**2111-1-27**] showed that this infection had
resolved but you should continue to tkae antibiotics through
[**2-1**]. During your hospital course, you also developed kidney
failure which may have been from one of the medications you were
taking. You also were confused so you were treated with
lactulose and [**Month/Year (2) 8005**] for hepatic encephalopathy. On [**2111-1-20**],
you had some twitching so an EEG was obtained which showed that
you were having seizures. You were treated with Dilantin and
Keppra and your seizures stopped.
We have made the following changes to your medications
1. We held your diuretics (Lasix and Aldactone) since you had
impaired kidney function. These may be restarted as an
outpatient depending on your kidney function and electrolytes.
2. We added Ertapenem and [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic and
antifungal medication which you will take through [**2-1**]
3. We added Phenytoin and Keppra for seizures
4. We added sucralfate for varices for 10 days, please make sure
not to take this medication within 2 hours of dilantin. They
need to be spaced at least 2 hours.
5. We decreased your gabapentin to 300 mg once daily because of
your renal function.
Please return to the ER or call your primary care doctor if you
develop confusion, abdominal pain, fever, chills, chest pain,
shortness of breath or any other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 2424**], MD
Phone:[**Telephone/Fax (1) 463**]. You have an appointment with him at 8:30 am
on [**2-3**].
You also have an appointment for endoscopy on [**2111-2-20**] at 8:30
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS.
Please follow up with Neurology regarding your seizures. You
have an appointment with Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] on [**4-7**] at 2:30 pm. Their office is on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building.
Please follow up with Surgery in the next 1-2 weeks. You have an
appointment with Dr. [**Last Name (STitle) 816**] on [**2-2**] at 8 am. His office
is at [**Last Name (NamePattern1) **]. on the [**Location (un) 436**]. At this time, he will
take out the stitches on your abdomen.
Please follow up with your pcp in the next few weeks as well.
Call Dr.[**Name (NI) 29566**] office when you are able.
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342
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44982
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Discharge summary
|
report
|
Admission Date: [**2171-8-20**] Discharge Date: [**2171-8-30**]
Date of Birth: [**2098-8-3**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 96167**]
Chief Complaint:
hypoglycemia, change in mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73 y.o. female found unresponsive in her home by her daughter
who lives below patient and states that she heard a "thud" and
went up to find mother unresponsive. EMS called and reports that
pt had FS of 41 and was posturing on route to OSH. Pt intubated
and taken to OSH where she was given lorazepam and loaded with
dilantin. Head CT showed no evidence of acute bleed. CXR
negative. Pt then transfered to [**Hospital1 18**] for further work up. Per
daughter, pt has been compliant with insulin.
In [**Name (NI) **], pt paralysed and comatose. Turned off propofol for neuro
eval. Pt started on insulin gtt. LP was negative
Past Medical History:
DM type 2, prior admits for DKA. Hx of hypoglycemis sz's.
Benign positional vertigo
HTM
Hypothyroid
Social History:
No ETOH
No drugs
Quit tob 22 yrs ago
Lives on floor above daughter
Family History:
DM2
Breast CA
Physical Exam:
T 96, BP 145/60, P 64, R 14, AC 600/14/60% sat100%
GEN: elderly African American female, obese, obtunded,
intubated
HEENT: pupils sluggishly reactive to light, equal, MMM
CV: Nl S1/S2, RRR, no M/R/G
PULMO: CTAB
ABD: BS+, NT, ND
EXT: no C/C/E, warm
Pertinent Results:
[**2171-8-20**] 01:27AM VIT B12-262
[**2171-8-20**] 01:27AM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.7
[**2171-8-20**] 01:27AM LIPASE-24
[**2171-8-20**] 01:27AM ALT(SGPT)-14 AST(SGOT)-25 ALK PHOS-97 TOT
BILI-0.3
[**2171-8-20**] 01:27AM GLUCOSE-157* UREA N-27* CREAT-1.2* SODIUM-139
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-18* ANION GAP-19
[**2171-8-20**] 06:15AM PT-12.7 PTT-29.2 INR(PT)-1.0
[**2171-8-20**] 06:15AM PLT COUNT-269
[**2171-8-20**] 06:15AM NEUTS-86* BANDS-1 LYMPHS-10* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2171-8-20**] 06:15AM WBC-9.9# RBC-3.75* HGB-10.1* HCT-31.6* MCV-84
MCH-27.0 MCHC-32.0 RDW-13.7
[**2171-8-20**] 06:15AM PHENYTOIN-11.0
[**2171-8-20**] 06:15AM GLUCOSE-344* UREA N-22* CREAT-1.1 SODIUM-135
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-17* ANION GAP-20
[**2171-8-20**] 07:34AM TYPE-ART RATES-/20 O2-100 PO2-452* PCO2-34*
PH-7.38 TOTAL CO2-21 BASE XS--3 AADO2-242 REQ O2-47
INTUBATED-INTUBATED
[**2171-8-20**] 01:20PM GLUCOSE-306* UREA N-22* CREAT-1.1 SODIUM-135
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-17* ANION GAP-19
[**2171-8-20**] 02:16PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 POLYS-14
LYMPHS-86 MONOS-0
[**2171-8-20**] 02:16PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-21*
POLYS-17 LYMPHS-83 MONOS-0
[**2171-8-20**] 02:16PM CEREBROSPINAL FLUID (CSF) PROTEIN-42
GLUCOSE-150
[**2171-8-20**] 04:42PM LACTATE-2.5*
[**2171-8-20**] 04:42PM TYPE-ART PO2-286* PCO2-30* PH-7.45 TOTAL
CO2-21 BASE XS--1
CSF-SPINAL FLUID: GRAM STAIN (Final [**2171-8-20**]): NO
POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID
CULTURE (Final [**2171-8-23**]): NO GROWTH.
URINE CULTURE (Final [**2171-8-27**]): MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
MRI HEAD [**2171-8-20**]: 1) Small focus of restricted diffusion in the
right hippocampus, not seen previously, which suggests either a
small acute infarct or possibly an artifact.
2) Unchanged evidence of chronic small vessel ischemic infarcts
in the white matter bilaterally. 3) Unremarkable MR angiogram of
the circle of [**Location (un) 431**]. The preliminary report had stated: No
significant interval change. No evidence of diffusion
abnormality. Again seen are regions of increased T2 signal
consistent with chronic small vessel ischemic infarcts.
CXR [**2171-8-20**]: There is no overt CHF, pneumonia, or pneumothorax
CXR [**2171-8-28**]: No pneumonia or CHF. Cardiomegaly
Brief Hospital Course:
Pt ruled-out for meningitis w/ negative LP, acute CVA w/ MRI, MI
w/ 3 Trop < 0.01, B12 wnl, tox screen negative, TSH=5.3 and
fasting cortisol=17.9, ruling these out as endocrine etiological
possibilities. Loaded w/ dilantin and benzos as presentation of
seizure-like activity. Given mild DKA, Pt was started on
insulin gtt, IVF, q4hr lytes, q1hr FS, and kept NPO. On the
second day of hospitalization the Pt becamse more alert and was
able to follow commands, the AG acidosis resolved. By the thrid
day of hospitalization her mental status had markedly improved,
she was extubated and transitioned back to her home meds.
[**Last Name (un) **] was consulted to tailor an insulin regimen that would
maintain euglycemia. Pt was moved to the medicine floor where
she continued to be monitored and managed for glycemic control
while feeding PO. Pt had some episodes of aggitation/confusion,
mostly at night, requiring the use of haldol. Psychiatry was
consulted and the Pt was put on haldol 5 mg [**Hospital1 **] subsequent to
which her episodes of aggitation and confusion resolved. Her
blood glucose continued to be difficult to control using Lantus,
however, she remained euglycemic for the twenty four hour period
prior to discharge on NPH 15 units in am and 5 units in pm (FS =
80-129), and was sent-out on this regimen. She was continued on
dilantin 100 mg TID with a serum dilantin level of 13.6 at
discharge. Her blood pressure was maintained using metoprolol 25
[**Hospital1 **], lisinopril 10 QD, and her hypothyroid was treated with
synthroid 88 mcg QD. ASA 325 QD and Citalopram 10 QD were
continued as well.
Medications on Admission:
ASA 325
Synthroid 75mcg QD
Lisinopril 10 QD
NPH 20 Qam, 20Qpm
Regular insulin 8 unints Qam
Metoprolol
Celexa
Discharge Medications:
1. Citalopram Hydrobromide 20 mg Tablet Sig: 0.5 Tablet PO QD
(once a day).
Disp:*15 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed units Subcutaneous as directed: 12 units in the morning
and 5 units at night.
Disp:*1 one month supply* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
hypoglycemia, mental status changes
Discharge Condition:
controlled serum glucose, baseline mental status
Discharge Instructions:
Seek immediate medical attention if you experience any change in
mental status, lightheadedness, shortness of breath, chest pain,
palpitaitons, severe nausea, vomiting or diarrhea.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] (PCP) [**Telephone/Fax (1) 3581**]
|
[
"437.1",
"294.8",
"386.11",
"780.39",
"276.2",
"599.0",
"780.09",
"244.9",
"250.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"88.91",
"88.41",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6652, 6725
|
4009, 5636
|
348, 355
|
6805, 6855
|
1539, 3986
|
7084, 7196
|
1233, 1249
|
5795, 6629
|
6746, 6784
|
5662, 5772
|
6879, 7061
|
1264, 1520
|
271, 310
|
383, 1008
|
1030, 1132
|
1148, 1217
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
618
| 185,691
|
26772
|
Discharge summary
|
report
|
Admission Date: [**2118-4-17**] Discharge Date: [**2118-4-29**]
Date of Birth: [**2039-8-22**] Sex: M
Service: MEDICINE
Allergies:
Zosyn / Vancomycin / Heparin Agents
Attending:[**First Name3 (LF) 1642**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
78M with h/o Parkinson's Disease, CAD s/p CABG, h/o TIA, s/p
recent hospitalization for pna ([**Date range (1) 65931**]) now with worsening
weakness. Per pt's wife since he got sick with the pneumonia his
Parkinson's has been acting up and he has been having increasing
trouble swallowing. She states he has been more weak and she has
been having trouble having him transfer and walking him to the
bathroom (his legs have been buckling under him). Wife states he
has had a worsening cough and has been feeling a little SOB.
Denies fevers, chills, nausea, vomiting, diarrhea.
.
In the ED, initial VS were T: 99.8F BP: 171/109 HR: 102 RR: 18
SaO2: 98% on 2L NC. Initial labs were notable for leukocytosis
to 17
(89% N). CXR demonstrated resolving RML and RLL PNA. Pt was
given Tylenol 650mg po, aspirin 325mg po, vancomycin 1g IV,
Zosyn 4.5g IV, ticlid 250mg, carbidopa 25/Levodopa 100, Comtan
200mg. Was also given metoprolol 75mg po and subsequently BP
dropped to systolics in the 80's. He was then given boluses of
1L NS x 3 and BP improved to 120's and he was transferred to the
MICU.
Past Medical History:
1. CAD s/p CABG and NSTEMIs ([**2-/2117**]: LIMA-LAD, SVG->Diag, OM1,
OM2, SVG->PDA); s/p PCI of proximal SVG-D1-OM 1-OM2 with DES in
[**6-29**]
and PCI of SVG-OM/D with DES in [**8-29**].
2. CHF: EF 30%
3. Parkinson's Disease
4. Hypercholesterolemia
5. HTN
6. h/o TIA
7. Bladder CA
8. Osteoporosis
9. s/p right hip fracture, ORIF in [**3-1**]
Social History:
Former prof [**First Name (Titles) **] [**Last Name (Titles) 65926**] at [**Location 2785**]. The patient
lives in [**Location **]. He lives with his wife on the same street as
his daughter. [**Name (NI) **] has another daughter who lives in [**State 3706**]. He
smoked until [**2076**], smoking one pack a day for fifteen years.
Family History:
Positive for father, who died of a stroke, mother who had a
stroke in her 90s and one brother had [**Name (NI) 5895**] disease.
Physical Exam:
VS: T: 97.7 BP: 138/72 HR: 73 RR: 24 SaO2: 100% on 2L NC.
GEN: pt very somnolent, awakens to voice but then falls asleep
again.
HEENT: PERRL, EOMI, OP slightly dry.
NECK: No carotid bruit, + elevated JVP.
HEART: unable to ausculatate heart sounds due to loud
respiratory noises.
LUNGS: very noisy upper airway noises, slightly decreased BS's
at R base.
ABDOMEN: Soft, NT/ND, NABS, no masses or bruits.
EXTREMITIES: LE's with trace edema. DPs 1+.
CNS: not answering questions. + cogwheel rigidity.
Skin: +rash on knees
Pertinent Results:
CXR [**2118-4-17**]: Two views of the chest demonstrate stable [**Month/Day/Year 1192**]
cardiomegaly, mediastinal contours, and sternal sutures. There
has been significant improvement in airspace opacity of the
right middle and lower lobes seen on [**2118-4-10**]. A small amount
of residual opacity remains in these locales. The left lung is
clear. There is no pleural effusion or pneumothorax. There has
been no change from [**2118-4-10**] in multiple thoracic vertebral wedge
deformities and associated kyphosis.
IMPRESSION: Improving right middle and right lower lobe
pneumonia.
.
ECG: NSR at 97. nl axis, borderline QT interval. Q's in III
(old). ST depressions in I, II, AVL, V3-6 (old), J point
elevation in V1-2 (old). No sig changes from prior.
.
[**4-19**] cxr:
IMPRESSION:
1. NG tube in proximal stomach.
2. Progressive multifocal pneumonia.
.
[**4-21**] head ct:
FINDINGS: There is no intra- or extra-axial hemorrhage, mass
effect, or shift of normally midline structures. Irregular low
attenuation foci in bilateral lentiform nuclei, left greater
than right with associated volume loss are consistent with
chronic lacunar infarction. Scattered focal low attenuation
lesions in the periventricular and subcortical white matter are
consistent with chronic microvascular ischemia. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. The surrounding soft tissue
and osseous structures are unremarkable. The visualized
paranasal sinuses and mastoid air cells are clear.
IMPRESSION: No intracranial hemorrhage or mass effect. No change
since [**2117-12-10**].
.
cxr [**4-21**]: IMPRESSION: Improved pulmonary edema. Worsening left
lower lobe pneumonia
.
RIGHT UPPER QUADRANT ULTRASOUND: The liver is normal in
echotexture with no focal masses. A nonshadowing gallstone or
sludge ball is seen within the gallbladder measuring 8 x 7 x 5
mm. The common bile duct measures 4 mm. There is no biliary
dilatation. The portal vein is patent with antegrade flow. There
is no ascites. The right kidney measures 11.2 cm, and there is
no hydronephrosis.
IMPRESSION: Normal right upper quadrant ultrasound.
Brief Hospital Course:
78 yo M with Parkinson's, CAD, s/p recent admission for pna now
with likely aspiration pna [**2-25**] increased secretions
.
Micu course involved, the patient had hypotension and was given
IVF and zosyn/vanc (concern for pna/sepsis). The patient had
angioedema and was switched to levo/flagyl. Given his
hypotension his lasix was held as were other bp meds. He failed
his speech and swallow and had an ngt placed. He was
normotensive and transferred to the floor.
.
Floor course:
# hypotension: The patient's hypotension resolved since
receiving IVF. The cause was likely multifactorial including
poor intake likely due to parkinsons's disease, increased
diarrhea and finally possibly some sepsis as with white count
and pneumonia. During the majority of the patient's course he
was npo so IVF were continued and he was treated for his
pneumonia. His blood pressure was normal on the floor and his
blood pressure medications were reintroduced as tolerated.
.
# pneumonia: The patient had presumed aspiration pneumonia as
the patient had increased secretions. In the MICU he was on
zosyn and vancomycin but had angioedema and due to this allergic
reaction, he was switched to levofloxacin and flagyl. He
continued to fail speech and swallow evaluations given his
increased secretions. During his course he developed an
increased white count, an increased work of breathing and
tachypnea. His cxr showed worsening and he was presumed to have
worsened aspiration pneumonia, especially given his ongoing risk
of aspiration. He was put on daptomycin, flagyl and aztreonam
and he improved, initially though he continued to aspirate and
his continued aspiration made his pneumonia worse to the point
where his prognosis was poor. The patient had an episode of
hypoxia and tachycardia, which was attributed to his increasing
secretions. He was aggressively suctioned and a scopalamine
patch was placed, but given this and his poor prognosis the
family decided to make the patient CMO. Antibiotics were
discontinued and the patient was given morphine and scopalamine
for comfort.
.
# Parkinson's: The family fears the patient's parkinson's is
worsening, though the patient's recent decline in functioning
and mentation could also be related to his infection. He was
continued on his home doses of carbidopa/levodopa and
entacapone, and he appeared less lethargic and bradykinetic as
his infection improved. The patient's outpatient neurologist,
Dr. [**Last Name (STitle) 65932**], was contact[**Name (NI) **] and he recommended keeping his
medications at the same dose and having an inpatient neurologist
see him. The inpatient team did not have any medication changes
to add, though they recommended Movement Disorders consult as
his dysphagia may have been related to Progressive Supranuclear
Palsy. During the patient's course he lost his NG tube and he
had difficulty with oral intake to the point where he could not
receive his parkinson's medications. The pharmacy did not carry
the oral disintegrating sinemet, and neurology said they could
not recommend alternative IV medications to treat his
parkinson's. Unfortunately without his medications the patient
became more bradykinetic and as his pulmonary status worsened a
G tube was declined and the patient was without medications.
.
# Nutrition: The patient failed his speech and swallow in the
MICU and had an NG tube placed. He was kept on IV fluids and
NPO, while awaiting a second speech and swallow evaluation.
Once he failed this tube feeds were started. Initially he
received tube feeds, and when another speech and swallow was
failed it was decided that since the patient was at risk with
tube feeds and eating, he would try eating. He pulled out his
NG tube, and at that point the family decided the patient would
continue a modified diet, but would likely continue to have
pneumonia based on his high risk of continued aspiration.
Palliative care was called in, and during a family meeting, the
family with the help of the team decided to have a G-tube
placed. The patient was found to have elevated INR, and the GI
team felt his risk of bleeding was very high and despite
reversal of his INR GI decided he was a poor candidate for a
Gtube given his worsening clinical status. The family decided
against the G tube given the risks and the patient was made cmo.
.
# Transaminitis: The patient developed a transaminitis that may
have been related to his medications as with medication
adjustment, his lft's improved. He had a hepatitis panel sent
and RUQ us sent, but the work-up was not completed as the
patient was made CMO, and the patient's LFT's were improving.
.
# Elevated INR: The patient was noted to have elevated INR
through his course this was likely multifactorial including from
abx, poor nutrition and liver disease. He improved with SC
vitamin k, though GI felt given this, his LFT's and his
pulmonary status the G tube should not be placed. The family
was in agreement with this plan.
.
# Melena: The patient was noted to have melena, and also blood
in his NGT, given his repeated failed attempts at NG tube
placement this was attributed to trauma, and his hematcrit was
followed closely and remained stable. The patient never
required blood products.
.
# thrombocytopenia: The patient developed a significant drop in
his platelets during his course and the concern was for HIT
versus his antibiotics. HIT antibodies were sent and all
heparin products were held. His HIT antibody was positive and
with the holding of heparin products the patient's
thrombocytopenia improved.
.
# Altered mental status: The patient was very lethargic during
his course, and this was attributed to his pneumonia as he
improved when his infection improved. Towards the end of his
course as his aspiration worsened and he was not able to get his
parkinson's medications the patient became somnolent and
lethargic. He remained in this state, though was then made cmo
and was comfortable.
.
# CHF: On admission the patient had an elevated BNP and a recent
EF of 30%. Given his initial hypotension and then diarrhea, his
lasix was held and his ins/outs and daily weights were followed.
Through the majority of the patient's course he was dry to
euvolemic. Once his diarrhea resolved, he became more
overloaded and fluids were stopped and he was diuresed.
Diuresis and fluids were stopped though once the patient was
made cmo.
.
# Diarrhea: The patient had profuse diarrhea and this was
concerning for c. difficile given antibiotic use. His
cdifficile was negative and he was supported with IV fluids.
.
# history of CAD s/p CABG: The patient had no active issues
during his course. He was continued on ASA, statin,
beta-blocker, and his ACE was added in once his pressure was
stable.
.
# History of TIA: The patient had no issues during his course
and was continued on ticlid.
.
# DNR/DNI: It was decided to make the patient DNR/DNI.
.
# CMO: On [**4-27**] the patient had hypoxia and tachycardia. His
respiratory status was worse and he was having increased
secretions. He was suctioned, and with many talks with family,
family understood poor prognosis and cmo was initiated.
Palliative care was very involved and per their recommendations
the patient was made comfortable with scopalamine and morphine.
Medications on Admission:
cholestyramine 4gm packet [**Hospital1 **]
asa 325mg po qday
ticlopidine 250mg po bid
metoprolol 75mgpo [**Hospital1 **]
lasix 60mg po qday
lisinopril 10mgpo qday
mvi qday
ca with vit d [**Hospital1 **]
zocor 40mg po qhs
fosamax 70mg po qweek
carbidopa/levodopa q3h
entacapone with carbidopa/levodopa
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Aspiration pneumonia
2. Thrombocytopenia
3. CHF
4. Parkinson's disease
5. Melena
6. Hypotension
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
"V10.51",
"287.4",
"276.51",
"790.92",
"428.0",
"414.00",
"332.0",
"E849.7",
"458.9",
"799.02",
"401.9",
"E934.2",
"578.1",
"507.0",
"V45.81",
"276.0",
"263.9",
"733.00",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12680, 12689
|
5008, 10596
|
305, 325
|
12831, 12841
|
2857, 3724
|
12894, 12901
|
2174, 2303
|
12651, 12657
|
12710, 12810
|
12325, 12628
|
12865, 12871
|
2318, 2838
|
257, 267
|
353, 1442
|
3733, 4985
|
10611, 12299
|
1464, 1810
|
1826, 2158
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,423
| 159,199
|
42771
|
Discharge summary
|
report
|
Admission Date: [**2122-1-27**] Discharge Date: [**2122-1-29**]
Date of Birth: [**2068-7-12**] Sex: M
Service: MEDICINE
Allergies:
Lidocaine
Attending:[**First Name3 (LF) 8115**]
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53M with NSCLC SCC stage IV (brain met s/p resection and
cyberknife) C1D8 carboplatin gemcitabine (first round last
Tuesday) who presented to heme onc clinic today with persistent,
severe fatigue and found to have HCT 17%. Pt reported dark BMs
for a week. He was sent to the ED for eval. Heme/onc recommended
CT torso to assess for hemorrrhagic pleural effusion from his
cancer, and also for intraabdominal mass. In ED, patient had one
episode of guaiac positive stool, NG lavage attempted but pt did
not tolerate placement. Patient complaining of ongoing shortness
of breath and had one episode of lightheadedness with standing
up in ED, but denies chest pain, n/v, abdominal pain, BRBPR,
hemotypsis or hematemesis.
.
In the ED inital vitals were, T 99.2 126 119/74 16 98% RA. Got 2
L NS in ED and ordered for 2 units blood. Started on protonix
gtt. Given cefepime for T 99.2. GI consulted, they will not
scope emergently unless he decompensates. Non-con CT of
abdomen/pelvis done to evaluate for RP bleed. CXR unchanged from
prior. Access is 20-gauge x 2.
.
On arrival to the ICU, patient reports stable shortness of
breath, denies lightheadedness, chest pain, abdominal pain, n/v
or other problems. [**Name (NI) **] also reports feeling warm this morning,
but no chills.
.
Review of systems:
(+) Per HPI
(-) Denies chills. Denies headache, rhinorrhea or congestion.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, abdominal pain. Denies
dysuria, frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
Past Medical History:
Pertinent Oncologic history (include past therapies, surgeries,
etc):
NSCLC squamous cell carcinoma stage IV
- [**11/2121**] Presented with constipation, R side weakness
- [**2121-12-12**] Presented to OSH, found to have L brain met, R lung
mass, malignant hypercalcemia, transferred to [**Hospital1 18**]
- [**2121-12-13**] CT and MRI head showed L hemispheric cortical
enhancing lesion with extensive surrounding edema and necrosis
- [**2121-12-15**] Bronchoscopy biopsy showed NSCLC SCC
- [**2121-12-18**] Underwent resection of L brain met
- [**2121-12-19**] MRI showed possible residual tumor
- [**2121-12-25**] Presented for initial outpatient oncology visit and
found to be hypoxic and tachycardic. Send to ED. Felt to be due
to COPD.
- [**2122-1-1**] Cyberknife to his residual brain met
- [**2122-1-16**] Zoledronic acid for Ca 16.4 and 2 unit RBCs
- [**2122-1-20**] cycle 1 of carboplatin and gemcitabine
.
Other Past Medical History:
- Diverticulitis [**2115**] s/p partial colectomy
- Ventral hernia from partial colectomy
- s/p L3-4 fusion and laminectomy [**2102**]
- s/p fall down stairs with head trauma
- Polyp on past colonoscopy (6 years ago per patient)
Social History:
- Tobacco: Started smoking age 13, average 2 to 2.5 PPD since
then, currently down to few cigarettes, last use yesterday, 100+
PYs
- Alcohol: Denies current use
- Illicits: Former cocaine use
- Occupation: Construction work
- Exposures: Asbestos, silica
- Social supports: Used to live on a boat in [**State 108**], but moved
to [**Location (un) 86**] to take care of his mother who has [**Name (NI) 2481**] and
lives in a nursing home. He is currently living with
friends/[**Name2 (NI) 92415**] at his family home.
Family History:
- Mother: [**Name (NI) 2481**] dementia
- Father: Prostate cancer
Physical Exam:
ADMISSION EXAM:
.
General: Chronically ill appearing male, [**Doctor Last Name 352**] appearing. Alert,
no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, decreased breath
sounds RLL, no wheezes, rales, rhonchi
CV: tachycardic, normal S1/S2, no murmurs, rubs, gallops
Abdomen: well healed midline surgical scar, +ventral hernia that
reduces on its own. Soft, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, some peripheral edema, LLE
> RLE. no clubbing, cyanosis.
.
DISCHARGE EXAM:
98.2 102/64 -118/69 107-122 22 98% RA
GENERAL: NAD
SKIN: warm and well perfused
HEENT: NCAT,anicteric sclera, pale conjunctiva, MMM
CARDIAC: tachycardic, S1/S2, no mrg
LUNG: Decreased breath sounds at right base
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding. ventral hernia noted
M/S: moving all extremities, however unable to lift left arm
against gravity, otherwise strength 5/5. trace LE edema
bilaterally. no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: awake, A&Ox3. CN II-XII intact
.
Pertinent Results:
ADMISSION LABS:
[**2122-1-27**] 11:45AM BLOOD WBC-9.8 RBC-2.36*# Hgb-5.1*# Hct-17.0*#
MCV-72* MCH-21.5* MCHC-29.9* RDW-20.2* Plt Ct-247#
[**2122-1-27**] 11:45AM BLOOD Neuts-72.8* Bands-0 Lymphs-18.2 Monos-7.9
Eos-0.8 Baso-0.2
[**2122-1-27**] 03:12PM BLOOD PT-14.2* PTT-32.7 INR(PT)-1.3*
[**2122-1-27**] 03:12PM BLOOD Fibrino-942*
[**2122-1-27**] 11:45AM BLOOD Gran Ct-7150
[**2122-1-27**] 11:45AM BLOOD UreaN-12 Creat-0.5 Na-134 K-4.0 Cl-101
HCO3-25 AnGap-12
[**2122-1-27**] 11:45AM BLOOD ALT-92* AST-53* LD(LDH)-1246* AlkPhos-129
TotBili-0.1
[**2122-1-27**] 11:45AM BLOOD Albumin-2.5* Calcium-10.6*
.
DISCHARGE LABS:
[**2122-1-29**] 06:05AM BLOOD WBC-8.5 RBC-3.16* Hgb-8.2* Hct-24.2*
MCV-77* MCH-25.8* MCHC-33.7 RDW-19.2* Plt Ct-244
[**2122-1-29**] 06:05AM BLOOD PT-13.0* PTT-29.7 INR(PT)-1.2*
[**2122-1-29**] 06:05AM BLOOD Glucose-107* UreaN-7 Creat-0.5 Na-132*
K-3.8 Cl-100 HCO3-26 AnGap-10
[**2122-1-29**] 06:05AM BLOOD ALT-81* AST-54* LD(LDH)-1112* AlkPhos-121
TotBili-0.4
[**2122-1-29**] 06:05AM BLOOD Calcium-9.4 Phos-1.7* Mg-2.0
.
MICROBIOLOGIC DATA:
[**2122-1-27**] Blood culture (x 2) - pending
[**2122-1-27**] MRSA screen - pending
[**2122-1-27**] urine culture - <[**Numeric Identifier 961**] organisms
.
IMAGING STUDIES:
[**2122-1-27**] CHEST (PORTABLE AP) - Two portable AP views of the chest
are compared to previous exam from [**2121-12-25**]. There is
stable right basilar opacity compatible with patient's known
lung mass. Elsewhere, the lungs are grossly clear.
Cardiomediastinal silhouette is again notable for thickening of
the right paratracheal stripe compatible with known mediastinal
adenopathy. Osseous and soft tissue structures are grossly
unremarkable.
.
[**2122-1-27**] CT ABD & PELVIS W/O CON - No evidence of a
retroperitoneal hematoma. Markedly increased retrocrural,
retroperitoneal, and mesenteric lymphadenopathy, as described
above. Incompletely evaluated large right lower lobe pulmonary
mass, not significantly changed in size compared to CT from
[**2121-12-15**]. [**Doctor Last Name **]-type ventral abdominal wall hernia,
involving the transverse colon. No evidence of obstruction or
strangulation. Non-specific lucency within the left iliac bone,
not significantly changed in appearance.
.
LENIS [**1-28**]: IMPRESSION: No bilateral lower extremity DVT.
Brief Hospital Course:
53M with NSCLC SCC stage IV (brain met s/p resection and
cyberknife) s/p C1 of carboplatin gemcitabine on [**1-20**] who
presented to clinic with fatigue found to have a HCT of 17 now
s/p ICU stay with 5 units PRBCs.
.
# GASTROINTESTINAL BLEEDING - Patient had guaiac positive stool
in the ED (confirmed by GI physician) with an unsuccessful
nasogastric lavage. There was initial concern for upper
gastrointestinal bleeding given his hematocrit of 17% (10% drop
since [**2122-1-20**]) - though that was after transfusion for a
hematocrit of 23% on [**2122-1-15**]. Patient has been taking Ibuprofen
for headache while on steroids, which could predispose the
patient to gastritis among other issues. Patient does report
history of polyps on colonoscopy 6-years prior and has known
diverticular disease, which could be a source for lower GI
bleeding. We initiated a Protonix infusion following a bolus and
consulted the GI specialists. He was maintained NPO with plans
for endoscopy, however HCT stabilized and he remained
hemodynamically stable without evidence of [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 92416**] or
hematochezia. He received 5 units of packed red cells on
admission for his hematocrit of 17%. His HCT stabilized between
24 and 25. Given risks associated with intervention and the lack
of evidence for acute bleeding the decision was made to
empirically treat with PPI without endoscopy. The protonix gtt
was changed to IV BID and then omeprazole 40 mg po BID. His INR
was elevated likely in the setting malnutrition and he was given
1 unit of PRBC and vitamin K. Patient was monitored overnight
and continued to remain stable. He was discharged with plans to
avoid NSAIDS and with a prescription for a PPI.
.
# SEVERE MICROCYTIC ANEMIA - Patient has unclear hematocrit
baseline and has known anemia with recent hematocrit of 23%
following recent transfusion in [**Hospital 20722**] clinic.
Chronic GI bleeding, marrow suppression given his underlying
malignancy vs. marrow suppressive therapy could be contributing.
We monitored his hematocrit serially and transfused as needed.
.
# METASTATIC NON-SMALL CELL LUNG CANCER - The patient is
status-post resection and cyberknife of brain metastatsis and
first cycle of chemotherapy. He was continued on his Keppra
dosing for seizure prophylaxis and oxycontin and oxycodone for
pain. The patient was evaluated by the palliative care team.
Patient decided at this time he is interested in full aggressive
care including CPR and intubation but not prolonged intubation.
Once he feels that he is declining and nearing death, he says
that he will likely choose to die without resuscitation but is
not at that point now. Patient was discharged with plans for
home visiting care (minimal services at this time) and potential
bridge to hospice should that be decided as the next step.
Patient has plans to follow up with his outpatient oncologist
next week and issues of goals of care will be discussed during
that visit.
.
# SINUS TACHYCARDIA - On reviewing his record, patient's
baseline heart rate has been in the 110-120s (lowest HR recorded
in clinic was 112), except for a single EKG from [**2121-12-17**]
documenting a rate of 80 bpm. Unclear etiology likely [**12-25**]
anemia. Patient continued to have sinus tachycardia despite
blood tranfusions and IVF making hypovolemia less likely. Had
CTA chest on [**2121-12-25**] which was negative for PE and patient
remained in no respiratory distress, without pleuritic chest
pain, and maintained oxygen saturations in the 90s on room air.
LENIs were negative for DVT. Also, likely component of
overlying anxiety.
.
# ASTHMA, COPD - Patient denies history of COPD, however given
his smoking history, this was likely. Patient did not appear to
be in exacerbation during admission. He was treated with
albuterol nebulizer treatments as needed.
.
# FEVERS - Patient had reported temperature of 99.2F in the ED,
and was given Cefepime for unclear source. The patient does have
stable and chronic non-productive cough, but his CXR did not
appear to demonstrate pneumonia. An infectious work-up was
performed with reassuring blood and urine cultures.
.
TRANSITION OF CARE ISSUES:
1. goals of care ongoing discussion: patient desires
chemotherapy but has been told he is unlikely to benefit. At
this time patient is full code. He was discharged with plans to
have a home hospice nurse (but not full hospice team).
2. patient will need his HCT checked at follow up
3. blood cultures pending at time of discharge
4. patient was full code on this admission
Medications on Admission:
Oxycontin 20 mg [**Hospital1 **]
Oxycodone 10 mg q4hrs prn for pain
Keppra 750 mg [**Hospital1 **]
Albuterol neb q6 hrs prn for shortness of breath
Nystatin swish/swallow 5 cc QID
Ondansetron 8 mg TID prn nausea
Prochlorperazine 10 mg q6hr prn nausea
Quetiapine 25 mg 0.5-1 tab qHS prn anxiety/insomnia
Ranitidine 150 mg [**Hospital1 **]
Ibuprofen 500 mg [**Hospital1 **] prn pain
Discharge Medications:
1. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*90 Tablet(s)* Refills:*0*
3. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) cc PO four
times a day: swish and swallow.
6. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia/anxiety.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Location (un) 1121**]
Discharge Diagnosis:
primary diagnoses: anemia, lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you while you were admitted to the
hospital. You were admitted because you were found to have a low
blood count. You were treated with multiple blood transfusions.
There was concern that you may be bleeding from your
gastrointestinal tract and you were evaluated by the
gastroenterology team. They felt that you did not need an urgent
procedure and recommended that you start a new medication called
omeprazole. You were monitored overnight on the oncology service
and your blood counts remained stable.
.
The following changes have been made to your medication regimen:
Please START taking
- omeprazole 40 mg twice daily
.
Please STOP taking
- ranitidine
- ibuprofen
.
Please take the rest of your medications as prescribed and
follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
.
Followup Instructions:
Department: RADIOLOGY
When: MONDAY [**2122-2-2**] at 11:15 AM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2122-2-2**] at 1 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2122-2-3**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 831**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 4908**] MD [**MD Number(2) 8116**]
Completed by:[**2122-1-29**]
|
[
"427.89",
"790.92",
"280.0",
"790.4",
"V12.72",
"V15.3",
"V15.88",
"162.5",
"E933.1",
"578.9",
"V45.72",
"493.20",
"V58.69",
"780.60",
"285.22",
"198.3",
"285.3",
"263.9",
"V45.4",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13277, 13347
|
7251, 11831
|
277, 284
|
13430, 13430
|
4929, 4929
|
14486, 15411
|
3634, 3702
|
12262, 13254
|
13368, 13409
|
11857, 12239
|
13581, 14463
|
5547, 6146
|
3717, 4356
|
4372, 4910
|
1607, 1865
|
231, 239
|
312, 1588
|
4945, 5531
|
13445, 13557
|
2854, 3084
|
3100, 3618
|
6163, 7228
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,798
| 130,870
|
33236+33237+57840
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2198-6-29**] Discharge Date: [**2198-7-10**]
Date of Birth: [**2136-7-29**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
esophageal caracinoma
Major Surgical or Invasive Procedure:
[**2198-6-29**] - laparoscopic esophagectomy
History of Present Illness:
61yM with T3 adenoCA esoph s/p neoadjuvant tx now s/p lap
esophagectomy. Initially presented in [**2-2**] with dysphagia,
anemia, fatigue. Found to have a GE junction tumor that was
biopsied. Had J tube placed prior to neoadjuvant therapy. Now
s/p laparoscopic esophagectomy.
Past Medical History:
PMH:DM2, HTN, CRI (1.5), obesity, low back pain,
depression/anxiety, gout, splenomegaly, reflux.
.
PSH: spinal fusion, s/p orchidectomy for torsion, R medial
meniscus repair, lap j-tube
Social History:
Denies etoh/drug use, ex-smoker of 5 years, works as a
medical assistant at St. [**Hospital 11042**] hospital
Family History:
FHx: Mother had breast CA, Father had leukemia, Grandmother had
throat CA
Physical Exam:
AFVSS
Gen: NAD, A+OX3, conversive with somewhat hoarse voice, pleasant
HEENT: EOMI, PERRL, thyroid not enlarged/tender, no
supraclavicular/axillary nodes palpable, neck JP in place with
clear drainage (small)
CV: RRR, 2+ radial and femoral pulses
Resp: CTAB
Abd: soft, NT/ND, no periumbilical LAD, no fluid wave
Ext: 1+ edema to b/l LE
Pertinent Results:
[**2198-6-29**] 03:06PM BLOOD WBC-3.7* RBC-3.42* Hgb-10.2* Hct-29.7*
MCV-87 MCH-29.9 MCHC-34.4 RDW-17.0* Plt Ct-78*
[**2198-6-30**] 02:09AM BLOOD WBC-4.0 RBC-3.14* Hgb-9.6* Hct-27.2*
MCV-87 MCH-30.4 MCHC-35.1* RDW-17.3* Plt Ct-81*
[**2198-7-1**] 04:19AM BLOOD WBC-8.5# RBC-3.73* Hgb-11.0* Hct-31.9*
MCV-86 MCH-29.4 MCHC-34.4 RDW-16.8* Plt Ct-125*#
[**2198-7-2**] 04:01AM BLOOD WBC-6.8 RBC-3.59* Hgb-10.5* Hct-30.9*
MCV-86 MCH-29.3 MCHC-34.0 RDW-16.5* Plt Ct-107*
[**2198-7-6**] 05:39AM BLOOD WBC-6.7 RBC-3.27* Hgb-9.8* Hct-28.1*
MCV-86 MCH-29.9 MCHC-34.8 RDW-16.3* Plt Ct-127*
[**2198-7-7**] 06:50AM BLOOD WBC-6.6 RBC-3.38* Hgb-10.0* Hct-29.0*
MCV-86 MCH-29.7 MCHC-34.6 RDW-16.3* Plt Ct-122*
[**2198-6-29**] 03:06PM BLOOD Plt Ct-78*
[**2198-6-30**] 02:09AM BLOOD Plt Ct-81*
[**2198-7-1**] 04:19AM BLOOD Plt Ct-125*#
[**2198-7-2**] 04:01AM BLOOD Plt Ct-107*
[**2198-7-3**] 02:17AM BLOOD PT-16.4* INR(PT)-1.5*
[**2198-7-6**] 05:39AM BLOOD PT-15.0* INR(PT)-1.3*
[**2198-7-7**] 06:50AM BLOOD Plt Ct-122*
[**2198-6-30**] 02:09AM BLOOD Glucose-137* UreaN-23* Creat-1.0 Na-142
K-4.3 Cl-109* HCO3-26 AnGap-11
[**2198-6-30**] 12:27PM BLOOD Glucose-146* UreaN-27* Creat-1.1 Na-140
K-4.2 Cl-106 HCO3-27 AnGap-11
[**2198-7-5**] 12:30PM BLOOD Glucose-183* UreaN-30* Creat-0.8 Na-138
K-4.8 Cl-101 HCO3-27 AnGap-15
[**2198-7-6**] 05:39AM BLOOD Glucose-165* UreaN-31* Creat-0.9 Na-139
K-4.2 Cl-102 HCO3-28 AnGap-13
[**2198-7-7**] 06:50AM BLOOD Glucose-149* UreaN-32* Creat-0.9 Na-135
K-4.2 Cl-100 HCO3-26 AnGap-13
[**2198-6-30**] 12:27PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2198-6-30**] 10:05PM BLOOD cTropnT-<0.01
[**2198-6-29**] 03:06PM BLOOD Calcium-8.0* Phos-3.8 Mg-1.6
[**2198-6-30**] 02:09AM BLOOD Calcium-8.0* Phos-4.3 Mg-1.9
[**2198-6-30**] 12:27PM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1
[**2198-6-29**] 09:24AM BLOOD Type-ART pO2-92 pCO2-37 pH-7.46*
calTCO2-27 Base XS-2 Vent-CONTROLLED
[**2198-6-29**] 01:02PM BLOOD Type-ART pO2-141* pCO2-49* pH-7.35
calTCO2-28 Base XS-0
[**2198-6-30**] 06:02PM BLOOD Type-ART pO2-89 pCO2-40 pH-7.43
calTCO2-27 Base XS-1 Intubat-NOT INTUBA
[**2198-6-30**] 10:49PM BLOOD Type-ART FiO2-60 pO2-147* pCO2-32*
pH-7.49* calTCO2-25 Base XS-2 Intubat-NOT INTUBA
Brief Hospital Course:
[**6-29**]: admitted post-op, stable, pain control with dilaudid PCA.
UOP 15-30cc/hr, received 3 x 500cc boluses with no effect. Cont
to monitor overnight
[**6-30**]: developed new onset Afib, received metoprolol 15 mg IV,
then bolused with amiodarone X 2 and started on an infusion. Had
sensation of chest presure, received IV dilaudid and sublingual
nitroglycerin with some relief. Switched to dilt drip with no
effect on HR control so switched back to amio gtt. Receiving prn
hydralazine for HTN. Then receiving prn metoprolol with amio
infusion. Wife upset re: husband's resp difficulties/ lack of
comfort, nursing supervisor spoke with her and situation
resolved. receiving lasix diuresis.
[**7-1**]: rapid Afib resolved with amio and dilt gtts. Dilt gtt then
stopped, HTN controlled with labetalol and hydral. Diuresed,
potassium repleted, tube feeds started at 10/hr
[**7-2**]: ST up to 160. Started on labetalol gtt. LEFT vocal chord
out per ENT fiberoptic. Notable edema. Hematoma LEFT chest- has
been demarcated.
[**7-3**]: Weaned off esmolol and started on metoprolol 50mg tid and
amio started on 0.25mg/min. Went back into fast afib so
amiodarone increased to 1mg/min and started received IV
lopressor. Tube feeds changed to Replete with fiber. Agitated
early a.m. and pulled out his A-line and a PIV- placed Mitts
over his hands. Appears AO X 2. Ativan held again. Consider
alternative- zyprexa?
[**7-4**]: HR stable, increased PO amiodarone
[**7-5**]: transferred from ICU, stable with pain significantly
improved
[**7-7**]: pulled R chest tube, CXR stable
[**7-10**]: J tube fell out, replaced
Medications on Admission:
coreg 25', diovan 160', lasix 20', prilosec 20', morphine &
klonapin prn, zoloft 100', allopurinol 300'
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: Ten (10) mL PO BID (2
times a day): per J-Tube.
Disp:*600 mL* Refills:*2*
2. Clonidine 0.1 mg/24 hr Patch Weekly [**Month/Year (2) **]: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
Disp:*14 Patch* Refills:*2*
3. Amiodarone 200 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO twice a day
for 2 days: start [**7-10**].
Disp:*8 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day
for 7 days: start [**7-12**].
Disp:*14 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day
for 7 days: start [**2198-7-19**].
Disp:*7 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily):
per J tube.
Disp:*30 Tablet(s)* Refills:*2*
7. Sertraline 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Clonazepam 0.5 mg Tablet [**Month/Day/Year **]: [**1-26**] Tablet PO TID (3 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID
(3 times a day): per J tube.
Disp:*180 Tablet(s)* Refills:*2*
10. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: [**6-8**] mL PO Q4H (every 4
hours) as needed for pain.
Disp:*300 mL* Refills:*0*
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
12. Replete/Fiber Liquid [**Last Name (STitle) **]: Eighty Five (85) cc PO hourly,
continuous.
Disp:*60 cans* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Esophageal carcinoma
Atrial fibrillation
anastamotic leak
Discharge Condition:
Stable, NPO with tubefeeds per J-Tube
Discharge Instructions:
You were seen in the hospital for a laparoscopic esophagectomy.
You are being discharged in stable condition, with feeds per
your J-tube as have already been explained to you. You should
not eat ANYTHING nor take anything in by mouth -- all of your
medications should be through your J-Tube. Please record your JP
output daily in a logbook and bring this with you to your
followup appointment.
If you experience any of the following, please call your doctor
or go to the emergency room:
*Fever > 101.2, chills, nightsweats
*Severe abdominal pain, retching, vomiting, nausea
*Chest pain, shortness of breath
*Drain output that is significantly increased over your normal
level
Followup Instructions:
Please call Dr.[**Name (NI) 1482**] office for a followup appointment
within one week. ([**Telephone/Fax (1) 1483**]
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2198-7-19**] 11:30
Completed by:[**2198-7-10**] Admission Date: [**2198-7-14**] Discharge Date: [**2198-8-7**]
Date of Birth: [**2136-7-29**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
- endotracheal intubation
- tracheostomy
- left chest tube thoracostomy
- indwelling drain placements in neck and perisplenic recess
- J-tube
History of Present Illness:
61 y/o gentleman with T3 adenoCA esoph s/p neoadjuvant therapy
now s/p lap esophagectomy on [**6-29**]. His postoperative course was
complicated by AF with RVR and a contained leak at the cervical
anastamosis. He is unable to give much history, as he has severe
dyspnea. His wife reports that he has been short of breath since
discharge to home on [**7-10**]. This has grown progressively worse
and became worrisome today when he was having difficulty
speaking because of the SOB, as well as complaining of chest
pain. His wife has a O2 saturation monitor at home and noted
that his sat's were in the 70's, at which time she decided to
bring him to the ED.
She denies that he has had any recent fevers or chills. She did
note some
increased purulent drainage around the cervical drain over the
last few days. He has been tolerating his tube feeds. She denies
any nausea or vomiting. He has been having somewhat regular
BM's.
On arrival to the ED today, he was noted to have O2 sat's in the
80's, despite being on a NRB. He also was noted to have
significant work of breathing, with accessory muscle use. It was
decided at that time that he should be intubated. He was also
given Vanco, Meropenem, Flagyl and Levoquinin the ED. He was
noted to have a rectal temp of 103, though his external temp was
98.6.
Past Medical History:
Esophageal cancer dx's in [**1-/2198**]
T3N+M0 s/p neo-adjuvant tx with chemo/xrt, s/p lap esophagectomy
and lap jtube [**2198-6-29**]
DM2
hypertension
Chronic renal insufficiency with baseline creatinine of 1.5
splenomegaly (x 10 years w/ workup negative)
GERD
Barrett's esophagitis
depression/anxiety
low back pain
gout
PSH:
spinal fusion
s/p orchidectomy for torsion
R medial meniscus repair
lap j-tube
Social History:
Denies Etoh/drug use, ex-smoker of 5 years, works as a
medical assistant at St. [**Hospital 11042**] hospital
Family History:
Mother had breast CA, Father had leukemia, Grandmother had
throat CA
Physical Exam:
VS: Temp: 103.6 (rectal) 98.6 (oral) P:86 BP:149/85 RR:40
O2Sat: 86% NRB
Gen: NAD. A&Ox3.
HEENT: Anicteric. Tacky mucosal membranes.
Neck: No JVD. No LAD. No TM.
CV: RRR.
Pulm: CTAB.
Abd: Soft. NT. ND. +BS.
DRE: Normal tone. No masses. No gross or occult blood.
Ext: Warm and well perfused. No peripheral edema.
Neuro: Motor and sensation grossly intact.
Pertinent Results:
[**2198-7-14**] 12:34AM PT-16.9* PTT-31.3 INR(PT)-1.5*
[**2198-7-14**] 12:34AM PLT COUNT-353#
[**2198-7-14**] 12:34AM NEUTS-92.1* LYMPHS-4.2* MONOS-3.2 EOS-0.4
BASOS-0.1
[**2198-7-14**] 12:34AM ALBUMIN-3.3*
[**2198-7-14**] 12:34AM ALT(SGPT)-17 AST(SGOT)-15 CK(CPK)-15* ALK
PHOS-78 TOT BILI-1.0
[**2198-7-14**] 12:34AM GLUCOSE-177* UREA N-33* CREAT-1.4* SODIUM-135
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
[**2198-7-14**] 12:41AM LACTATE-1.3 K+-4.6
[**2198-7-14**] 03:34AM TYPE-ART PO2-30* PCO2-53* PH-7.38 TOTAL
CO2-33* BASE XS-4
Brief Hospital Course:
Patient presented with severe dyspnea 2 weeks following
esophagectomy for esophageal CA which was complicated by AF with
RVR and a leak from the cervical anastomosis. He was intubated
in the emergency room and on imaging studies was found to have a
left hydropneumothorax, mediastinal fluid collection, and a
peri-splenic fluid collection. He was empirically treated with
Vancomycin 1250 mg IV Q 12H, Aztreonam 1000 mg IV Q8H and
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H.
His pleural fluid was sampled and was consistent with an empyema
with high amylase (7125 wbc, [**Numeric Identifier **] rbc, 84%P, 10%L, 6%M,
protein-3.3, glucose 29, ldh 1655, amylase [**Numeric Identifier 77210**], TG 60). The
cultures from this fluid have grown 2 colonies of GNR, Strep
spp, MRSA and Haemophilus. His LUQ fluid collection was sampled
and grew [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] non-albicans ( C. glabrata). He also had a
BAL which has grown MRSA. Per ID consult, vancomycin was
continued for MRSA infection. Flagyl for anaerobe coverage.
Aztreonam was discontinued. Given patient's penicillin allergy,
Ciprofloxacin 500 per jtube [**Hospital1 **] was started for gram negative
coverage. He was also started micafungin 100mg iv qday pending
sensitivity for non-albicans [**Female First Name (un) **].
On [**7-14**] IR attempted to drain abdominal fluid collection without
success. On [**7-14**] a left sided chest tube was placed which
drained 2200 cc of serosanguinous fluid. On [**7-15**] patient had
episode of Afib RVR to 120's treated with metoprolol and
amiodarone. On [**7-16**] IR inserted a pigtail which drained
substantial amounts of thick brown fluid from the perisplenic
collection. On [**7-25**] patient received tracheostomy for breathing
comfort and airway protection.
[**Hospital **] hospital course was also notable for waxing/[**Doctor Last Name 688**]
behavioral symptoms (agitation and somnolence) and increased
depression and anxiety. Patient was able to communicate his
distress via writing, and he reportedly wrote a note to staff
stating that he wished to die. Psychiatry was consulted and the
patient's Zoloft was increased from 100mg to 200mg on [**7-19**].
Patient did progressively better and was transferred to floor on
[**7-29**]. On [**7-31**] chest tube was removed off section and placed to
water seal with continued drainage. A follow up CXR showed no
pneumothorax. On [**7-31**] a video barium-swallow was also performed,
showing small anastomotic leak with most of the contrast passing
through into the stomach. The JP drain was left in place and
tube feeds were continued. On [**8-1**] pigtail drain in left flank
was removed. On [**8-1**], proper J-tube placement was confirmed by
abdominal XR. Sensitivities for fungal infection in perisplenic
space showed fluconazole sensitivity. On [**8-3**], the tracheostomy
tube was removed without complciations. The remainder of the
hospital course was uncomplicated and the patient was discharged
to rehabilitation facility on [**8-6**].
Medications on Admission:
1. Docusate Sodium 100mg (10ml Liquid (50mg/5ml) [**Hospital1 **] per Jtube
2. Clonidine 0.1 mg/24 hr Patch Weekly QWED
4. Amiodarone 200 mg PO BID for 7 days
5. Amiodarone 200 mg PO daily for 7 days: start [**2198-7-19**] (taper)
6. Furosemide 20 mg PO DAILY per Jtube.
7. Sertraline 100 mg PO DAILY
8. Clonazepam 0.25 mg PO TID per J tube.
10. Oxycodone 5 mg/5 mL Solution [**6-8**] mL PO Q4H PRN for pain.
11. Lansoprazole 30 mg DR PO BID
12. Replete/Fiber Liquid [**Month/Year (2) **]: Eighty Five (85) cc PO hourly,
continuous.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1)
Injection TID (3 times a day).
2. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical QID
(4 times a day) as needed for redness itching.
3. Clonidine 0.2 mg/24 hr Patch Weekly [**Month/Year (2) **]: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
4. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Year (2) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for pain.
5. Aripiprazole 10 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO DAILY (Daily).
6. Enalapril Maleate 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
7. Ciprofloxacin 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q12H
(every 12 hours).
8. Sertraline 50 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily).
9. Famotidine 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
10. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Docusate Sodium 50 mg/5 mL Liquid [**Month/Year (2) **]: One (1) PO BID (2
times a day) as needed for constipation.
12. Metoprolol Tartrate 50 mg Tablet [**Month/Year (2) **]: 1.5 Tablets PO TID (3
times a day).
13. Hydromorphone 4 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain: Hold for sedation, RR < 8.
14. Amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times
a day).
15. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [**Month/Year (2) **]:
One (1) Intravenous Q8H (every 8 hours).
16. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Year (2) **]: One (1)
Intravenous Q 12H (Every 12 Hours).
18. Lorazepam 2 mg/mL Syringe [**Month/Year (2) **]: One (1) Injection Q8H (every
8 hours) as needed for agitation/ anxiety.
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Year (2) **]: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
20. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
21. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Year (2) **]: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
22. Fluconazole 200 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
s/p laproscopic esophagectomy for esophogeal adenocarcinoma,
complicated by atrial fibrillation with rapid ventricular
response and esophogeal anastomotic leak with collections in
neck, left pleural space and perisplenic recess.
Discharge Condition:
Hemodynamically stable, pain under adequate control, and
tolerating tube feeds through J-tube.
Discharge Instructions:
Please call your doctor or return to the hosptial for any of the
following ...
- shortness of breath, chest pain
- signs or symptoms of infection, fevers, chills, increased
redness
or swelling around your wounds, new or increasing drainage
- nausea, vomiting
- or any other symptoms which concern you
Followup Instructions:
Please make an appointment to follow up with Dr. [**Last Name (STitle) **] in 2
weeks [**Telephone/Fax (1) 2981**].
Please make an appointment to follow up with Thoracic Surgery
(Dr. [**Last Name (STitle) **] in 2 weeks [**Telephone/Fax (1) 170**].
Please follow up with Infectious Disease in the urgent clinic on
[**8-30**] @ 1:30 pm (we made you an appointment) [**Telephone/Fax (1) 457**].
Completed by:[**2198-8-6**] Name: [**Known lastname 12528**],[**Known firstname 2147**] Unit No: [**Numeric Identifier 12529**]
Admission Date: [**2198-7-14**] Discharge Date: [**2198-8-7**]
Date of Birth: [**2136-7-29**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 203**]
Addendum:
Patient was planned to be discharged on [**8-6**] but was actually
discharged on [**8-7**] to rehabilitation facility. The interval
period was uneventful.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 3542**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**]
Completed by:[**2198-8-7**]
|
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"585.9",
"997.4",
"511.89",
"276.1",
"427.31",
"287.5",
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icd9cm
|
[
[
[]
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] |
[
"43.99",
"96.6",
"33.24",
"42.52",
"31.1",
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icd9pcs
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[
[
[]
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] |
19628, 19856
|
11709, 14759
|
8608, 8752
|
18217, 18313
|
11127, 11686
|
18664, 19605
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10662, 10733
|
15344, 17847
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17965, 18196
|
14785, 15321
|
18337, 18641
|
10748, 11108
|
8560, 8570
|
8780, 10088
|
10110, 10519
|
10535, 10646
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,765
| 190,940
|
7019
|
Discharge summary
|
report
|
Admission Date: [**2167-9-14**] Discharge Date: [**2167-10-25**]
Date of Birth: [**2098-4-26**] Sex: F
Service: MEDICINE
Allergies:
Oxycodone
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2167-9-16**] Central venous line placement
[**2167-9-17**] Bronchoscopy
History of Present Illness:
The patient is a 69 yo F with history of breast cancer and
secondary AML s/p induction therapy with 7+3 (multiple
complications) and subsequent dacogen therapy with continued
peripheral blasts throughout treatment who presents for
admission for more aggressive treatment for secondary AML (had
been deferred until after her son's wedding, which happened this
past weekend).
.
She was seen in onc clinic on [**9-14**] and reported fatigue that
began on Friday after receiving plts. She reports feelings
slightly better on Saturday (2 days PTA), but again felt
fatigued on Sunday and developed blisters on her lips and mouth
with bleeding. She also endorse very mild sore throat beginning
2 days PTA. She denies fevers and chills at home. She further
denied any SOB (PTA), cough, abdominal pain, N/V/diarrhea,
dysuria, or rashes. She has had no recent travel, sick
contacts, or recent dental procedures. Blood cultures were
drawn in clinic and she received a bag of platelets prior to
direct admission to the floor from clinic for treatment of her
AML.
.
She was febrile on presentation so cefepime was started for
neutropenic fever. CXR on admission demonstrated several
bilateral lung opacities, mostly in a perihilar distribution and
CT chest was recommended. Overnight last night, she developed
worsening hypoxia requiring 3L NC supplemental O2 (had
previously been on RA) and tachypnea although she reports her
breathing felt comfortable. CT chest was performed which showed
diffuse bilateral ground glass opacities concerning for
infection vs. pulmonary edema vs. pulmonary hemorrhage.
Vancomycin was started in addition to cefepime and ID and
pulmonary consults were obtained. Blood cultures from [**9-14**] are
growing enterococcus. Nasopharyngeal aspirate negative for
influenza, parainfluenza, adeno, and RSV. Based on the
appearance of her chest CT, ID and pulm agreed on bronch planned
for [**9-17**]. ID recommended adding azithromycin for possible
atypical pulmonary infection as well as treating for PCP given
appearance on imaging, neutropenia, and acute elevation of her
LDH so she was started on bactrim and prednisone prior to ICU
transfer. CVL was placed by IR on [**9-16**].
.
In the evening of her transfer, she became increasingly
tachycardic to the 120s (sinus) with RR as high as the 40s with
crackles extending up entire bilateral lung fields. ABG
performed on the floor 7.49/21/62 on 3L NC. She received 20mg
IV lasix and atrovent neb. She was on NRB and is now being
transferred to the floor for sepsis and worsening respiratory
status in the setting of developing multifocal pulmonary
infiltrate.
.
ROS: negative for HA, vision changes, fevers, chills, nausea,
emesis, hematemesis, abdominal pain, melena, hematochezia,
weight changes. positive as above.
Past Medical History:
1. Left breast cancer, diagnosed in [**2160**], s/p lumpectomy, XRT,
and chemotherapy (please see below in oncologic history for
details)
2. History of polio with leg brace ([**2101**])
3. History of tumor on spine
4. Osteoporosis
5. s/p tonsillectomy/adenoidectomy
6. s/p L knee replacement
7. s/p ORIF of femur and fusion of ankle s/p fracture [**2154**]
8. Multiple foot surgeries and an ankle fusion done for
post-polio syndrome
9. Sinus cyst removed, which was benign
ONCOLOGIC HISTORY:
-AML dx in [**1-2**], s/p 7+3 induction chemotherapy, complicated by
ARDS requiring intubation and then trach and PEG, RF requiring
HD until 2 weeks ago, was on biweekly HD, she was hospitalized
for a long course and then spent time in rehab. She is still not
at the same baseline of activities before this diagnosis.
-Breast Cancer- diagnosed in [**7-/2161**], with left sided mass on a
mammogram on [**2161-8-11**]. An ultrasound confirmed that the mass was
solid, and an U/S guided biopsy found a 3.7 cm grade 3
infiltrating left ductal cancer with clean lymph nodes, ER
positive, HER-2/neu negative, and negative LVI. She received
Cytoxan and Adriamycin x 4 and was on Femara for 4 years. She
was switched to tamoxifen in [**2166-2-23**] due to bone density
thinning. Her mammogram in [**2166-7-26**] was normal. Her last
BMD was in [**2165-4-25**] with one in [**2167-4-26**] pending.
.
OB/GYN HISTORY:
G3P2 with first full term pregnancy at age 29. Menarche at age
11 with menopause in early 50's. Took OCPs for approximately 3
years in the past and had been on estrogen for ~ 10 years but
has stopped this.
.
Social History:
She denies tobacco use and IVDU. She drinks alcohol socially.
She has one son who is a patent lawyer in [**Name (NI) 86**] and is engaged
and will be married in the fall on [**Location (un) **].
Family History:
There is no family history of breast, ovarian, or colon cancer.
Her father died of an MI at 65 yrs. Her mother died of "renal
disease."
Physical Exam:
VS: 98, 147/75, 18, 106, 99% RA
HEENT: anicteric, bucal mucosa with several lesions (right
lateral wall, left lateral wall, perimeter of tongue, 2 on
bottom lip, tongue coated in old darkened blood making difficult
to assess for thrush
NECK: Supple, no LAD
CHEST: CTAB
HEART: RRR, nl S1 and S2, no MRGs
ABDOMEN: Soft, NTND, no HSM
SKIN: No rash, multiple ecchymosis
EXT: left ankle larger than right in setting of prior ankle
fusion, 2+ DP pulses
NEURO: A&O x 3, MAE
Pertinent Results:
Admission Labs:
[**2167-9-14**] 01:30PM BLOOD WBC-12.2* RBC-3.09* Hgb-9.1* Hct-26.5*
MCV-86 MCH-29.5 MCHC-34.5 RDW-15.4 Plt Ct-6*#
[**2167-9-14**] 01:30PM BLOOD Neuts-0 Bands-0 Lymphs-31 Monos-28* Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-41*
[**2167-9-14**] 01:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2167-9-14**] 01:30PM BLOOD PT-14.6* INR(PT)-1.3*
[**2167-9-14**] 01:30PM BLOOD Gran Ct-210*
[**2167-9-14**] 01:30PM BLOOD UreaN-44* Creat-1.7* Na-138 K-3.9 Cl-107
HCO3-18* AnGap-17
[**2167-9-14**] 01:30PM BLOOD ALT-25 AST-35 LD(LDH)-790* AlkPhos-66
TotBili-0.5 DirBili-0.2 IndBili-0.3
[**2167-9-14**] 01:30PM BLOOD Calcium-9.0 Phos-1.7* Mg-1.7 UricAcd-7.4*
[**2167-9-14**] 04:15PM BLOOD Fibrino-206# D-Dimer-7047*
[**2167-9-15**] 06:15AM BLOOD Hapto-545*
Brief Hospital Course:
69 F w/ secondary AML s/p 7+3 (multiple complications) &
Dacogen, still w/ peripheral blasts presented with
enterococcemia. Hospital course complicated by diffuse aveleor
hemorrhage, VRE bacteremia from tunneled catheter line, C.-Diff
colitis and supra-ventricular tachycardia. Patient started on
Azacitadine 75mg/m2 for 7 days, and Gemtuzumab 3mg/m2 on Day 8
for AML therapy (Day 1 [**2167-9-24**]). Unfortunately, repeat bone
marrow showed no response (90% blasts). Patient at this time was
complaining of increasing dyspnea, demonstrated fluid overload
on exam and ECHO demonstrated a significantly decreased EF
25-30%. Patient was suffering from Stage 4 CHF. Patient and
family decided not to pursue additional chemotherapy treatments.
Over the course of the next week patient became unresponsive and
was unable to eat or swallow pills. Family decided on comfort
care measures. Social work, chaplain service, and medical staff
offered support. Patient passed on [**2167-10-25**].
Medications on Admission:
Allopurinol 100 mg daily
Famotidine 20 mg QOD or as directed
Dacogen (Decitabine, DNA Methylation Inhibitor) - stopped [**8-28**]
Hydroxyurea 1000 mg daily
Levofloxacin 250 mg QOD
Ativan 0.5-1 mg Q4-6 hrs
Metoprolol 12.5 [**Hospital1 **]
Prochlorperazine prn
Acyclovir 200 mg PO BID
Acetaminophen prn
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnoses:
- AML
- Enterococci bacteremia (VRE)
- Acute CHF
- Diffuse aveleor hemorrhage
- Supraventricular tachycardia
Secondary diagnoses:
- Breast cancer
- Osteoporosis
- Polio
Discharge Condition:
Patient passed [**2167-10-25**]
Completed by:[**2167-11-1**]
|
[
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"999.31",
"528.00",
"428.0",
"288.00",
"038.0",
"V43.65",
"428.21",
"486",
"138",
"584.9",
"995.92",
"V10.3",
"780.61",
"585.3",
"205.00"
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icd9cm
|
[
[
[]
]
] |
[
"99.28",
"99.05",
"99.04",
"33.24",
"00.14",
"38.93",
"86.05",
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
7876, 7885
|
6539, 7525
|
279, 356
|
8117, 8179
|
5696, 5696
|
5056, 5194
|
7906, 8034
|
7551, 7853
|
5209, 5677
|
8055, 8096
|
232, 241
|
384, 3185
|
5712, 6516
|
3207, 4826
|
4842, 5040
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,873
| 158,431
|
52954
|
Discharge summary
|
report
|
Admission Date: [**2110-7-21**] Discharge Date: [**2110-7-31**]
Date of Birth: [**2062-12-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
CC: Back Pain
Major Surgical or Invasive Procedure:
Epidural Abscess exploration/drainage
PICC line placement
History of Present Illness:
47 F with 1 week of back pain and fevers at home transferred
from OSH for management of a suspected epidural abscess.
Ms. [**Known lastname 109150**] has a long history of chronic back pain and left
radicular symptoms that she was told are related to cervical
stenosis. She was plannning for eventual back surgery.
On Monday (7 days prior to admission to [**Hospital1 18**]) she noted acute
worsening of lumbar back pain with right radicular symptoms
(typically only left) down to her toes. Also felt feverish
though she did not take her temperature. Also noted fatigue and
loss of appetite. Her last illness was was early [**2109**]. No fevers
since then. Last joint injection was also early [**2109**]. No history
of IV drug abuse.
Originally admitted [**7-20**] at [**Hospital3 628**]. Received
Vancomycin and one other (unclear which) antibiotic. MRI showed
new lumbar lesion and transferred to [**Hospital1 18**] for further
evaluation.
Vitals on arrival to [**Hospital1 18**] ED: T 97.9, P 94, BP 104/62, RR 18,
96% on RA. Evaluated by neurosurgey who felt the MRI
demonstrated degenerative changes and no abscess.
Review of Systems: No recent illnesses. Appetite is good and
weight is stable. No SOB, cough, PND, orthopnea. Had recent
work-up for chest pain that was negative. No bowel or bladder
difficulty. No BRBPR or melena. No LE edema. No rashes or [**Doctor First Name **].
Mood stated as good. Reports no problems filling or taking
prescriptions. Other systems reviewed in detail and all
otherwise negative.
Past Medical History:
Long history of low back pain from cervical stenosis followed
for several years by [**First Name4 (NamePattern1) 392**]
[**Last Name (NamePattern1) 1194**] Center
Fibromyalgia
Degenerative joint disease
Anxiety
Depression
Type 2 diabetes
Previous plantar fascial release x 2
Previous CCY
Social History:
Is homeless. Has a 32 pack year smoking history and stopped 1
week ago. Rare etoh use.
Family History:
Her father also had chronic back pain.
Physical Exam:
Vital Signs: T 98.8, P 100, BP 140/82, 96% on 2LNC
Physical examination:
- Gen: Well-appearing in NAD.
- HEENT: Conj/sclera/lids normal, PERRL, EOM full no nystagmus.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: Regular rhythm. Normal S1, S2. No murmurs or gallops. No
ankle edema.
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
Liver/spleen not enlarged. Liver span 6cm.
- Rectal: Normal sensation.
- Skin: No lesions, bruises, rashes.
- Neuro: Alert, oriented x3. Good fund of knowledge. CN 2-12
intact. No involuntary movements, atrophy. Normal tone in all
extremities. Motor [**5-7**] in upper and lower extremities
bilaterally. Sensation to light touch intact in upper and lower
extremities bilaterally. Finger-to-nose normal. Gait not tested
due to pain. Pronator drift negative.
- Psych: Appearance, behavior, speech, and affect all normal.
On Discharge: Site of back surgery clean dry and intact with
stitches in place.
Pertinent Results:
Chemistries:
- [**2110-7-21**] 08:23PM LACTATE-1.0 GLUCOSE-116* UREA N-10
CREAT-0.4 SODIUM-139 POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-28
ANION GAP-11
Hematology:
- [**2110-7-21**] 05:15PM WBC-10.3 (NEUTS-74.6* LYMPHS-18.3
MONOS-4.3 EOS-2.5 BASOS-0.4) RBC-3.25* HGB-10.4* HCT-29.9*
MCV-92 MCH-32.0 MCHC-34.7 RDW-13.3 PLT COUNT-276
- [**2110-7-21**] 05:15PM SED RATE-108*
Coagulation Studies:
- [**2110-7-21**] 05:15PM PT-12.5 PTT-33.3 INR(PT)-1.0
Labs on Discharge:
[**2110-7-27**] 02:40PM BLOOD ESR-128*
[**2110-7-24**] 11:20AM BLOOD ESR-137*
[**2110-7-21**] 05:15PM BLOOD ESR-108*
[**2110-7-27**] 04:05AM BLOOD ALT-49* AST-28 AlkPhos-154* TotBili-0.1
[**2110-7-24**] 11:20AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE
[**2110-7-27**] 04:05AM BLOOD CRP-80.2*
[**2110-7-25**] 06:10AM BLOOD CRP-198.2*
[**2110-7-24**] 11:20AM BLOOD CRP-244.7*
[**2110-7-21**] 05:15PM BLOOD CRP-295.7*
[**2110-7-24**] 11:20AM BLOOD HIV Ab-NEGATIVE
[**2110-7-28**] 06:59AM BLOOD Vanco-17.8
[**2110-7-24**] 11:20AM BLOOD HCV Ab-NEGATIVE
[**2110-7-31**] 06:13AM BLOOD WBC-9.8 RBC-3.38* Hgb-10.8* Hct-31.5*
MCV-95 MCH-31.8 MCHC-33.4 RDW-13.7 Plt Ct-552*
[**2110-7-31**] 06:13AM BLOOD Glucose-128* UreaN-14 Creat-0.7 Na-139
K-4.5 Cl-100 HCO3-31 AnGap-13
[**2110-7-27**] 04:05AM BLOOD ALT-49* AST-28 AlkPhos-154* TotBili-0.1
[**2110-7-31**] 06:13AM BLOOD Vanco-35.8*
Pertinent Imaging:
LUMBAR SPINE, TWO VIEWS. No previous spine films are on PACS
record for
comparison.
On view #1, surgical marker is present and overlies the
posterior elements of the lower lumbar spine, likely overlying
the L5-S1 level. Additional surgical material is present.
On view #2, two surgical markers are present. One overlies the
posterior
elements at the presumptive L4 level and the other overlies the
posterior
elements at the presumptive lower S1 level near the S1/2 disc
space.
CXR: FINDINGS: Normal lung volumes, no pleural effusions. Normal
size of the cardiac silhouette, normal appearance of the lung
parenchyma without evidence of focal parenchymal opacities
suggesting infection.
Pathology Tissue report: Pending prior to discharge.
[**2110-7-31**] 06:13AM BLOOD WBC-9.8 RBC-3.38* Hgb-10.8* Hct-31.5*
MCV-95 MCH-31.8 MCHC-33.4 RDW-13.7 Plt Ct-552*
[**2110-7-31**] 06:13AM BLOOD Glucose-128* UreaN-14 Creat-0.7 Na-139
K-4.5 Cl-100 HCO3-31 AnGap-13
[**2110-7-27**] 04:05AM BLOOD ALT-49* AST-28 AlkPhos-154* TotBili-0.1
[**2110-7-31**] 06:13AM BLOOD Vanco-35.8*
Pathology of biopsy:
Tissue adherent to dura, right L5-S1 region, excision:
- Fragments of bone, fibrocartilage and fibrovascular
tissue.
- No significant acute inflammation identified.
- AFB, GMS and Gram stains are negative for
micro-organisms.
Brief Hospital Course:
Ms. [**Known lastname 109150**] presented with acute worsening of her chronic back
pain. The initial evaluation by our neurosurgery team is that
this is not consistent with an epidural abscess. Given her
elevated ESR, a complete infectious work-up was pursued but was
negative, and patient continued to be febrile. Due to high
suspicion for epidural abscess an attempt at CT guided biopsy
was made however the area was felt to be too small to be
accessible by IR guided biopsy. The decision was made to take
the patient to the OR for open laminectoy of L5-S1 and
washout/biopsy of the suspicious area. In OR pt was found to
have a phlegmon with purulent fluid. She was started on
Vancomycin/ceftazidime/Flagyl postoperatively. On POD #1 Flagyl
discontinued. Cultures from OR all NGTD. Ceftazidime
transitioned to Ceftriaxone on [**7-27**].
Inflammatory markers trended down post-operatively. Pathologic
exam pending at the time of discharge. Given high suspicion for
infectious etiology with fever, leukocytosis and markedly
elevated inflammatory markers, decision was made to treat
empricially with vancomycin and ceftriaxone for a planned [**6-10**]
week course. Will continue combination therapy due to high
suscpicion for P. acnes and CoNS given recent procedures on L
spine. While in the ICU her blood pressure was stable, but she
was tachycardic,and was on 3.5L oxygen and desatted to 91% with
a clear lung exam. Her urine and blood cultures were negative.
On the floor her O2 sat improved and patient was successfully
weaned off of oxygen. The drain and VAT dressing were removed
from the site of the operation. The patient continued to do well
on the floor. Pathology was unrevealing as to the organism of
infection without acute inflammation and with negative AFB, GMS
and gram stains. Blood cultures are all negative as well. She
was released to a facility for the management of her multiple IV
antibiotic infusions.
1. Back pain s/p epidural abscess drainag/laminectomy she will
continue on antibiotics for 6 weeks of Vancomycin likely 1G
every 8 hours and Ceftriaxone 1 g q24 hrs. Labs should be faxed
to the ID team as stated on discharge paperwork. She is due for
a Vancomycin trough at 7am on [**8-1**] before restarting Vancomycin.
Patient will need the following: Laboratory monitoring required:
Please check weekly CBC with differential, BUN/Cr, Vancomycin
trough, ESR and CRP. Please have these
results faxed to [**Hospital **] [**Hospital 4898**] Clinic at [**Telephone/Fax (1) 1419**] beginning [**8-8**].
- she will need stitches removed on [**8-1**] and has follow up
with Neurosurgery on [**8-21**]. She was transitioned to MS
Contin 15mg [**Hospital1 **] for pain control and was given ativan for
sciatica pain.
2. DM
- patient was covered with sliding scale while in hospital but
should return to metformin after discharge.
3. Depression - patient showed no acute signs of depression, and
was continued on Paxil.
4. Hyperlipidemia - continued simvastatin.
Medications on Admission:
Metformin 500mg daily
Simvastatin 10mg daily
ASA 81mg daily
Paxil 40mg daily
Motrin PRN
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for muscle cramps.
Disp:*20 Tablet(s)* Refills:*0*
5. Vancomycin 500 mg Recon Soln Sig: 1000mg Recon Solns
Intravenous Q 8H (Every 8 Hours): start in the morning of [**8-1**]
if trough <20.
6. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours).
7. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for pain: hold for sedation. Tablet(s)
9. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
14. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
15. Outpatient Lab Work
Laboratory monitoring required: Please check weekly CBC with
differential, BUN/Cr, Vancomycin trough, ESR and CRP starting
[**8-8**]. Please have results faxed to [**Hospital **] [**Hospital 4898**] Clinic at
[**Telephone/Fax (1) 1419**].
16. Outpatient Lab Work
Vancomycin trough, morning of [**8-1**] at 7am
Please have results faxed to [**Hospital **] [**Hospital 4898**] Clinic at [**Telephone/Fax (1) 1419**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Epidural Abscess.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance.
Discharge Instructions:
Dear Ms. [**Known lastname 109150**],
You have been admitted to this facility for the treatment of
your back pain, which was caused by the epidural abscess that
was discovered on your admission. Your abscess has been explored
by the neurosurgical team and you had a drain placed for several
days. Your fever has subsided since your admission and you were
treated with antibiotics intravenously since you were admitted.
The nature of your abscess necessitates that you continue to
take antibiotics for several weeks, and thus we have inserted an
intravenous line into your right arm so that these could be
administered to you.
Your stitches are to be removed on [**8-1**].
The following changes have been made to your medication:
Antibiotics to be administered through your PICC line:
CeftriaXONE 2 gm intravenously every 24 hours
Vancomycin should be restarted on [**8-1**] in the morning if trough
is less than 20. Result of lab should be faxed to ID fellow at
number below. Start at 1G every 8 hours for a goal trough at
15-20. Trough should be rechecked immediately prior to the 4th
dose of 1G. Laboratory monitoring required: Please check weekly
CBC with
differential, BUN/Cr, Vancomycin trough, ESR and CRP starting
[**8-8**]. Please have results faxed to [**Hospital **] [**Hospital 4898**] Clinic at
[**Telephone/Fax (1) 1419**].
Other:
HYDROmorphone (Dilaudid) 2 mg every 4 hours prn for pain
Morphine SR (MS Contin) 15 mg twice daily
Tylenol every 8 hours
Lorazepam as needed for muscle cramps
STOP:
Percocet
Followup Instructions:
You have the following follow-up appointments.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2110-8-12**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROSURGERY
When: THURSDAY [**2110-8-21**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2110-9-5**] at 10:30 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
Completed by:[**2110-7-31**]
|
[
"V60.0",
"300.4",
"729.1",
"564.00",
"272.4",
"250.00",
"324.1",
"799.02",
"721.3",
"518.0",
"794.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"38.93",
"83.09"
] |
icd9pcs
|
[
[
[]
]
] |
11148, 11221
|
6212, 9204
|
330, 390
|
11283, 11283
|
3469, 3928
|
12988, 14041
|
2378, 2418
|
9342, 11125
|
11242, 11262
|
9230, 9319
|
11442, 12965
|
2433, 2485
|
2507, 3369
|
3383, 3450
|
1563, 1947
|
277, 292
|
3948, 6189
|
418, 1544
|
11298, 11418
|
1969, 2258
|
2274, 2362
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,489
| 175,196
|
45616
|
Discharge summary
|
report
|
Admission Date: [**2160-5-31**] Discharge Date: [**2160-6-7**]
Date of Birth: [**2088-9-8**] Sex: F
Service: MEDICINE
Allergies:
Betalactams / Ceftriaxone
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
altered mental status
hypertensive emergency
Major Surgical or Invasive Procedure:
right internal jugular central venous line placement-[**2160-5-31**]
History of Present Illness:
Pt is a 71yoW resident at [**Hospital3 1186**], presenting with change
in mental status. On day prior to pres pt became increasingly
lethargic, c/o mild abdominal pain. Labs were checked and pt was
noted to have leukocytosis. She was started on flagyl and IV
fluids empirically for c. difficile colitis given recent
history. She became increasingly lethargic there and today BP
was elevated at 240/110. Nitropaste was applied and patient was
transferred to [**Hospital1 18**] ED.
.
In the [**Hospital1 18**] ED head CT was significant for acute occipital
bleed 9mm x 7mm. She was seen by the neurology and neurosurgery
services. The neurology service found her exam to be non focal
and felt that her encephalopathy was not related to the bleed.
They recommended blood pressure control, repeat CT head in 24
hours, and MRI head once pt could remain still.
.
She was afebrile in the ED but was given Vancomycin,
Ceftriaxone, and Acyclovir out of initial concern for
meningitis. Once CT finding of bleed, and renal function showing
slight worsening, it was felt that meningitis unlikely to be
cause of encephalopathy and so no LP was performed. She received
1L NS in ED.
.
ROS: Answers no - no CP, SOB, Abd pain
Past Medical History:
HTN
DM
CKD
-stage iv, recently primary nephrologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] has
been discussing starting HD
Hyperparathyroidism
Anemia
Glaucoma - legally blind
Depression - on remeron
hypothyroidism
MGUS
CAD
- nl dobutamine echo in [**2158**]
- cath in [**2148**] with LAD disease
Social History:
Ms. [**Known lastname **] is a widowed mother of 12 children aged 37-50. She has
more than 50 grandchildren. She currently lives at [**Location 1188**]
house. Before that she lived with her [**Location **] [**Name (NI) 38329**] [**Name (NI) **]
and [**Name (NI) 97278**] two children. She received home health care 5 times
per week and also had a visiting nurse. [**First Name (Titles) **] [**Last Name (Titles) **]
[**Name (NI) 97279**] [**Name (NI) **] takes care of Ms. [**Known lastname **] finances, and she seems
to trust her. Patient and daughter at bedside state that her
living situation has certainly contributed to her depressed
state and that she should not return there. According to Ms.
[**Known lastname **], her daughter [**Name (NI) 6744**] [**Known lastname **] [**Name (NI) **] is her health care proxy.
She has never smoked, does not drink alcohol, and has not used
drugs
Family History:
non-contributory
Physical Exam:
On admission:
98 138/80 80 RR 14 98%RA
Quiet, no unprompted speaking
Pupils sluggish but reactive and symmetric
OP clear, adentulous, dry mucous membranes
No JVD
No TM
No carotid bruits
RRR nl s1s2 no mrg
Lungs with decreased bs b/l, clear
Abd soft nt nd nabs
Rectal with good tone, guaiac negative v soft brown/green stool
Ext w/o edema, wwp
Neuro: AA, answers when asked name "[**Known firstname 2155**]", all other
questions answers yes/no only, CN 3-12 intact (blind), MAE but
not cooperating with strength exam, babinski downgoing, follows
simple commands
.
Pertinent Results:
Studies:
[**2160-5-31**] CXR: no acute cardiopulmonary process
.
.
[**2160-5-31**]: CT abdomen/pelvis:
IMPRESSION:
1. Intermediate density material in left colon, sigmoid, and
rectum, which, in the absence of oral contrast administration
reflects high density material such as calcium or even
hemorrhage. No bowel wall thickening or other findings to
suggest ischemia.
2. Soft tissue lesion seen in the rectum. Clinical correlation
is recommended.
3. Left hip destruction with fluid in the joint space as seen on
previous examinations.
4. Multiple renal cysts which are incompletely characterized on
this examination, however, they are similar to the exam of
[**2160-3-5**].
.
[**2160-5-31**] CT head: IMPRESSION:
1. Acute hemorrhage within the left occipital lobe. No evidence
of mass effect.
2. Unchanged appearance of infarct of the left occipital lobe
and unchanged appearance of small vessel disease.
Final Attending comment:
The above mentioned left sided acute bleed is in the temporal
lobe, a tiny right anterior thalamic acute hemorrhage is also
seen.Findings are likely due to hypertension.
.
4/1507 CT head repeat: IMPRESSION:
Interval decrease in size of small left posterior
temporal/occipital lobe intraparenchymal hemorrhage. Stable
right anterior thalamic tiny hyperdensity. No new lesions
identified.
.
[**2160-6-1**] EEG: IMPRESSION: This is an abnormal EEG due to the slow
and disorganized
background and the bursts of generalized slowing. This suggests
a mild
encephalopathy, which may be seen with infections, toxic
metabolic
abnormalities or medication effect. No epileptiform features
were
noted.
.
.
Labs:
Admission:
WBC-8.0# RBC-4.08* Hgb-12.6# Hct-36.0 MCV-88 MCH-30.8 MCHC-34.9
RDW-15.3 Plt Ct-245 Neuts-73.3* Lymphs-22.9 Monos-3.5 Eos-0.1
Baso-0.2
PT-12.2 PTT-26.4 INR(PT)-1.0
Glucose-99 UreaN-58* Creat-3.9* Na-139 K-5.2* Cl-106 HCO3-23
AnGap-15
ALT-19 AST-28 AlkPhos-62 Amylase-133* TotBili-0.5 Lipase-43
Albumin-4.3 Calcium-12.7* Phos-5.3* Mg-3.2* freeCa-1.59*
.
Lactate-1.9
.
[**2160-6-1**] 01:20AM BLOOD CK(CPK)-24*
[**2160-6-1**] 07:55AM BLOOD CK(CPK)-24*
[**2160-6-1**] 01:20AM BLOOD CK-MB-3 cTropnT-0.10*
[**2160-6-1**] 07:55AM BLOOD CK-MB-NotDone cTropnT-0.08*
.
TSH-0.94 PTH-206*
Blood Osmolal-311*
.
SPEP-ABNORMAL B IgG-2075* IgA-209 IgM-43
.
BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
.
Discharge labs:
WBC-5.5 RBC-3.11* Hgb-9.1* Hct-28.1* MCV-90 MCH-29.4 MCHC-32.5
RDW-15.2 Plt Ct-189
.
Glucose-101 UreaN-34* Creat-3.3* Na-142 K-4.0 Cl-115* HCO3-21*
Calcium-9.9 Phos-4.4 Mg-2.1
.
.
[**2160-5-31**] 05:50PM
[**2160-6-1**] 01:28AM BLOOD
.
.
MICRO:.
.
[**2160-6-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-negative
[**2160-5-31**] Blood cultures x2 sets negative
[**2160-5-31**] URINE URINE CULTURE-negative
Brief Hospital Course:
Ms. [**Known lastname **] is a 71 year old female with who presented to the ED
from rehab with a change in mental status in setting of
hypertensive emergency, intracranial bleed, acute on chronic
renal insufficiency, hypercalcemia. She was admitted to the MICU
for inital care to control her blood pressure and monitor her
mental status. She was then transferred to the medical floor
once her blood pressure was better controlled. Her hospital
course is described below by problem.
.
### Change in mental status: Multifactorial including
hypertensive encephalopathy, mild worsening of renal failure,
possible c. difficile colitis, intracranial bleed, and
hypercalcemia. Her mental status returned to baseline with
treatment of hypercalcemia and hypertension. (see below). She
was then transferred from the MICU to the regular medical floor.
.
### Occipital intracranial hemorrhage: A 9mm ICH was seen on her
original CT head on presentation to the ED. Two consults were
obtained, neurology and neurosurg, both teams felt there was no
indication for surgery as the bleed was very small. Her SBP
goal was 130-160 given the bleed. A subsequent CT of the head
showed a slightly smaller area of bleed suggesting resolution.
.
### Hypertension: Her systolic blood pressure was initially 240.
She was started on a labetolol drip initally, and then
transitioned to oral agents including metoprolol, isosorbide
moninitrate, clonidine and hydralazine. The doses were titrated
upwards to achieve optimal control. Upon discharge her blood
pressure was within the 130-160 range. The doses can be
confirmed on her medication list.
.
### Acute Renal Failure: On presentation, she had only slightly
decreased GFR from baseline, and her urine lytes were consistent
with a pre-renal picture. Renal was consulted and felt that her
initial presentation was unlikely purely uremic encephalopathy.
There was no indication for urgent hemodyalisis. Her Cr
returned to baseline at discharge (~3.3) and she was making
adequate urine. She was treated with sevelamer (no calcium
acetate given her hypercalcemia) to control her phosphate
levels. She was started on sodium bicarb given her acidosis
which was thought to be attributed to her chronic renal
insufficiency. She has a follow up appointment with Dr. [**Last Name (STitle) **],
her outpatient nephrologist, in [**2160-6-17**].
.
### Hypercalcemia: Her hypercalcemia was likely secondary to
tertiary hyperparathyroidism compounded by her renal
insufficiency (her PTH was elevated in the 200's). An SPEP was
sent which was positive for monoclonal antibodies consistent
with her history of MGUS. She was treated with IVF (NS) and
furosemide and her calcium returned to [**Location 213**] range. She was
also given cinacalcet.
.
### Anemia: likely secondary to her chronic renal failure. She
was on aranesp as an outpatient was treated with epogen while an
inpatient. She was also continued on her iron supplementation.
Her HCT was stable at baseline in the low 30's.
.
### Possible C difficile colitis: She had a recent history of C.
diff and was complaining of abdminal pain at the rehab center.
They empirically started her on metronidazole and it was
continued in house. The final date of treatment should be
[**2160-6-14**] for a total 14 day course.
.
### Diabetes: Uncontrolled insulin dependent diabetes. She was
continued on an insulin sliding scale and her blood sugars were
fairly well controlled in house.
.
### Depression: Her mirtazapine was originally held but was then
restarted after she was out of the MICU and on the medicine
wards.
.
### Hypothyroidism: Continued on levothyroxine 50mcg daily
.
### FEN: She had a speech and swallow consult which showed she
did not aspirate despite her lack of teeth. She should continue
to eat a cardiac/diabetic diet and have sugar free shake
supplements with meals (TID).
TO DO:
please have labs checked on Monday [**2160-6-9**] including CBC,
sodium, potassium, chloride, bicarb, BUN, Cr, calcium,
magnesium, phosphorous, glucose.
Medications on Admission:
MVI
Levothyroxine
isosorbide
Rememeron
Metoprolol
Clonidine
Aranesp
insulin
Flagyl - started past few days
Discharge Medications:
1. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days: Last day of treatment is [**2160-6-14**].
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
8. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Aranesp Injection
17. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale Subcutaneous ASDIR (AS DIRECTED).
18. Outpatient Lab Work
please have labs checked on Monday [**2160-6-9**] including CBC,
sodium, potassium, chloride, bicarb, BUN, Cr, calcium,
magnesium, phosphorous, glucose.
19. finger sticks
Please check finger sticks for blood glucose before meals and at
bedtime. Use insulin sliding scale for correction.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis:
hypertensive emergency
intracranial hemorrhage -small in the occipital lobe
chronic renal insufficiency
Hypercalcemia
.
Secondary diagnosis:
anemia
diabetes type 2
CAD
hypothyroidism
Hyperparathyroidism
Glaucoma - legally blind
Depression
MGUS
Discharge Condition:
stable. normotensive.
Discharge Instructions:
You were admitted with an altered mental status and were found
to have very high blood pressure and a very small bleed in your
brain. You were admitted to the medical intensive care unit and
were given medicines to help your blood pressure.
.
Your blood pressure medicine doses have been changed. Please see
the medication list for the new medications and doses.
.
You should have your blood pressure checked at least once a day
to ensure it is below 160/90. If it is higher, please contact
your physician.
.
You are being treated for C.diff infection empirically. The last
day of treatment is [**2160-6-14**]. Please continue to take
metronidazole antibiotic as prescribed until then.
.
Please have labs checked on Monday [**2160-6-9**] including CBC,
sodium, potassium, chloride, bicarb, BUN, Cr, calcium,
magnesium, phosphorous, glucose.
.
Please call your PCP or go to the emergency room if you have
fevers >101, chills, shortness of breath, chest pain, altered
mental status, or any other symptoms which are concerning to
you.
Followup Instructions:
You should follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. We were unable to
make an appointment for you since it is the weekend. Please call
[**Telephone/Fax (1) 608**] to schedule an appointment. You will need to have
your creatinine and other labs drawn early next week.
.
The following appointments were in the computer and are listed
below as a reminder for you:
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2160-6-18**] 9:30
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2160-7-1**] 11:15
.
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2160-7-17**] 10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
Completed by:[**2160-6-8**]
|
[
"403.01",
"008.45",
"252.08",
"584.9",
"431",
"244.9",
"250.00",
"437.2",
"311",
"585.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12257, 12330
|
6357, 6855
|
329, 400
|
12637, 12661
|
3536, 4230
|
13742, 14721
|
2917, 2935
|
10545, 12234
|
12351, 12351
|
10413, 10522
|
12685, 13719
|
5919, 6334
|
2950, 2950
|
245, 291
|
429, 1640
|
4239, 5903
|
12511, 12616
|
12370, 12490
|
2965, 3517
|
6870, 10387
|
1662, 1991
|
2007, 2901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,784
| 106,004
|
1833
|
Discharge summary
|
report
|
Admission Date: [**2115-12-28**] Discharge Date: [**2115-12-31**]
Date of Birth: [**2036-1-27**] Sex: M
Service: MEDICINE
Allergies:
Allopurinol / Aspirin / Lopressor
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
HPI: 79M complicated medical history including cirrhosis with
history of multiple episodes of hepatic encephalopathy,
discharged 2 days PTA after being treated for hepatic
encephalopathy thought to be due to poor dietary compliance,
admitted with lethargy. Pt was home, when he reports feeling
weak and dizzy. On last hospitalization, abdominal u/s showed
hypoechoic liver lesion requiring further workup, CT since
unable to have MRI. In [**Name (NI) **], pt had 1 recorded rectal temp of
100.8, but was afebrile otherwise. He reported an episode of R
sided chest pain, which he reported to the ED team as being old.
There was no obvious evidence in his history of recent
hemorrhage, although he had a decrease in Hct in the ED.
Past Medical History:
1. Cryptogenic cirrhosis likely NASH.
2. CHF with an EF of 35% from [**2112**].
3. CAD status post stent x2.
4. AFib status post DDD pacer.
5. Hypertension.
6. history of CVA.
5. Diabetes, HbA1c [**6-23**]: 6.5
6. history of confusion, multiple admissions for hepatic
encephalopathy
7. history of multiple UTIs
8. history of pancytopenia.
9. Eosinophilic syndrome
10. Iron deficiency anemia, known trace pos stools.
11. Upper GI bleed.
12. Diverticulosis, grade II internal hemmorroids (cscope [**2110**])
13. Chronic renal insufficiency 1.2-1.6 at baseline.
14. s/p Left Total knee replacement
15. history of Gout
Social History:
Lives with his wife; daughter and son-in-law assist them. Worked
for the City of [**Location (un) **]. Was in the Army for 21 years. Denies
past or present tobacco usedenies alcohol consumptiondenies IV
drug use.
Family History:
His father with a MI at age 60. Two brothers with [**Name2 (NI) **] and
diabetes.
Physical Exam:
V: T: 97.0 HR 86 BP 96/43 R 17 Sat 99% RA
*
PE: G: NAD, somnolent, but responds to questions
HEENT: Dry MM
Lungs: BS BL, Occ crackles, no W/R
CV: Irregluar RR, S1S2, No MRG
Abd: Soft, Nt, ND, BS+
Ext: 0-1+ edema
Neuro: minimal asterixis, no gross focal deficits
Pertinent Results:
[**2115-12-31**] 06:30AM BLOOD WBC-3.2* RBC-3.36* Hgb-10.5* Hct-29.1*
MCV-87 MCH-31.3 MCHC-36.1* RDW-15.6* Plt Ct-138*
[**2115-12-27**] 11:44PM BLOOD WBC-6.9 RBC-3.77* Hgb-11.7* Hct-31.9*
MCV-85 MCH-31.0 MCHC-36.7* RDW-15.3 Plt Ct-149*
[**2115-12-31**] 06:30AM BLOOD Plt Ct-138*
[**2115-12-31**] 06:30AM BLOOD PT-18.2* PTT-34.6 INR(PT)-2.1
[**2115-12-27**] 11:44PM BLOOD Plt Ct-149*
[**2115-12-27**] 11:44PM BLOOD PT-22.9* PTT-43.9* INR(PT)-3.3
[**2115-12-31**] 06:30AM BLOOD Glucose-205* UreaN-18 Creat-1.0 Na-140
K-4.2 Cl-111* HCO3-22 AnGap-11
[**2115-12-27**] 11:44PM BLOOD Glucose-235* UreaN-67* Creat-2.5*# Na-134
K-4.4 Cl-101 HCO3-20* AnGap-17
[**2115-12-27**] 11:44PM BLOOD ALT-25 AST-31 CK(CPK)-225* AlkPhos-109
Amylase-33 TotBili-1.6*
[**2115-12-30**] 06:15AM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.4*
Mg-1.8
[**2115-12-28**] 09:50AM BLOOD Calcium-7.4* Phos-2.4* Mg-1.9
[**2115-12-29**] 03:53AM BLOOD Ammonia-79*
[**2115-12-28**] 11:05AM BLOOD Cortsol-33.7*
[**2115-12-28**] 10:35AM BLOOD Cortsol-26.4*
[**2115-12-28**] 03:38AM BLOOD Type-MIX pO2-45* pCO2-31* pH-7.43
calHCO3-21 Base XS--2 Intubat-NOT INTUBA Comment-GREEN TOP
Abdominal U/S - No ascites
CXR - negative
Echo - IMPRESSION: Mild symmetric left ventricular hypertrophy
with good basal
systolic function. ?distal septal/anterior hypokinesis. Mild
mitral
regurgitation.
Based on [**2107**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a moderate risk (prophylaxis recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
Discharge labs:
[**2115-12-31**] 06:30AM BLOOD WBC-3.2* RBC-3.36* Hgb-10.5* Hct-29.1*
MCV-87 MCH-31.3 MCHC-36.1* RDW-15.6* Plt Ct-138*
[**2115-12-27**] 11:44PM BLOOD Neuts-80.2* Lymphs-12.3* Monos-6.0
Eos-1.3 Baso-0.2
[**2115-12-31**] 06:30AM BLOOD Plt Ct-138*
[**2115-12-31**] 06:30AM BLOOD PT-18.2* PTT-34.6 INR(PT)-2.1
[**2115-12-28**] 09:50AM BLOOD Fibrino-587*#
[**2115-12-28**] 09:50AM BLOOD Ret Aut-1.8
[**2115-12-31**] 06:30AM BLOOD Glucose-205* UreaN-18 Creat-1.0 Na-140
K-4.2 Cl-111* HCO3-22 AnGap-11
[**2115-12-30**] 06:15AM BLOOD ALT-27 AST-30 AlkPhos-101
[**2115-12-29**] 03:53AM BLOOD CK(CPK)-91
[**2115-12-28**] 11:05AM BLOOD LD(LDH)-169 TotBili-0.9
[**2115-12-29**] 03:53AM BLOOD CK-MB-4 cTropnT-0.02*
[**2115-12-30**] 06:15AM BLOOD Albumin-3.1* Calcium-8.3* Phos-2.4*
Mg-1.8
[**2115-12-28**] 11:05AM BLOOD Hapto-106
[**2115-12-29**] 03:53AM BLOOD Ammonia-79*
Brief Hospital Course:
1. Hypotension: 79M with a history of Cirrhosis, with multiple
episodes of hepatic encephalopathy the most recent of which was
2 days prior to admission, admitted with somnolence and
lethargy, elevated ammonia. He was started on MUST protocol for
sepsis, it was also felt that he was likely hypovolemic. There
was no evidence of ascites on an U/S performed 4 days prior to
admission. He had no infiltrate on CXR. Based upon no apparent
evidence of infection, antibiotics were not given. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim
test was performed which showed normal funciton. Blood
cultures, urine cultures were drawn. Initially he was started
on Levophed drip for hyptension. He was treated aggressively
with Lactulose until he stooled. His BP recovered rapidly as
did his mental status. Once he was normotensive and no longer
confused he was transfered to the floor. On the floor his diet
was advanced slowly and Lactulose was continued. He did well
and had no further episodes of confusion or hypotension. He was
discharged home on Lactulose.
2. Hepatic encephalopathy/MS: He has a history of poor dietary
compliance. He was started on Lactulose Q2H until he had
multiple large BMs in the ICU. An Ultrasound was performed
which showed no ascites to tap. His mental status cleared and
he was transferred out of the ICU. While on the floor an EGD
was performed to evaluate for varices, this showed grade 1 varix
+ nodule.
3. Decr HCT: His admission HCT was low it was followed closely.
*
4. ARF: He was treated with IV fluids for his acute renal
failure. His creatinine resolved to 1.0 prior to discharge.
*
5. Afib: His INR was supratherapeutic on admission, Coumadin was
held and restarted
Medications on Admission:
Meds:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,TH,FR,SA).
9. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO 2X/WEEK
([**Doctor First Name **],WE).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO twice a
day.
Disp:*1080 ML(s)* Refills:*0*
11. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
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).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
4. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please resume INR checks as per your routine. First INR should
be checked no later than [**1-2**].
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Lisinopril 10 mg Tablet Sig: 0.5 Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
hypotension
hepatic encephalopathy
Discharge Condition:
good!
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 L
You have been evaluated for low blood pressure, dehydration and
confusion from your liver disease.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2116-2-6**] 3:30
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2116-2-6**] 3:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 9119**] [**Name12 (NameIs) 9120**] MEDICINE (PRIVATE) Where: ADULT
MEDICINE UNIT [**Hospital3 **] HEALTHCARE - 1000 [**Location (un) **] - [**Location (un) 2352**],
[**Numeric Identifier 9121**] Phone:[**Pager number **] Date/Time:[**2116-2-5**] 4:30
|
[
"710.5",
"250.00",
"428.0",
"456.21",
"V45.01",
"456.8",
"593.9",
"427.31",
"571.5",
"280.9",
"414.01",
"572.2",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
8341, 8390
|
4858, 6602
|
304, 310
|
8469, 8476
|
2369, 3958
|
8746, 9397
|
1959, 2043
|
7586, 8318
|
8411, 8448
|
6628, 7563
|
8500, 8723
|
3974, 4835
|
2058, 2350
|
256, 266
|
338, 1074
|
1096, 1713
|
1729, 1943
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,165
| 123,397
|
48280+48281+48282
|
Discharge summary
|
report+report+report
|
Admission Date: [**2117-11-18**] Discharge Date: [**2117-11-19**]
Date of Birth: [**2053-4-14**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lactose / vancomycin
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Hypotension and diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64 y.o. female s/p liver transplant on immunosuppression
(cellcept/prograf/pred), AF, atypical Aflutter s/p isthmus line
and PVI [**8-/2117**], hypertrophic cardiomyopathy currently on
disopyramide 300 mg [**Hospital1 **] and toprol XL 50 mg daily for her atrial
fibrillation, presented with gastroenteritis to OSH, got
Vanc/Zosyn/steroid and transferred to [**Hospital1 18**] for further
managment. Patient reports she has been feeling ill for the
past 2-3 days, however today became quite nauseous and vomiting
4 times, and had 4 episodes of profuse watery diarrhea. The
patient also report feverish with significant chills. EMS was
called, and upon EMS arrival the patient was noted to be mildly
cyanotic; fingerstick blood sugar was notably low at 45. The
patient received one amp IV dextrose during transport to
[**Hospital1 **]-[**Location (un) 620**] ED. She was given empiric antibiotics,
zosyn/vancomycin and stress dose steroids 100 mg hydrocortisone
for a borderline blood pressure at OSH, gave 1500cc. A chest
x-ray was done without evidence of pneumonia. Blood cultures
was drawn, UA was negative. Labs were notable for 2 of bands,
Alk Phos of 155, ALT 50, AST 42, Cr 1.1, INR of 3.6. She was
tranferred to [**Hospital1 18**] for further managment.
.
On arrival to [**Hospital1 18**], initial vital signs 99.8 74 97/64 20 100%
2L, did not take metoprolol today. Exam was notable for guaiac
negative, belly is non-tender, mild crackle at bases. Labs was
notable for K of 3.1, HCO3 of 19, AG=8, Ca of 6.5, phos of 1.3,
Mg 1.1. She received 3 L of normal saline and feels much
improved. However, she went into afib with RVR (bp was in the
90s). She was seen by cardiology in ED. She recieved
Diltiazem, Amiodarone (briefly then off per cardiology recs),
Propranolol (3mg), Acetaminophen (febrile 101), Mg and K are
being repleted, got Metoprolol ER prior to transfer. Vitals
prior to transfer, 110's, 91/56, 16, 91% RA.
Access: 18, 20x2.
Total IVF: 4.5L.
CXR: notable for pulmonary edema [**1-20**] to fluid resus.
.
Of note, On [**10-20**], she left low extremity cellulitis, which she
underwent Clindamycin 300 mg capsule q.i.d. x7 days. The
cellulitis improved. On [**10-28**], she had a colonoscopy for which
she held her [**Month/Year (2) **] for 5 days. On [**11-16**], Lifewatch
transmission around 1 am revealed atrial fibrillation with HRs
in 70s-150s as well as monomorphic NSVT at rates of 130-150 up
to 5 beats. Patient notes awakening from sleep with symptoms of
palpitations (fast, irregular heartbeat) but denied any chest
pain, SOB, LH, dizziness, or other symptoms. She had no had any
symptoms of AF since [**7-/2117**] when she was admitted to the
hospital for dehydration. She has not missed any medications.
Symptoms lasted less than an hour. Currently, she is at work and
feeling fine. Dr. [**Last Name (STitle) **] was made aware. Plan was to
continue disopyramide unchanged and increase Toprol XL to 50 mg
daily.
.
On the floor, she appears comfortable, converted to sinus on her
own.
Past Medical History:
1. CARDIAC RISK FACTORS: + Hypertension
2. CARDIAC HISTORY:
- Persistent atrial fibrillation, initially treated with
disopyramide and subsequently with amiodarone, atenolol, and
dofetilide all unsuccessful in restoring or maintaining sinus
rhythm. She is status post pulmonary vein isolation in [**8-/2117**]
and currently back on disopyramide and metoprolol.
- Atypical atrial flutter developed after PVI status post
successful cavotricuspid isthmus ablation in 10/[**2115**].
- Hypertrophic cardiomyopathy, last MRI in [**2115**] showed
hypertrophy confined to the distal third and true apex portions
of the left ventricle with an ejection fraction greater than
70%.
- Ascending aortic aneurysm, 4.2 x 4.3 cm in [**3-28**]
.
3. OTHER PAST MEDICAL HISTORY:
Liver transplant [**2095**], [**1-20**] primary biliary cirrhosis (vs.
atresia-- records contradict)
Thyroid colloid cyst
Stable Lung nodules
Rosacea
Retroperitoneal adenopathy
Skin cancer
Raynaud's syndrome
Cellulitis of thumb and left lower extremity
Keratosis on Left LE which has tract
Hernia repair
Portal shunt
C-section
Social History:
distant smoker; denies ETOH and IVDU; married with two sons;
elementary school social worker
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
3 maternal uncles: one CABG and two bypass surgerys
Physical Exam:
Admission exam:
VS: temp: 98.9 HR 61, BP 73/46 RR 16 Sat 100 2L.
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate, though very tired and drifting in and out.
HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm, no carotid bruits appreciated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular slow rhythm, normal S1, S2. II/VI systolic murmur
heard loudest at the axilla. No thrills, lifts. No S3 or S4
appreciated.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, mild
crackles at basis.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits
appreciated. Umbilical hernia of [**12-20**] cm.
EXTREMITIES: No c/c/e; no femoral bruits on either side.
PULSES: Right: Carotid 2+ DP 2+ PT by doppler
Left: Carotid 2+ DP 2+ PT by doppler
Discharge exam: Unchanged from above except as below:
GENERAL: A&Ox3, awake, NAD
Pertinent Results:
Admission labs:
[**2117-11-18**] 01:30AM BLOOD WBC-6.5 RBC-4.76 Hgb-14.5 Hct-44.2 MCV-93
MCH-30.4 MCHC-32.8 RDW-13.6 Plt Ct-88*
[**2117-11-18**] 01:30AM BLOOD Neuts-89.1* Bands-0 Lymphs-8.4* Monos-2.0
Eos-0.2 Baso-0.3
[**2117-11-18**] 05:18AM BLOOD PT-37.1* PTT-44.4* INR(PT)-3.6*
[**2117-11-18**] 01:30AM BLOOD Glucose-126* UreaN-19 Creat-0.7 Na-142
K-3.1* Cl-115* HCO3-19* AnGap-11
[**2117-11-18**] 05:18AM BLOOD ALT-19 AST-26 CK(CPK)-81 AlkPhos-70
TotBili-0.7
[**2117-11-18**] 01:30AM BLOOD cTropnT-<0.01 proBNP-431*
[**2117-11-18**] 05:18AM BLOOD CK-MB-3 cTropnT-<0.01
[**2117-11-18**] 01:30AM BLOOD Calcium-6.5* Phos-1.3*# Mg-1.1*
Imaging:
-CXR ([**2117-11-18**]) - Moderate pulmonary edema, new from [**2116-9-21**]
exam.
TTE ([**2117-11-18**]) - The left atrium is dilated. There is mild
symmetric left ventricular hypertrophy. There is isolated apical
left ventricular hypertrophy as well ([**Last Name (un) 51827**] variant
hypertrophic cardiomyopathy). Left ventricular systolic function
is hyperdynamic (EF 75%). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Discharge labs:
[**2117-11-19**] 06:05AM BLOOD WBC-5.1 RBC-4.77 Hgb-14.4 Hct-44.8 MCV-94
MCH-30.2 MCHC-32.1 RDW-13.6 Plt Ct-113*
[**2117-11-19**] 06:05AM BLOOD PT-34.2* PTT-42.1* INR(PT)-3.3*
[**2117-11-19**] 06:05AM BLOOD Glucose-154* UreaN-11 Creat-0.7 Na-140
K-4.0 Cl-108 HCO3-27 AnGap-9
[**2117-11-19**] 06:05AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.6
Brief Hospital Course:
64 y.o. female s/p liver transplant on immunosuppression
(cellcept/prograf/pred), AF, atypical Aflutter s/p isthmus line
and PVI [**8-/2117**], hypertrophic cardiomyopathy currently on
disopyramide 300 mg [**Hospital1 **] and toprol XL 50 mg daily for her atrial
fibrillation, presented with gastroenteritis to OSH, got
Vanc/Zosyn/steroid and transferred to [**Hospital1 18**] for further
managment. At [**Hospital1 18**], she went into Afib with RVR which was
controlled with dilt and BB
#Atrial fibrillation - Upon arrival to the [**Hospital1 18**] ED at transfer,
she was found to be in AFib with RVR. The 4-5 liters of fluid
she received prior to admission likely contributed to her AF due
to atrial stretch. She received metoprolol prior to transfer
and at [**Hospital1 18**], she got diltiazem when she spopntaneously
converted to NSR. HR remained well controlled during admission.
Her INR was supratherapeutic and warfarin was held during this
admission. At discharge, she has been instructed to hold
warfarin and follow-up in the [**Hospital1 18**]-[**Location (un) 620**] [**Hospital 3052**] on [**11-22**].
#Hypotension - Systolic BP was in the 90s at admission. This
was thought to be caused by her tachyarrhythmia while she was in
AF with RVR. She was briefly on phenylepherine which was weaned
when she converted back to NSR. There was also initially
concern for sepsis from a GI source given that she was
complaining of diarrhea, nausea and vomiting. She initially
received a dose of vanc/Zosyn which was then switched to
Cipro/Flagyl when her BP improved. Finally, we also considered
adrenal insufficiency in the setting of gastroenteritis as a
potential cause given that she is on chronic prednisone. She
was treated with stress dose steroids, hydrocortisone 100mg q8h,
which was converted to a prednisone taper at discharge.
#Diarrhea - She was thought to have a gastroenteritis with
concern for sepsis, as mentioned above. She continued to have
diarrhea during admission and was mildly guaiac positive with no
gross blood in stool. Hematocrit remained stable. This
suggests a hemorrhagic GI infection such as Yersinia,
Salmonella, of EHEC. Stool studies are pending at the time of
discharge. She will contine Cipro/Flagyl for a total of 7 days
as above.
#Hypertrophic cardiomyopathy - Pt has known diagnosis of HCM.
TTE during this admission showed hyperdynamic EF of 75% with
[**Last Name (un) 51827**] variant hypertrophic cardiomyopathy.
#S/p liver transplant - LFTs were at baseline and she did not
have any RUQ pain at admission. She was continued on her home
doses of tacro/cellcept and was given stress dose steroids with
a prednisone taper at discharge.
#Hypertension - She was hypotensive at admission and her home BP
meds were held. At discharge, she was restarted on lisinopril
but spirinolactone was held until she follows up with her PCP.
#Thrombocytopenia - Plt were approx 100 at admission, some of
which may have been dilutional from the fluid she received prior
to transfer. She may also be thrombocytopenic because of her
liver transplant. She had no evidence of bleeding during
admission.
#Pump/coronaries - No history of CAD and she did not have any
chest pain at presentation. There was no concern for ACS.
#Code status during this admission - FULL
#Transitional issues:
-Cipro and flagyl for 5 days after discharge (total 7 day
course)
-Prednisone taper as outlined in discharge paperwork
-Follow-up stool studies
-Follow-up blood cultures
Medications on Admission:
DISOPYRAMIDE 300mg by mouth twice a day
LISINOPRIL 5 mg by mouth once a day
METOPROLOL SUCCINATE 50 mg Tablet ER by mouth once a day
mycophenolate mofetil [CellCept] 1000 mg Tablet twice a day
PREDNISONE 5 mg by mouth qam
SPIRONOLACTONE 25 mg Tablet by mouth once a day
TACROLIMUS [PROGRAF] 1 mg Capsule by mouth b.i.d.
WARFARIN 4mg by mouth daily as per [**Last Name (un) **] clinic.
ZOLPIDEM 5 mg Tablet by mouth at bedtime prn
CALCIUM CARBONATE 400 mg by mouth twice a day
DOCUSATE SODIUM 100 mg by mouth twice a day as needed for PRN
HYDROCOLLOID DRESSING 2" X 2" Bandage - apply to wound daily
RANITIDINE HCL 150 mg Tablet by mouth twice a day
Discharge Medications:
1. disopyramide 150 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO Q12H (every 12 hours).
2. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
7. calcium carbonate 400 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day.
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
11. prednisone 10 mg Tablet Sig: taper, as below Tablet PO once
a day: [**11-20**] to [**11-22**] - 40mg
[**11-23**] to [**11-25**] - 30mg
[**11-26**] to [**11-28**] - 20mg
[**11-29**] to [**12-1**] - 10mg
Starting on [**12-2**], continue 5mg daily.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Atrial fibrillation with rapid ventricular response
Gastroenteritis
Secondary diagnoses:
Liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 101707**],
It was a pleasure taking care of you during your admission to
[**Hospital1 18**] for low blood pressure and rapid heart rate. You were in
atrial fibrillation with a fast heart rate when you arrived. We
gave you medications to slow the heart rate and you
spontaneously converted to a normal heart rhythm. You briefly
received medications to raise your blood pressure, called
pressors. We have stopped your spironolactone, please discuss
with your cardiologist or PCP about when to restart this.
For your diarrhea, we started you on antibiotics, Cipro and
Flagyl which you will continue for a total of 7 days. Please
make sure you are drinking enough liquid if you continue to have
diarrhea after leaving the hospital. We have tests pending to
see what was causing the diarrhea, you PCP can follow up these
tests.
Your INR was elevated on the day of discharge. You should have
your INR checked at the [**Hospital1 18**]-[**Location (un) 620**] coagulation clinic on
Monday [**11-22**]. Please do not take [**Month/Day (1) 197**] again until you have
your INR checked.
The following changes were made to your medications:
START Ciprofloxacin 750mg by mouth twice daily for 5 more days
START Flagyl 500mg by mouth every 8 hours for 5 more days
STOP [**Month/Day (1) 197**] until your INR is checked and you talk to your PCP
STOP docusate while you are having diarrhea
STOP spironolactone until you discuss with your PCP or
cardiologist
CHANGE prednisone to a taper as below:
[**11-20**] to [**11-22**] - 40mg
[**11-23**] to [**11-25**] - 30mg
[**11-26**] to [**11-28**] - 20mg
[**11-29**] to [**12-1**] - 10mg
Starting on [**12-2**], continue 5mg daily
Followup Instructions:
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: TUESDAY [**2117-11-23**] at 2:00 PM
With: [**First Name8 (NamePattern2) 3679**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
*This is a follow up appointment of your hospitalization. You
will be reconnected with your primary care provider after this
visit.
Department: CARDIAC SERVICES
When: TUESDAY [**2117-12-7**] at 10:00 AM
With: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Admission Date: [**2117-11-24**] Discharge Date: [**2117-11-26**]
Date of Birth: [**2053-4-14**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lactose
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Abnormal rhythm on outpatient cardiac event monitoring
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 64 year-old Female with a PMH significant for
persistent atrial fibrillation (treated with Disopyramide and
Metoprolol currently; previously on other anti-arrhythmics who
underwent PVI in [**8-/2117**]), atypical atrial flutter (s/p
cavotricuspid isthmus ablation in [**9-/2116**]), hypertrophic
cardiomyopathy, ascending aortic aneurysm, primary biliary
cirrhosis s/p liver transplantation in [**2095**] (on chronic
immune-suppression) who presents with abnormal rhythm strip
while being monitored from home via an event monitor. On
monitoring, her ventricular rate appeared to be in the 120-130s
with runs of a wide-complex tachycardia (ventricular tachycardia
vs. atrial fibrillation with aberrancy).
.
Of note, the patient had a recent CCU from [**2117-11-18**] to [**2117-11-19**]
after she presented to an outside hospital with concerns for
gastroenteritis and hypotension to the 80-90s systolic range;
which was empirically treated with Vancomycin, Zosyn and stress
dose IV steroids who was transferred to the [**Hospital1 18**] ED for further
management. On arrival, her GI losses were treated with IV
fluids and in the ED she developed atrial fibrillation with
rapid ventricular response to the 110s which was treated with
Diltiazem, Amiodarone and Metoprolol. She did spontaneously
revert to normal sinus rhythm following these medications. She
required CCU admission and Phenylephrine gtt for maintenance of
her tenuous blood pressure. She improved quickly, with
resolution of her GI symptoms and improvement of her blood
pressure off pressor support. Disopyramide 300 mg PO Q12 hours
and Metoprolol succinate 50 mg XL PO daily were continued for
rate and rhythm control. She was discharged on a 5-day course of
Ciprofloxacin and Flagyl for her presumed acute diarrheal
illness. She also had a supratherapeutic INR of 3.3 on
discharge, and her [**Hospital1 197**] was held and monitored closely. She
was discharged on [**2117-11-19**] in stable condition.
.
In the time since discharge, she has continued to feel
"sluggish." She continued taking Cipro and Flagyl as prescribed
and has continued to have 4-5 episodes of diarrhea per day,
which is unchanged from discharge. She has also been continuing
her prednisone taper.
.
Today, she felt that she was reverting back to atrial
fibrillation, when this happens she feels a pain which is hard
for her to characterize, but is described as a dull pain in both
her shoulders. She had activated her Life Watch device which
transmitted her current rhythm to the monitoring center. She
received a call from Dr.[**Name (NI) 7914**] office which noted the
wide complex tachycardia and asked her to come to [**Hospital1 18**]. She
was initially going to drive herself, but she was concerd that
she began to feel anxious, cold and had tingling in her hands.
She also reported that she could not easily palpate her radial
pulse. This concerned her and she called EMS who brought her to
[**Hospital **] Hospital with subsequent transfer to [**Hospital1 18**].
.
At [**Hospital **] hospital, she was in Afib with ventricular rate in
140s and received 2.5mg IV metoprolol. By report, she also
received amiodarone 150mg and the patient reported feeling
better after this. She was transferred to the [**Hospital1 18**] ED. She
was admitted to the CCU for further monitoring.
.
On arrival to the CCU, she is feeling well with no complaints.
She was in NSR with frequent PACs. Cardiac review of systems is
notable for absence of chest pain, dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or pre-syncope.
.
ROS: The patient denies a history of prior stroke/TIA, deep
venous thrombosis or pulmonary embolus. They deny bleeding at
the time of prior procedures or surgeries. Denies headaches or
vision changes. No cough or upper respiratory symptoms. Denies
chest pain, dizziness or lightheadedness; no palpitations.
Denies shortness of breath. No nausea or vomiting, denies
abdominal pain. No dysuria or hematuria. No change in bowel
movements or bloody stools. Denies muscle weakness, myalgias or
neurologic complaints. No exertional buttock or calf pain.
.
Past Medical History:
* Hypertension
* Persistent atrial fibrillation (initially treated with
Disopyramide, followed by Amiodarone, Atenolol and Dofetilide;
all unsuccessful in restoring or maintaining sinus rhythm; she
underwent pulmonary vein isolation in [**8-/2117**] - currently
maintained on Disopyramide 300 mg PO Q12H and Metoprolol
succinate 50 mg XL PO daily),
* Atypical atrial flutter (which developed after PVI status-post
successful cavotricuspid isthmus ablation in [**9-/2116**])
* Hypertrophic cardiomyopathy (last MRI in [**2115**] showed
hypertrophy confined to the distal third and true apex portions
of the left ventricle with an ejection fraction greater than
70%)
* Ascending aortic aneurysm (measuring 4.2 x 4.3- cm in [**3-/2116**])
.
* CABG: None
* PERCUTANEOUS CORONARY INTERVENTIONS: None
* PACING/ICD: None
.
PAST MEDICAL & SURGICAL HISTORY:
1. Liver transplantation, [**2095**] (secondary primary biliary
cirrhosis vs. atresia with autoimmune hepatitis in [**2096**])
2. Thyroid colloid cyst
3. Stable pulmonary nodules
4. Retroperitoneal adenopathy
5. Rosacea
6. Skin cancer
7. Raynaud's syndrome
8. Cellulitis of thumb and left lower extremity
9. Keratosis on left lower extremity
10. s/p hernia repair
11. Portal shunt
12. s/p C-section
Social History:
Patient lives at home with her husband; she is married with two
children (sons). She is an elementary school social worker.
Denies tobacco use or alcohol use; no recreational substance
use.
Family History:
Denies family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory. Three
maternal uncles: one CABG, two bypass surgeries
Physical Exam:
ADMISSION EXAM
VITALS: afebrile BP118/77 HR68 RR20 SpO2 97/2L NC
GENERAL: Appears in no acute distress. Alert and interactive.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. No xanthalesma.
NECK: supple without lymphadenopathy. JVD 2cm above clavicle.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Regular rate and rhythm, soft 1/6 systolic murmur heard
best at the LLSB. S1 and S2 normal. No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Clear to
auscultation bilaterally without adventitious sounds. No
wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft, non-tender, midly-distended, with hyperactivw bowel
sounds. No palpable masses or peritoneal signs. Abdominal aorta
not enlarged to palpation, no bruit. Small umbilical hernia.
EXTR: no cyanosis or clubbing. 1+ pitting edema [**12-21**] way up shin.
2+ peripheral pulses
DERM: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs
2+ throughout, strength 5/5 bilaterally, sensation grossly
intact. Gait deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE EXAM unchanged from admission
Pertinent Results:
ADMISSION LABS
[**2117-11-24**] 08:53PM BLOOD WBC-7.8# RBC-4.84 Hgb-15.1 Hct-45.0
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.6 Plt Ct-133*
[**2117-11-24**] 08:53PM BLOOD Neuts-82.4* Lymphs-11.4* Monos-4.7
Eos-1.4 Baso-0.1
[**2117-11-24**] 08:53PM BLOOD PT-17.3* PTT-34.6 INR(PT)-1.6*
[**2117-11-24**] 08:53PM BLOOD Plt Ct-133*
[**2117-11-24**] 08:53PM BLOOD Glucose-85 UreaN-12 Creat-0.8 Na-144
K-3.8 Cl-106 HCO3-32 AnGap-10
[**2117-11-25**] 03:02AM BLOOD ALT-22 AST-28 LD(LDH)-228 AlkPhos-80
TotBili-0.4
[**2117-11-24**] 08:53PM BLOOD cTropnT-<0.01
[**2117-11-24**] 08:53PM BLOOD Calcium-9.2 Phos-2.6* Mg-1.6
PERTINENT LABS AND STUDIES
CXR [**11-25**] As compared to the previous radiograph, there is a
marked
improvement. On today's image, the lung parenchyma is showing
normal
architecture and transparency. No pulmonary edema, no pneumonia,
no pleural effusions. Borderline size of the cardiac silhouette
with moderate tortuosity of the thoracic aorta.
DISCHARGE LABS
[**2117-11-26**] 07:15AM BLOOD WBC-6.4 RBC-5.10 Hgb-15.9 Hct-48.3*
MCV-95 MCH-31.2 MCHC-33.0 RDW-13.4 Plt Ct-132*
[**2117-11-26**] 10:31AM BLOOD PT-22.0* INR(PT)-2.1*
[**2117-11-26**] 07:15AM BLOOD Glucose-88 UreaN-20 Creat-0.9 Na-141
K-3.6 Cl-104 HCO3-30 AnGap-11
Brief Hospital Course:
64F with a PMH significant for persistent atrial fibrillation
(treated with Disopyramide and Metoprolol currently; previously
on other anti-arrhythmics who underwent PVI in [**8-/2117**]), atypical
atrial flutter (s/p cavotricuspid isthmus ablation in [**9-/2116**]),
hypertrophic cardiomyopathy, ascending aortic aneurysm, primary
biliary cirrhosis s/p liver transplantation in [**2095**] (on chronic
immune-suppression) who presents with wide complex
tachycardiawhile being monitored from home via an event monitor
# RHYTHM - Rhythm on LifeWatch monitoring appeared to be afib
with aberrancy, does not appear to be ventricular tachycardia.
She is s/p PVI and has been tried on multiple antiarrhythics in
the past, none of which have consistently maintained NSR. Upon
arrival to the CCU, she was in normal sinus rhythm and was
asymptomatic.
She was contninued on her home disopyramide and metoprolol
wasincreased to 25mg q8h. Her INR was subtherapeutic and she
was bridged with Lovenox until her INR was greater then 2.0.
#Diarrhea - Frequency and consistency of stools had not changed
since discharge last week. Stool studies from previous
admission were unrevealing. There was a note of "terminal
ileitis" from a prior GI note. It is possible that her
diarrhea, which was guaiac positive last admission, may be from
IBD. However, we would expect that this would have improved
with pulse of steroids she received last admission. Cellecpt
can also cause diarrhea, although she has been on this
medication for a few years and dose has not increased recently.
She finished her course of Cipro/Flagyl prescribed from last
admission.
# CORONARIES - no prior history coronary artery disease; no
cardiac catheterization procedures; last stress testing
performed [**2113**] - she exercised for 8-minutes with a modified
[**Doctor First Name **] protocol and had no EKG findings of concern with normal
myocardial perfusion imaging - presenting without chest pain,
EKG without evidence of active ischemia
# PUMP - last 2D-Echo performed on [**2117-11-18**] showing isolated
apical left ventricular hypertrophy as well ([**Last Name (un) 51827**] variant
hypertrophic cardiomyopathy); left ventricular systolic function
is hyperdynamic (EF 75%) with moderate tricuspid regurgitation.
Cardiac-MR from [**2117-10-5**] showing moderately increased left
ventricular cavity size with normal regional left ventricular
systolic function. The LVEF was normal at 62%. This admission,
she presents without evidence of volume overload on examination
- lungs are clear, no peripheral edema and JVP appears minimally
distended. She was continued on her home doses of lisinopril
and metoprolol.
#Hypertension - She is normotensive at admission, spironolactone
recently restarted by her PCP. [**Name10 (NameIs) **] was continued on home doses
of metoprolol, lisinopril and spironolactone as mentioned above.
#S/p Liver transplant - Not reporting any RUQ pain at this time.
She is currently taking Cellcept and tacrolimus for
immunosuppression, which were continued during this admission.
#Code status this admission: FULL
#Transitional issues:
-Will continue prednisone taper from prior admission
Medications on Admission:
1. Disopyramide 300 mg PO Q12 hours
2. Mycophenolate mofetil 1000 mg PO BID
3. Tacrolimus 1 mg PO Q12 hours
4. Metoprolol succinate 50 mg ER PO daily
5. Ciprofloxacin 750 mg PO Q12 hours (5-days, end [**2117-11-24**])
6. Metronidazole 500 mg PO Q8 hours (5-days, end [**2117-11-24**])
7. Calcium carbonate 400 mg PO BID
8. Lisinopril 5 mg PO daily
9. Ranitidine HCl 150 mg PO BID
10. Zolpidem 5 mg PO QHS PRN insomnia
11. Spironolactone 25mg PO daily (re-started [**11-24**])
12. Warfarin 2mg on [**11-24**] and 4mg after that (re-started [**11-22**])
13. Prednisone 30 mg PO daily (tapering to 20 mg PO daily [**11-26**]
to [**11-28**], 10 mg PO daily [**11-29**] to [**12-1**], resume 5 mg PO daily on
[**12-2**])
Discharge Medications:
1. disopyramide 150 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO Q12H (every 12 hours).
2. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
5. calcium carbonate 400 mg (1,000 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO twice a day.
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
11. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: start [**2117-11-26**].
Disp:*5 Tablet(s)* Refills:*0*
12. prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 3 days: STart [**2117-11-29**].
13. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
start [**2117-12-2**].
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Gastroenteritis
Chronic Diastolic Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had rapid atrial fibrillation and was transferred to [**Hospital1 18**]
for monitoring. We have increased your metoprolol and you are
now in a regular rhythm. You will need to return on Tuesday for
another procedure, the cardiology nurses will contact you at
home to arrange this procedure. Weigh yourself every morning,
call Dr. [**First Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5
pounds in 3 days. Continue to wear your event monitor at home
and send daily strips and strips if you are symptomatic.
.
We made the following changes to your medicines:
1. INCREASE metoprolol to 75 mg daily
2. CONTINUE your prednisone taper
3. STOP taking ciprofloxacin and metronidazole, you have
finished the prescribed course.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2117-12-7**] at 10:00 AM
With: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: MONDAY [**2118-2-21**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6475**], MD, MPH [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: CARDIAC SERVICES
When: WEDNESDAY [**2118-4-13**] at 4:00 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Admission Date: [**2117-12-2**] Discharge Date: [**2117-12-2**]
Date of Birth: [**2053-4-14**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lactose / vancomycin
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 yo female with history of persistent Afib s/p multiple
ablations now on disopyramide and metoprolol, atypical aflutter
s/p isthmus line and PVI [**8-/2117**], nonobstructive HOCM, AAA, and
PBC s/p OLT on immunosuppression presented to [**Hospital1 **] with
tachycardia and chest pain. Her afib started acutely today
accompanied by full left sided chest discomfort. She was feeling
generally unwell prior but attributed this to her procedure on
the previous day. Initially her HR was 160s with BPs 150/100.
Patient was given amiodarone 150mg bolus. Chest pain resolved
with rate control to HR 110-120 and BP 80s/60s. EP fellow
recommended cardioversion. Patient was cardioverted with 50J,
and converted to sinus rhythm (per report with wandering atrial
pacemaker with diffuse TWI), and HR 60s-70s with BP 90-100s
systolic. Initial trop before cardioversion was elevated at
0.143. She was chest pain free prior to transfer to [**Hospital1 18**].
.
At home, her lifewatch recently recorded four beats of NSVT for
which the patient was asymptomatic. There were no changes made
to her medication regimen. She also had a recent TEE on [**11-30**]
for unclear reasons.
.
On arrival to [**Hospital1 18**], her initial vitals in the ED were 98.5 56
92/50 20 98% 2L. The patient was chest pain free however was
bradycardic in the 50s. She reported fatigue and malaise since
the cardioversion but otherwise denied SOB. She received 4L of
IVF total and approximately 500mg of amio bolus + gtt which
stopped at 0115. Most Recent Vitals: 0215: 48-59 af- 15-
88/54-97%2l, low sao2 93%ra placed on 2L.
.
Currently, she is feeling well and is extremely fatigued.
Currently chest pain free without issue.
.
Cardiaac ROS:
+palps and CP only with afib with RVR
-syncope, presyncope, SOB, leg swelling, orthopnea, or PND
.
Past Medical History:
-Persistent Afib s/p multiple ablations now on disopyramide and
metoprolol, s/p ablation on [**2117-11-24**]
-atypical aflutter s/p isthmus line and PVI [**8-/2117**]
-Hypertrophic cardiomyopathy, last MRI in [**2115**] showed
hypertrophy confined to the distal third and true apex portions
of the left ventricle with an ejection fraction greater than
70%.
-Ascending aortic aneurysm, 4.2 x 4.3 cm in [**3-28**]
.
OTHER PAST MEDICAL HISTORY:
Primary biliary cirrhosis s/p OLT [**2095**] on chronic
immunosuppression
Thyroid colloid cyst
Stable Lung nodules
Rosacea
Retroperitoneal adenopathy
Skin cancer
Raynaud's syndrome
Cellulitis of thumb and left lower extremity
Keratosis on Left LE which has tract
Hernia repair
Portal shunt
C-section
Social History:
Patient lives at home with her husband; she is married with two
children (sons). She is an elementary school social worker.
Denies tobacco use or alcohol use; no recreational substance
use.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. 3 maternal
uncles: one CABG and two bypass surgerys
Physical Exam:
VS - 97.9 102/70 51 18 97% on RA 68.1 kg
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, bradycardic, no MRG, nl S1-S2
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, 1+ LE edema to the ankle bilaterally, 2+
peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - sleepy, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
[**2117-12-2**] 01:30AM BLOOD WBC-7.7 RBC-4.89 Hgb-14.7 Hct-46.1 MCV-94
MCH-30.1 MCHC-31.9 RDW-13.2 Plt Ct-125*
[**2117-12-2**] 06:50AM BLOOD WBC-5.7 RBC-4.78 Hgb-14.3 Hct-45.9 MCV-96
MCH-30.0 MCHC-31.2 RDW-13.3 Plt Ct-103*
[**2117-12-2**] 01:30AM BLOOD Neuts-79.6* Lymphs-14.3* Monos-5.1
Eos-0.6 Baso-0.3
[**2117-12-2**] 06:50AM BLOOD PT-21.8* INR(PT)-2.1*
[**2117-12-2**] 01:30AM BLOOD PT-22.7* PTT-39.6* INR(PT)-2.2*
[**2117-12-2**] 06:50AM BLOOD Glucose-92 UreaN-17 Creat-0.7 Na-141
K-4.2 Cl-111* HCO3-27 AnGap-7*
[**2117-12-2**] 01:30AM BLOOD Glucose-115* UreaN-22* Creat-0.7 Na-140
K-3.8 Cl-109* HCO3-25 AnGap-10
[**2117-12-2**] 06:50AM BLOOD CK(CPK)-63
[**2117-12-2**] 06:50AM BLOOD CK-MB-9 cTropnT-0.13*
[**2117-12-2**] 01:30AM BLOOD cTropnT-0.13*
[**2117-12-2**] 06:50AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.5*
[**2117-12-2**] 06:50AM BLOOD TSH-1.1
.
ECG: sinus arrhythmia. rate in 50s. QTc 480. LVH strain pattern.
Brief Hospital Course:
64 yo female with history of persistent Afib s/p multiple
ablations, atypical aflutter s/p isthmus line and PVI [**8-/2117**],
HOCM, AAA, and PBC s/p OLT on immunosuppression admitted for
atrial tachycardia s/p cardioversion and ablation at OSH.
.
# RHYTHM: Patient reportedly had episode of Atrial tachycardia
at OSH. She was cardioverted back into sinus rhythm and loaded
with amiodarone. Subsequently patient was hypotensive and she
was transferred to [**Hospital1 18**] for further monitoring. On arrival to
[**Hospital1 18**] patient was normotensive with sinus bradycardia. She was
started on amiodarone 200 mg po BID. The plan is to continue
this dose for 1 month, then decrease to amiodarone 200 mg daily.
She will have an outpatient ablation procedure scheduled. She
was discharged on her home warfarin dose. Her metoprolol was
decreased to 25 mg daily.
.
# CORONARIES: Patient has no prior history of CAD. Her last
stress in [**2113**] was normal. She initially presented to [**Location (un) 620**]
with chest pain and palpitations. Chest pain resolved with rate
control. ECG showed no evidence of active ischemia. Troponins
were stable at 0.13 x 2 with normal CKMB. Upon arrival to [**Hospital1 18**]
patient was chest pain free and remained chest pain free through
the remainder of admission.
.
# PUMP: Appeared euvolemic on exam. EF>55%. She was continued on
her home spironolactone. Metoprolol was decreased to 25 mg daily
at time of discharge given her bradycardia.
.
# Hypertension: Patient initially hypotensive after
cardioversion and amiodarone at OSH. She was given fluids and
transferred to [**Hospital1 18**]. Upon arrival to the floor, systolic blood
pressures in low 100s. Patient's blood pressures remained stable
throughout admission. Her lisinopril was held at discharge.
.
# S/p Liver transplant: Patient continued on home doses of
CellCept and Tacrolimus.
.
# Suspected AI: continue prednisone taper
.
# Thrombocytopenia: chronic
.
Transitional Issues
- Patient will need outpatient ablation procedure
- Patient will need blood pressure rechecked. If elevated can
consider restarting lisinopril.
- Heart rate will need to be monitored. Metoprolol may need to
be increased.
- No labs pending at time of discharge.
- Patient full code on admission
- contact: husband [**Name (NI) **] [**Telephone/Fax (1) 101709**]
Medications on Admission:
-lisinopril 5 mg Tablet by mouth once a day
-metoprolol succinate 75 mg Tablet ER 24 hr
-mycophenolate mofetil [CellCept] 1000 mg Tablet PO bid
-prednisone 10 mg Tablet by mouth qam, decrease to 5mg on [**12-2**]
-spironolactone 25 mg Tablet by mouth once a day
-tacrolimus [Prograf] 1 mg Capsule by mouth b.i.d.
-warfarin 2 mg Tablet 2 Tablet(s) by mouth daily
-nr zolpidem 5 mg Tablet by mouth at bedtime prn
-docusate sodium 100 mg Capsule by mouth twice a day prn
-hydrocolloid dressing 2" X 2" Bandage apply to wound daily
-ranitidine HCl 150 mg Tablet by mouth twice a day (OTC)
Discharge Medications:
1. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*1*
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Take 200mg twice daily for one month, then decrease to
200mg once daily.
Disp:*60 Tablet(s)* Refills:*1*
3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. hydrocolloid dressing 2 X 2 Bandage Sig: Apply to wound
Topical once a day.
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Supraventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 101707**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted after an episode of your known abnormal heart rhythm
(supraventricular tachycardia) with a fast heart rate. You were
cardioverted in the emergency room at [**Hospital1 **] to convert
your heart to a normal rhythm. You were also started on a
medication called amiodarone to help control your heart rhythm.
You will also have an ablation in the near future to prevent
your heart from entering an abnormal rhythm.
CHANGES to your medications:
START amiodarone 200mg twice daily. Take this dose for one
month. Then decrease to 200mg once daily.
DECREASE metoprolol succinate to 25mg daily
STOP lisinopril 5mg daily
You should weigh yourself every morning, and call your doctor if
weight goes up more than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2117-12-7**] at 10:00 AM
With: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2118-1-12**] at 2:40 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: MONDAY [**2118-2-21**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6475**], MD, MPH [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
Completed by:[**2117-12-3**]
|
[
"427.32",
"287.5",
"425.18",
"V58.61",
"V58.65",
"V10.83",
"401.9",
"441.4",
"V42.7",
"695.3",
"427.1",
"558.9",
"458.9",
"414.01",
"424.2",
"427.31",
"V45.89",
"428.0",
"518.89",
"V58.69",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
41176, 41182
|
37109, 39452
|
32510, 32516
|
41274, 41274
|
36162, 37086
|
42276, 43392
|
35341, 35508
|
40088, 41153
|
41203, 41203
|
39478, 40065
|
41425, 41952
|
7481, 7817
|
35523, 36143
|
13434, 13453
|
3483, 4151
|
5700, 5766
|
28096, 28150
|
41981, 42253
|
32459, 32472
|
32544, 34351
|
5801, 7465
|
41222, 41253
|
41289, 41401
|
4182, 4511
|
34816, 35118
|
35134, 35325
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,487
| 121,587
|
28846
|
Discharge summary
|
report
|
Admission Date: [**2143-10-7**] Discharge Date: [**2143-10-13**]
Date of Birth: [**2111-6-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
C1 fx s/p fall
Major Surgical or Invasive Procedure:
Halo placement.
History of Present Illness:
32 yo male s/p fall from 15 feet. No LOC, +ETOH, +cocaine,
Transfer from OSH for C1 ant arch and post lamina fx on Right.
Past Medical History:
PMH: none
PSH: r neck exploration and bilat leg wound exploration [**2-21**]
stabbing
[**Last Name (un) 1724**]: none
ALL: NKDA
Pertinent Results:
CXR: Visualized lungs are clear, without effusion. No fracture.
Trachea is midline.- prelim
pelvis: Bilateral hip and sacroiliac joint spaces are
maintained. No
fracture. Pubic symphysis is unremarkable -prelim
CT head: neg-prelim
CT c-spine: Fracture of the right anterior and posterior arch of
the C1 vertebra with avulsion fracture of the right insertion of
the transverse ligament.-prelim
MRI/MRA neck:Irreg. and narrowing of the flow signal in the
right vertebral artery at C1 fracture. intimal injury is
likely.-prelim
CT chest/A/P: No PTX/HTX/FA/FF/SOI/Frx.-final
Brief Hospital Course:
C1 fx - halo placed.
Hospital course complicated by etoh withdrawal, despite CIWA
protocal adherence. Pt supplemented with etoh.
Pt now doing very well. A/O x 3 and ambulating well.
Medications on Admission:
None
Discharge Medications:
1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
C1 fracture
Discharge Condition:
Stable
Discharge Instructions:
Take one tablet of coumadin (5 mg) once a day.
The medication you are taking is very important to prevent
stroke. However, it may increase your risk of bleeding so avoid
all activities that may cause you to bleed.
Please call or return to ED if you experience fever, chills,
shortness of breath, redness or drainage around your incision
sites, dizziness or lightheadedness.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 363**] in 8 weeks. Please call ([**Telephone/Fax (1) 18552**] [**Last Name (LF) 766**], [**10-13**] to set up appointment.
Please follow up with Dr. [**Last Name (STitle) **] in 1 week. Please call ([**Telephone/Fax (1) 61154**] [**Last Name (LF) 766**], [**10-13**] to set up appointment. You must
get your blood checked when you see Dr. [**Last Name (STitle) **] so he can adjust
your coumadin level.
|
[
"305.00",
"805.01",
"E884.9",
"291.81",
"305.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.94",
"93.41"
] |
icd9pcs
|
[
[
[]
]
] |
1625, 1631
|
1269, 1454
|
329, 346
|
1686, 1694
|
668, 883
|
2118, 2575
|
1509, 1602
|
1652, 1665
|
1480, 1486
|
1718, 2095
|
275, 291
|
374, 498
|
892, 1246
|
520, 649
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,694
| 107,683
|
54553
|
Discharge summary
|
report
|
Admission Date: [**2108-12-21**] Discharge Date: [**2109-1-2**]
Date of Birth: [**2062-1-2**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Penicillins / Sulfa (Sulfonamide Antibiotics) /
Clindamycin / Cephalosporins / Macrolide Antibiotics
Attending:[**Doctor First Name 2080**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. [**Known lastname 78131**] is a 46 [**Hospital **] transferred from [**Hospital **] [**Hospital 1459**]
Hospital on [**2108-12-20**] with suspected bacterial meningitis. She
initially presented to [**Hospital3 1443**] two mornings ago with
severe HA & N/V of ~12 hours duration. Head CT was negative, she
denied F/C, and she was discharged on medications for headache.
Twelve hours after discharge to home, she was found altered and
agitated at home by her mother, who brought her to [**Name (NI) **]
[**Name (NI) 1459**]. There she had a temp of 102, WBC 27, negative head CT
and CSF c/w bacterial meningitis (Tueb 1 3400 WBC; Tube 4 WBC
7000, 90% poly, gm stain mod WBC, few GPC). She was intubated
for airway protection with etomodate & succinate and was given
vanco 500 mg & chloramphenicol 1 g (given broad allergy mix). A
right IJ was placed.
Upon arrival to the ED here, she had T 100.6, BP 136/81, HR 127,
AC 100%. She was sedated on fentanyl and midazolam. She was
given decadron 10 mg IV as well as vanco 500 mg (for a total of
1 g), ampicillin, ceftriaxone and acyclovir. (The family
explained that her allergy to the [**Name (NI) 621**] was just rash and she
could be challenged on [**Last Name (LF) 621**], [**First Name3 (LF) **] ID.) She was given ~5L between
our ED and OSH.
Past Medical History:
Brain aneurysm s/p coiling (vs. surgery?) at [**Hospital1 112**], 1st surgery
[**2103-4-30**] followed by a 2nd surgery [**2103-9-3**].
Tubal Ligation
DMII/PCOS
Social History:
Drinks "one a night"
Former heavy smoker - quit in [**2103**]. [**2-21**] PPD for 25 years.
Sister and mother involved
Family History:
N/C
Physical Exam:
GENERAL: sedated, intuabed
HEENT: slight scleral edema laterally, [**Last Name (un) **]
LUNGS: CTA anteriorly
CARDIO: RR, no m/r/g
ABD: somewhat obese, non-distended
EXTREMITIES: no edema
SKIN: non-blanching echymotic pacthes on her right MTP joints as
well as dorsal surface of hand (outlined in pen by nurse; new
per mother); also similar marks on dorsal medial right forearm.
No petechiae throughout, no other rashes.
NEURO: sedated, intubated
Pertinent Results:
ADMISSION LABS:
[**2108-12-20**] 11:35PM PT-15.0* PTT-27.7 INR(PT)-1.3*
[**2108-12-20**] 11:35PM PLT COUNT-239
[**2108-12-20**] 11:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2108-12-20**] 11:35PM NEUTS-87* BANDS-3 LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2108-12-20**] 11:35PM WBC-22.8* RBC-4.60 HGB-14.1 HCT-39.8 MCV-87
MCH-30.6 MCHC-35.4* RDW-14.7
[**2108-12-20**] 11:35PM GLUCOSE-126* UREA N-14 CREAT-1.1 SODIUM-136
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-19
[**2108-12-20**] 11:36PM LACTATE-4.8*
[**2108-12-21**] 12:21AM LACTATE-2.3*
URINE:
[**2108-12-20**] 11:35PM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.028
[**2108-12-20**] 11:35PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2108-12-20**] 11:35PM URINE RBC-21-50* WBC->50 Bacteri-MANY
Yeast-NONE Epi-0-2
OTHER PERTINENT LABS:
[**2108-12-21**] 05:34AM BLOOD %HbA1c-6.0*
[**2108-12-22**] 03:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2108-12-25**] 04:52AM BLOOD HCG-negative
MICROBIOLOGY:
[**12-20**] BCx: negative
[**12-21**] BCx: negative
[**12-21**] UCx: negative
[**12-21**] Sputum: sparse yeast
[**12-23**] Catheter tip Cx: negative
[**12-23**] [**Last Name (un) **] Legionella: negative
[**12-24**] Sputum: sparse yeast
[**12-25**] Sputum: sparse yeast
[**12-28**] Cdiff: negative
[**12-29**] Stool Cx: negative
[**12-29**] UCx: negative
IMAGING:
CXR [**2108-12-20**]: Probable left lower lobe pneumonia. Pulmonary edema
cleared
CTA [**2108-12-23**]: 1)No pulmonary embolism, aortic dissection or
aneurysm. 2)Small bilateral pleural effusions with overlying
right lower lobe
atelectasis.
TTE [**2108-12-24**]: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Doppler
parameters are indeterminate for left ventricular diastolic
function. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No valvular
pathology or pathologic flow identified.
CT Abdoman and pelvis [**2108-12-25**]: 1. No evidence of pelvic abscess
or [**Last Name (un) **]. Small amount of free fluid in the pelvis. 2. 2.8 cm
simple left ovarian cyst. 3. Interval improvement in bibasilar
consolidation with residual basilar airspace opacities
concerning for infection. Stable small bilateral pleural
effusions.
CXR [**2108-12-26**]: 1. Patchy bilateral opacites, greater on the left,
compatible with pneumonia and/or edema. Slight interval
improvement of the left opacifications. 2. Endotracheal tube
terminating 9 cm above the level of the carina.
CT head/CTA head [**2108-12-27**]:
IMPRESSION: 1. CT head shows clipping for MCA and BA aneurysms.
No hemorrhage or hydrocephalus. Mild right mastoid fluid seen.
2. CTA head shows no aneurysms or occlusion.
3. CTV shows no sinus thrombosis.
DISCHARGE LABS:
Brief Hospital Course:
Ms. [**Known lastname 78131**] is a 46 yoF who presented with 24-26 hours of HA,
N/V and found to have evidence of bacterial menigitis on OSH w/u
of agitation and altered MS.
.
#. ALTERED MS/Group B Strep Meningitis: Patient was found to
have pansensitive Group B Strep meningitis from OSH CSF and
urine cultures. She was treated initially with broad spectrum
antibiotics, but was switched to Penicillin G, as per ID. No
primary source of infection was found for the Group B Strep and
all cultures drawn at [**Hospital1 18**] since [**12-21**] have been negative. CT
abdomen/pelvis was negative for abscess.
.
The patient did have persistently elevated WBC's during her
admission, despite IV antibiotics. As the patient had a history
of cerebral aneurysms that were coiled approximately 5 years ago
(titanium clips placed by Dr. [**First Name4 (NamePattern1) 3065**] [**Last Name (NamePattern1) **] at [**Hospital1 112**] Office#:
[**Telephone/Fax (1) 111608**], pager [**Numeric Identifier 44773**]), there was concern that these could
have become secondarily infected leading to persistent
infection. CTA/CTV of the head and orbits was performed as well
as MRI head and all were negative for abscess or dural venous
sinus thrombosis. ECHO was similarly negative for vegetations.
MRI did demonstrate some right-sided mastoid fluid, a known
sequelae of the patient's neurosurgery. ENT was consulted, but
they thought that since patient demonstrated clinical
improvement, no intervention was warranted. The patient's WBC
began trending down and she was discharged with a WBC of 13. She
has completed 12 days of antibiotics and has a plan for q4H IV
Penicillin G therapy for the next 3 weeks. Her mental status at
the time of discharge was at her baseline. She will be followed
by Dr. [**Last Name (STitle) 7443**] in ID with follow-up scheduled for early [**Month (only) 404**].
.
#. RESPIRATORY FAILURE: The patient was initially placed on a
ventilator for "airway protection" with altered MS. It was
difficult to wean her for several days, as the patient was
dysynchronous and required sedation. She had a CTA chest and was
found to have b/l pleural effusions and b/l infiltrate, but no
PE. The patient was extubated on [**12-26**] and did well with frequent
suctioning until her move to the general medicine floor. There
she was quickly weaned off supplemental oxygen and was breathing
room air comfortably until time of discharge.
.
#. PNEUMONIA, Group B Strep: Pt was found to have bilateral
infiltrate on CTA chest and there was concern that this was also
reflective of GBS infection. The patient was treated with
Penicillin G, as above.
.
#. GBS UTI: Patient was found to have GBS in a urine culture
from OSH. Urine cultures obtained at the [**Hospital1 18**] were all
negative. She was treated with Penicillin G, as above.
.
#. ARRHYTHMIA/QTC PROLONGATION ON OSH EKG: Patient had QTc
prolongation on an EKG at an OSH, but had no further prolonged
QTc during this hospitalization.
.
#. DMII/Insulin resistance/PCOS, well controlled no
complications: Patient on low dose Metformin for DMII, HbA1C
6.0, but has lost a significant amount of weight over the last 5
years that has led to improvement in blood sugars. As a result,
the patient was placed on a sliding scale as an inpatient, but
she did not require supplemental insulin.
.
#. Code: Patient remained FULL CODE throughout this
hospitalization.
Medications on Admission:
Metformin
Amitryptyline
Oxycodone
Butalbital
Gabapentin
Ativan
Sertraline
Flonase
Discharge Medications:
1. Outpatient Lab Work
Please draw a CBC, Basic Metabolic Panel, & Liver Function Tests
(including ALT, AST, Alkaline Phosphatase, Total Bilirubin) and
fax results to: Dr. [**Last Name (STitle) 7443**] at [**Telephone/Fax (1) 111609**]
2. Line flush instructions
Flush with 5 to 10ml NS before & after each medication
administration. Flush with 2 to 5ml Heparin Flush after access
unless contraindicated. Flush each lumen daily with 2 to 5ml
Heparin flush when not in use.
3. Penicillin G Pot in Dextrose 2,000,000 unit/50 mL Piggyback
Sig: 4 million units Intravenous every four (4) hours for 22
days: end date [**2108-1-24**].
Disp:*QS QS* Refills:*0*
4. Heparin Flush 10 unit/mL Kit Sig: Ten (10) units Intravenous
see instructions for frequency for 21 days: Flush line before
and after medication infusion with normal saline. Heparanize
infusion line in between infusions and unused lumens.
Disp:*21 days supply* Refills:*0*
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
6. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
7. Diphenhydramine HCl 25 mg Tablet Sig: 1-2 Tablets PO every
four (4) hours as needed for allergy symptoms.
8. Metformin Oral
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. Ativan Oral
11. Butalbital Compound Oral
12. Flonase 50 mcg/Actuation Spray, Suspension Nasal
Discharge Disposition:
Home With Service
Facility:
Critical Care Infusion Company
Discharge Diagnosis:
Primary: Group B Strep Meningitis
Secondary: Anxiety
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 due to meningitis. In the
hospital,
Medications: The following changes were made to your medication
regimen,
1. Penicillin: Please continue to take this medication until
[**1-24**].
2. Benadryl: You may take 25-50mg of Benadryl as directed to
prevent any allergic reaction the Penicillin, but as this can
may you drowsy, please do not drive while taking.
Followup Instructions:
You will need weekly blood work until you follow-up in the
Infectious Disease Clinic in [**Month (only) 404**]. You can go to any local
lab to have your blood drawn, but please bring your prescription
so that the results can be sent to your doctors.
.
Please follow-up with Dr. [**Last Name (STitle) 7443**] in the Infectious Disease Clinic
on [**2109-1-23**] at 10:30AM. To reschedule, please
call:[**Telephone/Fax (1) 457**]. This will be the physician in charge of
following your care.
|
[
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"995.92",
"V12.54",
"300.00",
"794.31",
"785.52",
"250.00",
"346.90",
"599.0",
"293.0",
"320.2",
"518.81",
"482.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11034, 11095
|
6043, 9452
|
398, 415
|
11192, 11192
|
2567, 2567
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2079, 2084
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|
2099, 2548
|
337, 360
|
443, 1740
|
2583, 3519
|
3541, 6001
|
11206, 11313
|
1762, 1925
|
1941, 2063
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,235
| 182,008
|
4438
|
Discharge summary
|
report
|
Admission Date: [**2167-6-10**] Discharge Date: [**2167-6-23**]
Date of Birth: [**2114-10-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetracycline
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Germ cell tumor w/metastases to lung
Major Surgical or Invasive Procedure:
CVL placement
Bronchoscopy
Intubation
Mechanical ventilation
Aline placement
History of Present Illness:
52 yo M with PMH DM I, CAD s/p CABG x2, asthma, mental
retardation, and germ cell tumor with mestastasis to LUL
invading the pulmonary artery as well as occluding the LUL
bronchus and LLL bronchus, who presents from an OSH for possible
debulking of the metastases. Pt was admitted to [**Hospital3 13347**] on [**2167-6-4**] for elective bronchoscopy, which found an
endobronchial growth occluding the take-off of the LLL and most
of the LUL. During the bx, the pt had massive hemoptysis
requiring intubation. Pt was transferred to the ICU and had
electrocautery, which successfully stopped the bleeding. He had
an additional 6 biopsies, which showed germ cell tumor,
nonseminoma metastasized from the testicles. By CT scan, it
appeared that the tumor was invading the pulmonary artery as
well. Pt was extubated in the ICU after 24hrs. He had pulmonary
edema secondary to his known cardiac disease, which improved
after lasix. His course was also complicated by [**Doctor First Name 48**], that
improved with fluid down to 1.1 from 1.49. He also had SOB
during the admission, worse with lying down, with a known R
pleural effusion.
.
Pt had TTE at the OSH on [**2167-6-8**] that showed normal EF, LV
normal size but wall motion difficult to assess, mild MV
thickening, trace MR,
.
Currently, the patient feels short of breath and has a cough,
but otherwise has no complaints. He says he's not sure of what
went on at the prior hospital. He says, "I don't know, I haven't
coughed up blood." "[**First Name8 (NamePattern2) **] [**Location (un) 4223**] is my doctor, and the cancer
isn't anything serious."
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Germ cell tumor metastasized to LUL and invading pulmonary
artery as well as LUL bronchus and LLL bronchus occluding
1,2,5,6,7,8,9,10
- Massive hemoptysis requiring mechanical ventilation
- Diabetes Type I, complicated by mid-foot amputation on the L,
and metatarsal amputation on the R foot
- CAD s/p CABG x2, at 25yo and 39yo
- Mental retardation,lives at home with his parents.
- Asthma
- CVA after CABG
- Seizure
- Chronic renal insufficiency (?baseline)
Social History:
Pt lives at home with his parents. His HCP is his mother,
[**Name (NI) 1258**] [**Name (NI) **] and his sister.
[**Name (NI) **] denies smoking, illicits or alcohol.
Family History:
unable to obtain
Physical Exam:
Admission Physical Exam:
VS - Temp 98.8F, BP 138/62, HR 105, R 18, O2-sat 99% 4L
GENERAL - sitting up in bed, receiving nebulizer treatment,
pleasant gentleman, NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
LUNGS - no use of accessory mm of breathing, diffuse inspiratory
and expiratory wheezes bilaterally, decreased BS at right lung
base, no crackles appreciated, though difficult to assess at
this time given pt with wheezing
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - well-healed scars on R and L lower extremities,
midfoot amputation on L, R 2nd tarsal amputation, no [**Location (un) **], warm,
unable to palpate DP or PT pulses bilaterally, legs appear
symmetric without palpable cords
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact
.
Discharge Physical Exam:
Pertinent Results:
Admission Labs:
.
Discharge Labs:
.
Reports:
CT chest w/o contrast:
Preliminary Report !! WET READ !!
1. 38 x 41 mm left upper lobe solid mass (2:17) compatible with
known germ
cell tumor. 28 x 35 mm hilar mass (2:25) compresses a left lower
lobe
bronchiole traversing through. 2. Ground glass opacities with
intersitial
markings in a "crazy paving" pattern in the upper zones (2:21)
may reflect an inflammatory or infectious process, or
lymphangenic spread of tumor. 3.
Rounded atalectasis at the right lung base (2:33) with
inspissated dense
impacted mucus. There is an adjacent loculated large right
pleural effusion with thickened wall, which may represent a
malignant effusion with pleural metastasis. Hyperdense
pleural-based masses (2:35) are most likely drop metastases. 4.
Left axillary and mediastinal lymphadenopathy. 5. Non-specific
tiny calcifications within the spinal canal (2:23). 6. s/p CABG.
Brief Hospital Course:
BRIEF MICU COURSE (MICU GREEN):
On [**2167-6-11**] he underwent flexible brochoscopy. The bronch showed
98% occlusion of the LUL and LLL which was not amenable to
stenting. A BAL was sent. During the procedure he became
hypertensive to the 180s and subsequently desaturated to 78% and
was noted to be wheezing. The procedure was stopped and he was
given nebs, lasix 40IV and nitropaste. He had an ABG which was
7.31/78/83 and was thereafter placed on BiPAP and transferred to
the MICU.
.
In the MICU, he was placed on bipap and given an additional 80mg
IV Lasix. He improved, was diuresed -2.5L and was weaned to
nasal canula. His code status was confirmed to be DNR but okay
to intubate for short-term, reversible causes. His home lasix
was changed to lasix 80mg IV BID. His blood pressure
medications were uptitrated to obtain better blood pressure
control. His Lisinopril was increased to 20mg daily and he was
given 1 dose of Captopril 6.25mg PO. His outpatint oncologist
was contact[**Name (NI) **] and the inpatient heme-onc team was consulted for
plans for chemotherapy. He has a history of hemoptysis after
bronchoscopy in the past but did not have a problem with this
while in the ICU. He was hypoglycemic to the 40s overnight on
[**2167-6-11**] and his lantus was decreased to 10 units per day. This
was likely from not eating during the day.
.
Given his tenuous respiratory status, he was transferred to the
[**Hospital Unit Name 153**] to receive chemotherapy in the ICU. According to
interventional pulmonology, there are no further options for
stenting or tumor debridement that they can offer.
.
[**Hospital Unit Name 153**] Course:
In the [**Hospital Unit Name 153**] he was electively intubated for hypoxia and concerns
that he would not tolerate the fluid loads of chemotherapy
without positive pressure ventilation. He was emphatically DNR
and was willing to accept intubation only as a temporary
measure. He was continued on treatment for post obstructive PNA
with vancomycin, aztreonam, and metronidazole. He tolerated his
chemotherapy (C1D1 cisplatin + etoposide [**2167-6-13**]). Howevever,
on day 6 of his chemo he developed persistent nausea and
vomiting, so extubation was deferred. He was hypotensive at
times, and on and off pressors. He was started on TPN for
nutrition due to his persistent nausea and vomiting. He was
ultimately weaned off the ventilator and extubated on [**2167-6-22**].
On [**2167-6-23**] he was doing very well, and was tolerating POs and
comfortable on NC O2. His only complaint was cough. He was
called out to OMED.
.
OMED Course:
On arrival on the floor he was conversant and comfortable. He
became suddenly unresponsive and cyanotic. A Code Blue was
called. Initially there was concern for seizure, and he was
emergently given lorazepam IV. Once he was placed on a cardiac
monitor he was found to be in coarse Vfib. Given concern for
torsade de pointes magnesium was given as an IV push as
amiodarone was drawn up. However, his mother and HCP, who was in
the room for the event, asked that resusitation be halted. The
patient had been clearly DNR, and she felt that further measures
were not consistent with his goals of care. He died with his
mother at the bedside. Pastoral care and SW were called to
assist the family with the mourning process. His ICU team was
present for the code and provided support for the family as
well.
.
Medications on Admission:
MEDICATIONS on TRANSFER from OSH:
Duoneb q4hr prn
Tegretol q4hr prn
Zetia 10mg po daily
Fluvoxamine 37.5 po bid
Heparin
Imipenem 500mg IV q6hr
Lantus insulin 25 units SC daily
ISS
Imdur 90mg po daily
Lisinopril 10mg po daily
Claritin 10mg po daily
Lopressor 25mg po bid
Zofran 4mg IV q4hr prn nausea
Zocor 80mg po qhs
Aldactone 25mg po daily
Advair 500/50 1 puff [**Hospital1 **]
Lasix 80mg [**Hospital1 **]
Discharge Medications:
na
Discharge Disposition:
Expired
Discharge Diagnosis:
Ventricular arrhythmia and sudden cardiac death
Metastatic germ cell cancer
Diabetes type I
CAD
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2167-6-24**]
|
[
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"250.81",
"428.0",
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"284.89",
"427.41",
"V45.81",
"317",
"V49.73",
"198.89",
"584.9",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93",
"38.91",
"96.04",
"96.6",
"96.72",
"99.25",
"33.22",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
8728, 8737
|
4839, 8243
|
325, 403
|
8877, 8886
|
3903, 3903
|
8939, 8974
|
2944, 2962
|
8701, 8705
|
8758, 8856
|
8269, 8678
|
8910, 8916
|
3937, 4816
|
3002, 3857
|
249, 287
|
431, 2261
|
3919, 3921
|
2283, 2745
|
2761, 2928
|
3884, 3884
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,281
| 117,934
|
29102+57627
|
Discharge summary
|
report+addendum
|
Admission Date: [**2158-6-14**] Discharge Date: [**2158-7-18**]
Date of Birth: [**2099-6-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
morbid obesity
Major Surgical or Invasive Procedure:
[**2158-6-14**]
1. Open laparoscopic adjustable gastric band placement.
2. Repair of incisional hernia with mesh.
3. Liver biopsy using Tru-Cut needle.
4. Biopsy of celiac lymph node.
[**2158-6-20**]
1. Exploratory laparotomy.
2. Partial gastrectomy.
3. Removal of Lap-Band and port.
4. Removal of hernia mesh.
[**2158-6-21**]
1. Reopening of abdomen.
2. Abdominal closure with mesh.
[**2158-7-4**]
Wound vacuum-assisted closure change
[**2158-7-10**]
Split-thickness skin graft to the abdomen 28 x 18
inches.
History of Present Illness:
Mr. [**Known lastname 4781**] is a 58-year-old gentleman with
longstanding morbid obesity refractory to attempts at weight
loss by nonoperative means. Preoperative weight was 321.6
pounds. Given his height, this translated to a body mass
index of 53.8 kg per meter squared. Co-morbidities included
diabetes mellitus type 2, history of autoimmune hemolytic
anemia, ITP, question of cirrhosis with nonalcoholic fatty
liver disease, hypertension, diabetic neuropathy,
hyperlipidemia, hypertriglyceridemia, venous stasis. He also
suffered from incisional hernia from an open splenectomy.
Also by CAT scan he was noted to have mesenteric
lymphadenopathy and there was long concern of a potential
hematologic anomaly and, therefore, a biopsy was necessary.
Past Medical History:
1. Autoimmune hemolytic anemia [**2-1**] (tx w/ prednisone taper
x2 months)
2. ITP after viral syndrome [**10-2**], refractory to IVIG and
prednisone, s/p open splenectomy, fascial repair
3. DM II
4. Atrial fibrillation
5. Morbid obesity
6. s/p appendectomy at age 3
7. s/p left thoracotomy for ?empyema
Social History:
He denied tobacco or recreational drug usage, has occasional
glass of wine
maybe two to 3 times a week, drinks one half pot of coffee twice
daily and diet soda 12-ounce can 3 times a day. He works
in administration and planning for 35+ years at the [**Company 2676**]
Company. He is married living with his wife age 59 and they
have
no children.
Family History:
His family history is noted for both parents deceased father
with cerebral
hemorrhage, diabetes and obesity; mother with lung CA, heart
failure, diabetes and obesity; sister living with ITP.
Physical Exam:
Blood pressure was 135/85, pulse 82, respirations 16 and O2
saturation 96% on room air. On physical examination [**Known firstname **] was
casually dressed, pleasant and in no distress. His skin was
warm, dry with no rashes. Sclerae were anicteric, conjunctiva
clear, pupils were equal round and reactive to light, fundi did
not demonstrate retinopathy, mucous membranes were moist, tongue
was pink, there was a [**Doctor First Name **]-like lesion left side lower buccal
mucosa and the oropharynx was essentially clear of exudates or
hyperemia. Trachea is in the midline and the neck was supple
with full range of motion, no adenopathy, thyromegaly or carotid
bruits, no JVD. Chest was symmetric and there was a well healed
left thoracotomy and sub-costal incision scars, lungs were clear
to auscultation bilaterally with good air movement. Cardiac
exam
was regular rate and rhythm, normal S1 and S2, no murmurs, rubs
or gallops. The abdomen was obese but soft and non-tender,
non-distended with positive bowel sounds with large ventral
hernia and likely second lower hernia more laterally. There was
no spinal tenderness or flank pain. Lower extremities were
noted
for bilateral venous stasis dermatitis left greater than right
with no ulcerations and tense 1+ edema. There was no evidence
of
joint swelling or inflammation of the joints. There were no
focal neurological deficits except for decreased sensation in
the
lower legs/feet/toes, gait appeared normal.
Pertinent Results:
[**2158-6-14**] 06:10PM WBC-26.0*# RBC-5.40 HGB-14.9 HCT-45.8 MCV-85
MCH-27.5 MCHC-32.4 RDW-14.6
[**2158-6-14**] 06:10PM HCV Ab-NEGATIVE
[**2158-6-14**] 06:10PM HBc Ab-NEGATIVE IgM HBc-NEGATIVE IgM
HAV-NEGATIVE
[**2158-6-14**] 06:10PM GLUCOSE-100 UREA N-16 CREAT-1.2 SODIUM-140
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-32 ANION GAP-13
[**2158-6-14**] 06:10PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.7
[**2158-6-14**]
SPECIMEN #1: LIVER, NEEDLE CORE BIOPSY (A).
DIAGNOSIS:
1. Moderate portal/septal and mild periportal and lobular
mononuclear inflammation.
2. Multiple lobular and single portal non-necrotizing
granulomas.
3. Minimal steatosis without ballooning or hyalin.
4. No bile duct injury or loss is identified.
5. Trichrome stain shows increased portal fibrosis with
established septa formation, bridging, and focal complete nodule
formation (Stage 4 fibrosis).
6. GMS, PAS-D, and AFB stains are negative for organisms.
Note: The finding of lobular and portal non-necrotizing
granulomas raises the possibility of an infectious process
versus an idiopathic systemic granulomatous disease such as
sarcoidosis
SPECIMEN #2: LYMPH NODE, MESENTERIC (B-C).
DIAGNOSIS
NONCASEATING GRANULOMATOUS LYMPHADENITIS. SEE NOTE
[**2158-6-19**] CT Abd/pelvis : 1. Moderate amount of free fluid and
free gas in the abdomen. The patient is day five post-repair of
incisional hernia and gastric band placement. The amount of free
fluid and gas within the abdomen is not expected at this stage
of the postoperative course. A site of perforation cannot be
identified on this suboptimal examination.
[**2158-6-24**] Liver US :
Limited study without evidence of cholelithiasis or secondary
findings to suggest acute cholecystitis.
Microbiology reports:
[**2158-7-10**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2158-7-3**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2158-7-1**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2158-7-1**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST, ESCHERICHIA COLI} INPATIENT
[**2158-7-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-7-1**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {ESCHERICHIA COLI, YEAST} INPATIENT
[**2158-6-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-28**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY
INPATIENT
[**2158-6-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-27**] FLUID,OTHER GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION};
ANAEROBIC CULTURE-FINAL INPATIENT
[**2158-6-27**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL INPATIENT
[**2158-6-26**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2158-6-25**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-25**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-25**] URINE URINE CULTURE-FINAL INPATIENT
[**2158-6-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST} INPATIENT
[**2158-6-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2158-6-24**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-22**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-22**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-21**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST} INPATIENT
[**2158-6-21**] URINE URINE CULTURE-FINAL INPATIENT
[**2158-6-20**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{PSEUDOMONAS AERUGINOSA}; ANAEROBIC CULTURE-FINAL INPATIENT
[**2158-6-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-20**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2158-6-19**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2158-6-16**] URINE URINE CULTURE-FINAL INPATIENT
[**2158-7-18**]
14.0* 3.62* 10.2* 32.3* 89 28.0 31.5 16.1* 839*
Source: Line-picc
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2158-7-18**] 10:39 PND
Source: Line-PICC; heparin dose: [**2148**]
[**2158-7-18**] 03:39 839*
Source: Line-picc
[**2158-7-18**] 03:39 14.9* 74.1* 1.3*
Source: Line-picc
LAB USE ONLY
[**2158-7-18**] 03:39
Source: Line-picc
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2158-7-18**] 03:39 901 9 0.6 134 3.8 98 26 14
Source: Line-picc
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2158-7-16**] 04:33 Using this1
Source: Line-picc
Using this patient's age, gender, and serum creatinine value of
0.8,
Estimated GFR = >75 if non African-American (mL/min/1.73 m2)
Estimated GFR = >75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 50-59 is 93 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2158-7-18**] 03:39 8.8 3.7 1.9
Brief Hospital Course:
Mr. [**Known lastname 4781**] was admitted to the hospital and taken to the
Operating Room for open gastric band, hernia repair and liver
biopsy. he tolerated the procedure well and returned to the
PACU in stable condition. He maintained stable hemodynamics
with adequate fluid resuscitation and his pain was controlled
with an epidural and PCA. He was transferred to the ICU for
further monitoring and continues fluid resuscitation. His
creatinine rose to 1.5 without any other abnormalities and began
to trend down to a baseline of 1.0. His Bariatric diet started
while in the ICU and he was able to get out of bed to a chair
with assistance.
After 48 hours he improved and was able to be transferred to the
Surgical floor for further monitoring.
He gradually was advanced to a stage 3 diet and tolerated it
well without abdominal pain or fullness. Due to his size, he
was evaluated by the Physical Therapy service to help increase
his ambulation. Following removal of his epidural catheter he
tolerated Roxicet for pain and was doing well and planning to go
home soon.
Unfortunately on [**2158-6-20**] he developed tachycardia, acute
respiratory failure requiring intubation and then was taken
emergently to the Operating for an exploratory laparotomy as he
had free air in the abdomen on CT scan. He had a good portion
of necrosis of the anterior stomach and therefore his lap band
was removed and he had a partial gastrectomy. His mesh was also
removed. His abdomen was left open and he was brought to the
ICU on multiple pressors, intubated and sedated. He returned to
the Operating Room the following day for a washout and placement
of Vicryl mesh to repair his hernia and this was tolerated well.
His WBC was elevated in the 30K range and he was on broad
spectrum antibiotics as well as antifungal. His multiple blood
cultures were negative but he had pseudomonas in his abdominal
wound as well as some [**Female First Name (un) **]. He eventually developed
pseudomonas in his sputum and treatment continued with Zosyn,
Ciprofloxacin, Vancomycin and Micafungin. He remained negative
for MRSA. His antibiotics finished on [**2158-7-8**] and his current
WBC is 14K. He has been afebrile.
His septic shock was gradually resolving as his pressor needs
diminished daily. From a pulmonary status he required vigorous
pulmonary toilet including bronchoscopy as he developed a left
lower lobe collapse and pseudomonas pneumonia. He was
eventually weaned from the respirator and successfully
extubated. He continues to wear his own CPAP mask at night and
he uses his incentive spirometer as well.
His nutritional needs during this period were taken care of with
TPN and following extubation his diet was gradually advanced
after multiple swallow studies. He remains on a Bariatric diet
at stage 5 now and is tolerating that well with close
observation by the nutritionist.
His surgical wound was eventually managed with a VAC dressing
and after good granulation he was taken to the Operating Room on
[**2158-7-10**] for a skin graft. The donor site is his right thigh
which is covered with a Xeroform dressing which will eventually
dry up. It appears crusty around the edges with some old blood
underneath and occasionally oozes if touched with movement. It
still needs to dry out some more in the mid portion. His
abdominal skin graft is healing well and this is also covered
with Zero form dressing and changed daily. He also has a 2 cm
wide port site wound in his right lower abdomen which is clean
and granulating. Saline damp to dry gauze is loosely packed
[**Hospital1 **].
From a cardiac standpoint he has a history of rapid atrial
fibrillation which was persistent when he was in septic shock.
He was treated with beta blockers which he remains on. He also
is being anticoagulated with IV heparin and Coumadin started
[**2158-7-17**]. His INR today is 1.3 and he received 5 mg of Coumadin
last night with plans for another 5 mg tonight. His goal INR is
2.5. His current dose of Heparin is [**2148**] units/hr and his PTT
on that dose was 64.9 with a goal of 60-80 His rhythm currently
is NSR at a rate of 80 on 25 mg of Lopressor [**Hospital1 **].
His renal status is back to baseline with a creatinine of 0.6.
He had been mobilizing fluid on his own but remains very
edematous and will resume Lasix daily at 40 mg. His pre op dose
was 40 mg TID and he may eventually need to have it increased
based on his creatinine and fluid balance.
Due to his extreme weakness and size he remains with a foley
catheter in place as he needs to stand to void and at this time
he is too weak to do so. He has not had a UTI.
Mr. [**Known lastname 4781**] is a diabetic and prior to his initial surgery
was on NPH insulin 6o units qAM ,26 units qPM and metformin
however over the last 2 weeks his blood sugars have been in the
90 to 110 range off all insulin and a Bariatric diet. He is
currently being checked pre meal and HS. See sliding scale
enclosed.
He is extremely anxious to get back home and desperate for a
disciplined Physical Therapy program to help him attain his
goals of independence. Hopefully after this protracted course he
will benefit from your program with the hopes of getting him
home soon. He will need to have a wound check with Dr. [**Last Name (STitle) **]
next week.
Medications on Admission:
AMIODARONE - 200 mg Tablet - 200mg Tablet(s) by mouth twice a
day
- No Substitution
FUROSEMIDE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 40 mg Tablet - 1 Tablet(s) by mouth three times a day
HYDROCODONE-ACETAMINOPHEN - 7.5 mg-750 mg Tablet - [**1-28**] Tablet(s)
by mouth every 4-6 hours as needed for as needed for pain
LEVOTHYROXINE - (Prescribed by Other Provider) - 50 mcg Tablet
-
1 Tablet(s) by mouth once a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1
Tablet(s) by mouth three times a day
NYSTATIN - (Prescribed by Other Provider) - 100,000 unit/gram
Powder - apply to affected areas twice a day as needed
Medications - OTC
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) -
500
mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1
Tablet(s) by mouth once a day
LORATADINE [CLARITIN] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once daily as needed for allergies
NOVOLIN R INNOLET - (Prescribed by Other Provider) - 300 unit/3
mL Insulin Pen - as directed Insulin(s) four times a day per
sliding scale
NPH INSULIN HUMAN RECOMB [HUMULIN N PEN] - (Prescribed by Other
Provider; Dose adjustment - no new Rx) - 300 unit/3 mL Insulin
Pen - as directed Insulin(s) twice a day 60 units q am 26 units
q
HS
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze/sob.
2. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
3. Atorvastatin 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily): please crush.
4. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: Ten (10) ml PO BID (2
times a day).
5. Duloxetine 20 mg Capsule, Delayed Release(E.C.) [**Month/Day (2) **]: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Senna 8.6 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO at bedtime as
needed for constipation .
7. Multivitamin Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily):
please crush.
8. Ascorbic Acid 500 mg/5 mL Syrup [**Month/Day (2) **]: 1000 (1000) PO DAILY
(Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: 2.5 Tablets
PO DAILY (Daily): please crush.
10. Zinc Sulfate 220 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO DAILY
(Daily): please crush.
11. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One
(1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
12. Dilaudid 2 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every four (4)
hours as needed for pain: please crush.
13. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever/pain: please crush.
14. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Last Name (STitle) **]: per sliding scale Intravenous ASDIR (AS
DIRECTED): Keep PTT 60-80.
15. 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.
16. Coumadin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: as
directed, adjust to keep INR 2.5.
17. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Lasix 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: please
crush.
19. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: 4-12 units
Injection four times a day: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
1. Diabetes mellitus type 2.
2. Morbid obese
3. Incisional hernia.
4. Nonalcoholic steatohepatitis.
5. Sepsis with suspected intra-abdominal source.
6. Gastric necrosis with perforation
7. Atrial fibrillation
8. Hypothyroidism
9. Left lower lobe collapse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital for gastric band placement
and hernia repair
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Bariatric Stage 5 diet
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. 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.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
Work hard with Physical Therapy and Occupational Therapy to
increase your strength and endurance.
Stage 5 diet
Follow your blood sugars closely after discharge from rehab.
you may need insulin again
Followup Instructions:
Call Dr. [**Last Name (STitle) 32668**] at [**Telephone/Fax (1) 12551**] for a follow up
appointment when you are discharged from rehab. He will need to
monitor your blood work and dose your coumadin.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2158-7-27**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2158-8-29**] 3:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3014**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2158-8-29**]
3:30
Completed by:[**2158-7-18**] Name: [**Known lastname 11910**],[**Known firstname 394**] Unit No: [**Numeric Identifier 11911**]
Admission Date: [**2158-6-14**] Discharge Date: [**2158-7-18**]
Date of Birth: [**2099-6-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3524**]
Addendum:
Please note that Mr. [**Known lastname **] IS on NPH insulin at a much
lower dose...10 units [**Hospital1 **] with blood sugars controlled in the
90-110 range.
Also please include in the final diagnosis ;
10. acute blood loss anemia
11. acute renal failure
12. septic shock
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1933**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**]
Completed by:[**2158-7-18**]
|
[
"338.18",
"998.0",
"244.9",
"427.31",
"274.9",
"272.4",
"459.81",
"285.1",
"571.8",
"553.21",
"280.9",
"789.59",
"278.01",
"518.0",
"283.0",
"357.2",
"E878.8",
"518.5",
"V58.67",
"250.60",
"584.9",
"263.9",
"V85.4",
"482.1",
"560.81",
"287.31",
"530.81",
"537.89",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"50.11",
"43.89",
"54.62",
"54.23",
"83.21",
"86.11",
"44.95",
"40.11",
"44.99",
"96.72",
"86.69",
"53.69",
"38.93",
"38.91",
"33.24",
"54.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
21614, 21818
|
9054, 14382
|
328, 840
|
18412, 18412
|
4037, 9031
|
20247, 21591
|
2334, 2526
|
15780, 18043
|
18134, 18391
|
14408, 15757
|
18693, 19205
|
2541, 4018
|
274, 290
|
868, 1623
|
19230, 20224
|
18427, 18564
|
1645, 1951
|
1967, 2318
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,032
| 183,568
|
16453
|
Discharge summary
|
report
|
Admission Date: [**2183-4-7**] Discharge Date: [**2183-4-10**]
Date of Birth: [**2132-12-25**] Sex: F
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
History of Present Illness:
50 year old woman with PMH of COPD with multiple previous
intubations, IV drug use now on methadone, hepatitis C, seizure
disorder, and tobacco abuse presents with increasing shortness
of breath over last day. She reports an associated cough with
yellow/greenish sputum. She also had a migraine headache,
similar to her usual migraines, associated with nausea and
vomiting. She denies fevers, chills. She reports a history of
smoke exposure 2 days prior to prenetation when she was staying
with her sister who fell asleep with a cigarette, causing her
pillow to smoke and her apartment to fill with smoke.
On presentation to the ED her O2 sat was 67% but improved to 92%
on 2 liters of oxygen. ABG's demonstrated acidemia with
hypercarbia, and she was placed on CPAP and vomited. CXR was
grossly clear. Repeat ABG was 7.19/96/19 so she was intubated to
improve oxygenation and ventilation. Her BP dropped to 70-80's
systolic post intubation as during previous intubations so a
femoral line was placed and she was given 4 liters of NS. She
was admitted to the [**Hospital Unit Name 153**] for respiratory support.
Past Medical History:
COPD/Intubations, Current Smoking, IVDU (Now on Methadone), HCV
Infection (Genotype 2), Migraine Headaches, Seizure Disorder.
Social History:
Smokes one pack per day. Denies EtOH abuse. On methadone
maintenance now, clean x 2yrs. She lives alone, has 2 children.
Works as a painter. She has a boyfriend
Family History:
Aunt-stroke
[**Name2 (NI) **] lupus, no hx of blood clotting
Physical Exam:
T98.9 P98 BP 148/82 R 18 67% RA -> 92% on 2.5L
Gen: uncomfortable, mild resp distress
HEENT: NCAT
Neck: supple
Resp: clear bilaterally
CV: RRR
Abd: soft NTND
Ext: no edema
Pertinent Results:
[**2183-4-7**] 11:44PM TYPE-ART PO2-19* PCO2-96* PH-7.19* TOTAL
CO2-38* BASE XS-3
[**2183-4-7**] 10:02PM TYPE-ART PO2-55* PCO2-76* PH-7.27* TOTAL
CO2-36* BASE XS-4 INTUBATED-NOT INTUBA
[**2183-4-7**] 10:02PM LACTATE-1.0
[**2183-4-7**] 09:30PM GLUCOSE-116* UREA N-16 CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-33* ANION GAP-10
[**2183-4-7**] 09:30PM ALT(SGPT)-22 AST(SGOT)-29 ALK PHOS-63
AMYLASE-48 TOT BILI-0.4
[**2183-4-7**] 09:30PM LIPASE-41
[**2183-4-7**] 09:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-4-7**] 09:30PM WBC-13.9*# RBC-4.21 HGB-13.1 HCT-38.6 MCV-92
MCH-31.0 MCHC-33.9 RDW-14.5
[**2183-4-7**] 09:30PM NEUTS-90.6* LYMPHS-7.8* MONOS-1.5* EOS-0
BASOS-0
[**2183-4-7**] 09:30PM HYPOCHROM-1+
[**2183-4-7**] 09:30PM PLT COUNT-192
[**2183-4-7**] 08:47PM TYPE-[**Last Name (un) **] PH-7.29*
[**2183-4-7**] 08:47PM GLUCOSE-108* LACTATE-3.2* NA+-142 K+-4.4
CL--103 TCO2-32*
[**2183-4-7**] 08:47PM freeCa-1.10*
CXR ([**2183-4-9**]): PA AND LATERAL CHEST: There has been interval
extubation. The lungs are hyperinflated. The diaphragms are
flattened and the retrosternal clear space is increased. There
is no focal air space consolidation. There is no effusion. There
is some linear atelectasis at both lung bases. There is no
pneumothorax. IMPRESSION: Interval extubation without focal air
space consolidation to represent pneumonia or aspiration. No
CHF.
Brief Hospital Course:
Ms [**Known lastname 46780**] was admitted to the [**Hospital Unit Name 153**], for a short course,
because of hypercarbic respiratory failure from a COPD
exacerbation. She required a short course of intubation and
mechanical ventiliation. Thereafter, she recovered to baseline
with steroids, nebulizers, and levofloxacin.
1) Resp Distress/COPD: Again, she had hypercarbic failure and
was initially intubated for a COPD exacerbation. Her CXR showed
only right basilar atelectasis and emphysema. An initial sputum
gram stain had 4+ GNRs but the subsequent culture was negative.
She initialyl had leukocytosis, but this also imprvoved. She was
given albuterol and atroven nebulizers and was transitioned from
solumedrol to a Prednisone taper. She was started on
Levofloxacin for a ten day course. Baseline PFTs were obtained,
but the results (which showed somewhat preserved lung volumes,
with marked decrease of her FEV1 and FEV1/FVC and DLCO) may not
have represented a true baseline given her resolving acute
pulmonary process. She was discharged with Pulmonary follow-up
and was given extensive counseling on smoking cessation - she
was started on Nicotine replacement.
2) Hypotension: Of note, the patient had a short episode of
hypotension in the ED after intubation. This responded to fluid
boluses. Her blood pressure was stable thereafter.
Medications on Admission:
Protonix, Keppra, Albuterol, Combivent.
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*30 capsule* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily): DO NOT SMOKE AND USE THE PATCH AT THE
SAME TIME. IF YOU START SMOKING AGAIN, STOP TAKING THE PATCH.
Disp:*30 Patch 24HR(s)* Refills:*0*
5. Prednisone 20 mg Tablet Sig: Please refer to instructions
Tablet PO DAILY (Daily) for 8 days: Please take 3 tablets (60
mg) from [**2183-4-11**] to [**2183-4-12**]. Then take 2 tablets (40 mg) from
[**2183-4-13**] to [**2183-4-14**]. Then take 1 tablet (20 mg) from [**2183-4-15**] to
[**2183-4-16**]. Finally, take [**2-9**] tablet (10 mg) from [**2183-4-17**] to
[**2183-4-18**].
Disp:*13 Tablet(s)* Refills:*0*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
Disp:*4 inh* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Acute Exacerbation of COPD.
Secondary/PMH
1. Intravenous Drug Abuse.
2. Migraines.
3. Seizure Disorder.
4. HCV Infection.
5. Idiopathic Anemia.
Discharge Condition:
Good/Stable.
Discharge Instructions:
1) Take your medications as instructed.
2) If you have any worsening shortness of breath, chest pain,
fevers, chills, or any other concerning symptoms, return to the
ER or call your doctor.
3) Continue to use the Nicoderm Patch to help you stop smoking.
If you start smoking again, which is STRONGLY DISCOURAGED, stop
using the patch.
4) Your last methadone dose (60mg) was on [**2183-4-10**] at 8AM.
Followup Instructions:
1) Please see your new primary doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for the
following appointment. This can be confirmed by calling
[**Telephone/Fax (1) 250**]. Please also inform Dr. [**Last Name (STitle) **] and your previous
doctor ([**Last Name (LF) **],[**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 26774**]) that you will be
transferring your care:
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2183-4-24**] 2:30
2) Please see your new lung doctor (Dr. [**Last Name (STitle) 575**] for the
following appointment. You may call 617-667-LUNG to confirm this
appointment:
Provider PULMONARY BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2183-5-6**]
11:00
Provider PULMONARY EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2183-5-6**] 11:15
Provider [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2183-5-6**] 11:15
3) Please speak with Dr. [**Last Name (STitle) **] about smoking cessation. You need
to quit smoking and both Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] [**Name5 (PTitle) 19039**] (lung
doctor) will help you.
4) Finally, see your liver doctor for the following appointment:
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 2424**], MD Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2183-7-22**] 10:45.
|
[
"070.70",
"780.39",
"304.01",
"491.21",
"305.1",
"518.81",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6579, 6585
|
3555, 4905
|
287, 327
|
6787, 6801
|
2083, 3532
|
7253, 8988
|
1813, 1876
|
4995, 6556
|
6606, 6766
|
4931, 4972
|
6825, 7230
|
1891, 2064
|
228, 249
|
355, 1470
|
1492, 1619
|
1635, 1797
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,423
| 181,606
|
44390
|
Discharge summary
|
report
|
Admission Date: [**2108-2-14**] Discharge Date: [**2108-2-17**]
Date of Birth: [**2026-6-13**] Sex: F
Service: MEDICINE
Allergies:
Metoclopramide
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
respiratory distress in setting of hypertensive emergency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81F with HTN, DMII , hx of CVA (Pontine) with residual right
sided weakness and dysarthria, vascular dementia (baseline AOx1-
x2), history of UTIs w/ indwelling catheter, who presents from
[**Hospital1 1501**] with acute onset of respiratory distress and hypoxia in the
setting of hypertensive urgency. As per EMS report, her O2 sat
was down to 80s% on RA and RR in the 20s. Her O2 sat improved to
mid 90s% with a non-rebreather. Her BP was 221/83 and HR at 75,
glucose 328.
On arrival to the ED her vitals were afebrile, 62, 148/65, mid
20s-30s, O2 Sat 100 on NRB. She was minimally verbal and overall
appeared uncomfortable. Her EKG showed sinus rhythm with LVH,
left axis deviation, and mild J point elevation in V1 and V2.
Her WBC was 23K with N:94 Band:0 L:3 M:2 E:1. Her cxray was
concerning for pulm edema and ? RLL pna. Her ABG was pH 7.33/
pCO2 56/ pO2 97/ HCO3 31. She was placed on bipap. She was then
started on 1 gm Vancomycin and 4.5 gm Zosyn for presumed
aspiration pneumonia. She was also started on nitroglycerin drip
for HTN and given 60 mg IV Lasix. She had minimal response to
the 60 mg IV lasix and she was placed on bipap.
On admission to the MICU her vitals were HR 61 BP 195/62 RR low
30s O2Sat 100% on Bipap. She had one episode of emesis while on
the bipap. She also had large amount of loose BM. She was using
accessory resp muscles. She was removed from the Bipap and
placed on a non-rebreather, her O2 sat remained in the upper
90s%. She was given 2 mg of IV morphine and 100mg of Lasix IV.
The foley was replaced since it had fallen during the transfer.
Of note the patient was admitted to [**Hospital1 18**] in [**Month (only) 547**], [**Month (only) **] and in
[**Month (only) **] of last year for similar episodes of UTI and hypertensive
urgency in the setting of nausea and vomiting. During her last
admission in [**Month (only) **], she was also found to have gallstone
pancreatitis, self-resolved.
Past Medical History:
- HTN
- Recent admissions [**4-/2107**] and [**9-/2107**] for hypertensive
emergency, [**9-/2107**] hypertensive emergency c/b ARF, Cr peak 2.1
- Renal U/S [**9-/2107**] showed no renal artery stenosis
- DMII
- Chronic UTIs, incontinence
- Grew pansensitive E. coli in [**9-/2107**]
- Indwelling Foley
- CVA '[**96**] with right sided weakness.
- Baseline dependent for all AADLs, incontinent of bowel and
bladder, unable to feed self.
- Baseline speech impairment, mostly non-verbal
- Vascular Dementia
- Depression
- ?Gallstone pancreatitis, self-resolved - admission on [**12/2107**]
- Hyperlipidemia
- Difficulty swallowing - aspiration risk
- Glaucoma
- Chronic diastolic CHF
- Most recent TTE in [**2100**]: EF 60-65%, mild RA enlargement,
otherwise normal
- Anemia
- Sacral Ulcer
Social History:
Lives at [**Hospital3 537**], dependent for all ADL's. no
EtOH/tobacco/other drugs. Not ambulatory, needs a mechanical
lift for transfers and is incontinent of bowel and bladder.
Family History:
unable to be obtained.
Physical Exam:
On Admission:
GEN: alert, minimally verbal, occ. making sounds, following
command to open eyes
HEENT: constant chewing motions, MMM
NECK: supple, JVP elevated at jaw line
PULM: Tachypenic, using accesory muscles for breathing, diffuse
rhonchi bilaterally, exp wheezing
CARD: RRR, nl S1/S2, no m/r/g
ABD: obese, soft, non-tender, +BS x 4 quads
EXT: no edema, + pulses, cool to touch
GU: Foley-> with sediment
SKIN: healing ulcer on buttocks/sacral area
NEURO: AOx1, openning eyes to command
Pertinent Results:
Admission Labs:
[**2108-2-14**] 04:40PM BLOOD WBC-23.8* RBC-3.78* Hgb-10.7* Hct-30.4*
MCV-81* MCH-28.4 MCHC-35.3* RDW-14.9 Plt Ct-339
[**2108-2-14**] 04:40PM BLOOD Neuts-94* Bands-0 Lymphs-3* Monos-2 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2108-2-14**] 04:40PM BLOOD PT-34.3* PTT-29.2 INR(PT)-3.5*
[**2108-2-14**] 04:40PM BLOOD Fibrino-682*
[**2108-2-14**] 04:40PM BLOOD UreaN-63* Creat-2.4*
[**2108-2-14**] 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Discharge Labs:
[**2108-2-16**] 06:55AM BLOOD WBC-19.8* RBC-3.39* Hgb-9.6* Hct-27.1*
MCV-80* MCH-28.3 MCHC-35.4* RDW-15.3 Plt Ct-312
[**2108-2-16**] 06:55AM BLOOD PT-49.3* PTT-40.4* INR(PT)-5.4*
[**2108-2-16**] 06:55AM BLOOD Glucose-146* UreaN-66* Creat-2.6* Na-138
K-4.9 Cl-96 HCO3-25 AnGap-22*
[**2108-2-16**] 06:55AM BLOOD Calcium-8.9 Phos-5.7* Mg-2.5
Cardiac Markers:
[**2108-2-14**] 04:40PM BLOOD cTropnT-<0.01
[**2108-2-14**] 04:40PM BLOOD proBNP-2509*
[**2108-2-15**] 03:35AM BLOOD CK-MB-2 cTropnT-<0.01
ABG:
[**2108-2-14**] 04:52PM BLOOD pH-7.32*
[**2108-2-14**] 05:31PM BLOOD Type-ART pO2-97 pCO2-56* pH-7.33*
calTCO2-31* Base XS-1 Intubat-NOT INTUBA
[**2108-2-15**] 03:32AM BLOOD Type-ART Temp-36.7 Rates-/20 FiO2-50
pO2-78* pCO2-50* pH-7.37 calTCO2-30 Base XS-1 Intubat-NOT INTUBA
Comment-NEBULIZER
Microbiology:
URINE CULTURE (Final [**2108-2-15**]): NO GROWTH.
Blood Culture: Routine (Preliminary) Set#2:
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **] @ 1:32PM [**2108-2-17**].
Isolated from only one set in the previous five days.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Anaerobic Bottle Gram Stain (Final [**2108-2-16**]) Set#1:
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **] 9-0953 [**2108-2-16**] 9:05AM.
GRAM POSITIVE COCCI IN CLUSTERS.
Urine:
[**2108-2-14**] 04:40PM URINE Blood-SM Nitrite-NEG Protein-150
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2108-2-14**] 08:41PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2108-2-14**] 04:40PM URINE RBC-[**3-17**]* WBC-[**12-2**]* Bacteri-MANY
Yeast-MOD Epi-0-2
[**2108-2-14**] 08:41PM URINE RBC-[**12-2**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
Studies:
CHEST (PORTABLE AP) Study Date of [**2108-2-14**] 4:34 PM
FINDINGS: There are low lung volumes. Cephalization and
prominence of the
vasculature is present however no overt pulmonary edema is seen.
Denser
consolidation at the bases likely represents atelectasis;
however,
infection/consolidation cannot be excluded. No pneumothorax is
seen. Trace
pleural effusion on the right may be present. There is mild
cardiomegaly.
The aorta is tortuous.
ECG Study Date of [**2108-2-14**] 4:39:32 PM
Sinus rhythm. Borderline P-R interval prolongation. Consider
left atrial
abnormality. Left ventricular hypertrophy by voltage in lead aVL
with ST-T wave abnormalities, strain and/or myocardial ischemia.
Since the previous tracing of [**2107-12-15**] ST-T wave abnormalities
are difficult to compare because of differences in artifact.
Brief Hospital Course:
81 yo fem with multiple medical problems including HTN, DMII,
CVA (Pontine), vascular dementia, and recurrent UTIs who
presents from [**Hospital1 1501**] with acute onset of respiratory distress and
hypoxia in the setting of hypertensive urgency.
# Goals of Care: [**2108-2-16**] a family meeting conference call was
held with the primary team, palliative care, and multiple family
members including the HCP. The decision was made to make Ms.
[**Known lastname 95171**] CMO with the goals of care targeted towards comfort,
which would be consistent with her goals, based on her
prognosis. She currently has multiple medical issues. We have
limited her tethers, and decreased vital signs to [**Hospital1 **]
(monitoring BP). We had been treating her bacteremia and
discontinued antibiotics prior to discharge (Coag negative
staph) to Hospice care. We treated her blood pressure for
comfort purposes, as well as allowed her to eat despite
aspiration risk, all with the goal of comfort in mind. She had
morphine 2-4mg IV available for dypnea or pain, though she did
not require any. We have arranged a proper medication list upon
discharge to Hospice. We discontinued lab draws, and monitored
her for symptom management. Her current issues are:
Bacteremia, Hypertension, ARF, upper extremity DVT, diastolic
CHF, and anemia, dementia and glaucoma. During admission, her
issues were as follows:
# Respiratory distress: On admission to the ICU pt was breathing
in the 30s, with use of accessory muscles, and hypoxic sating in
the 80s% on RA and hypercarbic. She was treated with lasix IV
160 mg with good urine output for flash pulmonary edema in the
setting of hypertensive emergency. She was no longer felt to be
volume overloaded the following morning and was run with a I/O
goal of net even. She was also started on vancomycin and zosyn
to treat a possible aspiration pneumonia given her CXR findings.
She was continued on 50% oxygen through a face tent with sats in
the high 90s to 100%, 90-92% on RA. BiPap was not considered
given her poor toleration of it earlier during her
hospitalization (vomited). She is DNI, this was confirmed with
her HCP. On the floor, she tolerated a one time dose of lasix
for further diuresis and her oxygenation improved to 92% on room
air
# Hypertensive Emergency: Pt had 3 admissions last year for
similar episodes with hypertension leading to respiratory
distress. Differential diagnosis included RAS and decompensated
dCHF. She arrived on the floor on a nitro drip, this was weaned
off soon after. As her oxygenation improved and she calmed down
her blood pressures improved. She was put on her home regimen
(Clonidine 0.1/0.2/0.2mg TID, Metoprolol 150mg TID, Amlodipine 1
mg daily, Isosorbide mononitrate ER 30mg daily) with improved
blood pressure control.
# Decompensated dCHF: Pt with hx of dCHF, although last ECHO was
in [**2100**]. Her symptoms were likely due to decompensated CHF and
worsening cardiac fx along with hypertensive urgency. JVP was
elevated on admission, BNP elevated at 2500 and appeared to have
pulmonary edema on CXR. She was diuresed with 260 mg of lasix
total over her stay. Her volume status and oxygenation improved.
# Bacteremia: Pt with elevated WBC 23K with left shift on
admission. Pt with hx recurrent UTIs and question of pna on
cxray. She was treated for aspiration pna as above. Urine
culture sent given h/o indwelling foley in place with sediment
noted, which was negative. She was covered broadly with
vanc/zosyn. Remained afebrile. She had blood cultures drawn
which showed Coagulase Negative Staph ([**2-15**] sets) and
Diphtheroides ([**1-15**] sets). Prior to discharge, her antibiotics
were discontinued for transition to hospice care.
# Acute renal failure: Secondary to hypoperfusion due to poor
forward flow. Prior Creat 2.1 during previous hospitalization
with baseline 1.7. This could also be due RAS. Monitored lytes,
creatinine.
# Nausea/vomiting: Pt has hx of gastroparesis and was previously
on reglan which caused tardive dyskinesia. As per family this
was stopped a "while ago". NG tube was placed given emesis while
BiPap on. This was removed and speech and swallow consult was
placed. Patient with no further nausea/vomiting. She is an
aspiration risk, but was allowed to eat a pureed diet for
comfort purposes.
# Upper ext DVT: Pt with hx of PICC-associated RUE DVT from last
admisson in [**12/2107**] which was being treated with coumadin. Held
coumadin given INR supra-therapeutic at 5.4 on last check. No
further labs were checked.
# Diabetes mellitus: Pt continued on home Lantus with humalog
SS.
# Normocytic anemia: Hx of anemia. Hct at baseline in low 30s.
Will guaiac stools. cont to monitor HCT
# Depression: Continue cymbalta
# Dementia: NPO with conservative diet advancement
# Glaucoma: Continue timolol.
# Transfer of care: She was transferred to her NH with hospice
care. She was DNR/DNI during this admission.
Medications on Admission:
collected from nursing home records
Novolin insulin sliding scale
<201: nothing
201-250: 2 units
251-300: 4 units
301-350: 6 units
>351: 8 units
Lantus 18u [**Hospital1 **]
Glucagon PRN
Coumadin ([**2-10**] - written in nusring home [**Month (only) 16**] - 8 mg for 4 days)
Clonidine 0.1/0.2/0.2mg TID
Metoprolol 150mg TID
Omeprazole 20mg daily
Timolol 0.25%, 1 drop OU daily
Amlodipine 10mg daily
Citalopram 10mg daily
Isosorbide mononitrate ER 30mg daily
Aspirin 81 mg daily
Acetaminophen 650 mg q4h PRN
Miralax PRN
Milk of Magnesia PRN
Lacrilube PRN
Dulcolax PR every 3 days
Colace 1 tab [**Hospital1 **]
MVI
Gas-X 1 tablet TID
Senna 1 tab [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Hypertensive Emergency
Acute on chronic kidney injury
Bacteremia
Secondary Diagnosis:
Diastolic heart failure (not decompensated)
Upper extremity DVT
Diabetes Mellitus Type II
Anemia
Depression
Glaucoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 95171**],
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] for very high blood pressure and fluid on your lungs
causing you to have a low oxygen level. We gave you medicine to
take fluid off of your lungs and gave you your blood pressure
medications. Your symptoms improved, and at the time of
discharge you were breathing on room air.
During your stay, you had multiple medical problems including
bacteria in your blood, high blood pressure, difficulty
breathing, acute on chronic kidney injury. We initially treated
your problems medical problems with various medications.
However, after discussing things with your family, the decision
was made to focus on keeping you comfortable going forward.
We made the following changes to your medications:
-STOPPED Coumadin
-STARTED Morphine for comfort for shortness of breath
-STARTED Miconazole powder for rash
We will avoid hospitalizing you in the future with the plan to
keep you comfortable at home.
Followup Instructions:
You will be seen by your Nursing Home physicians for follow-up
Completed by:[**2108-2-17**]
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26,741
| 150,267
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47669
|
Discharge summary
|
report
|
Admission Date: [**2109-5-14**] Discharge Date: [**2109-5-20**]
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Morphine
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 yo F h/o A fib s/p ablation with vent PM, CHF (EF 40%), HTN,
DM2, CAD p/w GIB. Pt was in USOH until 2 days prior to admission
when staff at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] noted grossly bloody BM. Caregiver
at [**Name2 (NI) **] unable to quantify volume. Since that time pt has had
three further grossly bloody BMS, including one this AM. Per
caregiver, the commode was completely full of bright red blood.
Hct checked and was 20, down from baseline of low 30s. Pt given
vit K 2.5 sc x1 and transferred to [**Hospital1 18**] for further management.
.
In the ED vitals: t 99.3, 127/56, hr 74, rr 13, 100% 3L NC.
Remained HD stable throughout her time in ED. NGL was negative.
Hct 21, inr 2.3. Pt given [**Hospital1 **] 40 mg iv x1. Pt received one
unit prbcs, one unit hanging en route. Pt transferred to [**Hospital Unit Name 153**]
for further management.
Past Medical History:
1. Left intertrochanteric hip fracture [**2105-12-5**] s/p open
reduction/internal fixation and recent open reductioin/internal
fixation revision on [**2106-1-21**]
2. Congestive heart failure with diastolic dysfunction (last
echo [**2106-1-21**] EF 55%)
3. Atrial fibrillation status post ablation with ventricular
[**Year/Month/Day 4448**] since [**2099**]
4. Gastroesophageal reflux disease (EGD showed chemical
gastritis in the past)
5. Hypertension
6. Noninsulin dependent diabetes mellitus x 6-7 years; HgA1C 6.4
([**2105-9-3**])
7. Hypothyroidism last TSH 1.7 ([**2105-9-14**])
8. Glaucoma
9. History of cerebrovascular accident (per records, patient
denies)
10. Status post cholecystectomy
[**12**]. Chronic renal insufficiency (baseline Cr 1.3 to 1.5)
12. History of delirium postoperatively
13. History of left lower extremity edema
14. Status post ? umbilical surgery (?herniorrhaphy)
15. Status post partial hysterectomy
16. CAD - stress test [**11/2104**] antinal type sx without ST changes
at limited level of exercise. Cath [**9-/2101**] with mild 2 vessel
disease: 1. OM1 50-60% proximal and 50% sub-branch 2. RCA
dominant 50% proximal and 40 % mid lesion
Social History:
SOCIAL HISTORY: The patient lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. She has a
cousin who lives nearby and helps her out. Had 9 children 5 of
whom are deceased. Denies tobacco, alcohol or drug use.
Family History:
FAMILY HISTORY: Father died in service during WWI. Mother and
older brothers, now all deceased, were healthy.
Physical Exam:
Temp 97.8
BP 127/56
Pulse 74
Resp 13
O2 sat 100% 2L NC
Gen - initially non-responsive, but once aroused, combative
HEENT - PER sluggishly RL, extraocular motions intact,
anicteric, mucous membranes dry
Neck - no JVD, no cervical lymphadenopathy
Chest - uncooperative with ecam, but on limited exam clear to
auscultation bilaterally
CV - regular, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No edema. 2+ DP pulses bilaterally
Skin - No rash
Pertinent Results:
Admit labs:
[**2109-5-14**] 01:00PM WBC-6.1 RBC-2.28*# HGB-6.9*# HCT-21.1*#
MCV-93 MCH-30.1 MCHC-32.6 RDW-16.3*
[**2109-5-14**] 01:00PM NEUTS-62.8 LYMPHS-26.5 MONOS-5.5 EOS-5.0*
BASOS-0.3
[**2109-5-14**] 01:00PM PLT COUNT-135*
[**2109-5-14**] 01:00PM PT-23.4* PTT-29.5 INR(PT)-2.3*
[**2109-5-14**] 01:00PM GLUCOSE-114* UREA N-41* CREAT-1.7* SODIUM-140
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-29 ANION GAP-11
.
Discharge labs:
.
[**5-16**] CXR: Lungs were clear of an acute process. The heart is
generally enlarged. A battery apparatus seen in the left
pectoral area with right atrial and right ventricular leads.
CONCLUSION: No evidence of active inflammatory disease or
failure.
..
..
ECG:
Regular ventricularly paced rhythm. Underlying rhythm is
probably atrial
fibrillation
Brief Hospital Course:
Ms. [**Known lastname **] is an 84 year old woman with history of dementia, CVA,
CHF, CAD, atrial fibrillation who presented with GI bleeding.
The following issues were addressed on this admission:
1.GIB: Appears to be lower GI bleed by history, though could be
brisk UGIB. Pt at risk for bleed given on coumadin and ASA at
home. GI was consulted and decided that because of the
patient's mental status intubation would be required for
preparation and scope for colonoscopy. Given her DNR/DNI status
it was decided that endoscopy would not be done at this time.
The patient's anticoagulation was reversed with FFP and Vitamin
K. Aspirin and coumadin held. A total of 7 units of pRBC's
given until hematocrit stabilized on [**5-17**]. Crit stable between
27-30 throughout [**Date range (1) 17392**] Given goals of care, decision made
not to pursue colonoscopy which would require sedation and
intubation. Decision made along with PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8467**], and HCP,
[**Name (NI) **] [**Name (NI) **]. For now aspirin and coumadin will continue to be
held, to be re-started at discretion of PCP. [**Name10 (NameIs) **] will need
daily hematocrit monitoring at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **].
.
2. Acute renal failure, chronic kidney disease: Likely all
secondary to hypovolemia, pre-renal. Improved with blood and
ivf's. Baseline appears to be around 1.1-1.2 Creatinine on
discharge 1.2 Ace inhibition to be re-started as outpatient,
held given acute renal failure.
.
3. Cardiovascular: Coronary artery disease: aspirin held
throughout given bleeding. Beta blocker and ace inhibitor held
with GI bleeding, hypovolemia, relative hypotension and renal
failure. Statin continued. NSTEMI: troponin leak, likely
demand in setting of GI bleeding. continue statin. Re-start
aspirin, ace, beta [**Last Name (un) 86928**] at discretion of Dr. [**Last Name (STitle) 8467**] as
outpatient.
Congestive Heart failure: LV systolic dysfunction with ef 40%.
Ace, beta blocker and outpatient lasix held given GI bleeding,
renal failure, hypotension. Lasix re-started on [**5-19**] as patient
with some shortness of breath, crackles on exam.
Atrial fibrillation: coumadin held in setting of large GI bleed.
Beta blocker held as above.
.
4. Hypernatremia: developed with fluid repletion, mostly NS.
Free water given and resolved.
.
5.Dementia/episodic delirium: Pt confused and often combative at
baseline [**First Name8 (NamePattern2) **] [**Last Name (un) **] caregivers. Continued risperdal, trazodone
and paxil.
.
6. UTI: hospital acquired UTI likely secondary to urinary
catheterization. Catheter removed on [**5-19**]. Cipro started [**5-19**].
Will require 7 day course, started [**5-19**] evening, urine culture
pending.
.
7.glaucoma: continued home eye drops
.
8.hypothyroidism: continued home synthroid. TSH mildly elevated
but free T4 wnl.
.
9. Osteoporosis: Actonel held given GI bleeding. Continued on
calcium
.
comm: [**Name (NI) 100701**] [**Name (NI) **] cousin/HCP [**Telephone/Fax (1) 100702**]
.
code: DNR/DNI
Patient to be discharged to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Plan discussed with
Dr. [**Last Name (STitle) 8467**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on day of discharge. Patient will
need daily hematocrit monitoring. Urine culture outstanding and
should be followed up.
Medications on Admission:
asa 81 mg daily
coumadin 2.5 mg daily
actonel 35 mg qweek
levothyroxine 125 mcg daily
brimonidine eye drops
lasix 20 mg daily
lisinopril 5 mg daily
metoprolol 25 mg daily
trazodone 25 mg tid prn agitation
trazodone 25 mg [**Hospital1 **]
lovastatin 20 mg daily
CaCO3 500 mg [**Hospital1 **]
MVI
risperdal 0.5 mg qhs/1 mg qhs
lumigan eye drops
lubricant eye drops
senna
promethazine prn
MOM prn
paxil 30 mg qhs
ibuprofen prn
robitussin prn
bisacodyl prn
tylenol prn
lactulose prn constipation
albuterol prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1.gastrointestinal bleed
2.renal failure
3.dementia
4.coronary artery disease/NSTEMI
Secondary:
1.congestive heart failure
2.glaucoma
3. hypothyroidism
4. osteoporosis
Discharge Condition:
stable, taking good PO, at baseline mental status which is
sometimes agitated and combative.
Discharge Instructions:
Please take medications as prescribed. If you begin to bleed
again, or have any other concerning symptoms please contact a
physician [**Name Initial (PRE) 2227**].
.
Take all your medications as prescribed.
.
Follow up as below.
.
Dr. [**Last Name (STitle) 8467**] is aware of your hospitalization and course. If you
have any questions you can contact him.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 8467**]. He is aware of your course and will
follow you at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **].
You also have the following appointments:
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2109-6-18**]
11:15
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2109-7-15**]
10:30
|
[
"584.9",
"V58.61",
"276.0",
"250.00",
"414.01",
"294.8",
"585.9",
"410.71",
"244.9",
"578.9",
"427.31",
"403.90",
"V45.01",
"365.9",
"428.0",
"599.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8128, 8201
|
4109, 7571
|
254, 261
|
8423, 8518
|
3294, 3713
|
8925, 9355
|
2670, 2765
|
8222, 8402
|
7597, 8105
|
8542, 8902
|
3730, 4086
|
2780, 3275
|
206, 216
|
289, 1188
|
1210, 2383
|
2415, 2638
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,724
| 149,365
|
37485
|
Discharge summary
|
report
|
Admission Date: [**2194-12-22**] Discharge Date: [**2195-1-7**]
Date of Birth: [**2157-12-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Respiratory Failure
Major Surgical or Invasive Procedure:
Intubation & mechanical ventilation
History of Present Illness:
37 yo F with PMH of recurrent bronchitis transferred from OSH
after presenting there BIBA after being found hypoxic to 50% on
RA and intubated in the field. Per her husband and mother, the
patient was feeling poorly when she went to work Friday night.
Came home Saturday morning and slept all day Saturday and
Sunday. Her mother called 911 when she found the patient
looking 'dusky' and she did not recognize her mother. [**Name (NI) **] EMS
report, she was 50% on RA. At OSH she was intubated, received a
dose of vanc/zosyn, CXR showed 'white out' and she was
transferred here.
In the ED here, she required high amounts of PEEP. When she was
switched to the vent she was bagged initially with sats 85-95%.
When she was first placed on the vent, O2 sats dropped to 70s%.
She was placed back on the bag and sats returned. Eventually
back on vent satting ok. Blood pressures were borderline 90-100
and she required dopamine for a short time but got 1L IVF and
dopa was weaned off prior to transfer to the unit.
In the ED, her FAST exam was negative, BHG negative, trop 0.04
(?0.6 at OSH but no documentation). Cards was c/s given concern
for pulmonary edema based on CXR which showed no pericardial
effusion, but overall 'squeeze' given her age. RIJ placed. VS
prior to transfer: BP:113/91 off dopa HR: 103 91% on 380x24 PEEP
18 100% FiO2. She was given decadron for unclear reason
(resident signing patient out did not know). No Tamiflu was
given.
ROS and history unable to be obtained as patient in intubated
and sedated.
Has a line
Past Medical History:
Recurrent Bronchitis/PNA
Morbid Obesity BMI of 55
Migraine
Social History:
Married, lives with husband. [**Name (NI) 1403**] at a prison.
- Tobacco: 1 pack every 3 days
- Alcohol: rare
- Illicits: none
Family History:
NC
Physical Exam:
Temp:102.2 R HR:100 BP:107/68 Resp:20 O(2)Sat:85% vent low
Constitutional: Comfortable; intubated
Head / Eyes: Normocephalic, atraumatic
Chest/Resp: Decreased air entry throughout but R = L; coarse
rhonci throughout all lung fields; hypoxic on vent - better with
bagging
Cardiovascular: sinus tachycardia; initially BP okay but
subsequently dropped, Normal first and second heart sounds
GI / Abdominal: Obese; Soft, Nontender, Nondistended
Musc/Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: paralyzed
Pertinent Results:
Admission labs:
[**2194-12-22**] 05:45PM BLOOD WBC-13.6* RBC-4.53 Hgb-13.5 Hct-40.4
MCV-89 MCH-29.9 MCHC-33.5 RDW-12.8 Plt Ct-211
[**2194-12-22**] 05:45PM BLOOD Neuts-90.1* Lymphs-5.4* Monos-3.4 Eos-0.5
Baso-0.5
[**2194-12-22**] 05:45PM BLOOD PT-14.0* PTT-21.3* INR(PT)-1.2*
[**2194-12-22**] 05:45PM BLOOD Glucose-287* UreaN-19 Creat-0.9 Na-137
K-4.2 Cl-101 HCO3-25 AnGap-15
[**2194-12-22**] 05:45PM BLOOD CK(CPK)-64
[**2194-12-22**] 05:45PM BLOOD CK-MB-NotDone
[**2194-12-22**] 05:45PM BLOOD cTropnT-0.04*
[**2194-12-22**] 05:45PM BLOOD Calcium-8.2* Phos-1.9* Mg-2.0
[**2194-12-22**] 06:52PM BLOOD Type-ART pO2-81* pCO2-65* pH-7.26*
calTCO2-31* Base XS-0
[**2194-12-22**] 05:48PM BLOOD Lactate-1.9
[**2194-12-22**] 05:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.031
[**2194-12-22**] 05:50PM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-100 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2194-12-22**] 05:50PM URINE RBC-0-2 WBC-[**1-23**] Bacteri-MANY Yeast-NONE
Epi-[**4-30**] TransE-0-2
[**2194-12-22**] 05:50PM URINE AmorphX-MOD
[**2194-12-22**] 05:50PM URINE
[**12-22**] ECG: Baseline artifact. Sinus tachycardia. Short P-R
interval. ST-T wave abnormalities. No previous tracing available
for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
102 112 78 332/405 58 9 86
[**12-22**] TTE: Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen. No aortic regurgitation is seen.
The mitral valve leaflets are not well seen. No mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Grossly preserved biventricular systolic function.
Limited emergency study.
[**12-23**] CXR: An ET tube is noted in situ, terminating 5.1 cm above
the carina. There is an NG tube which is partially visualized up
to the hemidiaphragms. There are diffuse bilateral alveolar
opacities,
predominantly affecting the right, left mid and lower lungs.
There is no
pneumothorax or appreciable pleural effusion. No displaced rib
fracture is
seen.
IMPRESSION: Extensive bilateral air space opacities opacities,
differential considerations include flash pulmonary edema
(cardiogenic and noncardiogenic), ARDS or severe multifocal
infection. Clinical correlation advised.
[**12-28**] CT Head/Neck: 1. No evidence of venous sinus thrombosis or
other intracranial vascular abnormalities.
2. Moderate paranasal sinus disease.
3. Diffuse cervical fat stranding and reactive nodes may be
related to volume overload versus patient body habitus
[**12-29**] CT Chest: 1. Mild bilateral multifocal pneumonia.
2. Bilateral small pleural effusions and associated compression
atelectasis.
3. Borderline enlarged mediastinal and axillary lymph nodes are
likely
reactive.
[**12-31**] Lower extrem U/S: Grayscale and color Doppler imaging of
the common femoral, superficial femoral, and popliteal veins are
performed bilaterally. Normal compressibility, flow, waveform,
and augmentation is demonstrated. No intraluminal thrombus is
identified.
IMPRESSION: No lower extremity deep venous thrombosis
bilaterally.
[**1-1**] CT Chest/Abd/Pelvis: 1. Findings concerning for persistent
bibasal pneumonia. 2. Small amount of free in the pelvis,a
non-specific finding.
MICRO:
[**12-22**] Influenza A/B: Negative
[**12-23**] Resp viral antigen screen/culture: Negative
[**12-24**] Sputum Cx: Commensal Respiratory Flora Absent. YEAST. RARE
GROWTH.
[**12-28**] BCx: +Coag negative staph
[**12-31**] UCx: YEAST. 10,000-100,000 ORGANISMS/ML.
[**12-31**] BAL: YEAST. 10,000-100,000 ORGANISMS/ML..
All other micro studies negative or pending at time of transfer
to the floor
Brief Hospital Course:
37F w/respiratory failure c/w viral ARDS, coagluase negative
staph bacteremia, adrenal insufficienty, rash, and conjunctival
hemorrhage
# Respiratory failure: The patient had been experiencing several
days of cough and malaise leading up to her respiratory failure
and altered mental status, which appeared consistent with
systemic viral process. After being intubated in the field, she
had a prolonged intubation in the MICU, with difficulty weaning
her ventilator settings, most notably her PEEP. Viral studies
including influenza and respiratory viral screen were negative.
She was finally extubated on [**1-2**] and subsequently did very well
on mask and nasal cannula. She did experience desaturations to
the 80's while sleeping, so CPAP was placed for likely
obstructive sleep apnea. She was initially placed on broad
spectrum antibiotics, which were later pulled off, although
zosyn was temporarily restarted for CT findings concerning for
sinusitis. Throughout her time in the MICU she was also treated
with albuterol and atrovent. The patient had an HIV antibody
test sent on day of transfer to the floor, which was ultimately
negative. She left after working with PT and uneventfully
weaning off of oxygen support.
# Hypotension: The patient was believed to be septic on arrival,
given fevers and leukocytosis. She initially did not require
pressors, but levophed was eventually started on [**12-23**]. Her
pressor requirement fluctuated throughout her stay in the MICU,
and was ultimately discontinued on [**1-1**].
# Adrenal Insufficiency: The patient's AM cortisol was checked
for persistent hypotension, and was found to be 3. She was
started on replacement steroid solumedrol. This was weaned to
dexamethasone 0.5 mg IV Q12 hours, at time of transfer to floor.
She uneventfully weaned to nothing on the floor.
# Facial/upper torso rash: The patient had multiple rashes and
episodes of hives all over her body. Per her family, she has a
history of having sensitive skin. Given peripheral eosinophilia,
this was believed to be [**12-23**] hypersensitivity reaction, possibly
to one of the antibiotics she received. She was treated with
steroid creams and PRN diphenhydramine. This was resolving at
the time of discharge.
# Conjunctival hemorrhage: The patient developed bilaterally
conjunctival hemorrhages, and ophthalmology was consulted. They
believed that such hemorrhages can occur with very high
ventilator pressures, and expected that the patient's hemorrhage
and edema would improve with time. Of note, the patient has some
baseline diplopia at home.
# Bacteremia: The patient had blood cultures positive for
coagulase negative staph. She completed a course of vancomycin
and MRSA precautions were temporarily instituted, before the
sensitivities returned from the micro lab.
# Diabetes Mellitus, Type 2: Treating with insulin boluses, off
gtt. On the floor she was briefly on SQ insulin, and then was
started on metformin with excellent glucose control while in
house.
# Sinusitis: The patient's CT scans revealed radiologic findings
c/w sinusitis. She was temporarily placed on zosyn, which was
later discontinued out of concern for allergic reaction. She was
also placed on fluticasone nasal inhaler.
Medications on Admission:
None
Discharge Medications:
1. [**Hospital 16836**] Medical Equipment
1 Bariatric Commode
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic TID (3 times a day) as needed for scleral
edema.
Disp:*1 tube* Refills:*2*
5. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q4H (every 4 hours).
Disp:*1 tube* Refills:*2*
6. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Disp:*1 bottle* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for asthma.
Disp:*1 inhaler* Refills:*2*
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed for asthma.
Disp:*1 inhaler* Refills:*2*
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 bottle* Refills:*2*
11. Metformin 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:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Respiratory Faillure NOS
Diabetes Mellitus
Diploplia
secondary
Recurrent Bronchitis
Migraines
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were transferred to [**Hospital1 18**] from another hospital because of
trouble breathing. You briefly required mechanical support for
your breathing, and eventually came off of the ventilator. You
did well, though we never discovered exactly why you had such
issues.
.
While you were here you complained of double vision and were
seen by our ophtalmologists who assured you you would go back to
your baseline.
.
Please note you were noted to have diabetes here and were
started on metformin. You must go to your PCP and discuss this.
.
The following changes were made to your medications:
You were started on metformin 500mg which you should take twice
per day.
You were started on Albuterol which you should take 2 puffs as
needed for wheezing.
You were started on atrovent which you should take 2 puffs twice
per day to prevent wheezing.
You were started on myriad eye ointments which you should use as
directed by the opthalmologists.
Followup Instructions:
MD: [**First Name5 (NamePattern1) 487**] [**Last Name (NamePattern1) 23430**]
Specialty: Internal Medicine/ PCP
[**Name Initial (PRE) 2897**]/ Time: Monday, [**1-19**], 2pm
Location: [**Street Address(2) **], [**Location (un) **]
Phone number: [**Telephone/Fax (1) 23431**]
Completed by:[**2195-1-13**]
|
[
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"693.0",
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"041.19",
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] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11207, 11262
|
6573, 9811
|
334, 371
|
11401, 11401
|
2762, 2762
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|
2210, 2743
|
275, 296
|
399, 1946
|
2778, 6550
|
11415, 11554
|
1968, 2029
|
2045, 2175
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,517
| 169,709
|
27098
|
Discharge summary
|
report
|
Admission Date: [**2125-2-21**] Discharge Date: [**2125-2-27**]
Date of Birth: [**2046-8-28**] Sex: F
Service: MEDICINE
Allergies:
Carbamazepine / Enalapril / Famotidine / Nifedipine /
Penicillins / Cozaar
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 78yoF with HTN, DM2, CAD s/p CABG admitted to the
[**Hospital Unit Name 153**] [**2125-2-22**] for shortness of breath. The states that she first
noted feeling short of breath on the night PTA. She was seen by
her home visiting nurse who noted SOB, and wheezing. There was
no CP, palpitations. No F/C. In the field her RR was 45 and o2
sat was 86% on room air. She was given po lasix and brought to
[**Hospital1 18**].
.
In the ED, she was noted to be in significant respiratory
distress, her vitals were t98.8 p79 bp 182/48 rr 40 sats 100% on
NRB. She was treated for suspected CHF and given ASA and nitro
gtt. ABG was noted 7.41/50/83 on 100% non rebreather.
.
She had a recent admission for syncope at [**Hospital1 112**] thought to be
secondary to orthostasis from BP meds. There was no evidence of
arrhythmia. EP study was negative for inducible VT.
.
In the ICU, her respiratory distress was thought to be secondary
to a COPD exacerbation. She improved significantly on IV
steroids and abx. She is now on room air with sats in the mid
90s. Course was notable for further workup/imaging of the
patient's known goiter. CT scan was performed over concern of
extrinsic compression of the trachea though she did not exhibit
stridor. It did show a large goiter, prox trachea 18.2 mm
diameter, mid with area of compression 16.4 x 9.4 mm, and distal
trachea 19.5 x 18.8 mm. IP evaluated patient and recommended
conservative therapy and f/u with repeat airway CT in [**2-24**] weeks.
Endocrine evaluated patient and recommended further studies to
determine if pt has thyroiditis vs. [**Doctor Last Name **] dz. Pt also went into
rapid atrial fibrillation hemodynamically stable overnight to HR
150s, improved with verapamil. Nasal aspirate positive for
influenza A and pt started on Oseltamivir.
Past Medical History:
Rib fractures T8-11 and T8-10 transverse processes noted during
syncope admission
HTN
CAD s/p CABG '[**16**], stents [**11-27**]
PVD
hyperlipidemia
nephrotic syndrome [**1-25**] DM2/HTN
MNG stable on US
OA in R knee and CMC
DM: retinopathy, nephropathy
CRI baseline cr 1.2
[**First Name9 (NamePattern2) **] [**Doctor First Name **] [**Telephone/Fax (1) 66567**]
Social History:
Lives alone and has home VNA. Walks with cane. No significant
smoking history, occasional tobacco.
Family History:
Non-contributory.
Physical Exam:
Vitals: T 98.1 p 88 bp 191/48 rr 20 97% RA
Gen: A+Ox3, anxious elderly AA woman, in NAD
HEENT: JVP flat, +enlarged thyroid bilaterally L>R, without
nodules, mild tenderness to palpation, no LAD
Lungs: minimal crackles bilaterally
Heart: s1 s2 no m/r/g
Abd: soft nt/nd +bs
Ext: no c/c/e
Neuro: non-focal.
Pertinent Results:
Thyroid uptake scan: Given recent IV contrast dye
administration, this study is non-diagnostic and can not
differentiate between Graves' disease and thyroiditis. If there
is persistent clinical concern, the study may be repeated again
6 weeks after IV contrast administration.
.
Nasal Aspirate: Rapid Respiratory Viral Antigen Test (Final
[**2125-2-22**]):
Positive for respiratory viral antigens except RSV.
Positive for Influenza A viral antigen.
.
Blood cx negative to date.
.
Urine cx negative.
.
CXR [**2-22**]: no pulm edema, no pna, no pneumothorax
.
ECG [**2-22**]: SR at 80 bpm. nl axis, LBBB pattern. Grossly unchanged
from previous ECG at [**Hospital1 112**] last week.
.
Chest CTA [**2125-2-22**]: 1. Multiple acute left-sided rib fractures and
fractures of the transverse processes of the 8 through 11th
thoracic vertebra on the left. No pneumothorax seen. 2. No
evidence of pulmonary embolism or thoracic aortic dissection. 3.
Nodular, heterogeneous thyroid gland. Correlation with
ultrasound may be performed if indicated clinically.
.
CT trachea [**2125-2-22**]: 1. Heterogeneous enlargement of both lobes of
the thyroid gland resulting in symmetrical compression and
coronal narrowing of the trachea reduced to 9 mm in coronal
dimension at the thoracic inlet compared to 19 mm in transverse
dimension below this level. 2. Bronchomalacia. 3. Trace left
pleural effusion. 4. Dependent centrilobular nodules in the left
upper lobe posteriorly most likely due to an aspiration or small
airways infection. Additional 2-3 mm diameter left upper lobe
nodule laterally is nonspecific but likely benign. If warranted
clinically, a one year followup CT could be performed to ensure
stability or resolution and to fully exclude a small lung
cancer. 5. Indeterminate left adrenal lesion. Statistically,
this is most likely due to an adenoma. However, if the patient
has a known malignancy, MR could be considered to further
evaluate this lesion if warranted clinically.
.
CXR [**2-21**]: No CHF, pneumothorax or focal consolidations.
.
Stress MIBI [**2125-2-15**]: mild reversible defect interpreted to be
c/w scar. LV EF 57% no WMA.
.
Echo [**10-28**] @ [**Hospital1 112**]: EF 60% no WMA, diastolic dysfxn
.
[**2125-2-21**] 12:40PM BLOOD WBC-17.6* RBC-3.83* Hgb-11.2* Hct-33.7*
MCV-88 MCH-29.1 MCHC-33.1 RDW-14.7 Plt Ct-320
[**2125-2-21**] 12:40PM BLOOD Neuts-89.9* Lymphs-5.4* Monos-4.3 Eos-0.1
Baso-0.3
[**2125-2-21**] 12:40PM BLOOD PT-12.2 PTT-22.1 INR(PT)-1.0
[**2125-2-21**] 12:40PM BLOOD Plt Ct-320
[**2125-2-21**] 12:40PM BLOOD Glucose-303* UreaN-62* Creat-1.3* Na-143
K-3.6 Cl-102 HCO3-29 AnGap-16
[**2125-2-21**] 12:40PM BLOOD CK(CPK)-182*
[**2125-2-22**] 06:33AM BLOOD ALT-21 AST-24 CK(CPK)-127
[**2125-2-21**] 12:40PM BLOOD CK-MB-6
[**2125-2-21**] 12:40PM BLOOD cTropnT-0.02*
[**2125-2-22**] 06:33AM BLOOD CK-MB-4 cTropnT-0.03*
[**2125-2-23**] 08:26AM BLOOD CK-MB-12* MB Indx-5.2 cTropnT-0.30*
[**2125-2-23**] 11:49AM BLOOD CK-MB-8 cTropnT-0.26*
[**2125-2-21**] 12:40PM BLOOD Calcium-8.6 Phos-3.9 Mg-2.5
[**2125-2-22**] 06:33AM BLOOD TSH-<0.02*
[**2125-2-23**] 08:26AM BLOOD T3-94 Free T4-2.3*
[**2125-2-23**] 11:49AM BLOOD Thyrogl-PND antiTPO-PND
[**2125-2-22**] 06:06AM BLOOD Type-ART pO2-128* pCO2-43 pH-7.42
calHCO3-29 Base XS-3
[**2125-2-21**] 01:46PM BLOOD Lactate-1.5 K-3.4*
[**2125-2-21**] 01:46PM BLOOD freeCa-1.16
[**2125-2-23**] 02:16PM BLOOD THYROTROPIN-BINDING INHIBITORY
IMMUNOGLOBULIN (TBII)-PND
Brief Hospital Course:
78yoF with HTN, DM, CAD s/p CABG, p/w respiratory distress and
AFib in setting of influenza A.
.
## Respiratory distress: Pt is much improved with IV steroids
and abx. Pt. has no known COPD history. + influenza A. CT
trachea showed evidence of small airway infection, and
significant narrowing of the trachea at the level of the
thoracic inlet by the patient's goiter. SOB unlikely due to
compression by trachea, since Pt. now improved without
intervention. CTA was negative for PE. Will continue steroids
for now (prednisone 60mg QD, no taper, as results of thyroid
studies are pending, and would want to continue steroids if Pt.
has [**Doctor Last Name 933**] or thyroiditis). The Pt. received atrovent nebs prn,
and was treated with oseltamivir for influenza A for 5 days
total. Recommmendation from IP was for repeat tracheal CT in
[**2-24**] weeks; if there is an acute change, Pt may need to undergo
rigid bronchoscopy and stenting. Also would recommend PFTs as
outpatient once pt recovers to clarify COPD issue. The Pt. was
discharged with a Rx for atrovent MDI to use TID, plus PRN
wheezing/SOB.
.
## AFib: Pt had new onset rapid AF, hemodynamically stable.
Likely secondary to pulmonary pathology/influenza. Responded to
verapamil, started on low dose BB. Now in NSR. Continue
metoprolol 25 mg [**Hospital1 **]. Would consider TTE as outpt to r/o
thrombus [**1-25**] AFib; most recent TTE in [**10-28**]. If AFib continues,
Pt. may need anticoagulation in the future.
.
## Goiter: Pt evaluated by endocrine. Thyroiditis vs. [**Doctor Last Name 933**] dz.
TSH very low (<0.02), free T4 2.1, T3 85; anti-TPO and
thyroglobulin pending. Thyroid technetium uptake scan was
unsuccessful given recent IV contrast. Pt. discharged on
prednisone 60mg qd, and methimazole. Doses of these medications
will need to be adjusted by Pt's PCP and endocrinologist.
.
## CAD: CE's elevated, index negative. Likely demand ischemia in
setting of bronchospasm and rapid tachycardia. Continue medical
management with ASA, plavix, statin, [**Last Name (un) **], BB.
.
## DM: continue lantus 25U qhs and ISS while in house, diabetic
diet. Pt. has had poor glycemic control while in house, both
hypo and hyperglycemia, possibly related to illness and change
in PO intake. Continue close monitoring as outpt. Pt. reports
that she is allergic to sugar substitutes and can only eat a
regular diet. Her lantus dose was decreased while she was in the
hospital due to several finger sticks <50. Poor glucose control
will likely persist while Pt. is on steroids.
.
## Leukocytosis w/ left shift: Likely secondary to high dose
steroids, will monitor.
.
## Renal insufficiency: Creatinine baseline unclear. [**Name2 (NI) 116**] have
chronic insufficiency from HTN and DM. Pt given hydration and
acetylcysteine for CTA.
.
## HTN: BP continues to be elevated. Now off nitro gtt. On home
meds, low dose BB.
.
## Adrenal adenoma: Incidentaloma on CTA. Will need hormonal
workup and f/u scan.
.
## Pulmonary nodule: Will need OP f/u in 1 year with repeat CT
scan.
.
## Rib pain: Pt s/p fall in past. Lidoderm patch QD.
.
## Ppx: heparin sc, PPI, bowel regimen.
.
## SW: Pt. very upset that ambulance took her to [**Hospital1 18**] rather
than [**Hospital1 112**], as she had requested. Explained that her care can
resume at [**Hospital1 112**] after discharge and that PCP will receive [**Name Initial (PRE) **]
discharge summary for this admission.
.
## Code: Full.
Medications on Admission:
ASA 325 mg po qd
plavix 75 mg po qd
atenolol 50 mg po qd
norvasc 10 mg daily
diovan 160 mg po qd
Imdur 90 po mg [**Hospital1 **]
HCTZ 25 mg po qd
Cardura 0.5 mg po qd
catapres 0.3/24hrs mg qweek
pravachol 80 mg qHS
lantus 30 qPM down from 40 previously
Beconase 40 1 puff [**Hospital1 **]
Acular 1 drop daily
oxycodone 5-10 mg q6 PRN
fentanyl patch 12mc/hr
Neurontin 100 mg po tid
claritin 10 mg po qd
.
Meds on transfer from [**Hospital Unit Name 153**] to medicine:
Amlodipine 10 mg daily
Artificial tears prn
Aspirin 325 mg daily
Benzonatate 100 mg TID
Plavix 75 mg daily
Clonidine TTS 1 patch QWED
Doxazosin 0.5 mg QHS
HCTZ 25 mg daily
SSI+Lantus 40 Qpm
Atrovent nebs prn
Imdur 90 mg daily
Lopressor 25 mg [**Hospital1 **]
Morphine IV prn
Oseltamivir 75 mg [**Hospital1 **]
protonix 40 mg daily
Pravastatin 80 mg daily
Prednisone 60 mg daily
Senna 1 tab [**Hospital1 **]
Valsartan 80 mg daily
.
Allergies:
carbemazepime--> rash
enalapril cough
famotidine dry mouth
nifedipine constipation
PCN rash
Cozaar facial swelling, itch
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
7. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): discuss tapering off this medication with your
PCP/Endocrinologist.
Disp:*60 Tablet(s)* Refills:*2*
12. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-25**]
Drops Ophthalmic PRN (as needed).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q8H (every 8 hours): may use more often if you are wheezing or
feel short of breath.
Disp:*1 canister* Refills:*2*
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD ().
18. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
19. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection three times a day as needed for
hyperglycemia: per sliding scale.
20. Oseltamivir Phosphate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
21. Methimazole 10 mg Tablet Sig: Three (3) Tablet PO QD ():
discuss adjustments with your PCP/Endocrinologist.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Principal:
1. Influenza A. Pneumonia.
2. Diastolic Heart Failure.
3. NSTEMI.
4. Multi Nodular Goiter.
5. Hyperthyroidism.
6. Tracheal Airway Compression.
7. Atrial Fibrillation.
8. Bronchospasm.
Secondary:
1. 3-Vessel Coronary Artery Disease s/p CABG.
2. Diabetes Mellitus.
3. Nephrotic Syndrome.
4. Hyperlipidemia.
5. Hypertension.
6. GERD.
7. Syncope x 2, negative EP evaluation.
8. Fractured ribs.
Discharge Condition:
Hemodynamically stable, breathing comfortably and with oxygen
saturation in mid-90s on room air.
Discharge Instructions:
Please continue to take all your medications exactly as
prescribed.
.
A detailed letter of your hospital course has been sent to Dr.
[**Last Name (STitle) 66568**] at [**Hospital6 1708**]. Please call her office
and make an appointment to see her within the next week.
.
If you experience chest pain, shortness of breath, or any other
concerning symptoms, please call Dr.[**Name (NI) 66569**] office or return
to the hospital.
Followup Instructions:
Please continue to follow up as you have been doing with Dr.
[**Last Name (STitle) 66568**] at [**Hospital6 1708**]. You have an appointment
set up with her as previously scheduled at 9:00am on [**2125-3-12**]. Please call to try to arrange a sooner appointment if
possible.
You will also need an outpatient Endocrinology appointment. Dr.
[**Last Name (STitle) 66568**] can help you arrange this at the [**Hospital6 13185**].
You will need to have follow up arranged for your:
(1) thyroid goiter, to see if further imaging or studies are
indicated. You are taking two medications, methimazole and
prednisone, which will need to be adjusted based upon labs that
are still pending, to determine what is causing your thyroid
disease. You should discuss this further with your PCP and
Endocrinologist.
(2) blood pressure, to adjust your antihypertensive medications
(3) blood sugar, to adjust your insulin regimen
(4) heart failure, to adjust your diuretic medications
Completed by:[**2125-2-27**]
|
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74,353
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16917
|
Discharge summary
|
report
|
Admission Date: [**2110-9-12**] Discharge Date: [**2110-9-18**]
Date of Birth: [**2063-1-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
fever, rigors
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 47642**] is a 47 year old man with h/o renal cell ca with
mets to brain/lung, C1D19 Avastin/Torisel, who presents from
home with rigors, transferred from [**Hospital1 18**] [**Location (un) 620**] ED to our ED
for further evaluation and admission.
Patient had rigors at home starting around 1pm today. He noted
some mild pain ([**4-17**]) superior to his port-a-cath site this AM,
which has since resolved. No erythema or warmth at the site. He
did not feel like he had fevers while he was at home. He called
the oncology triage RN and was advised to go to the ED.
At [**Hospital1 18**] [**Location (un) 620**], the patient was found to have fever to 104,
but was otherwise hemodynamically stable. He had a mild frontal
headache, but no photophobia, vision changes, lightheadedness,
or neck stiffness. Intermittent nausea, but no vomiting. Labs
notable for WBC 3.4 N77%, elevated lactate 4.5. Blood cultures
x2 were drawn and sent. UA and CXR were negative. Patient was
given 2LNS and Cefepime 2g IV, Vanc 1g IV and transferred to
[**Hospital1 18**] [**Location (un) 86**]. Also given Tylenol, Zofran, and Toradol for
headache, fever, and nausea.
In the ED, initial VS were: 99.4 105 103/51 16 98%2L. Lactate
noted to be rising to 5.3 Continued to spike fevers to 102.4, so
patient was given Tylenol 1g x1 and 1LNS. Patient admitted to
ICU given concern for rising lactate, otherwise hemodynamically
stable. Vitals prior to transfer 100.8 121/48 110 31 98%2L.
In the ICU, initial VS 98.5 102 137/78 22 98%RA. Only complaint
at this time is mild leg soreness from lying on stretchers all
day, but otherwise no issues. Right upper chest achiness from
this AM has resolved. Mild HA has resolved. No runny nose, sore
throat, cough, SOB, CP, vomiting, abdominal pain. Normal BM
yesterday morning.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Renal Cell Carcinoma
- diagnosed [**2101**]
- s/p L nephrectomy
- mets to brain and lung
- s/p resection of brain lesion and cyberknife therapy [**4-18**]
- started on Avastin/Torisel [**2110-8-25**]
HTN
Hypothyroidism
Vitamin B12 deficiency
GERD
Social History:
Lives in [**Location 620**], married. Software engineer, from [**Country 2559**].
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
No family h/o cancer. Father died from septicemia.
Physical Exam:
Physical Exam on Admission:
Vitals: 98.5 102 137/78 22 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: mild tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no [**Doctor Last Name 515**]
sign, well-healed R sided scar
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, appropriate, no focal deficits on exam
ACCESS: R sided portacath, mild erythema and tenderness at
suture site superior to the portacath
.
Physical Exam on Discharge:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, appropriate, 5/5 strength in upper and lower
extremities; sensation intact to light touch. w/o focal deficits
SKin: 2cm incision from removed R sided portacath, no erythema,
warmth, tenderness, or induration at site.
Pertinent Results:
ADMISSION LABS:
[**2110-9-12**] [**Hospital1 **] [**Location (un) 620**] ED labs:
CBC 3.4>14.4/42.2<153 N77
CHEM 138/4.0/101/21.1/16/1.6<141 Ca 8.7
Alb 3.5 TP 7.1 Tbili 0.45 AP 198 ALT 107 AST 77
Lactate 4.5
UA bland
[**2110-9-12**] 10:29PM LACTATE-5.3*
PERTINENT INTERVAL LABS:
[**2110-9-16**] 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2110-9-16**] 06:00AM BLOOD HCV Ab-NEGATIVE
[**2110-9-16**] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2110-9-16**] 08:02AM URINE Hours-RANDOM UreaN-326 Creat-106 Na-103
K-29 Cl-104
DISCHARGE LABS:
[**2110-9-18**] 05:51AM BLOOD WBC-5.7# RBC-4.29* Hgb-12.4* Hct-36.0*
MCV-84 MCH-29.0 MCHC-34.6 RDW-13.9 Plt Ct-135*#
[**2110-9-18**] 05:51AM BLOOD Neuts-48* Bands-0 Lymphs-35 Monos-12*
Eos-4 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2110-9-18**] 05:51AM BLOOD PT-12.6 PTT-24.9 INR(PT)-1.1
[**2110-9-18**] 05:51AM BLOOD Glucose-156* UreaN-7 Creat-1.1 Na-138
K-3.5 Cl-102 HCO3-21* AnGap-19
[**2110-9-18**] 05:51AM BLOOD ALT-161* AST-188* LD(LDH)-637*
AlkPhos-163* TotBili-0.6
[**2110-9-18**] 05:51AM BLOOD Albumin-3.8 Calcium-8.4 Phos-1.4* Mg-2.1
HBV/HCV VIRAL LOAD ([**2110-9-18**]): NO VIRUS DETECTED
MICRO:
[**2110-9-12**] BCx @ [**Location (un) 620**]: [**5-12**] GPC
[**2110-9-12**] 10:15 pm BLOOD CULTURE #3.
**FINAL REPORT [**2110-9-15**]**
Blood Culture, Routine (Final [**2110-9-15**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
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---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final [**2110-9-13**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 2227 ON
[**9-13**] - 4I.
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2110-9-13**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
BLOOD CULTURES ([**Date range (1) 47643**]): NO GROWTH
BLOOD CULTURES ([**Date range (1) 47644**]): NGTD
[**2110-9-14**] catheter tip: NO GROWTH
STUDIES:
[**2110-9-12**] CXR: No definite pulmonary consolidation is seen. Hilar
lymphadenopathy. Known pulmonary metastases not visualized on
this exam.
[**2110-9-13**] RUQ U/S:
1. Borderline size of the common bile duct which measures 6 mm.
Please
correlate with biochemical markers and note that the distal duct
could not be assessed and choledocholithiasis is not excluded.
2. Increased echogenicity of the liver compatible with fatty
infiltration. More advanced forms of liver disease such as
cirrhosis/fibrosis cannot be excluded.
[**2110-9-15**] ECHO:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. The estimated
pulmonary artery systolic pressure is normal. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
[**2110-9-18**] R FOOT /ANKLE:
In the right foot, there is mild degenerative change of the
first MTP. There is a large osteophyte at the talar neck. Small
plantar calcaneal
enthesophyte. Os trigonum. Degenerative changes talonavicular
joint. No
fracture or malalignment.
In the right ankle, there is mild bimalleolar soft tissue
swelling without
fracture identified. Mild tibiotalar spurring, likely attesting
to prior
ligamentous injury. Similar findings at the lateral malleolus
and lateral
talus. No acute fracture. Talar dome and ankle mortise are
intact.
Brief Hospital Course:
========================
BRIEF HOSPITAL SUMMARY
========================
Mr. [**Known lastname 47642**] is a 47 year old man with h/o renal cell ca with
mets to the brain and lung, C1D19 Avastin/Torisel (last dose
[**2110-9-8**]), who presents with fevers and rigors, found to have GPC
bacteremia.
========================
ACTIVE ISSUES
========================
#. MSSA Bacteremia: The initial blood cultures from [**Location (un) 620**] grew
out S aureus in [**5-12**] bottles, as did the initial cultures at
[**Hospital1 18**] following transfer. Source is likely R sided portacath
that was placed 2 months ago, as the site is mildly erythematous
and tender. Vancomycin and Cefepime were started to treat S
aureus bacteremia while awaiting sensitivity information. An
echocardiogram was obtained to check for any cardiac
involvement; which did not show any evidence of vegetations.
Following discussion with the Oncology service, the port was
removed by Interventional Radiology on [**2110-9-14**]. His antibiotic
regimen was changed to nafcillin when sensitivities returned as
MSSA. Pt will be treated with nafcillin, through PICC placed day
before discharge, for a total 4 week course (to end on [**2110-10-13**]).
Pt remained afebrile for entire course outside of the ICU.
#. Transaminitis: Patient with acute transaminitis of unclear
etiology. RUQ U/S unremarkable for any ductal dilation, e/o
fatty infiltration. [**Month (only) 116**] be related to Torisel, nafcillin, but
temporal relationship not perfect. Values not high enough to be
consistent with shock liver (and pt never hypotensive in ICU).
AST/ALT/LDH elevated (see labs attached -- ALT/ASTs in mid
100s). Levels remained stable the 24 hrs prior to discharge.
Hepatology followed this patient while on the floor, and
recommendations were appreciated. All hepatitis serologies and
viral loads negative.
# Thrombocytopenia: Plts 118 when admitted. Decreased into the
60Ks and 70Ks, POtentially from marrow suppression from acute
infection. HIT unlikely, consdiering 4Ts scale score of 1.
Heparin antibodies negative. Smear showed abnormal RBCs, in
setting of acute infection and metastatic renal cell carcinoma.
PLTS 135K by day of discharge.
#. [**Last Name (un) **]: Cr 1.6 on admission, up from baseline 1.0-1.2, likely
[**3-12**] to volume depletion. Improved to baseline with IVF and PO
fluid intake. Patient appears euvolemic at this time. Will
encourage PO fluid intake. 0.86% FENA, which points to
pre-renal mechanism.
#. Foot pain: On day of discharge, pt experienced [**9-17**] R foot
pain w/ no known cause. Had similar issue a few months back,
which resolved w/out treatment. Pain localized to dorsal and
plantar surfaces of foot. Foot and ankle films demonstrate no
fractures. Likely plantar fasciitis. Ibuprofen x 5 days.
#. Renal cell ca: Metastatic disease to the brain and lung. s/p
treatment with IL-2 and Sutent, now C1 of Avastin/Torisel. To be
followed by outpt oncologist.
========================
INACTIVE ISSUES
========================
#. HTN: BP stable, continued home metoprolol
#. Hypothyroidism: continued home levothyroxine
========================
TRANSITIONAL ISSUES
========================
1. Medications
- START nafcillin 2 grams every 4 hours for 25 days to end on
[**2110-10-13**]
- START ibuprofen 200 mg Tablet: Take 2-4 Tablets every eight
(8) hours as needed for pain for 5 days.
2. PICC line placed for IV access
3. Will need to consider utility of replacing port in outpatient
setting.
4. Pt to follow w/ outpt oncologist.
5. Pt should not continue long term NSAIDs considering
renal/liver impairments.
Medications on Admission:
Levothyroxine 100mcg PO daily
Simvastatin 20mg PO daily
Metoprolol 25mg PO BID
Pantoprazole 40mg PO daily
Vitamin B12 1000mcg SC qmonth
Discharge Medications:
1. nafcillin 2 gram Recon Soln Sig: Two (2) grams Injection
every four (4) hours for 25 days: To end on [**2110-10-13**].
Disp:**qs for 25 days grams* Refills:*0*
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) mcg Injection
once a month.
7. ibuprofen 200 mg Tablet Sig: 2-4 Tablets PO every eight (8)
hours as needed for pain for 5 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Primary Diagnosis:
Methicillin sensitive bacteremia
Secondary Diagnoses:
metastatic renal cell carcinoma
plantar fasciitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 47642**], it was a pleasure taking care of you in the
hospital. You were admitted because you were having rigors and
chills at home. We found that you had a bacteria in your blood,
and started to treat you with antibiotics. We suspected that the
source of your infection was your port, which we took out. Your
liver numbers briefly rose during your hospitalization, but
started to trend down upon your discharge. You were also having
some foot pain on your discharge. Your foot x-ray did not show
any fracture, and we gave you Ibuprofen for pain control.
When you leave the hospital:
- START nafcillin 2 grams every 4 hours for 25 days to end on
[**2110-10-13**]
- START ibuprofen 200 mg Tablet: Take 2-4 Tablets every eight
(8) hours as needed for pain for 5 days.
We did not make any other changes to your medications, so please
continue to take them as you normally have been.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2110-9-22**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2110-9-22**] at 1 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2110-9-22**] at 1 PM
With: DR. [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**2110-10-22**] 10:20a [**Hospital Ward Name **],[**Last Name (un) **]
RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
PSYCHIATRY HMFP
[**2110-10-6**] 09:50a ID,[**Doctor Last Name **],[**Doctor First Name **]
LM [**Hospital Unit Name **], BASEMENT
ID WEST (SB)
[**2110-10-2**] 10:00a [**Last Name (LF) **],[**First Name3 (LF) 640**] T.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
[**2110-10-2**] 08:20a [**First Name9 (NamePattern2) 7548**] [**Hospital Ward Name **] SYMPHONY
[**Hospital6 29**], [**Location (un) **]
RADIOLOGY
|
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icd9cm
|
[
[
[]
]
] |
[
"86.05",
"38.97"
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icd9pcs
|
[
[
[]
]
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13826, 13871
|
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2625, 2874
|
2890, 3022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,193
| 191,836
|
8055
|
Discharge summary
|
report
|
Admission Date: [**2187-11-26**] Discharge Date: [**2187-12-2**]
Date of Birth: [**2153-4-8**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 28789**]
Chief Complaint:
elevated blood pressure
Major Surgical or Invasive Procedure:
primary LTCS and BTL
History of Present Illness:
34 y/o G2P1 w h/o of end state kidney disease on HD now at 29
wks 2 days (EDC [**2188-2-9**] based on US) presents from ATU with
elevated BP 190/111. Seen in ATU regularly after HD. She was
started on Lopressor (25mg) 1 week ago, which had been stopped
from [**Date range (1) 28790**]/06 due to hypotension. Currently complains of HA.
Denies visual changes and RUQ pain.
Past Medical History:
PNC:
(1)Dating EDC [**2187-2-9**] by 24 wk US
(2)Labs: A+/Ab-,RI,RPRnr,HbsAg-,HIV-,CF-,HepC-,GLT nl (111)
(3)US: nl FFS
PAST MEDICAL HISTORY:
-chronic HTN- was taken off anti-HTN meds (Altrace and
Lopressor) due to fainting 2 months ago. Restarted on Lopressor
-on hemodialysis since [**2187-6-16**] (mon, tues, [**Last Name (un) **], fri, sat
secondary to htn induced renal failure.
PAST OBSTETRIC HISTORY:
-CS [**2185**] at 36 wks 5lbs 15oz, son born with cleft lip/palate
c/b by kidney graft rejection
PAST GYNECOLOGIC HISTORY
-significant for infertility (previous pregnancy IUI)
PAST SURGICAL HISTORY:
-s/p kidney transplant in [**2180**], (living related [**Last Name (un) 28791**]),
rejection [**2-/2187**]
-s/p LTCS [**2185**]
-AV fistula placement left arm ([**7-/2187**])
Social History:
married; lives with husband and son
denies tobacco, alcohol, illicit drug use
Family History:
none
Physical Exam:
VITALS: Temp 98.3 HR 88 RR 20 weight 213lbs.
BP 160/91-> 161/94 ->155/81->156/81 ->142/79
GENERAL: NAD
HEART: RRR
LUNGS: CTA
ABDOMEN: soft NT
EXTREMITIES: trace edema bilaterally reflexes 1 bilaterally
Pertinent Results:
[**2187-11-26**] WBC-9.1 RBC-3.48 Hgb-11.2 Hct-34.2 MCV-98 Plt-146
[**2187-11-28**] WBC-11.9 RBC-3.61 Hgb-11.7 Hct-35.0 MCV-97 Plt-130
[**2187-11-29**] WBC-16.3 RBC-3.89 Hgb-12.5 Hct-38.3 MCV-99 Plt-126
[**2187-12-1**] WBC-13.1 RBC-3.61 Hgb-11.7 Hct-34.3 MCV-95 Plt-172
[**2187-11-26**] PT-12.0 PTT-24.0 INR-1.0
[**2187-11-28**] PT-11.8 PTT-23.8 INR-1.0
[**2187-11-26**] Glu-82 BUN-12 Cre-4.3 Na-143 K-3.7 Cl-101 HCO3-30
AGap-16
[**2187-11-27**] Glu-83 BUN-13 Cre-4.5 Na-141 K-3.9 Cl-102 HCO3-28
AGap-15
[**2187-11-30**] Glu-51 BUN-22 Creat-5.3 Na-138 K-4.0 Cl-96 HCO3-29
AGap-17
[**2187-12-1**] Glu-79 BUN-23 Creat-5.4 Na-139 K-4.3 Cl-96 HCO3-32
AGap-15
[**2187-12-2**] Glu-73 BUN-38 Creat-7.6 Na-136 K-4.5 Cl-93 HCO3-28
AGap-20
[**2187-11-26**] ALT-11 AST-12 LD-214 TotBili-0.3
[**2187-11-28**] ALT-9
[**2187-11-30**] ALT-2 AST-10 LD(-246 AlkPhos-102 TotBili-0.4
[**2187-11-26**] Albumin-2.9 Calcium-8.6 Phos-3.5 Mg-1.8 UricAcd-3.8
[**2187-11-28**] Calcium-9.3 Phos-2.4 Mg-1.6 UricAcd-2.1
[**2187-12-2**] Calcium-8.9 Phos-4.4 Mg-1.9
[**2187-11-28**] FK506-1.8
[**2187-11-29**] FK506-2.6
[**2187-11-30**] FK506-2.1
[**2187-12-1**] FK506-2.7
Brief Hospital Course:
34y/o G2P1 admitted at 29+2 weeks gestation with elevated blood
pressures; hx ESRD on hemodialysis.
.
Ms [**Known lastname **] [**Known lastname 28792**] had elevated blood pressures (140-160/80-94) as
well as a headache while in triage. Preeclampsia labs were
normal, with the exception of the elevated creatinine (4.3),
which was consistent with her baseline. She was admitted for
close observation. Although her blood pressures were elevated
and there was a concern for preeclampsia, it was a difficult
diagnosis to make since she was anuric. The goal for her blood
pressure was to keep systolic between 140-160 and diastolic
between 90-100. If she became hypotensive during dialysis, which
is common, the concern is fetal well-being. But on the other
hand, if hypertensive, the concern is maternal stroke. She was
counseled about the goals of her admission. She was fluid
restricted to <1000 cc/day. A renal consult was obtained and
after their evaluation, they planned to continue hemodialysis
five times per week through her portacath. Her Lopressor was
increased to 50mg at night and 25mg in the morning. ATU testing
on the day of admission was reassuring with BPP [**7-24**], AFI 17.8,
vertex, tracing was appropriate for gestational age. She was
betamethasone complete on [**2187-11-13**] and the NICU was consulted.
Her most recent growth scan was on [**11-19**], EFW 1216g (55%).
.
HD#2
The morning of hospital day #2, her blood pressure was 148/86
and she was asymptomatic. Hemodialysis was started and her blood
pressure was elevated to 170-180/100. She remained asymptomatic.
She was given an additional dose of Lopressor (50mg) with no
improvement, BPs remained elevated at 200s/117-120. Hemodialysis
was terminated and she was transferred to labor and delivery.
After discussions with the renal team and anesthesia, the
decision was made to proceed with delivery for severe
preeclampsia, based on blood pressures. She was taken to the
operating room and underwent a repeat low transverse cesarean
section and bilateral tubal ligation under general anesthesia.
Baby boy was delivered from vertex, weight 1325g, apgars 7,8.
Baby was transferred to the NICU immediately for prematurity.
Dilantin was started for seizure prophylaxis until 24 hours
postpartum. Her blood pressures improved to 130-150/70-90.
.
HD#3/POD#1
Blood pressures 120-156/90's on Lopressor. Pain controlled with
Dilaudid. Pt complained of shortness of breath, lungs had
crackles had the bases, and her oxygen saturation was 92% on 4
liters of oxygen. It was felt that she had fluid overload and
the plan was to dialyze, which was peformed shortly after. Her
blood pressures remained elevated during hemodialysis,
160-170/90-111. A total of 2.7 liters was removed. Her
respiratory status improved slightly until later that evening
when she again reported shortness of breath. Her oxygen
saturation was 92-94% on 5 liters of oxygen, and she had
decreased lung sounds at the bases. She was given Nifedipine
for her elevated blood pressures. CXR findings were consistent
with pulmonary edema.
.
HD#4/POD#2
Hemodialysis was repeated in the morning due to persistent
shortness of breath. Blood pressures still elevated and oxygen
saturation 93% on 5 liters of oxygen. Approximately 3 liters of
fluid was removed after hemodialysis and her symptoms had
improved. Nifedipine 60 mg CR was started for BP control,
Lopressor was continued. IV fluids were discontinued.
Preeclampsia labs were stable with the exception of a slight
drop in platelets to 126. A bedside echo revealed no significant
change from a prior study and her EKG was unchanged as well,
normal sinus rhythm. Repeat CXR showed severe pulmonary edema.
The decision was made to transfer her to the ICU for management
of her pulmonary edema and hypertension. Hemodialysis performed.
.
HD#5/POD#3
Clinically improved. Blood pressures 130-160/80's. Hemodialysis
performed and patient transferred back to gyn floor. Medicine
team continued to follow. Labs stable, creatinine 5.3.
.
HD#6/POD#4
No issues. Blood pressures 140-160/70-102. Started on Lovenox
for DVT prophylaxis. Hemodialysis now three times per week.
.
HD#7/POD#5
Blood pressures still elevated, but stable. Incision opened
spontaneously requiring packing. Hemodialysis removed 2 liters
of fluid. Discharged home.
Medications on Admission:
prenatal vitamines, prednisone 5mg qd, lopressor 50mg qd,
prograft 2mg qd, macrobid 50mg qd, phoslo 666mg tid, ambien 5mg
qd, MVI, sensipar, zofran
Discharge Medications:
Prednisone 5 mg (1) Tab PO DAILY
Oxycodone-Acetaminophen 5-325 mg (1) Tab PO Q4-6H prn
Metoprolol Tartrate 50 mg (2) Tabs PO BID
Cinacalcet 30 mg (1) Tab PO DAILY
Tacrolimus 1 mg (1) Cap PO BID
Calcium Acetate 667 mg (2) Caps PO TID W/MEALS
Nifedipine 60 mg SR (2)Tabs po daily
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
single intrauterine pregnancy
end stage renal failure
severe preeclampsia
small separation of skin edges - fascia intact
Discharge Condition:
good
Discharge Instructions:
No heavy lifting or strenuous exercise for 4 weeks. No driving
while on narcotics. Call for temp >100.4, headache, visual
changes, upper abdominal pain, dizziness, increased vaginal
bleeding, redness or discharge from your incision
Followup Instructions:
1 week with Dr [**Last Name (STitle) **] for incision check
6 weeks for postpartum visit
Completed by:[**2187-12-6**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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|
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,250
| 119,899
|
46848
|
Discharge summary
|
report
|
Admission Date: [**2205-12-17**] Discharge Date: [**2205-12-21**]
Date of Birth: [**2132-5-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
CC: dyspnea.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. [**Known lastname 1007**] is a 73-year-old woman with a history of chronic
obstructive pulmonary disease on home O2 (4L @ night, 2L in the
AM) since [**2205-7-11**], diastolic hf (ef>55%), atrialf
fibrillation, history of stroke, HTN, and CAD s/p MI in [**2175**]'s
presenting with shortness of breath since last night.
The patient was in her normal state of health and had recently
been seen on [**12-16**] in her pulmonologists office for evaluation.
She states she woke up in the middle of the night to use the
bathroom, used her wheel chair to get to the bathroom, and
developed shortness of breath on route. By the time she made it
back to her bed, her SOB had resolved. She awoke the next
morning "panting", but made it to breafkast at her [**Hospital 4382**] facility. She mentioned feeling generally uncomfortable
throughout the meal, without any focal chest pain or profound
SOB. After breakfast she went back to her room to take a nap,
and woke up to use the bathroom again around 9:30 AM. She
reports her SOB with minimal exertion in her wheel chair was
"Out of control" and prompted her to call 911. She denies any
history of PND, but asserts 2 pillow orthopnea. Denies leg
swelling, recent travel/long trips, or sick contacts. She
reports having a mild dry cough for the last 2-3 days wihtout
any sputum production. Deneis fevers, chills, nausea, vomiting,
diarrhea, palpiations, dizziness, or syncopal episodes.
.
Initially in the emergency room vitals were T=98.1, HR:74, BP
138/87, RR 26, and 92% on 4L NC. Desaturations noted on NC to
85%. Placed on 10 L NRB with sats climbing to about 94%. Exam
in the ED was notable for wheezes throughout with crackles at
the bases. A bedside US was performed which showed no effusion,
and CXR was consistent with b/l pulmonary edema. EKG showed
aflutter without RVR, and no ischemic changes. BNP was 1831,
and CE's were negative x1. Labs were also notable for lactate
of 2.3. Repeat Potassium was 4.0 presumably after nebulizer
treatments. Patient was given 60 mg IV Lasix, 125 IV
Solumedrol, Combivent nebs, and 750 mg levofloxacin for
presumptive pneumonia.
.
Vitals at time of admission were 98.5, 82, 143/74, 24-28, 91% on
the non-rebreather. Patient with peripheral lines for
intravenous access, noted to be a hard stick.
.
Upon admission to the floor, the patient generally feels [**Doctor Last Name **].
Denies any chest pain, profound SOB, or discomfort. She
continues to require 10L face mask to sat at 96%.
Past Medical History:
1. Primary CNS lymphoma in cerebellum, frontal lobes, left
temporal lobe, and right occipital lobe
- dx in [**7-16**]
- S/p 6 cycles of high dose MTX, changed to Rituxan and Temodar
in [**9-16**], last cycle [**10-17**]. Per pt, is now cancer free and being
monitored with serial outpt MRIs. Followed by Dr. [**Last Name (STitle) 4253**].
2. Stroke (x3, all in [**1-15**], posterior circulation;
3. Hypertension
4. Hyperlipidemia
5. Subarachnoid hemorrhage (while on coumadin for stroke.
[**2200-10-1**])
6. Diastolic dysfunction, last ejection fraction =55%
7. Hypothyroidism/multinodular goiter -seen by endo, has MNG and
chronically low TSH for unclear reasons
8. CAD s/p MI in the 80s
9. GERD
10. s/p cholecystectomy for gallstones ([**2195**])
11. Atrial fibrillation - not on coumadin due to subarachnoid
hemorrhage
12. Chronic bronchitis/COPD
13. Neovascular glaucoma complicated by right eye blindness-not
compliant with drops
14. Hyperparathyroidism, primary. mild. followed by Endocrine.
Only intermittent mild Hyper Ca
[**10**]. Mild Vit D def
16. Anxiety/depression
17. OSA- severe mixed sleep disorder breathing
Social History:
Home: lives in [**Hospital1 **] senior living; ambulates with a cane,
but also uses a wheelchair as needed
Occupation: retired [**Hospital1 18**] nurse, previously worked on 7 [**Hospital Ward Name 1826**]
as a gynecology nurse
EtOH: Denies
Drugs: Denies
Tobacco: 90 pack-year smoking history (3 PPD x 30 years), quit
smoking in [**2178**]
Family History:
Father - Esophageal problems, unsure of the specifics, hx of
[**Name (NI) 5895**]
Mother - Bradycardia, AAA
Physical Exam:
General: Morbidly Obese female, on face mask O2
Vital signs: HR: 90, SPO2 93% on 10L facemask, BP 160/80, RR 22
HEENT: Anicteric sclera. Pink conjunctiva. Poor dentition. No
oral lesions or ulcers noted.
Neck: Palpalbe mass on right side of neck c/w history of thyroid
goiter abotu 3cm x 2cm. Non painful to palpation. Rest of neck
supple.
Lungs: Good air movement, clear to auscultation B/L.
Heart: Irregulary irregular. No murmurs, rubs, or gallops
appreciated, no carotid bruits. Normal intensity S1/S2.
Abdomen: obese abdomone. Soft. NBS. NT. Organomegaly not
appreciated.
Extremities: Trace edema. 1+ DPP/PTP pulses. Warm, dry
extremities.
Neurological: AOx3. CNII-XII intact. Slight left sided droop
with smile at baseline, otherwise rest of CNVII distribtuion
equal. [**5-15**] UE strength throughout B/L. [**4-15**] Extension strength
on RLE, [**5-15**] flexion strength on RLE, [**5-15**] LLE strength
throughout. Gross sensation intact. Gait not tested- patient
in wheel chair at baseline.
Pertinent Results:
Admission Results:
.
[**2205-12-17**] 12:55PM BLOOD WBC-5.7 RBC-3.70* Hgb-11.9* Hct-37.6
MCV-101* MCH-32.0 MCHC-31.6 RDW-15.4 Plt Ct-385
[**2205-12-17**] 12:55PM BLOOD UreaN-13 Creat-0.8 Na-141 K-6.7* Cl-105
HCO3-26 AnGap-17
[**2205-12-17**] 02:00PM BLOOD ALT-17 AST-22 LD(LDH)-254* AlkPhos-146*
TotBili-0.5
[**2205-12-17**] 12:55PM BLOOD proBNP-1831*
[**2205-12-17**] 12:55PM BLOOD cTropnT-<0.01
[**2205-12-17**] 02:00PM BLOOD Albumin-3.9 Calcium-9.0 Phos-3.8 Mg-2.1
Iron-39
[**2205-12-17**] 11:14PM BLOOD Type-ART O2 Flow-10 pO2-70* pCO2-28*
pH-7.45 calTCO2-20* Base XS--2
[**2205-12-17**] 01:07PM BLOOD Lactate-2.3*
[**2205-12-17**] 11:14PM BLOOD Lactate-2.7*
.
EKG ([**2205-12-17**]): Atrial fibrillation with diffuse ST-T wave
abnormalities are non-specific. The QTc interval appears
prolonged but it is difficult to measure. Since the previous
tracing of [**2205-8-24**] ventricular rate is slower and further ST-T
wave changes are present.
.
CXR ([**2205-12-17**]): Diffuse hazy opacity with pulmonary vascular
indistinctness and left pleural effusion likely bilateral, most
consistent with volume overload and congestive failure. If
indicated, consider repeat radiography after appropriate
diuresis to assess for underlying infection.
.
Interval Results:
.
CTA Chest With and Without Contrast ([**2205-12-17**]):Right upper lobe
ground-glass opacity which is stable since [**2203-8-5**], merits a
12-month followup to assess for stability.
Brief Hospital Course:
A/P: Ms. [**Known lastname 1007**] is a 73 yo female with multiple medical issues
including pmhx of primary CNS lymphoma, diastolic HF, cad s/p
MI, afib, hx of stroke, OSA and COPD on home oxygen p/w
shortness of breath for the last 24 hours.
.
# Shortness of breath: Patient's presentation was perplexing
for pulmonary cause vs. cardiovascular cause. While patient
carries a history of COPD, recent pulmonary function tests were
s/o restrictive lung disease, with FEV1/FVC>95%. DLCO <35% as
well, s/o interstitial lung disease, severe CHF, emphysmea, or
PE. Given hypoxia refractory to nebulzier treatments, BNP>1800,
and CXR that shows effusions and mild vascular congestion,
pulmonary congestion thought to be contributing to SOB.
Negative for ACS, and did not have infectious presentation. Did
receive 1 dose of levaquin in ED prior to ICU presentation, but
did not continue in ICU. Did not initially receive CT as hard
IV access. Received supplemental oxygen requing 10 L venturi
mask to saturate in the low 90's. Received 40 mg IV lasix in ED
prior to MICU presentation with diuresis of about 800cc's over
24 hours. Placed on CPAP o/n as history of OSA. Able to
diurese another 500 cc's without additional Lasix s/p CPAP.
Had PICC line placed as hard IV access, and had CT chest with
contrast performed. Negative for PE but did show incidental,
stable since [**7-/2203**] ground glass opacity near RUL to be folowed
up w/ in 1 year. No effusions seen on chest CT. Oxygen demand
titrated down to 4-6L NC for 90-94% saturation. SOB thought to
be [**2-12**] chronic OSA, and pulmonary effusions from dCHF.
Oxygenation with CPAP thought to dilate pulmonary vasculature,
increasing right to left side filliing/CO/renal perfusion and
diuresis. Replaced on home lasix dosing (60 mg PO bid), with
slow up titration to regular dose (restarted at 60 mg PO [**Month/Day (2) 24018**]
prior to MICU d/c).
.
Case discussed with pt.s primary pulmonologist (Dr. [**Last Name (STitle) **] at
length. Pt. has sleep disordered breathing, and with CPAP
occasionally experiences Cheynes-[**Doctor Last Name **] respirations. Dr. [**Last Name (STitle) **]
recommended supplemental O2 alone at night while sleeping to
keep o2 sats over 88%. If this is not possible with 2-8 litres
per minute of O2 via nasal cannula, then will need to resume
cpap: autoset cpap, Oxygen: 4-8 litres, target O2 sat with cpap
of 92%.
.
is arranging.
.
#Afib: In aflutter w/out rapid ventricular rate. On baby
aspirin [**Name2 (NI) 24018**], not coumadin given history of SAH. Was not on
rate control. Placed on metoprolol 12.5 mg [**Hospital1 **] on MICU day 1,
with HR's dropping to high 50's and BP's decreasing to
90's/40's. DC'd metoprolol. Rate remained stable in 70s.
Continued aspirin.
.
#History of OSA: has been in discussion with pulmonologist re:
CPAP. Given body habitus and restrictive state, began CPAP with
oxygen. Will need arrangements for obtaining home CPAP.
.
#Hx of dHF: documented EF>55%. No cardiology notes since [**2201**].
Does not appear to be on BB, probably [**2-12**] symptomatic
bradycardia (see above). Continued ACE-I and control of
hypertension. Restarted furosemdie 60 mg [**Hospital1 **] for volume control
(inintally started on [**Hospital1 24018**] on MICU day 2). No TTE was done as
last TTE was four months PTP.
.
#Hx of stroke/CAD/MI: continued HTN control, HLD control, and
ASA for secondary prevention. Did not place on BB per above.
.
#History of CNS lymphoma: last Chemo in [**2202**]. Seems to be in
remission. On lamotrigine 100 mg in the AM, 125 in the PM for
seizure ppx. Continued.
.
#Hypothyroidism/multinodular goiter: seen by endo, has MNG and
chronically low TSH for unclear reasons. Is not currently on
thyroxine. Last TSH <0.02 in [**2205-9-11**]. FT4 within normal
range.
.
#GERD: cont. omeprazole.
.
#Neovascular glaucoma complicated by right eye blindness:
continued Timolol, latansoprost, and brimodine drops.
.
#Hyperparathyroidism: primary. mild. followed by Endocrine.
Calcium was 9 on MICU day 1. Continued cinacalcet.
Medications on Admission:
* Prescriptions *
amlodipine
10 mg Tablet
1 Tablet(s) by mouth once a day [**2205-12-13**]
Modified [**Doctor Last Name **],
[**Doctor First Name 569**] 30 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**First Name (Titles) 25720**] [**Last Name (Titles) 67029**]ew Reprint Modify
atropine
1 % Drops
1 drop in the right eye twice a day [**2204-12-25**]
New [**Doctor Last Name **],
[**Doctor First Name 6131**] 1 Bottle 4 (Four) [**Last Name (LF) **], [**Name8 (MD) **] MD [**First Name (Titles) 25720**] [**Last Name (Titles) **]w
Reprint Modify
brimonidine
0.2 % Drops
1 drop ou twice daily, directly after Timolol [**2205-12-9**]
Renewed [**Doctor Last Name **],
[**Doctor First Name 354**] 1 Bottle 4 (Four) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH [**Last Name (NamePattern4) 25720**]
Renew Reprint Modify
cinacalcet [Sensipar]
30 mg Tablet
1 Tablet(s) by mouth twice a day (Prescribed by Other Provider)
[**2205-9-23**]
Recorded Only [**Doctor First Name 55182**],
[**Doctor Last Name **] [**Doctor Last Name 25720**] Renew Modify
fexofenadine
60 mg Tablet
1 Tablet(s) by mouth once a day [**2205-3-13**]
Renewed [**Doctor Last Name 9703**],
[**Doctor First Name 2801**] 30 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern4) 25720**] Renew Reprint Modify
fluticasone
50 mcg Spray, Suspension
2 sprays(s) each nostril once a day per nursing home notes,
patient is taking 2 sprays in each nostril twice daily (Dose
adjustment - no new Rx) [**2205-12-4**]
Recorded Only [**Last Name (un) **],
[**Doctor First Name **] [**Doctor First Name 25720**] Renew Modify
furosemide
20 mg Tablet
3 Tablet(s) by mouth twice a day [**2205-7-30**]
New [**Doctor Last Name **],
[**Doctor First Name 569**] 180 Tablet 3 (Three) [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**First Name (Titles) 25720**] [**Last Name (Titles) 67029**]ew Reprint Modify
hydrocortisone
2.5 % Cream
apply to affected area as directed twice a day. Not to be used
on face. 60 gram tube [**2205-11-11**]
New [**Doctor Last Name **],
[**Doctor First Name 569**] 1 Tube 1 (One) [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**First Name (Titles) 25720**] [**Last Name (Titles) **]w
Reprint Modify
nr lactulose
Dosage uncertain
(Prescribed by Other Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 23934**] [**2205-10-15**]
Recorded Only [**Last Name (un) **],
[**Doctor First Name **] [**Doctor First Name 25720**] Modify
lamotrigine [Lamictal]
100 mg Tablet
1 Tablet(s) by mouth twice a day along with one tab of 25 mg for
total daily dose of 225 mg (Prescribed by Other Provider; Dose
adjustment - no new Rx) [**2205-9-23**]
Recorded Only [**Doctor First Name 55182**],
[**Doctor Last Name **] [**Doctor Last Name 25720**] Renew Modify
latanoprost [Xalatan]
0.005 % Drops
1 drop in the right eye at bedtime [**2205-12-9**]
Renewed [**Doctor Last Name **],
[**Doctor First Name 354**] 1 Bottle 4 (Four) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH [**Last Name (NamePattern4) 25720**]
Renew Reprint Modify
lisinopril
5 mg Tablet
1 Tablet(s) by mouth once a day (Prescribed by Other Provider)
[**2205-9-23**]
Recorded Only [**Doctor First Name 55182**],
[**Doctor Last Name **] [**Doctor Last Name 25720**] Renew Modify
omeprazole [Prilosec]
20 mg Capsule, Delayed Release(E.C.)
1 Capsule(s) by mouth once a day (Prescribed by Other Provider)
[**2203-12-28**]
Recorded Only [**Last Name (un) **],
[**Doctor First Name **] [**Doctor First Name 25720**] Renew Modify
oxybutynin chloride
5 mg Tablet
1 Tablet(s) by mouth before sleep and as needed in the morning
[**2205-11-11**]
Restarted [**Doctor Last Name **],
[**Doctor First Name 569**] 60 Tablet 3 (Three) [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**First Name (Titles) 25720**] [**Last Name (Titles) **]w
Reprint Modify
Geriatric Alert
nr oxycodone-acetaminophen [Roxicet]
5 mg-325 mg Tablet
[**1-12**] Tablet(s) by mouth every four (4) hours as needed for
moderate to severe pain (Prescribed by Other Provider: [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] [**2205-10-15**]
Recorded Only [**Last Name (un) **],
[**Doctor First Name **] [**Doctor First Name 25720**] Renew Modify
nr oxygen
2 lpm nocturnal Need overnight oximetry on 2LPM. Diagnosis: OSA.
Hypoxemia of 67% during PSG [**2204-8-4**] [**2205-10-17**]
New [**Year (4 digits) 611**],
[**Location (un) **] 1 0 (Zero) [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**First Name (Titles) 25720**] [**Last Name (Titles) **]w
Modify
quetiapine [Seroquel]
25 mg Tablet
1.5 Tablet(s) by mouth at bedtime (Dose adjustment - no new Rx)
[**2205-8-20**]
Recorded Only [**Last Name (un) **],
[**Doctor First Name **] [**Doctor First Name 25720**] Renew Modify
simvastatin
40 mg Tablet
1 Tablet(s) by mouth at bedtime (Prescribed by Other Provider)
[**2204-1-31**]
Recorded Only [**Last Name (un) **],
[**Doctor First Name **] [**Doctor First Name 25720**] Renew Modify
timolol [Betimol]
0.5 % Drops
1 drop ou twice daily [**2205-12-9**]
Renewed [**Doctor Last Name **],
[**Doctor First Name 354**] 1 Bottle 4 (Four) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH [**Last Name (NamePattern4) 25720**]
Renew Reprint Modify
tramadol
50 mg Tablet
0.5 (One half) Tablet(s) by mouth three times a day (Prescribed
by Other Provider) [**2205-9-23**]
Recorded Only [**Doctor First Name 55182**],
[**Doctor Last Name **] [**Doctor Last Name 25720**] Renew Modify
* OTCs *
acetaminophen
500 mg Tablet
2 Tablet(s) by mouth three times a day as needed for pain
(Prescribed by Other Provider; OTC) [**2205-9-23**]
Recorded Only [**Doctor First Name 55182**],
[**Doctor Last Name **] [**Doctor Last Name 25720**] Renew Modify
aspirin
81 mg Tablet, Delayed Release (E.C.)
1 Tablet(s) by mouth daily (OTC) [**2205-9-23**]
'Not Taking as Prescribed' Removed
Start date: [**2205-6-7**] [**Doctor First Name 55182**],
[**Doctor Last Name **] [**Doctor Last Name 25720**] Renew Modify
docusate sodium [Colace]
100 mg Capsule
1 Capsule(s) by mouth twice a day (Prescribed by Other Provider;
Dose adjustment - no new Rx) [**2205-9-23**]
Recorded Only [**Doctor First Name 55182**],
[**Doctor Last Name **] [**Doctor Last Name 25720**] Renew Modify
nr guaifenesin [Guiatuss]
Dosage uncertain
(Prescribed by Other Provider) [**2205-10-15**]
Recorded Only [**Last Name (un) **],
[**Doctor First Name **] [**Doctor First Name 25720**] Modify
multivitamin
Tablet
1 Tablet(s) by mouth daily (OTC) [**2205-6-11**]
Recorded Only [**Location (un) 6781**],
[**Doctor First Name **] [**Doctor First Name 25720**] Renew Modify
senna
8.6 mg Tablet
2 Tablet(s) by mouth at bedtime (Prescribed by Other Provider;
OTC) [**2205-9-23**]
Recorded Only [**Doctor First Name 55182**],
[**Doctor Last Name **] [**Doctor Last Name 25720**] Renew Modify
Sort by Drug Class Checked Meds: [**Doctor Last Name 25720**] Renew
Reprint Hold
Not Taking as Prescribed
Comment Receipt Monograph
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
10. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. atropine 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
12. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
13. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
diastolic heart failure, acute on chronic
obstructive sleep apnea (sleep disordered breathing)
atrial fibrillation and flutter, rate controlled off of nodal
agents, not on anticoagulation due to history of SAH
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:
see below
Followup Instructions:
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2206-1-7**] at 1 PM
With: [**Doctor Last Name **] [**Doctor Last Name **] [**Doctor Last Name 22344**], OD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PSYCHIATRY
When: TUESDAY [**2206-1-14**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5750**], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST Best Parking: Main Garage
Department: SURGICAL SPECIALTIES
When: MONDAY [**2206-1-20**] 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
|
[
"428.0",
"401.9",
"202.80",
"412",
"491.20",
"427.32",
"252.01",
"428.33",
"327.23",
"427.31",
"414.01",
"V12.51",
"241.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
20642, 20725
|
7031, 11119
|
331, 337
|
20978, 20978
|
5558, 7008
|
21188, 22183
|
4396, 4506
|
19094, 20619
|
20746, 20957
|
11148, 19071
|
21154, 21165
|
4521, 5539
|
278, 293
|
365, 2869
|
20993, 21130
|
2891, 4023
|
4039, 4380
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,097
| 175,321
|
12783
|
Discharge summary
|
report
|
Admission Date: [**2117-6-17**] Discharge Date: [**2117-8-6**]
Date of Birth: [**2059-4-3**] Sex: M
Service: SURGERY
Allergies:
Codeine / Demerol
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
failure to thrive,
persistent nausea and vomiting
Major Surgical or Invasive Procedure:
Roux-en-Y choledochojejunostomy, gastrojejunostomy, j-tube,
Lysis of Adhesion
IVC filter
NGT
History of Present Illness:
This 58 yo male with long term nausea and vomiting [**12-25**] gastric
outlet obstruction and hx of recurrent pancreatitis and etoh
abuse went to outside ER with intractable nausea and vomiting fo
the past 2 days and unable to tolerate po intake. He was
admitted for failure to thrive and symptom control. In OSH he
underwent EGD on [**2117-6-15**] which demonstrated high grade gastric
outlet obstruction which is rather concerning. he's therefore
transferred for further evaluation and management. on arrival pt
has no complaint including pain.
Past Medical History:
-nausea and vomiting [**12-25**] gastric outlet obstruction at the level
of duodenum due to extrinsic compression by the pancrease.
- recurrent pancreatitis with multiple pancreatic pseudocysts
and distal common bile duct stricture.
- htn
- niddm
- c diff related diarrhea
- gastric ulcer [**2108**]
- alcohol abuse
- major depression requiring ECT in the past
- severe spinal stenosis from c3-c6 with myelomalacia and
central cord syndrome with profund bilateral lower extremity
weakness.
- chronic pain
- cervical laminectomy and fusion after decompression of c3-c6
[**3-/2117**]
- cholecystectomy
- appendectomy
- partial gastrectomy for peptic ulcer perforation.
Social History:
non smoker, no alcohol or illicit drugs currently
Physical Exam:
temp 96.6, bp 119/71, hr 63/min, resp 18/min, sats 96% RA.
comfortable at rest
no jvd, no nodes
rrr, nl s1+s2, no m/r/g
ctab, nl effort
[**Last Name (un) 103**] soft, mild epigastric discomfort, no rebound/guarding, nl
bs
no o/c/c
a&o x 3, cns [**1-4**] intact
Pertinent Results:
[**2117-6-23**] 07:40AM BLOOD WBC-7.3 RBC-4.01* Hgb-12.2* Hct-36.0*
MCV-90 MCH-30.6 MCHC-34.0 RDW-16.4* Plt Ct-221
[**2117-6-23**] 07:40AM BLOOD Glucose-130* UreaN-14 Creat-0.6 Na-142
K-4.1 Cl-111* HCO3-23 AnGap-12
[**2117-6-21**] 05:15AM BLOOD ALT-15 AST-26 LD(LDH)-123 AlkPhos-568*
TotBili-0.6
[**2117-6-18**] 01:27AM BLOOD Lipase-29
[**2117-6-21**] 05:15AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.2
Mg-1.3* Iron-68
[**2117-6-20**] 04:30AM BLOOD CEA-2.6
.
CTA ABD W&W/O C & RECONS [**2117-6-19**] 12:36 PM
IMPRESSION:
1. Mass-like conglomerate of calcifications in the head of the
pancreas that may be the cause of biliary obstruction. Marked
intrahepatic, extrahepatic and pancreatic duct dilatation.
2. Apparent mass in the second portion of the duodenum that may
be of inflammatory or neoplastic etiology.
3. Interstitial thickening and mild bronchiectasis at both lung
bases that may be related to chronic aspiration.
.
EGD [**2117-6-21**]
Retained fluids in stomach
Deformity of the distal bulb
A deformity was noted in the distal bulb. The endoscope could
not advanced beyond this area.EUS: Changes c/w severe chronic
pancreatitis noted in the body of the pancreas. Unable to
advance the echoendoscope into the duodenal bulb and beyond.
EUS was performed using a linear echoendoscope at 7.5 frequency:
The body of the pancreas was imaged through the body of the
stomach. Multiple hyperechoic strands and calcifications were
noted within the body of the pancreas. The pancreatic duct could
not be identified. These findings were consistent with severe
chronic pancreatitis. The echoendoscope could not be advanced
into the duodenal bulb, therefore, the rest of the pancreas
could not be examined.
Otherwise normal EGD to second part of the duodenum
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2117-6-26**] 1:47 PM
IMPRESSION:
1. Pulmonary embolism involving segmental arteries of the left
lower lobe. Findings are discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the
time of dictation.
2. Interstitial thickening and scattered areas of tree-in-[**Male First Name (un) 239**]
opacity. This is a nonspecific finding, as noted above, may be
related to chronic aspiration.
3. Hilar lymphadenopathy and prominent mediastinal lymph nodes
as noted. 4. Intrahepatic biliary dilatation again identified.
.
BILAT LOWER EXT VEINS [**2117-6-27**] 4:03 AM
IMPRESSION: No evidence of deep vein thrombosis of the lower
extremities.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2117-7-6**] 11:46 AM
CONCLUSION:
1. No definite evidence of a segmental or subsegmental pulmonary
embolism or an aortic dissection.
2. Interstitial thickening, scattered areas of tree-in-[**Male First Name (un) 239**]
opacity and scattered patchy opacities in the lungs likely are a
combination of recurrent aspiration and consolidation.
3. Incompletely evaluated intrahepatic biliary dilatation likely
represents sequelae of obstruction due to pancreatic neoplasm.
.
Cardiology Report ECHO Study Date of [**2117-7-6**]
INTERPRETATION:
Findings:
LEFT VENTRICLE: Severe global LV hypokinesis. Severely depressed
LVEF.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. The
patient has runs of a supraventricular tachycardia. Results
Conclusions:
1. There is severe global left ventricular hypokinesis (LVEF =
20%) with minor
regional variations. The bases are more dynamic in comparison to
the distal
aspects of the left ventricle.
2. There is moderate global right ventricular free wall
hypokinesis, greater
function in the base in comparison to the apex.
3. There is an echodensity in the right pulmonary artery
(artifact vs
thrombus). Cannot rule out thrombus in the PA.
.
PERSANTINE MIBI [**2117-7-9**]
The calculated left ventricular ejection fraction is 30%.
IMPRESSION: 1. No obvious ischemic changes with exercise -
please see above
discussion. 2. Moderate global hypokinesis, EF 30%, with mildly
dilated LV
cavity.
.
CT C-SPINE W/O CONTRAST [**2117-7-16**] 2:56 PM
IMPRESSION: Moderate narrowing of the spinal canal at C5 level
due to osteophyte. This is not an acute finding.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2117-7-17**] 4:52 PM
IMPRESSION:
1. No evidence of any pulmonary embolus.
2. Scattered areas of alveolar infiltrate with tree-in-[**Male First Name (un) 239**]
opacity bilaterally which are relatively unchanged when compared
with the previous CT from [**2117-6-26**]. Note is also made of
some mucous plugging and debris in the right mainstem bronchus.
The overall appearances are most suggestive of chronic
aspiration.
3. Subcentimeter mediastinal lymphadenopathy.
.
CT ABDOMEN W/CONTRAST [**2117-7-26**] 11:52 AM
IMPRESSION:
1. Marked intrahepatic and extrahepatic duct dilatation with
interval development of pneumobilia when compared with the
previous CT from [**2117-6-19**].
2. Pancreatic appearances consistent with chronic pancreatitis.
3. Dilatation of proximal loops of small bowel with fecalization
and distal decompression.
4. IVC filter in situ.
5. Atelectasis in the left base and airspace disease which may
represent chronic aspiration.
6. Bronchiectatic changes in right base.
.
ABDOMEN (SUPINE ONLY) [**2117-7-29**] 10:45 AM
IMPRESSION: Few dilated loops of small bowel, consistent with
ileus. Relatively unchanged compared to prior study.
.
Brief Hospital Course:
58 yo man with extensive gastric outlet obstruction history
presented with n&v to osh. egd revealed high grade gastric
outlet obstruction that they were unable to pass. pt's
transferred for egd and further therapy.
.
#) GI: pt presents with nausea and vomiting and was noted to
have high grade gastric outlet obstruction.
- npo
- iv rehydration.
- for gi consult with plan for repeat egd in am.
He had a repeat EGD on [**2117-6-21**] which should showed Retained
fluids in stomach, deformity of the distal bulb. The endoscope
could not advanced beyond this area.
EUS: Changes c/w severe chronic pancreatitis noted in the body
of the pancreas.
These findings were consistent with severe chronic pancreatitis.
The echoendoscope could not be advanced into the duodenal bulb,
therefore, the rest of the pancreas could not be examined.
Otherwise normal EGD to second part of the duodenum.
He was NPO and started on TPN. The TPN continued for a week
prior to the OR in order to maximize his nutritional status as
he came in very weak and emaciated.
#) Major Depression: He was seen by Social Work and Psych. He
had previously been on Prozac, but states that he noticed
diminished effect. He was NPO due to his GOO and so we started
Remeron (dissolvable tabs) increased to 30mg HS. Social work and
Psych continued with supportive care.
Post surgery, when taking PO's, he was on Duloxetine.
#)Pulmonary Embolism
On [**2117-6-26**], he had an acute onset of dyspnea and was transferred
to the SICU with LLL segmental PE. Lower extremity US showed no
DVT. He was started on Heparin and his PTT was kept therapeutic.
Vascular was consulted and performed a CT Venogram, followed by
placement of an IVC filter through the right groin. He tolerated
this procedure well.
#)Pain
He was on a Morphine PCA, and we continued with Fentanyl patch,
Toradol, Remeron, Ativan. He complained of constant chronic
pain, that was not well controlled initially. On discharge, his
pain was well controlled with gabapentin 300mg qhs, oxycodone SR
40mg [**Hospital1 **], oxycodone-acetaminophen [**11-24**] tab q4hr prn
He was schedule to go to the OR on [**2117-7-6**].
While at holding area and following uneventful placement of a an
epidural at C5 level. In route to OR, patient became apneic and
'blue", unresponsive and, reportedly, pulseless. BCLS/ACLS
protocols were initiated. he was intubated and received 1 mg
epinephrine, with immediate response and return of pulse and BP
(sinus tach). TEE obtained in the OR showed global HK with an
estimated LVEF 20% with moderate MR (a change from an outside
echo that reported normal LV). A SG catheter placed showing mean
PA pressure of 18 mmHg. He was transferred to SICU on Epi
infusion (0.02 mcg/kg/min). he has since been intubated and able
to converse. Hemodynamically he has been stable.
Initial ABG: 7.14/63/202
Initial PA catheter numbers: CVP 5, PA 32/13/20, CO 6.8, CI 6.3,
SVR 377
ECG showed TWI in V2-6 (new compared to ECG [**6-21**])but no gross ST
segment deviation. Otherwise no change.
CTA was performed to evaluate for recurrent PE and was negative
for this entity but showed: "Evaluation of the lung parenchyma
reveals areas of interstitial thickening and areas of tree-in-
[**Male First Name (un) 239**] opacity, this is a nonspecific finding and most likely
is related to chronic recurrent aspiration due to gastric outlet
obstruction in this patient. There are scattered ill- defined
patchy opacities in both lungs likely representing
infectious/inflammatory etiology"
Transthoracic echocardiogram was done as well and showed
findings
contradictory to those of the TEE (although labeled as a
suboptimal study): Left ventricular wall thicknesses are normal.
The left ventricular cavity is unusually small. Left ventricular
systolic function is hyperdynamic (EF>75%). Right ventricular
chamber size and free wall motion are normal. There is no
pericardial effusion.
He then transferred out to the floor and continued to await
surgery, continuing on TPN.
A pharmacologic stress was performed on [**2117-7-12**] and showed no
anginal symptoms or ischemic ST segment changes.
He went to the OR on [**2117-7-13**] for:
1. Double bypass (choledochoenterostomy with a Roux-en-Y
formation; gastroenterostomy).
2. Repair of small bowel enterotomies x3.
3. Takedown and repair of a coloenteric fistula.
4. J-tube placement.
5. Extended adhesiolysis.
Post-operatively he went to the ICU and remained intubated
overnight. He was extubated the next day and did well.
Pain: His pain was moderately controlled with a PCA. He was seen
by the pain service and they continued to adjust his meds. Once
we started tubefeedings, Gabapentin 300mg HS, Acetaminophen
650mg, Duloxetine 30 mg PO were put down the tube. He was mostly
comfortable at time of discharge, but still having some cervical
pain. A CT of the cervical spine showed moderate narrowing of
the spinal canal at C5 level due to osteophyte. A soft collar
was worn for comfort.
.
Abd/GI: He had a NGT and was NPO with IVF and TPN. The NGT was
self D/C'd on POD 2. He complained of some nausea and this was
likely a combination of the large amount of narcotics and
pulling the NGT early and ileus.
His incision was C,D,I and staples were removed.
Tube feedings were started and slowly advanced to goal. We also
advanced his PO diet and he was tolerating a regular diet by POD
9. He was moving along well until POD 13, when he developed an
Ileus, and vomit [**Male First Name (un) **] over 1 liter. He was made NPO and received
a NGT. He was put back on PO meds. The ileus resolved with
conservative treatment of NPO and NGT. The patient's diet was
advanced slowly from sips to clears to full liquids and
eventually a regular diet. In order to supplement his
nutrition, tube feeds were commenced starting at 10 cc/hr and
were slowly increased to a goal of 80. The tube feeds were
eventually cycled starting at 18hours per cycle starting at 4pm
through 10 am, in order to encourage PO intake during the day.
We decreased the tubefeedings to 70 cc/hr over 16 hours as he
complained of some loose stool with the higher rate. The tube
feedings were weaned off as his calorie counts revealed 1830
kcal and 83 gram of protein.
PT: Physical therapy evaluated the patient and concluded there
was significant deconditioning and soft tissue symptoms which
would require rehabilitation as the patient is significantly
below baseline. They recommend a short term rehabilitation stay
as the patient has an excellent prognosis to regain
independence. Due to his med/nutrition needs, rehabilitation
can best meet all of his needs.
Medications on Admission:
zofran 4mg iv q6h prn, albuterol nebulizer qid prn, protonix
40mg daily [**Hospital1 **], heparin 5000 units tid, viscous xylocaine 5 cc
q3n prn, flagyl 500mg iv q8h, valium 2mg iv bid, zithromyax
250mg daily
ativan 1 mg q6h prn iv, dilaudid 2mg iv q2h prn
Discharge Medications:
1. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QHS (once a day (at bedtime)) as needed.
Disp:*20 ML(s)* Refills:*0*
2. 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*
3. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO BID (2 times a day).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*1*
5. Duloxetine 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*
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*25 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
Disp:*15 Lozenge(s)* Refills:*2*
11. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: See Sliding Scale Subcutaneous twice a day: Give 4 units
70/30 qbreakfast. 5 units 70/30 qdinner.
.
12. Humalog 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous four times a day: See Humalog Sliding Scale.
13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3671**] Rehabilitation & Nursing Center - [**Location (un) 1514**]
Discharge Diagnosis:
Recurrent EtOH pancreatitis
Gastric outlet obstruction
Nausea and vomitting
Persistent Hyperglycemia
Depression
Chronic Aspiration
PEA arrest after thoracic epidural bolus
Chronic Neck Pain
Central cord syndrome w/ profound bilateral extremity weakness
Discharge Condition:
good
tolerating diet
pain moderately controlled.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2117-8-27**] 8:00
Completed by:[**2117-8-6**]
|
[
"303.91",
"996.79",
"707.00",
"577.1",
"296.20",
"E849.7",
"E879.8",
"427.5",
"577.2",
"401.9",
"576.2",
"250.00",
"568.0",
"537.0",
"569.81",
"E938.7",
"336.8",
"560.89",
"507.0",
"415.19",
"518.0",
"261"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.60",
"96.07",
"38.7",
"99.15",
"96.04",
"51.36",
"38.93",
"44.39",
"45.13",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
16356, 16461
|
7671, 14296
|
324, 419
|
16758, 16809
|
2050, 7648
|
17898, 18080
|
14604, 16333
|
16482, 16737
|
14322, 14581
|
16833, 17875
|
1768, 2031
|
235, 286
|
447, 995
|
1017, 1686
|
1702, 1753
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,719
| 117,538
|
49660
|
Discharge summary
|
report
|
Admission Date: [**2123-12-19**] Discharge Date: [**2124-1-4**]
Date of Birth: [**2078-6-20**] Sex: F
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Sternal hematoma.
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
woman status post aortic root replacement for aortic ectasia
in [**2123-1-23**]. The patient has had multiple hospitalizations
since that time for wound debridement and superficial sternal
infections.
The patient was recently involved in a motor vehicle
accident, [**2123-12-4**], as an unrestrained driver with
airbag deployment, head-on into a truck at approximately
50-60 mph. The patient sustained facial and nasal fractures,
bruises to chest and knees. She was evaluated at [**Hospital6 10443**] and was also found to have a T12-L1 compression
spine fracture.
He was transferred to [**Hospital3 12564**] Facility on
[**12-17**], when the patient noticed a lump on her chest at
the top of her sternum. The patient stated that it started
approximately one inch and reported that it increased in size
steadily since that time. The patient stated that it was
very tender to touch.
She had no complaints of fever, chills, drainage,
palpitations, or radiation of pain.
MEDICATIONS ON ADMISSION: OxyContin 30 mg b.i.d., Vioxx 25
mg q.d., Colace 100 mg b.i.d., Prevacid 30 mg q.d., Senokot 2
mg q.d., Dulcolax 1 q.d., Vancomycin 1 g b.i.d., Dilaudid 2-6
mg q.4-6 hours p.r.n., Milk of Magnesia 30 q.d. p.r.n.,
Ativan 0.5 mg q.d.
PAST MEDICAL HISTORY: Aortic ectasia status post aortic root
replacement in [**2123-1-23**]. Sternal wound debridement in
[**2123-6-25**]; further sternal wound debridement in [**2123-9-25**]. Zenker's diverticulum. Gastroesophageal reflux
disease. Hypertension. Nephrolithiasis. Depression.
Anxiety. Cholecystectomy. Appendectomy. Total abdominal
hysterectomy. Exploratory laparotomy. Lysis of adhesions.
ALLERGIES: CODEINE, ERYTHROMYCIN, SULFA, PREDNISONE,
TETRACYCLINE, BACTRIM, AMPICILLIN, AMOXICILLIN, ALBUTEROL,
ATROVENT.
PHYSICAL EXAMINATION: Vital signs: On admission the patient
was afebrile, heart rate 96, blood pressure 170/70,
respirations 20. General: The patient was alert and
oriented times three. She was in no acute distress. She was
slightly anxious. HEENT: Pupils equal, round and reactive
to light. Moist mucous membranes. No jugular venous
distention. Cardiovascular: Regular, rate and rhythm. No
murmurs, rubs, or gallops. Positive swelling in the
suprasternal region, 5 x 5 cm area, with erythema. Chest:
Breath sounds even and unlabored. Clear to auscultation
bilaterally. Abdomen: Soft, nontender, nondistended.
Extremities: No erythema or edema.
HOSPITAL COURSE: The patient was admitted to Cardiothoracic
Surgery and scheduled for CAT scan of her chest. This showed
a collection of the anterior to the manubrium, with an
enlarged pseudoaneurysm measuring 3.3 x 5.6.
On [**12-22**], the patient was brought to the Operating Room
at which time she underwent an aortic root replacement and
coronary artery bypass grafting times one. Please see the
operative report for full details.
In summary the patient had an aortic root replacement and
coronary artery bypass grafting times one with saphenous vein
graft to the right coronary artery and an intra-aortic
balloon placement at that time.
She was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient had an intra-aortic
balloon pump at 1:1, Milrinone 0.5 mcg/kg/min, Dobutamine 5
mcg/kg/min, and Levophed, Propofol, and .................
Upon arrival in the Cardiothoracic Intensive Care Unit, the
Levophed was weaned to off, and the patient was started on
Nitroglycerin which was gradually increased to 2.5
mcg/kg/min.
Additionally, the patient arrived in the Cardiothoracic
Intensive Care Unit with an open chest, and paralytics were
initiated at that time.
Following her arrival in the Intensive Care Unit setting, the
Plastic Surgery Service, as well as Infectious Disease
Service were consulted.
On postoperative day #1, the patient remained with an open
chest, continued on paralytics. Her Dobutamine was weaned to
off. Her Milrinone was weaned to 0.1 mcg/kg/min. She
tolerated these procedures and remained hemodynamically
stable.
On postoperative day #2, the patient remained hemodynamically
stable. Her cardioactive drips were weaned as tolerated.
On postoperative day #3, the patient returned to the
Operating Room at which time she underwent a clean-out of her
chest and primary closure of her chest. She tolerated that
procedure well and was again transferred to the
Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient had the intra-aortic
balloon pump at 1:1 and Milrinone at 0.25 mcg/kg/min.
Following her return to the Cardiothoracic Intensive Care
Unit, the patient's paralytics were discontinued. Her
sedation was discontinued. She was allowed to awaken and was
weaned on the ventilator to pressure support ventilation.
On the following morning, the patient's intra-aortic balloon
pump was weaned and successfully removed. The patient's
Milrinone was weaned to off, and her PA line was removed.
Following removal of the intra-aortic balloon pump, the
patient was further weaned from her ventilator and
successfully extubated.
Over the next several days, the patient had an uneventful
Intensive Care Unit stay. She remained in the Cardiothoracic
Intensive Care Unit to evaluation her hemodynamically and
from a respiratory standpoint, and furthermore, until her MRI
of the spine could be completed to additionally evaluate her
reported compression fractures and assess her neurological
status.
On postoperative day #8, the patient was transferred from the
Cardiothoracic Intensive Care Unit to .................. for
continuing postoperative care and cardiac rehabilitation.
She continued to be followed by not only the Cardiothoracic
Service but also by the Infectious Disease Service, as well
as the Neurosurgery Service.
It was their recommendation following MRI to continue the
patient in a brace for up to three months and to have
follow-up with her outside hospital neurosurgeon, as the MRI
showed no obvious cord compression, and only a slight bulge
at L1 with no compromise.
The patient's stay on ............ was relatively uneventful.
Her activity level was advanced with the assistance of the
nursing staff and Physical Therapy Service.
On postoperative day #14, it was decided that the patient was
stable and ready to be transferred to rehabilitation.
DISCHARGE PHYSICAL EXAMINATION: Vital signs: Temperature
98.5??????, heart rate 96 in sinus rhythm, blood pressure 110/70,
respirations 20, oxygen saturation 94% on room air. Weight
preoperatively was 80 kg, discharge 90 kg. General: The
patient was alert and oriented times three. She moves all
extremities and follows commands. Chest: Clear to
auscultation bilaterally. Cardiovascular: Regular, rate and
rhythm. S1 and S2. Incision with Steri-Strips, open to air,
clean and dry. Abdomen: Soft, nontender, nondistended.
Positive bowel sounds. Extremities: Warm and well perfused
with no edema. Left saphenous vein graft site with
Steri-Strips and open to air, clean and dry.
DISCHARGE LABORATORY DATA: Sodium 135, potassium 4.0,
chloride 97, CO2 26, BUN 13, creatinine 0.5, glucose 121;
white count 11, hematocrit 37.6, platelet count 649.
DISCHARGE MEDICATIONS: Vancomycin 1 g b.i.d., stop date of
[**1-30**], Rifampin 300 mg q.8 hours, to be continued
indefinitely, Gentamicin 100 mg q.8 hours, stop date of
[**1-8**]. Following completion of Gentamicin course, the
patient is to start on Levofloxacin 500 mg q.d., and this is
to continue indefinitely. Aspirin 325 mg q.d., Lansoprazole
30 mg q.d., Lorazepam 1 mg q.h.s., Heparin 5000 U t.i.d.,
Colace 100 mg b.i.d., Metoprolol 75 mg b.i.d., Hydromorphone
2-4 mg q.4-6 hours p.r.n., Ibuprofen 400 mg q.6 hours p.r.n.,
Simethicone 40-80 mg q.i.d. p.r.n., Cyclobenzaprine 10 mg
t.i.d. p.r.n.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Status post aortic root replacement.
2. Coronary artery bypass grafting times one with saphenous
vein graft to right coronary artery.
3. Zenker's diverticulum.
4. Gastroesophageal reflux disease.
5. Hypertension.
6. Nephrolithiasis.
7. Depression.
8. Anxiety.
9. Status post cholecystectomy.
10. Status post appendectomy.
11. Status post total abdominal hysterectomy.
12. Status post exploratory laparotomy and lysis of
adhesions.
DISCHARGE STATUS: The patient is to be discharged to
rehabilitation.
FOLLOW-UP: She is to have follow-up with Dr. [**Last Name (STitle) 1140**] from
[**Hospital3 **] Neurosurgery Department in one month.
Follow-up with Infectious Disease Clinic, Dr. [**First Name (STitle) **], [**First Name3 (LF) **] 5,
10 a.m. Follow-up with Dr. [**Last Name (STitle) 1537**] in one month.
Additionally, the patient is to have a CBC, BUN, creatinine,
LFTs, and Vancomycin trough checked on a weekly basis with
the results faxed to Dr.[**Name (NI) 103853**] office in the Infectious
Disease Clinic, [**Telephone/Fax (1) 1419**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2124-1-4**] 13:18
T: [**2124-1-4**] 13:26
JOB#: [**Job Number 103854**]
|
[
"300.00",
"E878.1",
"530.81",
"401.9",
"805.4",
"998.59",
"311",
"997.2",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.41",
"37.61",
"39.61",
"36.11",
"86.22",
"97.44",
"38.93",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
7471, 8053
|
8106, 9436
|
1246, 1479
|
2705, 6596
|
6619, 7447
|
165, 184
|
213, 1219
|
1502, 2022
|
8078, 8085
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,711
| 101,806
|
7658
|
Discharge summary
|
report
|
Admission Date: [**2103-8-3**] Discharge Date: [**2103-8-13**]
Date of Birth: [**2041-1-21**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Benadryl Decongestant
Attending:[**Last Name (un) 2888**]
Chief Complaint:
Chest and Abdominal Pain
Major Surgical or Invasive Procedure:
Pericardiocentesis with drain placement
Pericardial drain removal
Hemodialysis
Attempted thrombectomy of HD graft in left arm by interventional
radiology
Placement of tunneled HD line through left IJ by interventional
radiology
History of Present Illness:
62 year old male with a pmh of ESRD s/p failed graft on HD, Hep
C genotype 1, DMII, HTN, HLD who presents from an OSH with
pericarditis complicated by pericardial effusion.
.
His OSH course is as follows:
He had an admission prior to this [**Date range (1) 27855**] with pleuritic CP
and rub, diagnosed with pericarditis. Also, new LBBB and tropI
of 0.125. Echo showed small effusion and normal wall motion,
mild AS, mild MR, unchanged from baseline. He was treated with
NSAIDs. Due to LBBB, prolonged PR and underlying dCHF (between
dialysis sessions) his dilt was stopped and coreg (3.125) was
added. He was discharged on 50mg TID of indocin.
.
Several days after discharge he developed general weakness,
vague diffuse low abd pain, and fatigue. Dialysis was
complicated by hypotension (new) and required fluid. [**8-2**]
admitted to OSH with hypotension of 75/50 and above symptoms. He
was fluid resuscitated, fluid responsive. CT A/P showed
diverticulosis (no inflammation) and a mod pericardial effusion
(incidental). RUQ U/S with GB wall thickening, otherwise
unremarkable.
.
He was admitted to the ICU, BPs maintained 100s-140s and HRs
50s-70s. Treated presumptively for adrenal insufficiency with
hydrocortisone. Echo showed circuferential pericardial effusion
(2.1-2.2 cm) reportedly without evidence of tamponade. His
vitals remained stable and his labs were unremarkable (stable
anemia HCT ~30) and WBC elevation of 19 after steroids.
Creatinine 8.9, sodium 131. He was transferred from OSH
([**Hospital1 1562**]) to [**Hospital1 18**] for further management.
.
At [**Hospital1 18**], he was admitted to inpatient medicine. He is
comfortable without any acute complaints. He does still have
mild chest discomfort that has persisted throughout his
admission at the OSH. He also has vague lower abdominal pain,
but is otherwise without any acute complaints. No SOB, no
orthopnea, no PND.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia,
+Hypertension
2. OTHER PAST MEDICAL HISTORY:
- ESRD secondary to FSGN, s/p failed graft placement and now
temporarily off of the [**Hospital1 **] list (due to current illness)
on hemodialysis from FSGS; AV graft is thrombosed (he is
dialyzed now through temp groin line)
- Hepatitis C genotype 1, biopsy showed fibrosis grade I
- Gout
- s/p Partial parathyroidectomy (adenoma)
- Neuropathy
Social History:
Lives in [**Hospital1 1562**] with his wife and daughter. [**Name (NI) **] is a former
smoker that quit many years ago. No alcohol or drugs. He is a
cab driver.
Family History:
No renal disease in family, father with CAD age 50s. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals: T:98.1 BP:120/72 P:64 R:18 18 O2: 99% - Pulsus 18
(doppler)
General: Alert, oriented, no acute distress, mildly fatigued
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~8, no LAD
Lungs: Clear to auscultation bilaterally, basilar crackles no
wheezes, rales, ronchi
CV: Normal rate, Regular rhythm, distant heart sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis, trace edema
Neuro: Oriented. No gross deficits.
.
DISCHARGE EXAM:
VS: Tm 98.1 BP 122/57 P 81-86, R18, 100%RA
Pulsus: 8
Gen: well-appearing male in NAD
HEENT: NCAT MMM EOMI anicteric
Neck: Supple without LAD, JVD not discernable
Pulm: CTA b/l without wheeze or rhonchi
Cor: RRR (+)S1/S2 without m/g, former drain site c/d/i
Abd: Soft, non-distended, non-tender to palpation, NABS
Extrem: 1+ LE edema b/l, good distal pulses, warm and well
perfused
LUE fistula with palpable cords. RLE with increased edema, pain
with passive movement.
Neuro: CNII-XII grossly intact, moving all extremities,
mentating well
Lines/Drains: RUE PICC, tunneled HD catheter
Pertinent Results:
#ADMISSION LABS:
[**2103-8-4**] 02:15AM BLOOD WBC-12.1*# RBC-2.82* Hgb-8.7*# Hct-27.6*#
MCV-98 MCH-30.9 MCHC-31.5 RDW-16.3* Plt Ct-302
[**2103-8-4**] 02:15AM BLOOD PT-16.5* PTT-67.6* INR(PT)-1.6*
[**2103-8-4**] 02:15AM BLOOD
[**2103-8-4**] 02:15AM BLOOD Glucose-202* UreaN-51* Creat-6.4*#
Na-132* K-4.6 Cl-97 HCO3-22 AnGap-18
[**2103-8-4**] 02:15AM BLOOD ALT-51* AST-49* CK(CPK)-46*
[**2103-8-4**] 02:15AM BLOOD Albumin-2.8* Calcium-7.7* Phos-5.5*
Mg-2.0
.
#DISCHARGE/PERTINENT LABS:
[**2103-8-13**] 03:24PM BLOOD Hct-28.2*
[**2103-8-13**] 04:00AM BLOOD WBC-7.6 RBC-2.45* Hgb-7.8* Hct-24.4*
MCV-100* MCH-31.6 MCHC-31.7 RDW-15.5 Plt Ct-294
[**2103-8-12**] 03:50AM BLOOD WBC-7.6 RBC-2.64* Hgb-8.2* Hct-26.0*
MCV-98 MCH-30.9 MCHC-31.4 RDW-15.6* Plt Ct-272
[**2103-8-11**] 02:50AM BLOOD WBC-7.1 RBC-2.68* Hgb-8.4* Hct-26.4*
MCV-98 MCH-31.4 MCHC-32.0 RDW-15.6* Plt Ct-253
[**2103-8-10**] 04:07AM BLOOD WBC-8.4 RBC-2.81* Hgb-8.5* Hct-28.1*
MCV-100* MCH-30.3 MCHC-30.3* RDW-15.8* Plt Ct-292
[**2103-8-9**] 05:47AM BLOOD WBC-7.0 RBC-2.70* Hgb-8.4* Hct-27.1*
MCV-100* MCH-31.1 MCHC-31.0 RDW-16.2* Plt Ct-285
[**2103-8-8**] 04:40AM BLOOD WBC-9.7 RBC-2.90* Hgb-9.0* Hct-28.3*
MCV-98 MCH-31.0 MCHC-31.7 RDW-16.5* Plt Ct-309
[**2103-8-7**] 04:23AM BLOOD WBC-9.7 RBC-2.97* Hgb-9.3* Hct-29.2*
MCV-98 MCH-31.1 MCHC-31.6 RDW-16.9* Plt Ct-327
[**2103-8-6**] 05:12AM BLOOD WBC-11.8* RBC-2.94* Hgb-9.2* Hct-28.8*
MCV-98 MCH-31.3 MCHC-32.0 RDW-17.2* Plt Ct-332
[**2103-8-5**] 06:30AM BLOOD WBC-12.2* RBC-3.07* Hgb-9.6* Hct-30.3*
MCV-99* MCH-31.3 MCHC-31.6 RDW-17.6* Plt Ct-372
[**2103-8-13**] 04:00AM BLOOD PT-25.1* PTT-55.0* INR(PT)-2.4*
[**2103-8-12**] 10:06AM BLOOD PT-24.9* PTT-138* INR(PT)-2.4*
[**2103-8-12**] 10:06AM BLOOD PT-24.9* PTT-138* INR(PT)-2.4*
[**2103-8-11**] 05:41PM BLOOD PTT-73.7*
[**2103-8-10**] 07:36AM BLOOD PTT-87.1*
[**2103-8-10**] 04:07AM BLOOD PT-17.7* PTT-64.0* INR(PT)-1.7*
[**2103-8-9**] 05:47AM BLOOD PT-14.9* PTT-98.4* INR(PT)-1.4*
[**2103-8-8**] 04:40AM BLOOD PT-15.0* PTT-40.6* INR(PT)-1.4*
[**2103-8-7**] 04:23AM BLOOD PT-15.8* PTT-106.6* INR(PT)-1.5*
[**2103-8-6**] 05:12AM BLOOD PT-13.8* PTT-30.6 INR(PT)-1.3*
[**2103-8-5**] 06:30AM BLOOD PT-14.7* PTT-29.9 INR(PT)-1.4*
[**2103-8-7**] 04:23AM BLOOD ESR-70*
[**2103-8-13**] 04:00AM BLOOD Glucose-147* UreaN-53* Creat-8.9*#
Na-130* K-4.4 Cl-91* HCO3-30 AnGap-13
[**2103-8-11**] 02:50AM BLOOD Glucose-83 UreaN-25* Creat-5.7*# Na-130*
K-4.0 Cl-90* HCO3-31 AnGap-13
[**2103-8-9**] 05:47AM BLOOD Glucose-94 UreaN-35* Creat-6.2*# Na-132*
K-3.9 Cl-93* HCO3-33* AnGap-10
[**2103-8-7**] 04:23AM BLOOD Glucose-126* UreaN-45* Creat-6.6*# Na-135
K-4.4 Cl-97 HCO3-29 AnGap-13
[**2103-8-6**] 05:12AM BLOOD Glucose-159* UreaN-105* Creat-10.6*#
Na-133 K-5.2* Cl-95* HCO3-21* AnGap-22*
[**2103-8-7**] 04:23AM BLOOD ALT-36 AST-35 AlkPhos-36* TotBili-0.5
[**2103-8-6**] 05:12AM BLOOD ALT-45* AST-37 LD(LDH)-176 AlkPhos-40
TotBili-0.3
[**2103-8-13**] 04:00AM BLOOD Albumin-2.3* Calcium-6.8* Phos-2.7 Mg-1.8
[**2103-8-11**] 02:50AM BLOOD Calcium-6.8* Phos-2.6*# Mg-1.7
[**2103-8-10**] 04:07AM BLOOD TotProt-5.4* Calcium-7.6* Phos-5.0*
Mg-1.8
[**2103-8-8**] 04:40AM BLOOD Calcium-7.5* Phos-6.3* Mg-1.9
[**2103-8-6**] 05:12AM BLOOD Albumin-2.8* Calcium-7.2* Phos-6.1*
Mg-2.1
[**2103-8-5**] 06:30AM BLOOD Calcium-7.6* Phos-6.0* Mg-2.1
[**2103-8-6**] 05:12AM BLOOD %HbA1c-5.2 eAG-103
[**2103-8-10**] 09:21AM BLOOD Cryoglb-NEGATIVE
[**2103-8-6**] 05:12AM BLOOD TSH-2.0
[**2103-8-6**] 12:55PM BLOOD dsDNA-NEGATIVE
[**2103-8-5**] 06:30AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:160
[**2103-8-10**] 04:07AM BLOOD PEP-NO SPECIFI
[**2103-8-9**] 05:47AM BLOOD C4-32
[**2103-8-6**] 05:12AM BLOOD C3-73*
[**2103-8-7**] 04:23AM BLOOD HIV Ab-NEGATIVE
[**2103-8-6**] 12:55PM BLOOD C2-Test
[**2103-8-6**] 09:30AM OTHER BODY FLUID WBC-2675* Hct,Fl-10.5*
Polys-67* Lymphs-23* Monos-5* Eos-2* Atyps-1* NRBC-1* Macro-2*
[**2103-8-6**] 09:30AM OTHER BODY FLUID TotProt-4.9 Glucose-129
LD(LDH)-1113 Amylase-32 Albumin-2.2
.
#STUDIES:
[]2D-ECHOCARDIOGRAM: [**2103-8-4**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The 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. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is a large pericardial
effusion. There is sustained right atrial collapse, consistent
with low filling pressures or early tamponade. There is
significant, accentuated respiratory variation in
mitral/tricuspid valve inflows, consistent with impaired
ventricular filling.
IMPRESSION: Large circumferential effusion with
echocardiographic evidence of early tamponade physiology.
.
[]2D-ECHOCARDIOGRAM (POST-PERICARDIOCENTESIS): [**2103-8-6**]
Left ventricular wall thicknesses and cavity size are normal.
There is an anterior space which most likely represents a
prominent fat pad. No residual pericardial effusion identified.
Compared with the prior study (images reviewed) of [**2103-8-4**], the
pericardial effusion has resolved and tamponade physiology is no
longer suggested.
.
[]EKG [**2103-8-3**]:
Sinus rhythm with first degree atrio-ventricular conduction
delay. Borderline left axis deviation. Diffuse non-diagnostic
repolarization abnormalities. [**Last Name (un) **] QRS voltage in the precordial
leads. Compared to the previous tracing of [**2100-10-6**] there is no
diagnostic change.
Rate PR QRS QT/QTc P QRS T
72 [**Telephone/Fax (3) 27856**]/455 0 -25 129
Brief Hospital Course:
[]BRIEF CLINICAL COURSE:
62M w/ hx ESRD s/p failed graft on HD, Hep C genotype 1, DMII,
HTN, HLD who presents from an OSH with pericarditis complicated
by pericardial effusion. The patient was intially admitted to a
general medicine service. On [**8-4**], he developed atrial
fibrillation and was found to have significant tamponade
physiology, so was transferred to the cardiology service. A
pericardiocentesis was performed on [**8-6**], and he was transferred
to the CCU following the procedure. He was transferred back to
the inpatient cardiology team on [**8-9**], and he was discharged on
[**2103-8-13**].
.
[]ACTIVE ISSUES:
# Pericardial Effusion: On the floor, the patient was found to
have a pulsus paradoxus of 15mmHg. An echo demonstrated a large
effusion with significant tamponade physiology. He developed
atrial fibrillation at this time (see below) with rates in the
90s-100s, but beta blockers were not used given the patient's
hypotension, which was thoguht to be secondary to the tamponade
physiology. On [**8-6**], the patient underwent pericardiocentesis
with drain placement. Approximately 720cc of bloody fluid was
removed initially. An additional ~500cc of bloody fluid was
collected from the drain in the following two days. In the CCU,
the patient was nto hypotensive and did not demonstrate
tamponade physiology. Hi pulsus was measured to be 6-12mmHg in
the days following drainage. Echo following the
pericardiocentesis demonstrated resolution of the effusion. The
drain was removed on [**8-7**], and repeat echo demonstrated some
fluid surrounding the heart, which was thought to be
post-procedural inflammation as opposed to reaccumulation of an
effusion. Back on the cardiology floor, the patient had stable
pulsus checks daily and a repeat ECHO prior to discharge
demonstrated stable pericardial effusion. In terms of the
etiology of the pericarditis and pericardial effusion, uremia
was thought to be unlikely by the nephrology consult service,
given that the patient is regularly dialyzed. A viral etiology
was thought to be most likely and we continued the patient on
twice weekly colchicine dosing, though no specific pathogen was
identified. Malignancy was considered, but the pericardial
fluid showed no malignant cells on cytology. TB was considered,
but PPD was negative. Cryoglobulinemia was considered given the
patient's hepatitis C, and testing revealed negative
cryoglobulins. Autoimmune etiology was considered, and testing
revealed +[**Doctor First Name **] but negative dsDNA. The patient will follow up
with his outpatient cardiologist, his PCP, [**Name10 (NameIs) **] surgery,
and will return on [**8-22**] for a f/u ECHO to monitor.
.
# Atrial Fibrillation: On the medicine floor early in the
patient's hospitalization, the patient developed atrial
fibrillation. He converted to normal sinus rhythm, and remained
in sinus rhythm during his CCU stay. Due to the risk of
paroxysmal afib, he was started on heparin drip. This was
continued during his CCU stay. His CHADS2 score was [**12-29**]. The
cardiology floor team considered whether or not to anticoagulate
the patient with warfarin, and they decided to continue bridge
the patient to coumadin with a heparin drip; the patient was
therapuetic at discharge. The patient was continued on
carvedilol. He came into the hospital on diltiazem, but this
was held in favor of the carvedilol. The patient also
reportedly had LBBB on EKG at OSH. Here he had anterior
fascicular block, which was consistent with prior EKGs.
.
# Mild Diastolic Heart Failure: As per OSH report, the patient
has mild diastolic heart failure. Diastolic heart failure is
not clearly mentioned in [**Hospital1 18**] records or ECHOs and may need to
be reassessed after complete resolution of the current
pericardial disease.
.
# ESRD on HD with Thrombosed [**Last Name (un) **] graft: On admission to CCU,
BUN>100 and Cr>10 with associated anemia thought to be secondary
to the renal disease. The patient also has a graft in the left
upper extremity which has clotted multiple times. It was
stented in the past, but has re-thrombosed. A temporary HD line
was placed at the OSH, and he did not miss dialysis. The
temporary line was pulled after the patient was admitted to the
CCU, and he was sent to IR for an attempted thrombectomy. IR
removed a thormbus, but the graft reclotted within 10 minutes.
Therefore, a tunnel line was placed in the LIJ into the
brachiocephalic. However, there was stenosis at the confluence
of the left innominate/SVC junction, and the tunnelled line
obstructed the flow that had been previously able to get through
this stenosed vessel. This resulted in edema of the patient's
left arm. On [**8-9**], the patient returned to IR for balloon
expansion of the brachiocephalic through the tunneled line.
After the procedure, the edema subsided substantially within 24
hours. The patient was continued on his home Nephrocaps and
Phoslo. He received Epo with dialysis. he was follwed by
nephrology and received 3x weekly dialysis while here.
.
# HTN: Patient had relatively low pressures prior to admission
to the CCU compared to baseline, likely secondary to atrial
fibrillation and early tamponade. He was not at all hypotensive
after the pericardiocentesis procedure. His hypertension was
treated with lisinopril and carvedilol. His home diltiazem was
discontinued.
.
# DM: Patient treated with insulin sliding scale.
.
# HLD: Simvastatin was continued.
.
# Hep C: The patient's LFTs were not elevated boyond his
baseline.
.
# Gout: Inactive.
.
[]TRANSITIONAL ISSUES:
-patient will start back on his old HD regimen of TU, TH, SAT.
Patient discharged on a monday after received HD, will f/u on
Tuesday for HD session.
-patient will have his INR monitored by Dr. [**Last Name (STitle) 27857**].
-The patient will return on [**8-22**] for f/u TTE to
monitor for an evolving effusion.
Medications on Admission:
Preadmission medications listed are correct and complete
Information was obtained from Patient
1. Indomethacin 50 mg PO TID (recently added for pericarditis)
2. Carvedilol 3.125 mg PO BID (this was started recently when
dilt was being held, then it was held when dilt was restarted)
3. Omeprazole 20 mg PO DAILY
4. Diltiazem 60 mg PO QAM
5. Diltiazem 120 mg PO QPM
6. Calcium Acetate 667 mg PO TID W/MEALS
7. fenofibrate *NF* 160 mg Oral daily
8. Simvastatin 20 mg PO HS
9. Nephrocaps 1 CAP PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Lisinopril 10 mg PO DAILY
- also took Lactulose 15cc PRN constipation until recently
- was also on Hydrocortisone recently at OSH for pericarditis
Discharge Medications:
1. Outpatient Lab Work
Please check INR, CBC, on [**2103-8-16**] and fax results to
[**Last Name (LF) 27857**],[**First Name7 (NamePattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1105**] at [**Telephone/Fax (1) 27858**]
2. Carvedilol 3.125 mg PO BID
3. Calcium Acetate 1334 mg PO TID W/MEALS
RX *calcium acetate 667 mg 2 tablet(s) by mouth Three times a
day with meals Disp #*120 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Simvastatin 20 mg PO HS
7. Colchicine 0.3 mg PO TUESDAY AND FRIDAY
RX *colchicine [Colcrys] 0.6 mg 0.5 (One half) tablet(s) by
mouth TUESDAY AND FRIDAY Disp #*5 Tablet Refills:*0
8. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Omeprazole 20 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Pericardial effusion
DVT
Secondary diagnosis
End Stage Renal Disease
Hepatitis C
Hypertension
Diabetes
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 24049**],
It was a pleasure taking care of you.
You were admitted to [**Hospital1 69**] for
having fluid around your heart that caused an irregular heart
rhythm. You had the fluid removed and were monitored with
multiple ultrasounds of your heart that showed no further fluid
accumulation. You will follow up with your outpatient primary
care physician, [**Name10 (NameIs) **] cardiologists and you will get a routine
echocardiogram. Please contact your primary care physician if
you experience increased swelling or pain in your legs. We wish
you and your family the best.
Followup Instructions:
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 27859**]
Specialty: Primary Care
When: Monday [**2103-8-20**] at 9:40am
Address: [**Last Name (un) 27860**], UNIT [**Unit Number **], [**Hospital1 **],[**Numeric Identifier 27861**]
Phone: [**Telephone/Fax (1) 27862**]
*This is a follow up appointment for your hospitalization. You
will be reconnected with your primary care provider, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 27863**], after this visit.
You should also call your docotor's office tomorrow to discuss
monitoring of your blood tests while you are on the blood
thinner medication (coumadin)
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27864**], MD
Specialty: Cardiology
When: Wednesday [**2103-8-29**] at 1:45pm
Location: CARDIOVASCULAR SPECIALISTS
Address: 90 TER HEUN DR, STE#300, [**Hospital1 **],[**Numeric Identifier 19665**]
Phone: [**Telephone/Fax (1) 19666**]
Department: CARDIAC SERVICES
When: WEDNESDAY [**2103-9-5**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name **] CENTER
When: FRIDAY [**2103-10-12**] at 10:30 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ECHO LAB
When: WEDNESDAY [**2103-8-22**] at 1 PM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,920
| 139,698
|
31137+57734
|
Discharge summary
|
report+addendum
|
Admission Date: [**2100-7-26**] Discharge Date: [**2100-8-5**]
Date of Birth: [**2025-10-12**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
dysarthria, L hemiparesis
Major Surgical or Invasive Procedure:
Tracheostomy
PEG tube placement
History of Present Illness:
74yo man with PMH significant for Parkinson's disease,
hypertension, and orthostatic hypotension, presents with
dysarthria and left hemiparesis as a transfer from [**Hospital2 **] [**Hospital3 6783**]
Hospital s/p IV tPA administration. History is mostly obtained
from the OSH records, as the patient is too dysarthric to
provide
a full history. He does endorse the provided history. Per
report,
he was well until around 1pm [**7-25**], when he had acute onset of
dysarthria, left facial droop, and then left hemiparesis. It
seems that he was able to walk with a cane (usually walks
unassisted) into the hospital, but then symptoms worsened. He
presented 15-20mins later. Examination at the OSH was notable
for
dysarthria, expressive aphasia, left facial droop, left
hemiparesis, and upgoing left toe. NIHSS was 15 (3 for face, 4
for LUE motor, 2 for LLE motor, 1 for ataxia, 1 for sensory, 2
for language, and 2 for dysarthria). A head CT showed no acute
abnormalities. Labs were unremarkable. He was given IV tPA with
infusion ending at 3pm. BPs ranged from 130-152/80s-90s while
there. He reportedly had some improvement with the tPA per the
report, but the patient denies any significant change. He was
transferred to [**Hospital1 18**] ED due to lack of ICU beds.
On ROS at the OSH, he denied fevers, chills, cough, dyspnea,
chest pain, palpitations, nausea, and vomiting.
Past Medical History:
hypertension
Parkinson's disease
orthostatic hypotension
diverticulosis/hemorrhoids
thalassemia
depression/anxiety
macular degeneration
erectile dysfunction
s/p appendectomy
Social History:
no tobacco or EtOH. Not married.
Family History:
"noncontributory" per OSH
Physical Exam:
VS: T 97.1, HR 86, BP 166/94->150/80s, RR
22, SaO2 100%/RA
Genl: NAD, lying in bed
HEENT: NCAT, dry MM
Neck: no carotid bruits
CV: RRR, nl S1, S2, no m/r/g
Chest: CTA bilaterally x crackles at bases, R>L
Abd: soft, NTND, BS+
Ext: warm and dry
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Grossly attentive. Speech is stuttering and very
dysarthric. He has normal comprehension and repetition; naming
intact. Unable to test [**Location (un) 1131**] due to blurred vision without
glasses present. Registers [**2-20**], recalls [**1-23**] in 5 minutes. No
right-left confusion. No evidence of visual neglect.
Cranial Nerves: Fundoscopic examination reveals sharp disc
margins. Pupils equally round and reactive to light, 7 to 5 mm
bilaterally. No RAPD. Visual fields are full to confrontation.
Extraocular movements intact bilaterally with gaze-evoked
sustained nystagmus bilaterally. Sensation intact V1-V3 to cold,
light touch, and pinprick. Left facial droop. Hearing intact to
finger rub bilaterally. Palate elevation unable to appreciate.
Sternocleidomastoid full, decreased shrug on left. Tongue likely
midline given facial droop.
Motor: RUE w/ cogwheel rigidity, LUE flaccid, BLE hypertonic
(L>R). RUE>RLE tremor. RUE full strength; RLE full strength x
difficulty with dorsiflexion and toe extension. LUE no movement,
LLE able to flex at hip (barely antigravity) and at knee ([**1-25**]).
Sensation: Intact to light touch and symmetric to vibration.
Decreased pinprick and cold sensation in left arm, but not
decreased in leg. No extinction to DSS.
Reflexes: 2 in R [**Hospital1 **], br, [**Last Name (LF) **], [**First Name3 (LF) **], 3 in L [**Hospital1 **], br, [**Hospital1 **], 2+ L [**Hospital1 **],
tr R ankle, unable to elicit in L ankle. R toe withdraws on
plantar stim, L toe upgoing.
Coordination: unable to test
Gait: not tested
Pertinent Results:
OSH Labs:
141 107 21
------------< 107
3.8 25 1
ca 9.2
INR 1.1, PTT 27
6.8 > 34.2 < 145
ALT 16, AST 15, AP 63, TBili 0.6, Alb 4.7, Tprot 7.2
<br>
IMAGING:
OSH head CT: "small well corticated lucent lesion in the
posterior calvarium slightly left of midline... nonaggressive"
OSH CXR: nl
<br>
MRI/MRA Head:
1. There is an acute infarct involving the right side of the
[**Hospital1 **].
2. There is no evidence of hemorrhage.
3. There is no stenosis of the basilar artery.
<br>
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 maneuvers (post-Valsalva). 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 root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Dilated thoracic aorta. No cardiac cause of embolism
identified.
<br>
Carotid Duplex
There is a widely patent right internal carotid artery and a
widely patent left internal carotid artery with antegrade flow
in both vertebral arteries. This is a normal carotid duplex.
<br>
CTA Chest
1. Pulmonary embolism of the subsegmental branch of right apical
region of the right upper lobe. However the study is some
whatsuboptimal. If clinical concern exists, the study can be
repeated. This finding was discussed with doctor [**Doctor Last Name 27492**] at the
attending review at 9:20 Am at [**2100-7-29**].
2. Atelectatic changes are noted within the posterior segment of
the right lower lobe and basilar segment of the left lung.
3. Cholelithiasis with no evidence of cholecystitis.
4. Multiple hypodense liver lesions which are too small to
characterize. The largest one is located within segment VI and
measures 13 mm.
5. Both kidneys contain contrast material on the non-contrast
phase of the study suggesting prior contrast
admninistration/renal failure.
<br>
CTA Head:
Based upon the preliminary data available, including careful
review of the source image data, there is no evidence for
basilar artery thrombosis, but only very slight atherosclerotic
irregularity of this vessel. There is no hemodynamically
significant stenosis involving the basilar artery. The left
vertebral artery is the dominant vessel. The tributaries of the
circle of [**Location (un) 431**] are patent, allowing for moderate
atherosclerotic calcification of the cavernous portions of both
internal carotid arteries.
Finally, the pontine infarct is visible, though the parameters
chosen for CT angiography, as opposed to conventional brain
imaging, do not reveal the hypodense area with equivalent
clarity. Within the limitations of the present technique, there
does not appear to be definite overt increase in size of this
prominent right paracentral pontine infarct.
<br>
IR-guided Dobhoff placement
Procedure: 8 Fr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] tube was inserted under
continous flouroscopic guidance via the nasal cavity. The tube
could be advanced till the fundus of the stomach. Multiple
attempts of further advancement were unsuccessfull. Further
advancement is defered at the moment due to severe limitations
in patient's mobility and continous oxygen dependence. Tube
position was confimed using opitray contrast. Patient tolerated
the procedure well, with no immediate post procedural
complications.
<br>
Extremity U/S
No evidence of lower extremity DVT.
No upper extremity DVT.
<br>
EEG: This is an abnormal portable EEG in the waking and drowsy
states. There were no focal, lateralized, or epileptiform
features
noted.
<br>
CXR [**7-31**]: AP chest compared to [**7-27**] through 10:
Mild cardiac enlargement and mediastinal vascular engorgement
suggests volume overload and/or cardiac decompensation.
Consolidation has worsened in the right lower lung since [**7-28**], consistent with pneumonia.
A catheter device cannulates the esophagus to the upper abdomen.
<br>
Brief Hospital Course:
Mr. [**Known lastname 73503**] is a 74-year-old man with a history of
Parkinson's Disease and hypertension who presented with
dysarthria, left facial droop, and left hemiparesis. His
hospital course was as follows:
1. Neuro: STROKE, right [**Known lastname **]. He arrived at [**Hospital1 18**] as a transfer
from [**Hospital2 **] [**Hospital3 6783**] Hospital after receiving tPA at that facility
for the stroke. MRI/MRA performed here confirmed the right
pontine stroke. He was initially admitted to the neuro ICU,
where he did well with no complications, and was transferred to
the floor. Carotid ultrasound revealed widely patent vessels. A
transthoracic echocardiogram (TTE) revealed no thrombus, ASD, or
PFO. His BP was initially allowed to auto-regulate and was
generally well-controlled; he was put on metoprolol for rate
control (see below) and did not require other anti-hypertensives
to meet his goal of < 140/90. His cardiac enzymes were negative
and Hemoglobin A1c was 5.8. LDL was found to be 128, so he was
started on Lipitor 20; his LDL goal will be < 70. He was kept
euthermic and normoglycemic with Tylenol and insulin sliding
scale, respectively. Cardiac telemetry revealed paroxysmal
atrial fibrillation (see below), suggesting the etiology.
He continues to have a left facial droop, dense left hemiplegia,
and severe dysarthria.
2. Neuro: Parkinson's disease. Initially, records of his
outpatient medications were unavailable. Complicating this,
there was difficulty obtaining NG tube, so he did not receive
his medications for 48 hours. Even after resuming meds, he
remained fairly rigid. His Sinemet dose was increased to 5 times
per day, but this resulted in visual hallucinations. Ultimately,
his outside records were obtained and he was placed on the
correct doses of his anti-parkinsonian medications as listed
under Discharge Medications.
3. ID: Fevers, likely aspiration pneumonia. When he became
febrile, chest x-ray revealed basilar consolidations consistent
with aspiration pneumonia. He was started on a 7-day course of
levofloxacin and metronidazole, which will be completed at the
end of the day on [**8-6**].
4. Pulm: Pulmonary Embolus. He acutely decompensated on [**7-28**] with
decreased responsiveness, tachypnea, and increased work of
breathing. He was transferred back to the Neuro ICU, where he
stayed for two days. CXR revealed the above aspiration
pneumonia, and a Chest CTA revealed a pulmonary embolus. He was
treated with antibiotics and started on a Heparin drip for the
PE. He continued to have severe airway obstruction and sleep
apnea due to oropharyngeal hypotonia. He was therefore given a
tracheostomy by General Surgery on [**8-3**]. He was then started on
Coumadin for the PE, which he will need to continue for 6
months. He was continued on the Heparin gtt, goal PTT 50-70,
until the INR is [**1-23**].
5. Renal: Hyponatremia. This was due to hypovolemia and
responded to normal saline.
6. GI/FEN: NG tube was unable to be placed on the floor despite
repeated attempts. He was therefore given a post-pyloric tube
under fluoroscopic guidance by Interventional Radiology. This,
too, was delayed by 24 hours when the patient refused the
initial attempt in IR. Once the Dobhoff was placed, tube feeds
were initiated per the recommendations of Nutrition. After
failing several swallowing studies, a PEG was placed by General
Surgery on [**8-3**] after discussions with the patient and his
health care proxy. Tube feeds will continue indefinitely.
7. Heme: Thalassemia. His hematocrit was stable between 25 and
30.
8. Ophtho: Conjunctivitis. He developed a purulent discharge
with red eye. He completed a 7-day course of ciprofloxacin
ophthalmic drops with resolution of the signs and symptoms.
9. CODE: FULL
10. Communication: Health Care Proxy is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]:
[**Telephone/Fax (1) 73504**] or [**Telephone/Fax (1) 73505**].
11. Disposition: He was discharged to the Health
Alliance/[**Hospital 16844**] Rehabilitation Center ([**Telephone/Fax (1) 73506**]).
Medications on Admission:
Sinemet 100/25 qid
Florinef - unknown dose ("small"), ?[**Hospital1 **]
Mirapex 0.5 mg po tid
Buspirone 10 mg po bid
Effexor 75 daily
Allergies: NKDA
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Venlafaxine 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Check INR daily; goal INR [**1-23**].
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed: Please swab, as patient cannot
swallow.
7. Acetylcysteine 10 % (100 mg/mL) Solution Sig: 2-5 MLs
Miscellaneous Q2H (every 2 hours) as needed: For trach
secretions.
8. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
9. Buspirone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
10. Pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day.
11. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 5 doses: Ends on night of [**8-6**].
12. Levofloxacin 250 mg/10 mL Solution Sig: Twenty (20) mL PO
once a day for 1 doses: Ends with dose on [**8-6**]. Total 500 mg
dose.
13. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Nine [**Age over 90 1230**]y (950) Units/hr Intravenous ASDIR (AS
DIRECTED): Check PTT q6h; goal PTT is 50-70. Discontinue once
INR is [**1-23**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16844**] Hospital - [**Location (un) 1157**]
Discharge Diagnosis:
Primary:
1. Stroke, right [**Location (un) **]
2. Paroxysmal atrial fibrillation
3. Pulmonary embolus
<br>
Secondary:
1. Parkinson's Disease
Discharge Condition:
Fair condition. Trach in place for airway protection, PEG tube
in place for feeding. Neuro exam notable for severe dysarthria,
left facial droop and left hemiparesis, along with right-sided
resting tremor and cogwheel rigidity.
Discharge Instructions:
You have been evaluated for weakness and difficulty speaking.
You were found to have had a stroke in the right side of your
[**Last Name (LF) **], [**First Name3 (LF) **] area of below your brain that conducts the nerves to
muscles on the left side of your body. You have been started on
Lipitor to help control your cholesterol to prevent a second
stroke.
Additionally, you have been found to have intermittent atrial
fibrillation, an irregular heart beat. You've also been found to
have a pulmonary embolus. For these two conditions, you have
been started on a Heparin drip and Coumadin. You will need to
have your Coumadin checked regularly.
If you develop further specific muscle weakness, loss of
sensation, double vision, dizziness, difficulty speaking or
swallowing, chest pain, shortness of breath, palpitations, or
any other symptom that is concerning to you, please call your
PCP or your neurologist or go to the nearest hospital emergency
department.
Followup Instructions:
Once you are discharged from rehab, please call [**Telephone/Fax (1) 2574**] to
schedule an appointment in the [**Hospital 878**] clinic with Dr.
[**Last Name (STitle) **]. You should be seen in 4 weeks from the time of your
return home.
Please also call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 16258**], at [**Telephone/Fax (1) 73507**] at that
time. You should be seen in his office in [**12-22**] weeks after
returning home.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
Completed by:[**2100-8-5**] Name: [**Known lastname 12200**],[**Known firstname **] Unit No: [**Numeric Identifier 12201**]
Admission Date: [**2100-7-26**] Discharge Date: [**2100-8-5**]
Date of Birth: [**2025-10-12**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12202**]
Addendum:
At the request of the rehab facility, the patient was discharged
on therapeutic Lovenox doses rather than the Heparin drip as a
bridge to therapeutic INR.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4955**] Hospital - [**Location (un) 4329**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 12203**]
Completed by:[**2100-8-5**]
|
[
"427.31",
"507.0",
"372.30",
"300.4",
"401.9",
"276.52",
"415.19",
"332.0",
"276.1",
"362.50",
"282.49",
"V58.61",
"434.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"31.1",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16671, 16874
|
8365, 12444
|
343, 377
|
14293, 14523
|
4016, 4180
|
15535, 16648
|
2051, 2079
|
12646, 14002
|
14129, 14272
|
12470, 12623
|
14547, 15512
|
2094, 2338
|
277, 305
|
405, 1786
|
2767, 3997
|
4189, 8342
|
2377, 2751
|
2362, 2362
|
1808, 1984
|
2000, 2035
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,708
| 194,358
|
37511+58155+58156
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2131-12-31**] Discharge Date: [**2132-1-7**]
Date of Birth: [**2056-2-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfasalazine / Sulfa (Sulfonamide Antibiotics) / Parnate
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
bilateral arm pain
Major Surgical or Invasive Procedure:
coronary artery bypass graft x2 (LIMA-LAD, SVG -obtuse marginal)
History of Present Illness:
75 year old female presented to outside ED yesterday complaining
of neck pain radiating down both arms to her hands, occuring
intermittently over the last few days with a headache. On
admission to OSH tropin was 0.03, 6.79 and
peak this am at 8.24. She was transferred to [**Hospital1 18**] for further
evaluation and cardiac catheterization.
Past Medical History:
- COPD
- CHF
- Pulmonary fibrosis diagnosed CT [**2126**]
- Osteoporosis with compression fractures
- Hypercholesterolemia
- Hypertension
- GERD
- Anxiety/Depression
- Insomnia
- Post-surgical hypothyroidism
- Melanoma removed from back, left axillary lymph node
dissection [**2107**].
- Right knee and hip replacement.
Social History:
Widowed. Has one child. Worked as a quality inspector for
[**Company 2892**],
retired [**2116**]. Denies ETOH. Quit smoking in [**2119**] and was a
45ppy
smoker. Does not have any pets. No birds in house. No recent
travels. No molds in house. Currently lives in [**Hospital3 **]
facility.
Family History:
Mother deceased from complications related to RA. Father
deceased age 52 from MI. Brother has CAD. Sister deceased from
traumatic fall.
Physical Exam:
Admission Physical Exam
Pulse:87 Resp:16 O2 sat:98/2L
B/P Right:112/48
Height:5'6" Weight:128 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x- well healed anterior cervical thyoidectomy
scar] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left:+2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right:+2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2131-12-31**] 03:00PM GLUCOSE-84 UREA N-18 CREAT-1.1 SODIUM-137
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-20* ANION GAP-12
[**2131-12-31**] 03:00PM WBC-10.0# RBC-3.57* HGB-10.3* HCT-31.0*
MCV-87 MCH-29.0 MCHC-33.3 RDW-16.0*
ECHO [**2132-1-1**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. 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.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
[**2132-1-7**] 06:20AM BLOOD WBC-12.6* RBC-4.36 Hgb-12.4 Hct-37.6
MCV-86 MCH-28.4 MCHC-33.0 RDW-15.7* Plt Ct-310
[**2131-12-31**] 03:00PM BLOOD WBC-10.0# RBC-3.57* Hgb-10.3* Hct-31.0*
MCV-87 MCH-29.0 MCHC-33.3 RDW-16.0* Plt Ct-148*#
[**2132-1-1**] 02:29PM BLOOD PT-13.0 PTT-44.3* INR(PT)-1.1
[**2131-12-31**] 03:00PM BLOOD PT-12.8 INR(PT)-1.1
[**2132-1-7**] 06:20AM BLOOD UreaN-21* Creat-0.8 Na-140 K-4.1 Cl-105
[**2132-1-7**] 06:20AM BLOOD UreaN-21* Creat-0.8 Na-140 K-4.1 Cl-105
[**2131-12-31**] 03:00PM BLOOD Glucose-84 UreaN-18 Creat-1.1 Na-137
K-4.3 Cl-109* HCO3-20* AnGap-12
[**2131-12-31**] 03:00PM BLOOD ALT-62* AST-145* CK(CPK)-129 AlkPhos-410*
TotBili-0.6 DirBili-0.3 IndBili-0.3
Brief Hospital Course:
On [**2132-1-1**] Ms.[**Known lastname 84254**] was taken to the operating room for an
urgent coronary artery bypass graft x2(Left internal mammary
artery to left anterior descending artery and
saphenous vein graft to obtuse marginal artery)with Dr.[**First Name (STitle) **].
Cardiopulmonary Bypass time= 33 minutes. Cross Clamp time=26
minutes. She tolerated the procedure well and was transferred to
the CVICU intubated and sedated requiring levophed for optimal
cardiac support. She awoke neurologically intact and was
extubated on POD#1 without difficulty. Due to her history of
COPD, aggressive pulmonary hygiene post extubation was
initiated. Narcotics were discontinued due to confusion. Pain
controlled with Ultram. Weaned off pressors, started on
Beta-blockers/Statin/Aspirin and diuresis was initiated. All
lines and drains were discontinued in a timely fashion. She
continued to progress and was transferred to the step down unit
on [**2132-1-4**] for further monitoring. Physical Therapy was
consulted for evaluation of strength and mobility. The remainder
of her hospital admission was essentially uneventful. Due to her
baseline respiratory comprimise, she remains O2 dependent and
continues her steroid taper that was initiated preop by [**Doctor Last Name 11710**],
[**First Name7 (NamePattern1) 11709**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. She was cleared for discharge to [**Hospital3 7665**]
by Dr.[**First Name (STitle) **] on POD# 6. All follow up appointments were advised.
Medications on Admission:
Lipitor 40 mg daily,Klonipin 1mg TID,Zoloft 50mg daily,ADVAIR
250 mcg-50 mcg 1P [**Hospital1 **],LASIX 40 mg Tablet daily,KCL 20meq daily,
LEVOTHYROXINE 75 mcg daily, OMEPRAZOLE 20mg daily, ONDANSETRON
4mg PRN,PREDNISONE - 5 mg Tablet - 7 Tablet(s) by mouth daily
35mg x 3 days then 30mg x 3 days, then 25mg x 3 days, then 20mg
x 3 days, then 15 mg x 3 days, then 10 mg x 3 days, then 5 mg x
3 days thenstop.(?when prescribed),ZOLPIDEM 12.5 mg HS,
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] daily, Vicodin 5/550mg
PRN, Doxepin 200mg HS
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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 for fever, pain.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
10. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. doxepin 25 mg Capsule Sig: Eight (8) Capsule PO HS (at
bedtime).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. prednisone 5 mg Tablet Sig: Three (3) Tablet PO daily () for
3 days.
14. prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
3 days.
15. prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 3
days.
16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
18. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
19. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
20. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
21. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day) as needed for cough.
Tablet Sustained Release(s)
Discharge Disposition:
Home With Service
Facility:
n/a
Discharge Diagnosis:
COPD,CHF,Pulmonary fibrosis,Osteoporosis with compression
f
r
a
ctures,Hypercholesterolemia,HTN,GERD,Anxiety/Depression,Insomnia
s/p thyroidectomy,Melanoma removed from back, left axillary
lymph node
dissection [**2107**],Home oxygen,s/p Laparoscopic repair of giant
paraesophageal hernia,s/p R TKR,B THR, s/p appendectomy, s/p
tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait with walker- deconditioned. oxygen
dependent
Incisional pain managed with ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
[**1-6**]+ lower extremity
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 have a follow up appointment scheduled with
your surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2132-1-28**] at 1:45pm
your PCP, [**Last Name (STitle) 84255**] office will call you with an appointment
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**0-0-**]
Date/Time:[**2132-1-29**] 11:00 for follow up for your esophageal
surgery.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2132-1-7**] Name: [**Known lastname 13395**],[**Known firstname 194**] Unit No: [**Numeric Identifier 13396**]
Admission Date: [**2131-12-31**] Discharge Date: [**2132-1-7**]
Date of Birth: [**2056-2-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfasalazine / Sulfa (Sulfonamide Antibiotics) / Parnate
Attending:[**First Name3 (LF) 265**]
Addendum:
Resumed Home med: Klonopin prn on DC summary
Discharge Medications:
22. Klonopin 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed: for anxiety.
Discharge Disposition:
Home With Service
Facility:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2132-1-7**] Name: [**Known lastname 13395**],[**Known firstname 194**] Unit No: [**Numeric Identifier 13396**]
Admission Date: [**2131-12-31**] Discharge Date: [**2132-1-7**]
Date of Birth: [**2056-2-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfasalazine / Sulfa (Sulfonamide Antibiotics) / Parnate
Attending:[**First Name3 (LF) 265**]
Addendum:
It should be reflected that the patient is a75 year old female
presented to an outside ED complaining of neck pain radiating
down both arms to her hands.
On admission to OSH her tropin was 0.03, on transfer to [**Hospital1 8**]
was 6.79 and peaked at 8.24.
She was brought urgently to the operating room for coronary
bypass grafting.
Her discharge diagnosis should reflect:
Coronary artery disease-s/p myocardial infarction
Discharge Disposition:
Home With Service
Facility:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2132-2-26**]
|
[
"297.8",
"285.29",
"515",
"780.52",
"V43.65",
"733.00",
"428.0",
"V43.64",
"276.2",
"272.0",
"V10.82",
"V13.51",
"293.9",
"414.2",
"530.81",
"V46.2",
"244.0",
"311",
"492.8",
"458.9",
"410.71",
"414.01",
"401.9",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.15",
"37.23",
"39.61",
"38.93",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
11966, 12120
|
4071, 5597
|
342, 409
|
8641, 8934
|
2333, 4048
|
9856, 10829
|
1470, 1611
|
10852, 10944
|
8275, 8620
|
5623, 6157
|
8958, 9833
|
1626, 2314
|
284, 304
|
437, 782
|
804, 1138
|
1154, 1454
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,206
| 186,590
|
34286
|
Discharge summary
|
report
|
Admission Date: [**2108-10-3**] Discharge Date: [**2108-10-17**]
Date of Birth: [**2036-4-4**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left leg weakness
Major Surgical or Invasive Procedure:
Lumbar puncture, intubation/extubation, PEG placment.
History of Present Illness:
HPI: 72 yo LHM with a prior SAH ([**2106**]), HTN, HLD, was out
bowling
today, as he does routinely on a Wednesday morning at 10 am, and
while attempting to bend down and aim the ball, his left leg
suddenly felt weak, numb, and heavy. He could not move his left
leg, and the EMS took him to his nearest hospital. He was found
to have a 3.4 x 2.4 cm new parenchymal hemorrhage at the right
vertex in the parietal lobe with a small amount of blood
tracking
along the falx, with associated sulcal effacement without
midline
shift in his CT head.
ROS: negative for aphasia, vertigo, headache, seizures, syncope,
palpitations, chest pain, dyspnea, nausea, abdominal pain,
dysuria, fevers or chills.
Past Medical History:
Admitted to medicine with a SAH and stroke in [**2106**] (Small SAH
over the right cerebral convexity with an evolving cortical
infarct, 7 x 5 mm calcified mass in the R CP angle likely a
meningioma)
HTN
HLD
Polio with no residual paralysis
Social History:
Non-smoker, drinks 1-4 beer daily, lives with his wife.
Family History:
Father : valve replacement
Mother : died of pancreatic Ca.
Physical Exam:
T-97 BP-189/110 HR-90 RR-16 O2Sat-99%
Gen: Lying in bed, talking incessantly, R eye pterygium
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, but not date. Attentive,
says DOW backwards. Speech is fluent with normal comprehension
and repetition, however, he perseverates with subject matter; he
has an anomia for low frequency objects (called a hammock on the
stroke card a hamper, when asked about parts of a watch, stated,
"why do I need to know that." No dysarthria. [**Location (un) **] and writing
intact. Registers [**2-28**], recalls 0/3 in 5 minutes. No right left
confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Discs are well demarcated bilaterally. Visual
fields
are full to confrontation. Extraocular movements intact
bilaterally, no nystagmus. Sensation intact V1-V3. Facial
movement symmetric. Hearing intact to finger rub bilaterally.
Palate elevation symmetrical. Sternocleidomastoid and trapezius
normal bilaterally. Tongue midline, movements intact
Motor:
Normal bulk bilaterally. Tone increased in the left leg. No
observed myoclonus or tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 - - - - - - -
Sensation: Intact to light touch, pinprick, vibration preserved
in the medial malleoli b/l. JPS reduced in the left big toe. No
extinction to DSS
Reflexes:
+2 and symmetric in the arms, 2 in the legs.
Left Babinski, Right predominantly a withdrawal response
Coordination: finger-nose-finger with mild dysmetria noted on
the
left, heel to shin normal on the R only, RAMs normal.
Gait: he cannot walk due to his L leg
At time of discharge neurological examination included:
VS 98.1F/Tm 98.8F 118/63 (SBP 113->140); HR 90-100; RR 16-20; O2
sat 95%-99% on RA.
Mental status:
Fluctuates between being awake, opening eyes to voice and
requiring noxious stimulation to open eyes. During either time
of fluctuation, does not respond to commands. Able to express
pain with grimace but no vocal output. Abulic.
CNs: 5->3mm pupils b/l, VF intact to threat b/l, face appears
symmetric, able to stick out tongue spontaneously. Unable to
assess sensation.
Motor: RUE rigid, spastic, antigravity, decreased bulk. LUE
[**1-2**] throughout. RLE spastic, retracts both legs from stimuli,
slight response to stimuli in L arm.
Sensory: withdraws to noxious in all extremities.
Pertinent Results:
Labs on admission:
[**2108-10-3**] 04:46PM BLOOD WBC-6.5# RBC-4.67 Hgb-13.8* Hct-40.7
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.4 Plt Ct-195
[**2108-10-3**] 04:46PM BLOOD PT-11.7 PTT-23.6 INR(PT)-1.0
[**2108-10-3**] 04:46PM BLOOD Glucose-101 UreaN-16 Creat-1.0 Na-141
K-4.3 Cl-103 HCO3-29 AnGap-13
[**2108-10-4**] 02:07AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1 Cholest-212*
[**2108-10-4**] 02:07AM BLOOD Triglyc-70 HDL-74 CHOL/HD-2.9 LDLcalc-124
[**2108-10-3**] 04:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2108-10-3**]
5:35 PM
FINDINGS: Non-contrast head CT with coronal and sagittal
reformations were
provided. There is a 2.4 x 2.7 x 2.8 cm parenchymal hemorrhage
in the high
convexity of the right posterior frontal lobe. There is also
surrounding areas of linear hyperdensity likely representing
subarachnoid hemorrhage. There is also likely a small amount of
adjacent acute SDH layering along the midline falx. Overall,
findings suggest intraparenchymal hemorrhage with cortical
breakthrough and hemorrhage extending to the extra-axial space.
Compared with the prior outside hospital CT, there is slight
interval increase in size of the intraparenchymal hemorrhagic
focus. Surrounding hypodensity is compatible with edema. There
is again note made of patchy subcortical and periventricular
white matter hypodensity which is likely related to underlying
microvascular ischemic disease. There is no shift of midline
structures or evidence of downward transtentorial herniation.
Global involutional changes compatible with age-related atrophy.
Vascular calcifications along the carotid siphon is noted
bilaterally. The paranasal sinuses are clear. Mastoid air cells
and middle ear cavities are well aerated. No calvarial fracture
is seen.
IMPRESSION:
Parenchymal hemorrhage at the right frontal high convexity with
cortical
breakthrough and resultant adjacent extra-axial hemorrhage.
Overall, slightly larger when compared with outside hospital
study. Given the location of the hemorrhage and the underlying
white matter disease, the possibility of amyloid angiopathy may
be considered. An underlying lesion cannot be excluded, though
none was seen on a prior brain MR from [**2107-8-3**].
CT head [**10-6**]
FINDINGS: There is new intraparenchymal hemorrhage of the left
frontal lobe,
with adjacent subarachnoid blood. There is a rim of edema around
this new
hemorrhage, which measures approximately 4.1 cm (TRV) x 2.4 cm
(AP). The
right posterior frontal lobe parenchymal hemorrhage with
adjacent subarachnoid
hemorrhage is similar in size and morphology to the previous
study. The
ventricles are similar in size and configuration. There is no
uncal or
transtentorial herniation. There is no shift of midline
structures. [**Doctor Last Name **]-
white matter differentiation is preserved. No intraventricular
blood is
identified. Basal cisterns are patent. The paranasal sinuses and
mastoid air
cells remain clear.
IMPRESSION:
1. New left frontal parenchymal hemorrhage with adjacent
subarachnoid
hemorrhage and surrounding edema.
2. Little change of the right posterior frontal lobe parenchymal
hemorrhage
with adjacent subarachnoid hemorrhage
MR head w/ and w/o, MRV
IMPRESSION:
1. Redemonstration of the areas of acute-subacute hemorrhage, in
the right
frontal/parietal location and acute hemorrhage, in the acute
intraparenchymal
hemorrhage, in the left frontal lobe. The etiology for the
hemorrhage is
unclear from the present study. Can relate to amyloid
angiopathy, HTN,
or other etiologies; no obvious mass lesions, aneurysm noted;
assessment for
cortical venous thrombosis is limited due to superimposed SAH
and cannot be
completely excluded. Major venous sinuses are patent, however.
D/w Dr.[**Last Name (STitle) 656**] by Dr.[**Last Name (STitle) **] on [**2108-10-7**].
2. Areas of subarachnoid hemorrhage, in the right frontal lobe
as well as
part of the parietal lobe, better seen on the prior study.
3. No other areas of abnormal enhancement. Small foci of
increased DWI
signal in the cerebellar hemispheres are artifactual.
4. Patent major intracranial arteries without focal
flow-limiting stenosis,
occlusion or aneurysm.
CT head [**10-7**]
NON-CONTRAST HEAD CT: The patient is noted to be intubated with
an NG tube in
place. Areas of intraparenchymal hemorrhage within the posterior
right
frontal lobe and also the left frontal lobe, with surrounding
edema and with
nearby regions of subarachnoid appear similar to that seen one
day prior.
There is no shift of normally midline structures nor effacement
of the basal
cisterns. Size and configuration of the ventricles is unchanged.
No new acute
intracranial hemorrhage is seen, nor evidence of large vascular
territory
infarction. Periventricular white matter hypodensities are noted
as well as
vascular calcifications along the carotid siphons. The paranasal
sinuses and
mastoid air cells remain well aerated.
IMPRESSIONS: Intraparenchymal hemorrhage in bilateral frontal
lobes along the
superior convexity, with surrounding edema and foci of
subarachnoid hemorrhage
not appreciably changed in size or configuration compared to one
day prior. No
new focus of acute hemorrhage seen.
CT head [**10-8**]
IMPRESSION: Minimal change from the study done one day prior,
with
redemonstration of bilateral intraparenchymal hemorrhage similar
in size, and no new focus of hemorrhage.
CT head [**10-11**]
IMPRESSION: Stable or slightly decreased in size bilateral
intraparenchymal hemorrhage with small amount of subarachnoid
extension, surrounding edema, and Mild hydrocephalus.
CXR [**10-9**]
Pulmonary mediastinal vascular engorgement are new, but there is
no pulmonary
edema. Atelectasis at the right base is mild. There are no
findings to
suggest pneumonia. Heart size normal. Nasogastric tube is coiled
in the
stomach. No pleural abnormality
CXR [**10-11**]
IMPRESSION: Malpositioned PICC, recommend retraction by 4.5-5
cm, for a tip location at the superior cavoatrial junction
EEG:
[**10-6**]
IMPRESSION: Abnormal EEG due to the effects of Propofol inducing
a
drug-induced light plane of anesthesia. No discharging features
were
seen.
[**10-7**]
IMPRESSION: Abnormal EEG due to diffuse slowing over both
anterior and
posterior head regions with some excess of slowing at times over
the
left hemisphere and more marked in the left anterior quadrant.
The
record is suggestive of a diffuse moderate encephalopathy with
accentuation over the left hemisphere and to the left anterior
quadrant.
No frank epileptiform discharges were seen
[**10-12**]
IMPRESSION: This telemetry captured no pushbutton activations.
Routine
sampling showed a slow background with occasional bursts of
generalized
slowing, indicating widespread encephalopathy. Medications,
metabolic
disturbances, and infection are among the most common causes.
There
were no prominent focal abnormalities, but encephalopathies may
obscure
focal findings. There were no epileptiform features. No
electrographic
seizures were seen
ECHO [**10-8**]
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is high (>4.0L/min/m2). Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No definite
structural cardiac source of embolism identified.
Studies at time of discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2108-10-16**] 04:36AM 7.8 3.45* 10.3* 29.7* 86 30.0 34.9 13.4
302
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2108-10-16**] 04:36AM 100 35* 0.7 141 3.9 107 28 10
ENZYMES & BILIRUBIN
ALT AST LD(LDH) CK(CPK) AlkPhos
[**2108-10-4**] 02:07AM 21 21 131 52
Albumin Calcium Phos Mg
[**2108-10-16**] 04:36AM 3.0* 7.8* 2.8 2.0
Cholest Triglyc HDL CHOL/HD LDLcalc
[**2108-10-4**] 02:07AM 212* 70 74 2.9 124
PITUITARY TSH
[**2108-10-6**] 05:50AM 0.66
Microbiology:
MRSA screen negative
BCx [**10-7**] - negative
GRAM STAIN (Final [**2108-10-8**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2108-10-10**]):
MODERATE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
LEGIONELLA CULTURE (Final [**2108-10-15**]): NO LEGIONELLA
ISOLATED.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2108-10-11**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
CSF [**10-11**]
ANALYSIS WBC RBC Polys Lymphs Monos Macroph
[**2108-10-11**] 04:02PM 2 565* 10 40 0 50
#4; #4
[**2108-10-11**] 04:02PM 3 710* 50 25 0 25
Brief Hospital Course:
72 yo man w/history of prior SDH, now presenting with left leg
weakness, found to have an intraparenchymal hemorrhage.
1. Neuro - CT scan showed a 2x3cm intraparenchymal hemorrhage.
He had a repeat CT scan on [**10-4**] which showed stable hemorrhage.
He was transferred to the floor on [**10-4**]. Overnight on [**10-5**] he
became more confused, with rhythmic R arm twitching and R gaze
deviation. He was given Ativan, and then loaded with Dilantin
in order to stop his seizure. A stat repeat head CT showed an
extensive new left frontal lobe hemorrhage. On his way back
from CT he became apneic, and was intubated and transferred to
the ICU. He underwent a routine EEG which showed no signs of
seizure. He was extubated on [**10-8**], however his mental status
did not clear significantly. He underwent continuous EEG
monitoring which showed findings consistent with encephalopathy
and no frank seizure activity.
Given seizure on single AED and now extensive cortical bleeds,
he was started on Keppra and Dilantin 1g [**Hospital1 **] and Dilantin 100mg
TID. Dilantin level goal is [**10-16**] trough. At time of discharge
Dilantin level was 15. Patient will require dilantin level
follow up on a weekly basis until stable levels are achieved.
Of note, patient had been on keppra prior to admission, and has
had irritability on this medication. Should he be deemed at
some point acceptable for monotherapy, would recommend the use
of Dilantin.
The hemorrhage was felt to be due to either a hypertensive or
amyloid etiology. MRI did not show evidence of acute stroke and
ECHO did not find a source for a thrombus, making hemorrhagic
stroke much less likely, along with a repeat hemorrhage. Given
the extent and location of the hemorrhages and MRI findings, the
most likely etiology was felt to be amyloid angiopathy.
For HTN control, patient was treated with lisinopril 10mg daily,
metoprolol 25mg TID and hydralazine prn. On day of discharge,
patient's SBP ranged between 110 - 130 mmHg on BB and ACE-I. He
did not require Hydralazine prn over the last 3 days of hospital
stay.
Patient's outpatient Neurologist is Dr. [**Last Name (STitle) 37041**] in [**Hospital1 189**], MA,
NE Associates.
2. ID - On [**10-8**] he developed a fever and was thought to have an
aspiration pneumonia. He was initially started on
vancomycin/zosyn/flagyl. As his mental status was not clearing
significantly, and he was also noted to have a stiff neck, he
underwent an LP, which was negative for any sign of infection.
Sputum cultures eventually grew h. influenzae and he was
narrowed to levoquin, continued for a total of 10 days, ended on
[**10-16**]. EEG showed encephalopathy.
3. Pulmonary. On [**11-2**] patient was noted to have multiple
episodes of apnea on telemetry with desaturations to < 80% O2.
Apneic episodes varied between 10-20 seconds. It was felt that
location of ICH would not account for apneic episodes. It was
felt that he may have had underlying OSA. As patient's
alertness improved, [**10-15**] - [**10-16**] no apneic episodes were noted.
It is recommended that continuous O2 monitoring be maintained
to assess for further apneic episodes, and should they recurr,
an evaluation for OSA or CPAP trial can be performed.
4. Nutrition. Due to above hemorrhage and prolonged ICU stay,
patient required nutritional support, initially via NGT,
followed by PEG tube placement on [**10-15**]. This was
uncomplicated, PEG TF were reached to goal at time of discharge.
He will require nutrition follow up. Albumin on [**10-16**] was 3.0.
5. Anemia. Patient was admitted with HCT of 40, felt to be
hemoconcentrated. During admission, HCT trended down to 32-33
by HD 4 and remained stable, fluctuating in 29-32 range until
discharge (HD 14, 29%). Anemia was normocytic. He was
maintained on Famontidine while in ICU. He was guiac positive
after PEG placement, felt to be secondary to some mucosal injury
s/p procedure. Pt. remained HD stable. He will require a HCT
check within one week of discharge.
Contact: [**Name (NI) **] [**Name (NI) 2716**] (wife) [**Telephone/Fax (1) 78917**]
(cell)/[**Telephone/Fax (1) 78918**] (sister-in-law)
Medications on Admission:
Keppra [**Hospital1 **], dose unknown
Lisinopril 5 mg (dose uncertain)
Simvastatin
Discharge Medications:
1. Phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) mg PO
TID (3 times a day).
2. Levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID
(2 times a day).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. HydrALAzine 10 mg IV Q6H:PRN SBP>160
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
7. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain / fever.
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
10. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Lorazepam 1-2 mg IV Q4H:PRN sz > 3 minutes or clusters
call house officer if planning to administer
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Outpatient Lab Work
Weekly CBC, chem 10 after discharge from the hospital.
Phenytoin level by [**2108-10-19**]
14. Famotidine 40 mg/5 mL Suspension Sig: Twenty (20) mg PO once
a day.
Discharge Disposition:
Extended Care
Facility:
Heritage Manor
Discharge Diagnosis:
Primary: Multiple intracranial hemorrhages, right, left. Likely
due to amyloid angiopathy in setting of hypertension
Secondary: Subarachnoid hemorrhage, HTN
Discharge Condition:
Alert, awake, abulic, significant R and L extremity weakness.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a new right head bleed. Your
course was complicated by a prolonged seizure, and a new bleed
on the left side of your brain. Your seizure was felt to be due
to this bleed. You were also diagnosed with a pneumonia and
were treated with antibiotics. Due to the above head bleeds,
you were left with significant disability and will require
rehabiliation.
Please ensure to take your medications as prescribed, multiple
changes were made to your list.
Please make sure to follow up with all of your appointments.
Should you develop any new symptoms that are concerning to you,
please call your physician, [**Name10 (NameIs) **] go to the nearest emergency room.
Followup Instructions:
Please call your primary care doctor, [**Last Name (un) **],[**Doctor Last Name **] J. at
[**Telephone/Fax (1) 16777**] to arrange follow up after your discharge from
rehabilitation.
Please call the office of your neurologist, Dr. [**Last Name (STitle) 37041**], [**Last Name (NamePattern1) 78919**], [**Hospital1 189**], MA - ([**Telephone/Fax (1) 78920**] to arrange follow up
after discharge from the rehabilitation if you will not follow
up with [**Hospital1 18**] neurology.
Please follow up with the Neurologist at [**Hospital1 18**], Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**]
[**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2108-11-19**] 2:30
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2108-10-17**]
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icd9cm
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[
[
[]
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icd9pcs
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19809, 19850
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333, 388
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20052, 20116
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4445, 4450
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1469, 1530
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18528, 19786
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20140, 20849
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276, 295
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416, 1114
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2540, 3813
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8730, 14198
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4465, 8721
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3829, 4426
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1944, 1944
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1136, 1379
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1395, 1453
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,556
| 107,052
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28923
|
Discharge summary
|
report
|
Admission Date: [**2199-8-3**] Discharge Date: [**2199-8-15**]
Date of Birth: [**2142-12-14**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
BRBPR, LLQ pain
Major Surgical or Invasive Procedure:
Sigmoidoscopy, Colonoscopy, Esophagoduodenoscopy
History of Present Illness:
56M w/ hx of mitral valve repair, diverticulitis, multiple
episodes of lower and upper GIB presenting with 2 days of LLQ
pain and BRBPR, presenting to OSH with INR of 14 on morning of
admission. 2 days ago began having LLQ pain, sharp as knife,
constant, progressive. Last normal stool 2-3 days ago and have
been getting darker and darker until morning of admission when
LLQ pain was [**7-7**] and noticed bright red blood in stool, then
second stool then greenish, diarrhea, foul smelling and "coffee
groundish." Denied having any dizziness when standing up. Called
EMS when pain was [**9-6**]. Had one episode of small vomitus at
[**Hospital1 **] who which was gastroocult positive. Guiaic positive. At
OSH got 2u ffp + vit k 10 iv. ivf. 1g ceftriaxone, Protonix 80
bolus, 8/h. no recent abx use or change in coumadin dose, no
recent changes in diet. No headache, no shortness of breath or
chest pain.
In the ED, Initial Vitals/Trigger: 18:40 6 116 151/79 16 95%
Getting cont IVF, 1 more units FFP (got 2U FFP and vit k iv 1o
at [**Hospital1 **]),1mg IV dilaudid for llq pain (morphine not
working)40meq K PO, 40meq K IV, 4mg zofran, 1mg lorazepam. CT
abdomen and pelvis was done.
Past Medical History:
Mitral valve repair-mechanical valve [**2167**]
Hypertension
s/p appendectomy
lower and upper GI bleeds
diverticulitis
Social History:
Lives with and takes care of his mother. [**Name (NI) 1403**] at [**Company 44081**]in the parking/transportation department, works
nights. No tobacco, occ social EtOH, no illicit drug use.
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, uncomfortable appearing
HEENT: Sclera anicteric, bloodshot, MMM, oropharynx clear, EOMI,
PERRL 1-2mm
Neck: supple, JVP not elevated, no LAD
CV: tachycaric, regular, S1 + S2, MV mechanical click audible
without stethoscope, heard throughout chest and abdomen,
holosystolic murmur heard at LSB
Lungs: few right basilar crackles, left lung clear to
auscultation, no wheezes, rales, ronchi
Abdomen: tense, distended, tenderness to percussion at LLQ,
tenderness to light palpation at LLQ, bowel sounds present,
unable to appreciate organomegaly due to distension, no rebound
appreciated, no guarding
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, grossly normal sensation, gait deferred,
Discharge Physical Exam:
Vs: Afebrile, stable
GEN: Alert. Cooperative. No acute distress.
HEENT/NECK: PERRLA. EOMI. Mucous membranes pink/moist.
LUNGS: Clear to auscultation B/L. No wheezes or crackles
CV: S1, S2 with mechanical click audible throughout. Pulses
equal throughout.
ABDOMEN: BS present. Soft. Tender to palpation over LLQ. No
rigidity, rebound, or guarding.
EXTREMITIES: No pitting edema, No gross deformities, clubbing,
or cyanosis.
Pertinent Results:
ADMISSION:
[**2199-8-3**] 07:00PM BLOOD WBC-10.3 RBC-3.69* Hgb-12.6* Hct-33.9*
MCV-92 MCH-34.3* MCHC-37.2* RDW-14.4 Plt Ct-183
[**2199-8-3**] 07:00PM BLOOD PT-32.1* PTT-47.0* INR(PT)-3.1*
[**2199-8-4**] 01:49AM BLOOD PT-20.0* INR(PT)-1.9*
[**2199-8-3**] 07:00PM BLOOD Glucose-131* UreaN-14 Creat-1.2 Na-137
K-2.8* Cl-93* HCO3-29 AnGap-18
[**2199-8-3**] 07:00PM BLOOD ALT-30 AST-49* AlkPhos-81 TotBili-0.6
[**2199-8-3**] 07:00PM BLOOD Albumin-3.8 Calcium-8.5 Phos-2.1* Mg-1.4*
[**2199-8-3**] 07:15PM BLOOD Lactate-4.5*
[**2199-8-3**] 07:00PM BLOOD Lipase-42
.
IMAGING/STUDIES:
CT-Angio Abdomen/Pelvis [**2199-8-3**]:
IMPRESSION:
1. No evidence of active gastrointestinal bleeding.
2. Numerous colonic diverticula without associated inflammatory
changes.
3. Small hiatal hernia.
4. Mural fatty replacement of the ascending colon, suggestive
of sequela of a prior inflammatory process.
5. Status post mitral valve replacement.
.
Chest X-Ray [**2199-8-7**]: Cardiac size is top normal. Bibasilar
opacities, larger on the left side, could be due to atelectasis
but superimposed infection cannot be excluded. If any, there is
a small right pleural effusion. There is elevation of the right
hemidiaphragm. There is mild vascular congestion. Sternal
wires are aligned. Patient is status post MVR.
.
CT-Abdomen/Pelvis [**2199-8-7**]:
IMPRESSION: Interval development of small right greater than
left pleural effusions with bibasilar subsegmental atelectasis.
No acute intra-abdominal pathology identified
.
MICRO:
Blood Culture, Routine (Final [**2199-8-9**]): NO GROWTH.
MRSA SCREEN (Final [**2199-8-6**]): No MRSA isolated.
FECAL CULTURE (Final [**2199-8-6**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2199-8-6**]): NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2199-8-5**]): NO E.COLI
0157:H7 FOUND.
Blood Culture, Routine (Final [**2199-8-13**]): NO GROWTH.
C. difficile DNA amplification assay (Final [**2199-8-9**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
.
PRE-DISCHARGE:
[**2199-8-8**] 08:17AM BLOOD Lactate-1.0
[**2199-8-11**] 05:25AM BLOOD WBC-6.1 RBC-3.32* Hgb-10.9* Hct-32.0*
MCV-96 MCH-32.6* MCHC-33.9 RDW-15.1 Plt Ct-218
[**2199-8-11**] 05:25AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9
[**2199-8-12**] 07:00AM BLOOD UreaN-9 Creat-1.1 Na-136 K-4.2 Cl-101
HCO3-24 AnGap-15
[**2199-8-15**] 06:55AM BLOOD PT-14.3* PTT-76.9* INR(PT)-1.3*
Brief Hospital Course:
56 yo M with PMH MVR on coumadin, hypertension, LBIG and UGIB,
and recurrent diverticulitis presenting with persistent left
lower quadrant pain and bright red blood per rectum.
Active Issues:
# Lower GIB: Unclear precipitant. Patient was supratherapeutic
on warfarin (INR 14), which was held initially. Lactate was
initially elevated, but trended downward. Flex sigmoidoscopy was
unrevealing. CTA and CT-abdomen/pelvis were unrevealing. GI
performed EGD and colonoscopy and found diverticuli but no
definitive sources of bleeding. The patient reported no signs of
bleeding or melenic stools since the evening of [**8-4**] and
thereafter, his HCT was stable and had been trending upward. The
patient was treated with IVF and proton pump inhibitors and his
bleeding remained stable for the rest of the admission.
# LLQ pain, presumed diverticulitis: However AVM vs ischemic
colitis vs diverticular disease vs hemorrhoidal causes were all
considered. Lactate was initially elevated but was normal by
time of discharge. Pain was treated with Dilaudid, first IV,
then PO. The patient had a single recorded fever during his
stay, and he was started on ciprofloxacin and metronidazole for
empiric treatment of a GI infection. However, C. Diff and stool
cultures were negative. His pain gradually improved and was at a
bearable level by time of discharge. He remained afebrile the
rest of his admission.
# Mechanical mitral valve replacment on warfarin with goal INR
2.5-3.5. Given INR of 14 on admission, warfarin was held.
Unclear etiology for admission INR of 14 given no history of
antibiotic use or changes in diet. [**Month (only) 116**] be related to poor PO
intake since LLQ pain began. Heparin drip started when INR
decreased below 2, while Coumadin was still being held. Once the
patient's GI workup was complete (as above) with no further
bleeding, warfarin was restarted. The INR responded slowly so
heparin drip bridging was switched to enoxaparin bridging on
discharge.
Chronic Issues:
# HTN: The patient's home metoprolol was initially held, but was
restarted on [**2199-8-5**]. The patient remained clinically stable
thereafter
# Anxiety: The patient's home diazepam was initially held and he
remained clinically stable on lorazepam prn.
Transitional Issues:
1) The patient will need follow-up of his INR to therapeutic
range of 2.5-3.5 before discontinuing his enoxaparin bridging.
Medications on Admission:
warfarin 5 mg Tab Oral 1 Tablet(s) M,W,F,[**Doctor First Name **]
warfarin 7.5 mg Tab Oral 1 Tablet(s) Tu,Th,Sa
amlodipine 5 mg Tab Oral
metoprolol tartrate 50 mg Tab Oral 1 Tablet(s) Twice Daily
diazepam 5 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime for
sleep
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC Q12H Duration: 14 Days
RX *enoxaparin 100 mg/mL 1 injection every twelve (12) hours
Disp #*28 Syringe Refills:*0
2. Amlodipine 5 mg PO BID
3. Metoprolol Tartrate 50 mg PO BID
4. Warfarin 7.5 mg PO 3X/WEEK (TU,TH,SA)
5. Warfarin 5 mg PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR)
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*7 Tablet Refills:*0
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 3 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
8. Diazepam 5 mg PO QHS
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
10. Acetaminophen 1000 mg PO TID
RX *Acetaminophen Pain Relief 500 mg [**1-28**] tablet(s) by mouth
q8h:PRN Disp #*100 Tablet Refills:*0
11. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
hold for RR<12 or somnolence
RX *oxycodone 5 mg [**1-28**] tablet(s) by mouth q4h:PRN Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastrointestinal Bleeding, Abdominal Pain
Secondary: Diverticulosis, Mechanical Valve,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure to care for you at [**Hospital1 827**]. You were transferred here because you were
bleeding in your digestive tract and had abdominal pain, as well
as an INR of 14. We treated you with blood products, IV fluids,
pain medications, and agents to lower your INR. We also stopped
your warfarin(coumadin) and started you on a heparin drip for
your mechanical valve. Your bleeding stopped during your
admission.
.
To assess your bleeding and pain, we performed CT-scans of your
abdomen and the GI team performed several endoscopies.
Unfortunately, we could not find a definitive source of your
symptoms. Most likely, the symptoms are related to your chronic
diverticular disease (small outpouchings of your colon. It is
likely these have become inflamed (diverticulitis) and bled. We
are treating you for possible diverticulitis with antibiotics.
We recommend that you eat a low-residue or low-fiber diet to
help avoid future episodes of diverticulitis.
.
We restarted your warfarin (Coumadin)and put you on heparin drip
as we waited for your INR to return to its normal range. On your
day of discharge, your INR was 1.3 and we switched you to an
injectable blood thinner, called Enoxaparin. It is important you
take this injection every 12 hours until your INR is back within
range.
.
Please note the following changes to your medications:
You should START taking Ciprofloxacin (Cipro) and Metronidazole
(Flagyl) antibiotics until you finish the full course.
You should START enoxaparin (Lovenox) every 12 hours until your
INR is between 2.5-3.5.
You may continue the rest of your medications as previously
prescribed.
Followup Instructions:
Please followup with your PCP to check/adjust your INR and
warfarin dosing:
.
Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Monday: [**2199-8-19**] at 2:45 PM
Location: COMMUNITY PHYSICIANS ASSOCIATES, INC.
Address: [**Street Address(2) 4472**] [**Apartment Address(1) 19251**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 61899**]
Completed by:[**2199-8-24**]
|
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icd9cm
|
[
[
[]
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] |
[
"45.23",
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icd9pcs
|
[
[
[]
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9646, 9652
|
5726, 5904
|
320, 371
|
9792, 9792
|
3244, 5703
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1953, 1970
|
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9943, 11300
|
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8003, 8128
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5919, 7710
|
399, 1587
|
9807, 9919
|
7726, 7982
|
1609, 1729
|
1745, 1937
|
2801, 3225
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,219
| 184,375
|
359
|
Discharge summary
|
report
|
Admission Date: [**2172-1-5**] Discharge Date: [**2172-2-13**]
Date of Birth: [**2096-8-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Weakness / confusion
Major Surgical or Invasive Procedure:
Placement of a SVC tunnelled hemodialysis catheter
Placement of a subclavian central line
Placement of a percutaneous cholecystostomy
Intubation
Placement of a femoral central line
History of Present Illness:
This 75 year old man with a past medical history significant for
CVA, atrial fibrillation, and chronic renal insufficiency
presented with worsening confusion & agitation x 1 day. He also
had headache, nausea, unsteady gait, dyspnea on exertion, and
dizziness. His wife called the patient's primary care doctor
who referred them to the emergency department. According to the
patient's wife these symptoms had been getting progressively
worse over the past 3 weeks. The patient denied pruritis, chest
pain, shortness of breath, or abdominal pain.
.
The patient was seen by his PCP [**Last Name (NamePattern4) **] [**2172-1-2**] (3 days prior to
admission), and at that time had malise, fatigue, poor appetite,
difficulty walking, and nausea. He had an unchanged MRI of his
head at that time, and his BUN/cr were elevated but close to his
baseline 78 & 5.7 respectively). During that office visit he
denied shortness of breath, chest pain, abdominal pain, nausea,
or diarrhea. He did mention that he had started taking
amitriptyline one week prior.
Past Medical History:
- cerebrovascular accident with residual aphasia
- atrial fibrillation
- hypertension
- chronic renal insufficiency (creat baseline 5.0-5.3)
- Anemia
- Gout
Social History:
lives with wife, lives on [**Location (un) 470**] with elevator
Family History:
Non-contributory
Physical Exam:
VS: afebrile, vital signs stable
HEENT: NCAT, PERRL, anicteric, EOMI, MMM
Neck: supple, no LAD, no JVD, no carotid bruits
Resp: Bibasilar crackles
Cards: RRR nl S1 S2, no m/g/r
Abd: nl BS, soft NT, ND, no HSM
Ext: no edema, +2DP/PT
Neuro: A&Ox3 but at times confused about history, CN II-XII
intact, 5/5 strength throughout, nl sensation.
Pertinent Results:
ADMISSION LABS:
CBC: WBC 7.3, Hgb 9.9, Hct 31.1, plt 142
N:78.1 L:13.7 M:4.5 E:3.1 Bas:0.7
Chem7: Na 138, K 4.6, Cl 98, HCO3 25, BUN 84, Cr 6.6, glc 136,
AG 20
base line BUN (), Cr ()
Ca: 11.8 Mg: 2.3 P: 4.9
PT: 19.7 PTT: 35.4 INR: 2.5
UA: SG 1.013, tr blood, Prot 100
CK: 30 Trop-*T*: 0.03
.
RADIOLOGY:
[**2172-1-5**] CT Head: no intracranial bleed
[**2172-1-6**] Renal u/s: no hydronephrosis. Evidence of bilateral
chronic renal parenchymal disease
[**2172-1-8**] CXR: Right IJ line. Cardiomegaly.
[**2172-1-10**] CXR: New patchy right infrahilar opacity.
[**2172-1-14**] RUQ u/s: Distended gallbladder, pericholecystic fluid.
[**2172-1-15**] HIDA: c/w cholecystitis
[**2172-1-16**] CXR: new LLL atelectasis & ? patchy consolidation.
[**2172-1-20**] CT head: limited, no definite evidence of acute
intracranial hemorrhage or mass effect.
[**2172-1-20**] CXR: Improved LLL opacity. New moderate-sized layering
right pleural effusion.
[**2172-1-22**] CTA: No pulmonary embolism. Bibasilar consolidations,
left greater than right. Bilateral pleural effusions.
Cardiomegaly.
[**2172-1-22**] LE U/S: No evidence of deep venous thrombosis.
MICROBIOLOGY:
[**2172-1-21**] SPUTUM - S aureus and rare yeast
[**2172-1-21**] BLOOD CULTURE INPATIENT Pending
[**2172-1-21**] BLOOD CULTURE INPATIENT Pending
[**2172-1-21**] SPUTUM - S aureus ([**Last Name (un) 36**] gent, tetra, vanco)
[**2172-1-21**] UCX neg
[**2172-1-21**] BLOOD CULTURE INPATIENT Pending
[**2172-1-21**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) INPATIENT
Pending
[**2172-1-21**] BLOOD CULTURE INPATIENT Pending
[**2172-1-21**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) INPATIENT
Pending
[**2172-1-21**] BLOOD CULTURE INPATIENT Pending
[**2172-1-21**] BCX - ENTEROCOCCUS FAECIUM ([**Last Name (un) 36**] vanco)
[**2172-1-17**] Bile CX neg
[**2172-1-17**] BCX neg x 2
[**2172-1-16**] BCX neg x 1
[**2172-1-16**] BILE CX neg
[**2172-1-13**] BCX neg x 2
[**2172-1-6**] BCX neg x 2
Brief Hospital Course:
75 yo M with PMH of CVA, Afib, CRI p/w confusion/agitation,
nausea, weakness, and acute on chronic renal failure. Admitted
for acute dialysis and work up of confusion. Hospital course
complicated by two episodes of aspiration pneumonia
necessitating ICU admission and a left frontal-parietal stroke
resulting in right hemiparesis and persitant delerium. He was
noted to be hypercalcemic with elevated 1,25-vit D levels and
associated with a new renal mass and enlarged spleen. This was
felt to be related to a paraneoplastic syndrome likely from a
lymphoma with renal and splenic involvement. On his second ICU
transfer the patient remained pressor dependent despite
treatment with antibiotics and stress dose steroids. Given his
overall poor prognosis for meaningful recovery, his family
decided to withdrawl care. The patient was maintained on
minimal sedation while pressors were stopped and he was
extubated. He passed away within minutes of stopping his
vasopressors.
Medications on Admission:
MVI
Stool softener
Iron 65mg po q day
Diovan 160mg
Diltiazem 180mg
Allopurinol 100mg
Furosimide 40mg
Prevacid 30mg
Coumadin 3mg 5 times per week
Epogen q week
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
End stage renal failure from HTN
CVA
Atrial Fib
Aspiration pneumonia
Sepsis
Hypercalcemia of malignancy (?lymphoma)
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
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5455, 5461
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4235, 5217
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333, 516
|
5629, 5639
|
2267, 2267
|
5692, 5699
|
1875, 1893
|
5426, 5432
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5482, 5608
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5243, 5403
|
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1908, 2248
|
273, 295
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544, 1598
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3044, 4212
|
2283, 2602
|
1620, 1778
|
1794, 1859
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,108
| 175,833
|
12846+12847
|
Discharge summary
|
report+report
|
Admission Date: [**2154-6-11**] Discharge Date: [**2154-6-21**]
Date of Birth: [**2089-6-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy
IR embolization
History of Present Illness:
65 yo M with multiple medical problems presented to [**Name (NI) **] on Thursday [**6-6**] with bright red blood per rectum. He
had a colonoscopy on Friday [**6-7**] which showed multiple
diverticuli but he is not sure where in the colon the
diverticuli were located. No intervention was performed. His
bleeding
stopped and he was discharged on Sunday. He began experiencing
copious amounts of bright red blood per rectum again the
afternoon of admission. He went to [**Hospital3 2783**] and was
given 2 units of pRBC and transferred to [**Hospital1 18**]. He has minimal
lower abdominal crampy pain. He has not had any fever, chills,
shortness of breath, chest pain. He does have fatigue.
In our ED, initial VS 98.7 100 117/62 16 100. Initial PE
notable for pallor and bright red blood per rectum. NG lavage
reportedly negative. Given an additional 2U PRBC in our ED.
Briefly with SBP 60s. Given 1U FFP and 2U with approximately 3L
NS. No other medications given. On aspirin, [**Hospital1 **]. No chest
pain. Upon transfer from ED, SBP 90s, HR 80s and 100/2L. His
access includes three PIVs 16g, 18g, 20g.
GI consult was contact[**Name (NI) **] and thought with diffuse bleeding from
below and minimal role for EGD or colonoscopy given poor
visualization. At the soonest, would plan for colonoscpy
[**2154-6-13**]. Discussed with surgical team. Has AAA s/p repair with
graft so increased risk of aorto-enteric fistula. CTA would be
used to rule-out fistula but GI fellow thinks this unlikely at
this time unless significantly worsens. Per discussion with ED
resident, IR paged about tagged RBC scan.
Past Medical History:
Diverticulosis
AAA
CAD s/p CABG and stenting, EF 25% to 30% ([**2154-5-14**])
CVA
HTN
HLD
GERD
obsessive compulsive disorder
PSH:
Sigmoid colectomy for perforated colectomy in [**2124**]
S/p ostomy reversal ([**Hospital3 3583**])
s/p triple vessel CABG [**2137**]
s/p multiple cardiac stents ([**2141**], [**2149**], [**4-/2154**] - Dr [**Last Name (STitle) **];
lastly with stenting of the mid-LCx with a 3.5 x 23mm Promus
drug eluting stent
s/p Endovascular aneurysm repair [**2153**] ([**Doctor Last Name **])
Social History:
On disability since his CVA in [**2141**]. Divorced with 2 children.
Non smoker, 2 drinks/week
Family History:
Mother - deceased at [**Age over 90 **] y/o, CAD. Father - 83 y/o, CAD s/p
cardiac catheterization. 1 brother - 61 y/o A&W. Denies any FHx
of melanoma, breast or colon cancer.
Physical Exam:
Vitals: 97.6, 75, 108/71, 15 and 100/RA
Gen: Alert and oriented, NAD, with pallor and diaphoresis
HEENT: scleral pallor, MMM
CV: tachycardic, sinus rythmn
Pulm: CTA b/l anteriorly
Abd: soft, active bowel sounds, mildly tender in lower abdomen
Ext: [**2-14**] but mildly diminished pulses in radial pulses
bilaterally
Pertinent Results:
CBCs:
[**2154-6-11**] 06:07PM BLOOD WBC-12.3*# RBC-4.10* Hgb-13.4*# Hct-37.8*
MCV-92 MCH-32.7* MCHC-35.5* RDW-13.3 Plt Ct-241#
[**2154-6-12**] 12:04AM BLOOD WBC-11.5* RBC-2.77*# Hgb-8.5*# Hct-24.0*#
MCV-87 MCH-30.6 MCHC-35.2* RDW-14.8 Plt Ct-216
[**2154-6-12**] 05:59AM BLOOD WBC-10.4 RBC-4.26*# Hgb-12.7*# Hct-36.5*#
MCV-86 MCH-29.9 MCHC-34.9 RDW-15.1 Plt Ct-140*
[**2154-6-12**] 09:14PM BLOOD WBC-9.6 RBC-3.56* Hgb-11.5* Hct-31.0*
MCV-87 MCH-32.3* MCHC-37.1* RDW-15.9* Plt Ct-115*
[**2154-6-13**] 08:40AM BLOOD Hct-27.7*
[**2154-6-14**] 04:39AM BLOOD WBC-7.8 RBC-3.97* Hgb-12.0* Hct-34.8*
MCV-88 MCH-30.2 MCHC-34.5 RDW-15.8* Plt Ct-150
[**2154-6-16**] 06:06AM BLOOD WBC-3.8* RBC-3.68* Hgb-11.1* Hct-33.2*
MCV-90 MCH-30.0 MCHC-33.3 RDW-15.9* Plt Ct-200
[**2154-6-21**] 05:59AM BLOOD WBC-5.3 RBC-3.59* Hgb-10.6* Hct-31.8*
MCV-89 MCH-29.6 MCHC-33.4 RDW-15.6* Plt Ct-332
.
COAGS:
[**2154-6-11**] 06:07PM BLOOD PT-13.5* PTT-27.4 INR(PT)-1.2*
[**2154-6-14**] 11:22PM BLOOD PT-13.2 PTT-24.8 INR(PT)-1.1
.
FIBRONIGEN:
[**2154-6-12**] 12:04AM BLOOD Fibrino-248
[**2154-6-12**] 05:59AM BLOOD Fibrino-253
[**2154-6-12**] 09:48AM BLOOD Fibrino-265
.
CHEMISTRIES:
[**2154-6-11**] 06:07PM BLOOD Glucose-129* UreaN-21* Creat-1.0 Na-139
K-4.7 Cl-109* HCO3-20* AnGap-15
[**2154-6-16**] 06:11PM BLOOD Glucose-85 UreaN-18 Creat-0.8 Na-142
K-4.3 Cl-108 HCO3-22 AnGap-16
.
Cardiac Enzymes:
[**2154-6-13**] 08:10PM BLOOD CK-MB-3 cTropnT-<0.01
[**2154-6-13**] 08:10PM BLOOD CK(CPK)-73
[**2154-6-14**] 04:39AM BLOOD CK-MB-3 cTropnT-LESS THAN
[**2154-6-14**] 04:39AM BLOOD CK(CPK)-39*
.
MICRO:
[**2154-6-11**] 9:47 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2154-6-14**]**
MRSA SCREEN (Final [**2154-6-14**]): No MRSA isolated.
.
IMAGING/PROCEDURES:
[**6-13**] CT-A ABD/PEL:
IMPRESSION:
1. Evidence of active bleeding site in the mid transverse colon.
2. Soft tissue nodule adjacent to pancreatic tail is unchanged
since the
prior CT.
3. Patent aortobiiliac stent graft without evidence of endoleak.
.
KUB [**6-15**]:
There is dilatation of small bowel loops up to 4.8 cm with a few
air-fluid
levels. There is air in the colon including the sigmoid and
probably the
rectum. The dilatation has increased from CT. This is
nonspecific and could be ileus or early obstruction and
follow-up is recommended.
.
[**6-15**] CT A/P:
PROVISIONAL REPORT:
FLUID FILLED LOOPS OF BOWEL WITH NO DEFINATE TRANSITION POINT.
MILD
INFLAMMATORY CHANGES AT THE DISTAL ANATOMOSIS SITE IN THE LEFT
LOWER QUADRANT [**Month (only) **] BE SEQULAE OF RECENT ANATOMOSIS VERSUS FAT
NECROSIS. NO DRAINABLE ABSCESS OR COLLECTION. TRACE FREE FLUID
IN THE ABDOMEN AND PELVIS.
Brief Hospital Course:
65M with history of diverticular bleeding and profuse bleeding
per rectum.
1. GI bleed: With known diverticuli and BRBPR, suspicion was for
a large diverticular bleed and patient was admitted to the MICU
for stabilization. However, given h/o AAA repair, a AE fistula
was ruled out first with CT-A. No graft leak was identified, but
active extravasation was seen in the mid-colon. The patient went
emergently to IR for angioembolization of the mid transverse
colon. He required 14 units of pRBCs for stabilization, plus 5
FFP, 3 Platelets. After this intervention, he continued to have
occasional maroon stools, and HCT drifted down to 27. 1
additional unit pRBCs transfused, with stabilization of HCTs. GI
performed colonoscopy which showed pan-colonic diverticulosis
with some pseudomembranes, but no active bleeding. Patient was
transferred to medical floor where serial monitoring of Hct was
continued, initially [**Hospital1 **] and then daily. Patient did have 1
episode of bright red blood requiring 1 additional UpRBC but
subsequent stools were guiac negative. At time of discharge,
Hct had stabilized at 30 - 31. Follow up was arranged with
gastroenterology. Of note, patient may need referral to general
surgeon for semi-elective hemicolectomy in several months. If
possible, patient should wait until at least 1 year from last
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] (see below) so that he can safely stop [**Last Name (Prefixes) 4532**].
2. CAD s/p CABG and DES 1 month prior to admission: [**Last Name (Prefixes) **] and
ASA were initially held given his active bleeding. Once this
issue was stabilized, his [**Last Name (Prefixes) 4532**] and ASA were restarted ASAP.
However, since the pt developed an ileus (see below), and was
NPO, his ASA was changed to PR, and instead of [**Last Name (LF) 4532**], [**First Name3 (LF) **]
integrillin drip was recommended by cardiology, who followed
closely during his admission. He did occasionally complain of
chest pain, but this was usually in the setting of anxiety, and
there was never any ekg changes, and serial cardiac enzymes were
always flat. Once ileus had resolved and patient had no
further signs of rebleeding, oral aspirin 81mg was resumed and
[**First Name3 (LF) 4532**] restarted. Additionally patient was restarted on his
bblocker and 1/2 dose of ACEI. As patient had no symptoms of
angina and blood pressure was still low, imdur was held on
discharge.
3. N/V ileus - After his colonoscopy, for which he was
electively briefly intubated, he developed profound nausea and
bilious vomiting. A KUB showed air in colon and possible dilated
SB loops. A repeat CT abdomen pelvis did not show SBO. Surgery
was consulted and also did not think there was an SBO. An NG
tube was placed, and over the course of 2 days over 2 liters of
bilious material was suctioned. On [**6-17**], the tube was clamped
successfully and diet advanced. After patient began to have
bowel movements, NGT was removed (see below regarding subsequent
diarrhea)
4. colonic pseudomembrane/ diarrhea - on colonoscopy, GI
reported small pseudomembranes adherent to the mucosa in the
ascending colon, possibly compatible with pseudomembranous
colitis. Once patient's ileus resolved he also began to have
profuse watery diarrhea with some abdominal cramping.
Differential dx included infection (especially c.diff), ischemia
(in setting of prior partial colectomy plus recent
embolization), vs physiologic/ diet related. Infectious
evaluation was negative including c. diff x 3 and lactate was
normal. With advancement of diet from clears, diarrhea
improved.
5. Hypertension: Initially, home medications were held in
setting of acute bleeding. Following embolization with
stabilization of bleed antiypertensives were slowly added back
to medication regimen, beginning with bblocker and 1/2 dose of
home ACEI. By time of discharge, blood pressure was still well
controlled with SBP from 100- 110s, so imdur was not restarted.
6. Hyperlipidemia: Severe coronary history. Continued home
statin when not NPO
Medications on Admission:
- Lipitor 80 mg qday
- [**Month/Day (4) **] 75 mg qday
- Isordil dinitrate 40 mg qday
- Lisinopril 10 mg qday
- Metoprolol 25 mg qday
- ASA 325 mg qday
- MVI
- Fish oil 1,200 mg-144 mg daily
- Vit E
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*10 Tablet(s)* Refills:*0*
3. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain: please do not exceed
more than 4 grams tyelenol per day.
Disp:*15 Tablet(s)* Refills:*0*
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Diverticular Bleed
Ileus
Hypotension
Secondary Diagnosis:
Coronary Artery Disease s/p recent [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with rectal bleeding from a
diverticular bleed. You required a large amount of blood
products- in total 15 units of red blood cells through your
hospital stay. The interventional radiologists embolized the
vessel causing the bleed.
During your hospitalization, you also developed severe
constipation caused by an ileus. You were treated
conservatively with bowel rest and a nasogastric tube. Your
symptoms improved; you started having bowel movements and you
tolerated a normal diet.
Please make the following changes to your medication regimen:
1. Please STOP your imdur until seeing your cardiologist or
primary care physician
2. Please REDUCE your lisinopril to 5mg until you see your
primary care physician
3. When you have abdominal pain, take tyelenol first. If that
does not relieve your symptoms you make take a percocet (please
do not drink or drive while taking this medication as it can
make you sleepy).
4. You may take ambien as needed for sleep
Followup Instructions:
Department: RADIOLOGY
When: MONDAY [**2154-10-14**] at 11:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: ADULT SPECIALTIES
When: TUESDAY [**2154-11-12**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Admission Date: [**2154-6-21**] Discharge Date: [**2154-6-22**]
Date of Birth: [**2089-6-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20018**]
Chief Complaint:
Weakness, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 39521**] is a 65 yo M with CAD s/p CABG and PCI with DES, AAA
s/p endovascular repair, hx of CVA, ischemic CMP (LVEF 25-30%),
and recently discharged earlier in the day following
hospitalization for massive LGIB requiring embolization, who
presents with extreme exhaustion, weakness, and cold sweats.
.
He states that he felt well after leaving the hospital, but when
he got home, he was very tired. He took a 2-3 hour nap, and when
he woke up, he was feeling even more exhausted. He had chills,
sweats, and felt very cold. He also had lightheadedness without
vertigo. He experienced some left lower chest and abdominal
discomfort. He also reports DOE. He denied n/v, cough, sore
throat, leg swelling. PO intake had been decreased throughout
his hospitalization and he had only just started eating clears.
He estimates ~[**10-22**] lb weight loss.
.
He presented to the ED due to his malaise. Overnight, he had [**5-16**]
episodes of greenish watery diarrhea, no blood. Last BM at 5:30
AM. No hx of antibiotic use during his previous hospitalization.
.
This morning, his abdominal pain is now decreased from [**7-20**] to
[**5-20**], and is L > R. He states that it feels like diverticulitis.
Denies bloating, n/v, lightheadedness, chest pain. He still
feels weak but not as exhausted as yesterday. He has had no
trouble getting up and walking to the bathroom on his own.
.
Past Medical History:
Diverticulosis
AAA s/p endovascular repair
CAD s/p CABG (LIMA-LAD, SVG-OM1, SVG-OM2, ?SVG-OM3) and PCIs
(last intervention [**4-/2154**] mid-LCx with 3.5 x 23mm Promus drug
eluting stent)
Infarct-related CMPY (EF 25%-30%; [**2154-5-14**])
Stroke
HTN
HLD
GERD
Obsessive compulsive disorder
Social History:
Denies tobacco, drinks 2 drinks/week, denies illicit drug use.
Lives alone at home.
Family History:
No premature CAD, SCD
Physical Exam:
Vitals: 98.2, 110/60, 76, 16, 98%RA
General: Awake, alert, NAD, pleasant, appropriate, cooperative.
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no significant murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3.
Pertinent Results:
[**2154-6-21**] 09:00PM PLT COUNT-329
[**2154-6-21**] 09:00PM NEUTS-84.0* LYMPHS-8.6* MONOS-5.3 EOS-2.0
BASOS-0.2
[**2154-6-21**] 09:00PM WBC-9.2# RBC-3.78* HGB-11.5* HCT-33.9* MCV-90
MCH-30.5 MCHC-34.0 RDW-16.0*
[**2154-6-21**] 09:35PM PT-14.1* PTT-32.2 INR(PT)-1.2*
[**2154-6-21**] 09:35PM cTropnT-<0.01
[**2154-6-21**] 09:35PM GLUCOSE-86 UREA N-8 CREAT-0.9 SODIUM-139
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-23 ANION GAP-12
[**2154-6-21**] 09:45PM HGB-12.0* calcHCT-36
[**2154-6-21**] 09:45PM LACTATE-1.2 K+-4.0
Brief Hospital Course:
# Weakness, lightheadedness: Likely due to deconditioning and
low PO intake during long hospitalization. Guaiac negative in
ED. We walked with him in the [**Doctor Last Name **] and he was very stable on his
feet. Hct stable (33.9 -> 33.0). Felt much better after eating
breakfast and lunch.
.
# Diarrhea: Started having greenish watery diarrhea overnight
after admission. Low suspicion for C. diff as no antibiotics
were administered during recent hospitalization. His whole
clinical picture may be due to viral gastroenteritis causing
general malaise and abdominal discomfort. Diarrhea ceased in the
morning. We sent stool cultures, C. diff toxin and gave him 500
cc IVF since he had had low PO intake for the past 15 days. He
also started taking in good POs.
.
# Left-sided chest and abdominal pain: Not typical of his
anginal pain, possibly just gas pain from viral gastroenteritis.
Cardiac enzymes negative x 2.
.
# CAD s/p CABG and DES: ASA, clopidogrel, atorvastatin,
metoprolol were continued.
.
# HTN: Home BP meds continued with hold parameters.
.
# HLD: Continued home atorvastatin, omega-3 FAs.
.
# FEN: Cardiac diet, IVF as above
# PPX: Heparin SC
# Emergency contact: [**Name (NI) 39522**] (brother), [**Telephone/Fax (1) 39523**]
Medications on Admission:
Lisinopril 5 mg daily
Metoprolol Succinate 25 mg daily
Clopidogrel 75 mg daily
Aspirin 81 mg daily
Atorvastatin 80 mg daily
Zolpidem 2.5 mg qhs prn
Vitamin E 400 unit daily
Omega-3 Fatty Acids daily
Oxycodone-Acetaminophen 5-325 mg prn
Multivitamin daily
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Zolpidem 5 mg Tablet Sig: [**1-12**] Tablet PO HS (at bedtime).
7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Viral gastroenteritis, chest pain
Secondary diagnoses: Hypertension, hyperlipidemia, history of
stroke, diverticulosis with recent lower gastrointestinal bleed,
coronary artery disease status post coronary artery bypass
grafting and placement of drug-eluting stent
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 with weakness and
chest/abdominal pain. You also developed diarrhea overnight. We
checked your blood count (hematocrit), which was stable, and
there was no evidence of gastrointestinal bleeding. There was no
evidence of heart damage on your labs. We gave you intravenous
fluids. Your symptoms resolved. When you get home, continue to
eat and drink in order to restore your energy.
.
We have made no changes in your medications.
Followup Instructions:
Please keep your scheduled appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 9054**] [**Name (STitle) 6481**], on [**2154-6-28**] at 10:00 AM. Please
call [**Telephone/Fax (1) 4775**] if you need to reschedule.
Completed by:[**2154-6-22**]
|
[
"997.4",
"414.8",
"428.0",
"428.22",
"560.1",
"008.8",
"E879.8",
"300.3",
"787.91",
"786.50",
"401.9",
"530.81",
"285.1",
"458.9",
"V12.54",
"V45.81",
"562.12",
"V45.3",
"V45.82",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"39.79",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19021, 19027
|
16760, 18006
|
13632, 13639
|
19355, 19355
|
16208, 16737
|
19992, 20286
|
15494, 15517
|
18311, 18998
|
19048, 19048
|
18032, 18288
|
19506, 19969
|
15532, 16189
|
19122, 19334
|
4590, 5893
|
13572, 13594
|
13667, 15065
|
11330, 11448
|
19067, 19101
|
19370, 19482
|
15087, 15377
|
15393, 15478
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,854
| 123,406
|
27770
|
Discharge summary
|
report
|
Admission Date: [**2148-7-3**] Discharge Date: [**2148-7-8**]
Date of Birth: [**2089-3-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Lipitor
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**7-4**] Redosternotomy/L atrial mass excision
History of Present Illness:
60yoF who was scheduled to undergo a left shoulder surgery,
found to have left atrail mass on preoperative echocardiogram.
Admitted for preop cardiac cath.
Past Medical History:
CAD
HTN
lipids
DM
hypothyroidism
anxiety/depression
GERD
psoriatic arthritis
exogenous obesity
chronic diarrhea
CABG [**2143**]
l5, s1 discectomy
TAH and unilateral salpingo-oopherectomy
rotator cuff surgery
right THR
bilat bunioectomy
tonsillectomy
Social History:
retired nursing instructor
lives alone in adult community
[**12-11**] ppd tobacco x 41 years
no etoh
Family History:
brother with CABG age 45
mother deceased age 64 cardiac tamponade
father deceased age 42 "coronary occulsion"
Physical Exam:
NAD
RRR, no M/R/G
Lungs CTAB
Abd benign
trace peripheral edema
Pertinent Results:
[**2148-7-6**] 07:20PM BLOOD WBC-9.2 RBC-3.27* Hgb-9.4* Hct-26.2*
MCV-80* MCH-28.9 MCHC-36.1* RDW-16.1* Plt Ct-214
[**2148-7-6**] 01:29AM BLOOD WBC-9.1 RBC-3.36* Hgb-9.5* Hct-26.1*
MCV-78* MCH-28.4 MCHC-36.6* RDW-15.6* Plt Ct-229
[**2148-7-6**] 07:20PM BLOOD Plt Ct-214
[**2148-7-5**] 05:33AM BLOOD PT-13.1 PTT-32.4 INR(PT)-1.1
[**2148-7-6**] 07:20PM BLOOD Glucose-178* UreaN-10 Creat-1.0 Na-136
K-4.3 Cl-101 HCO3-24 AnGap-15
[**2148-7-6**] 01:29AM BLOOD Glucose-129* UreaN-9 Creat-1.1 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
Brief Hospital Course:
She was admitted preoperatively for cardiac cath which showed
patent bypass grafts x 3. She was then taken to the operating
toom on [**2148-7-4**] where she underwent a redo-sternotomy, excision
of left atrial mass/myxoma. She was tranferred to the SICU in
critical but stable condition. A CXR immediately post
operatively showed right sided collapse for which she underwent
a bronchoscopy which showed secretions, a post bronch xray
showed marked improvement. She was extubated and weaned from her
vasoactive drips by POD #1. She was transferred to the floor on
POD #2. She did well postoperatively, and was ready for
discharge on [**2148-7-8**].
Medications on Admission:
altace, atenolol, aricept, lasix, synthroid, lisinopril,
metformin, elavil, trazadone, wellbutrin, zoloft, prilosecx,
humolog/NPH, immodium, MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Bupropion 150 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QAM (once a day (in the morning)).
3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Tablet(s)
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
7. Nortriptyline 10 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
8. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
9. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
11. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
12. 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*
13. NPH 4 units [**Hospital1 **]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Left atrial myxoma
CAD
HTN
psoriatic arthritis
exogenous obesity
chronic diarrhea
hyperlipidemia
DM
hypothyroid
anxiety/depression
GERD
CABG [**2143**]
s/p L5, S1 discectomy [**2116**]
TAH & unilateral salpingo-oopherectomy
Right rotator cuff surgery
R THR
B bunionectomy
tonsillectomy
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage or weight gain more than 2
pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incision.
No heavy lifting or driving.
Followup Instructions:
Dr. [**Last Name (STitle) 11493**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2148-7-10**]
|
[
"300.4",
"997.3",
"V43.64",
"401.9",
"244.9",
"696.0",
"518.0",
"212.7",
"250.00",
"272.4",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.22",
"88.55",
"33.24",
"99.04",
"88.52",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
3868, 3923
|
1694, 2343
|
295, 345
|
4253, 4261
|
1147, 1671
|
4502, 4614
|
937, 1048
|
2538, 3845
|
3944, 4232
|
2369, 2515
|
4285, 4479
|
1063, 1128
|
243, 257
|
373, 530
|
552, 803
|
819, 921
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,620
| 199,961
|
14583+56550
|
Discharge summary
|
report+addendum
|
Admission Date: [**2115-6-29**] Discharge Date: [**2115-7-10**]
Date of Birth: [**2057-1-10**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
gentleman, who was going to an outside hospital for
preoperative testing for right cataract surgery when his left
prosthetic leg slipped and he fell hitting his back. He
developed back pain, which persisted. He denied weakness,
numbness, or bowel or bladder changes.
PHYSICAL EXAMINATION: On admission, his temperature was
97.8, heart rate 88, blood pressure 169/68, respiratory rate
14, and sats 96 percent. Patient was examined in the ICU.
He was awake, alert, and oriented times three. Speech was
fluent. Pupils are equal, round, and reactive to light. He
had no nystagmus. Face was symmetric. Tongue was midline.
Motor strength: He was [**6-5**] in all muscle groups in his upper
and lower extremities. Sensation was intact to light touch
throughout. His reflexes are 1 throughout. He has a left
below the knee amputation. Lungs were clear to auscultation.
Abdomen was obese, soft, nontender, nondistended, positive
bowel sounds.
His MRI shows disruption of the anterior longitudinal
ligament from T8 to T9 with widening of the disk space. No
fracture and positive epidural fat.
PAST MEDICAL HISTORY: Fibrosarcoma of the upper back, which
was resected in [**2089**].
Type 2 diabetes.
Hypertension.
Left below the knee amputation.
Neuropathy.
Right cataract.
Cellulitis in the right leg in the past.
MEDICATIONS ON ADMISSION:
1. Metoprolol 100 b.i.d.
2. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 q.d.
3. Metformin 500 b.i.d.
4. Glipizide 10 b.i.d.
5. Actos 15 q.d.
6. Lasix 40 b.i.d.
7. SubQ Heparin 5000 q12.
8. Decadron 4 q.6.
HOSPITAL COURSE: The patient was admitted to the
Neurosurgery service. He was evaluated for this T7 to T8.
He does have a fracture of the T7-T8 disk in addition to
ligamentous injury. He was admitted to the ICU for close
neurologic observation. He remained neurologically intact.
He was seen by Dr. [**Last Name (STitle) 1906**] for this fracture, and felt at the
time he would most likely need surgery to stabilize the back.
He was followed by Renal service for his chronic renal
insufficiency, but no definitive treatment was initiated, but
was just watching his BUN and creatinine.
He had an echocardiogram on [**2115-7-2**] that showed an EF of
60 percent with left ventricular hypertrophy and mild A-V
sclerosis. He was also seen by the Pulmonary service for his
snoring and his sleep apnea for which he is receiving BiPAP.
The patient was fitted for a TLSO brace and was out of bed
with Physical Therapy.
Patient was transferred to the regular floor on [**2115-7-4**]
and was seen for a second opinion by Orthopedic Surgery, who
recommended surgical stabilization of this fracture in his
back. However, Dr. [**Last Name (STitle) 1327**] was also consulted and felt that
this particular case, the risk of major of periop morbidity
and mortality was extremely high about 75 percent and that
surgery would require extensive plastic surgery intervention
with flap closure due to his previous fibrosarcoma resection,
and that the patient should try conservative treatment at
this time using the TLSO brace and be followed closely with
serial radiographs. Therefore, the patient was seen by
Physical Therapy and Occupational Therapy, and found to
require acute rehab.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 150 mg p.o. b.i.d. Hold for heart rate less
than 60 and systolic blood pressure less than 100.
2. Senna two tablets p.o. b.i.d.
3. Colace 10 mg p.o./p.r. q.d. prn.
4. Pioglitazone 15 mg p.o. q.d.
5. Glipizide 10 mg p.o. b.i.d.
6. Insulin-sliding scale.
7. Hydralazine 50 mg p.o. q.6h. Hold for systolic blood
pressure less than 120.
8. Furosemide 40 mg p.o. q.d.
9. Percocet 1-2 tablets p.o. q.4h prn.
10. Heparin 5000 units subQ q.8h.
11. Famotidine 20 mg p.o. q.24h.
12. Colace 100 mg p.o. b.i.d.
DISCHARGE CONDITION: The patient's condition was stable.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) 1327**] in two
weeks' time with repeat plain films of his thoracic spine.
DR.[**Last Name (STitle) **],[**First Name3 (LF) 742**] 14-AAA
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2115-7-9**] 15:46:30
T: [**2115-7-9**] 16:13:52
Job#: [**Job Number 43009**]
Name: [**Known lastname **], [**Known firstname 389**] Unit No: [**Numeric Identifier 7806**]
Admission Date: [**2115-6-29**] Discharge Date: [**2115-7-12**]
Date of Birth: [**2057-1-10**] Sex: M
Service: NSU
This is a discharge summary addendum for the dates of [**2115-7-10**] to [**2115-7-12**]: The patient continued to do well
while under Neurosurgical care during the last three days of
his admission. Repeat chemistry laboratories were sent on
[**2115-7-11**] revealing an increase in his creatinine from
3.6 one week prior to 4.1. Due to this increase, the Renal
team was reconsulted, and the patient was restarted on IV
fluids normal saline at 100 for hydration.
Renal's re-evaluation was that the patient had some mild
prerenal azotemia on top of his chronic renal failure and
agreed with our start of IV fluids. Additionally, they
recommended at this time to hold the patient's Lasix, to
discontinue the patient's hydralazine, and to decrease his
metoprolol dose back to 100 b.i.d. as he had been maintaining
stable blood pressures. For the patient's chronic anemia,
the Renal team also recommended starting him on iron as well
as epoietin. The patient continued to do well with good
urine output and his Foley was D/C'd on [**7-11**].
On [**7-12**], a repeat check of his creatinine had shown a
decrease to 3.8, which is well within the patient's baseline
value for his chronic renal failure. He voided well after
his Foley was removed, and chemistry values were stable on
the morning of discharge with the exception of a potassium
that was mildly elevated at 5.3, and to rechecked to be 4.6.
The patient was without any further new complaints, and he
was discharged back to rehab in stable condition.
DISCHARGE DIAGNOSES: Ankylosing spondylosis with ligament
disruption of T8-T9.
T7-8 fracture.
Insulin dependent-diabetes mellitus.
Chronic renal failure.
Left below the knee amputation.
Hypertension.
Obstructive-sleep apnea.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Rehab.
DISCHARGE MEDICATIONS:
1. Tylenol 325 1-2 tablets p.o. q.4-6h. prn.
2. Colace 100 mg one capsule p.o. b.i.d.
3. Pepcid 20 mg one tablet p.o. b.i.d.
4. Heparin 5000 units subQ every eight hours.
5. Percocet 1-2 tablets p.o. q.4-6h prn breakthrough pain
only.
6. Sliding scale insulin as directed.
7. Albuterol inhaler 1-2 puffs q.6h. prn.
8. Atrovent inhaler two puffs q.4-6h. prn.
9. Glipizide 10 mg p.o. b.i.d.
10. Pioglitazone 15 mg p.o. q.d.
11. Dulcolax 10 mg p.o. q.d. prn.
12. Senna 8.6 mg two tablets p.o. b.i.d. prn.
13. Metoprolol 100 mg p.o. b.i.d.
14. Epoietin alpha 10,000 units one injection a week.
The patient received his first dose on [**Last Name (LF) 3032**], [**2115-7-12**].
15. Iron 325 one tablet p.o. q.d.
DISCHARGE INSTRUCTIONS: Diet: Renal/diabetic diet.
Activity: Needs acute PT/OT. Patient should be out of bed
with a TLSO brace on at all times. He must wear the TLSO
brace when sitting up or when he is out of bed.
He should renal status closely. He was instructed to call
his physician or return to the Emergency Department if there
is any fevers/chills, temperature greater than 101.5,
redness/swelling/drainage from the surgical site, or if he
was unable to eat or drink.
FOLLOW UP: The patient will follow up on [**2115-7-23**] with
neurosurgeon, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. The patient was instructed
to go to the Clinical Center [**Location (un) **] for x-rays at 1 p.m.,
and then he will see Dr. [**Last Name (STitle) **] at 2 p.m. at [**Hospital Unit Name 7807**] in the [**Hospital **] Medical Building.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 7808**]
Dictated By:[**Last Name (NamePattern1) 7809**]
MEDQUIST36
D: [**2115-7-12**] 12:14:45
T: [**2115-7-12**] 12:56:32
Job#: [**Job Number 7810**]
|
[
"805.2",
"E885.9",
"720.0",
"403.91",
"780.57",
"285.9",
"250.60",
"707.0",
"847.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6485, 6521
|
6252, 6463
|
6544, 7289
|
3494, 4033
|
1550, 1789
|
1807, 3468
|
7314, 7772
|
7784, 8382
|
487, 1296
|
165, 464
|
1319, 1524
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,193
| 175,586
|
23081
|
Discharge summary
|
report
|
Admission Date: [**2186-10-28**] Discharge Date: [**2186-12-9**]
Date of Birth: [**2118-10-27**] Sex: M
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS: Biliary obstruction.
Coronary artery disease.
Congestive heart failure.
History of myocardial infarction.
Status post coronary artery bypass graft.
History of atrial fibrillation.
Chronic renal insufficiency.
Status post bilateral inguinal hernia repair.
Hypertension.
Status post insertion of pacemaker and implantable
cardioverter defibrillator.
DISCHARGE DIAGNOSIS: Toxic metabolic delirium.
Respiratory failure.
Bilateral pleural effusions.
Failure to wean from ventilation.
Adult respiratory distress syndrome.
Atrial fibrillation.
Ventricular tachycardia.
Congestive heart failure.
Hypertension.
Coronary artery disease/myocardial ischemia.
Liver failure.
Superior mesenteric artery thrombosis, status post
exploratory laparotomy with thrombectomy.
Diarrhea.
Volume overload.
Malnutrition.
Hypokalemia.
Hyponatremia.
Acute renal failure.
Anemia.
Pneumonia.
Bandemia.
Sepsis.
Staphylococcal bacteremia.
Adrenal insufficiency.
HISTORY OF HOSPITAL COURSE: Mr. [**Known lastname 59459**] was a 67 year old male
with an extensive past medical history as noted in the
admission diagnosis who was transferred to the [**Hospital3 **]
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2186-10-28**] with
questionable obstructive jaundice for which he was
transferred directly to the Medical Service to the Intensive
Care Unit. Upon workup for this obstructive jaundice,
Surgery was consulted and it was noted that the patient was
having a significant gastrointestinal bleed and was, in fact,
found on computerized tomography scan to have a superior
mesenteric artery thrombosis which was felt to be the cause
of his abdominal pain rather than biliary problem in origin.
He was taken urgently to the Operating Room on [**2186-10-29**], and at that time underwent an exploratory laparotomy
and a thrombectomy of a superior mesenteric artery
thrombosis. There was no necrotic bowel and no bowel was
resected. The patient had a long and protracted
postoperative course subsequent to that time which was 41
days in duration and is most easily explained by systems.
Neurologically, the patient's main issue was change in mental
status. This was felt to be secondary to his overall septic
state, his liver failure, resulting in a toxic metabolic
syndrome. There was no evidence of any sort of mass effect
or bleed or central nervous infection. Throughout the course
of his hospitalization his mental status continued to
deteriorate as he became more obtunded. He did become more
arousable in the final week of his hospitalization but never
truly reached an alert and oriented baseline.
Respiratory, as noted during the patient's postoperative
Intensive Care Unit course his respiratory status was
complicated by development of significant pleural effusions
and pulmonary edema which were secondary to pneumonias. The
patient suffered a volume overload. He developed an adult
respiratory distress syndrome type picture at the mid point
of his hospitalization and failed to wean from the ventilator
over the course of his hospitalization. During attempts to
wean the patient from the ventilator, he suffered from
several episodes of apnea for which no etiology was found.
In order to relieve his effusions, diuresis was attempted as
were thoracenteses but the effusions continued to recur,
compromising the patient's pulmonary function.
Cardiovascular, the patient had a history of atrial
fibrillation which significantly complicated his hospital
course, secondary to hypotension from that source, in
addition to his septic update. Eventually we were able to
reach rate-controlled state with his atrial fibrillation
using Digoxin as his blood pressure did not tolerate any sort
of calcium channel blockade or beta blockade. Towards the
end of his hospitalization the patient continued to
experience runs of nonsustained ventricular tachycardia. His
pacer was notably shut off on the day he was made Comfort-
Measures-Only. The patient came in with a baseline ejection
fraction of 20 percent which made managing his huge fluid
shifts extremely difficult. Although diuresis was attempted,
the patient continued to experience recurrent episodes of
fulminant congestive heart failure which complicated his
hepatic function secondary to severe venous congestion. All
attempts were made to augment his cardiac contractility with
the use of Digoxin, but in the end, this was not successful.
Gastrointestinal, as noted the patient came in an superior
mesenteric artery thrombosis which was treated with urgent
operation and there was no bowel resected. He was
anticoagulated postoperatively for this and his atrial
fibrillation and never again during his hospitalization
demonstrated any evidence of bowel ischemia.
Regarding his liver function, the patient's status continued
to deteriorate up until the mid point of his hospitalization
at which point his bilirubin reached above 40. On workup
this was found not to be secondary to hemolysis or an
obstructive process but in fact, after consultation with the
Hepatology Service, is most likely secondary to his sepsis,
his total parenteral nutrition and his severe congestive
heart failure resulting in venous congestion. We attempted
to reduce the venous congestion through continuous venovenous
hemodialysis in order to improve the patient's liver
function. Unfortunately after decreasing to total bilirubin
of 30 we did not really see any improvement, although we had
stopped his total parenteral nutrition and were treating his
sepsis as aggressively as possible. The patient's main fluid
issues were secondary to huge volume shifts. He was well
over 25 kg positive at times in terms of body weight
secondary to the huge volumes he required to maintain his
intravascular status during his septic state. These shifts
contributed to his pulmonary edema and his congestive heart
failure. We were aggressive in our measures to diurese him
with a variety of diuretics and as noted below we even
attempts continuous venovenous hemodialysis after
consultation with the Nephrology Service. The patient also
had significant electrolyte abnormalities secondary to
nasogastric suctioning, diarrhea and fluid shifts which were
aggressively corrected.
Renally the patient went into acute renal failure with
progressively worsening BUN and creatinine, reaching an
azotemia with a BUN in the mid 100s. The Nephrology Service
agreed that continuous venovenous hemodialysis was
appropriate to see if we could improve the patient's status.
This was attempted for one week and although it did clear his
azotemia, upon discontinuation of continuous venovenous
hemodialysis his renal function continued to return towards
his baseline.
Hematologically, as noted the patient was anticoagulated with
heparin and Coumadin for his thrombosis and atrial
fibrillation. He had no significant episodes of bleeding but
did require some blood transfusions for anemia which is felt
to be secondary to decreased production.
The patient had a number of infectious disease issues which
included pneumonia secondary to methicillin-resistant
Staphylococcus aureus and generalized sepsis which was also
Staphylococcal in etiology. There was a question of fungemia
secondary to [**Female First Name (un) 564**] growing on catheter tips and in his
sputum for which he was started on Caspofungin. The patient
was tired on a variety of broad-spectrum antibiotics and was
maintained during the final week and a half through his
hospitalization on Vancomycin, Zosyn, Metronidazole and
lastly we added Caspofungin for essentially total
antimicrobial coverage, although he failed to improve on
this.
By postoperative day Number 41, as the patient's mental
status had failed to significantly improve and the patient
remained in respiratory failure with failure to wean from
ventilation, even after undergoing tracheostomy, and as the
patient continued to require significant amounts of
vasopressor support from Levophed and Pitressin, along with
his hepatic and renal failure, it was felt that the patient
had multiorgan system failure which he would not recover from
and after extensive discussion with the family and Ethic
Services, it was felt the patient should be made Comfort-
Measures-Only.
On [**2186-12-8**], as noted above the patient was made
Comfort-Measures-Only at which time all medical and
ventilatory support was withdrawn. Discussion for autopsy
was offered to the patient's family and they elected only for
an isolated hepatic autopsy to determine the cause for the
patient's liver failure but did not otherwise consent to a
general autopsy.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**], M.D. [**MD Number(2) 12418**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2186-12-8**] 16:14:58
T: [**2186-12-8**] 16:58:04
Job#: [**Job Number 59460**]
|
[
"427.31",
"570",
"263.9",
"584.9",
"038.10",
"V64.41",
"427.1",
"428.0",
"557.0",
"934.1",
"V09.0",
"117.9",
"996.62",
"995.92",
"482.41",
"518.5",
"V53.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.06",
"31.1",
"23.09",
"99.15",
"89.64",
"54.19",
"43.11",
"39.95",
"39.56",
"99.07",
"33.24",
"34.04",
"96.6",
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] |
icd9pcs
|
[
[
[]
]
] |
559, 1156
|
1174, 9096
|
179, 537
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,574
| 112,554
|
10408
|
Discharge summary
|
report
|
Admission Date: [**2128-2-4**] Discharge Date: [**2128-2-7**]
Date of Birth: [**2080-5-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Hypoxia, dyspnea, and tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47M with DM1, CKD, recent admission for MRSA PNA requiring
intubation and DKA in late [**Month (only) 1096**] (discharged to rehab [**1-29**]),
was at rehab this morning when he was awoken for routine vitals
and was diaphoretic, dyspneic, and hypoxic to 70% on RA as well
as tachycardic to 130s. O2 up to NRB, given lasix 40mg with
diuresis of 1L and lopressor and transferred to our ED.
In the ED, sat was 68-74% on RA on arrival, able to speak in
full sentences. CXR shows similar multifocal opacities to last
admission, but also new RLL infiltrate as well as some worsening
effusions/congestion. Added zosyn; last dose of vanc was [**2-3**].
Unable to wean down from [**Last Name (LF) 34474**], [**First Name3 (LF) **] admitting to ICU. VS on
transfer: 88, 119/62, 95% on 50% [**First Name3 (LF) 34474**], RR 12.
Past Medical History:
- IDDM c/b peripheral neuropathy
- Medullary sponge kidney
- Nephrolithiasis
- chronic low back pain
- gastritis
- gastroparesis
- depression/anxiety
- HTN
Social History:
Divorced though still in contact with ex-wife. Lived with his
father in [**Name (NI) **], MA, prior to hospitalization in [**Month (only) 1096**].
Smoked [**1-23**] ppd x 20 yrs but no longer smokes. Patient denies
abusing any recreational drugs and denies ETOH abuse, though
recent OMR notes indicate that his ex-wife reported hx of
substance abuse.
Family History:
Mother: Leukemia, currently undergoing chemotherapy
Father: CAD, HTN
Physical Exam:
VS: 98.7 126/63 78 20 97% 50% facemask
GEN: pale middle aged white man, appears older than stated age
HEENT: PERRL 3-2mm, anicteric sclera
RESP: poor airmovement throughout, esp decreased at R base, no
wheezing, no crackles
CV: Reg Nml S1, S2, no M/R/G
ABD: Soft, Distended, NT, + BS
EXT: Mild (2+) peripheral edema, warm, 1+ DP pulses
NEURO: alert and oriented, interactive. moving all four
extremities.
SKIN: scabs over recent R IJ site
Pertinent Results:
[**2128-2-4**] 11:30AM GLUCOSE-214* UREA N-26* CREAT-2.2* SODIUM-136
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-29 ANION GAP-13
[**2128-2-4**] 11:30AM CK(CPK)-15*
[**2128-2-4**] 11:30AM cTropnT-0.06*
[**2128-2-4**] 11:30AM CK-MB-NotDone proBNP-[**Numeric Identifier 34475**]*
[**2128-2-4**] 11:30AM WBC-10.2 RBC-2.74* HGB-8.2* HCT-24.9* MCV-91
MCH-29.9 MCHC-32.9 RDW-17.0*
[**2128-2-4**] 11:30AM NEUTS-74.8* LYMPHS-18.8 MONOS-5.6 EOS-0.2
BASOS-0.7
[**2128-2-4**] 11:30AM PLT COUNT-671*#
[**2128-2-4**] 11:30AM PT-14.6* PTT-31.0 INR(PT)-1.3*
[**2128-2-4**] 11:47AM LACTATE-1.3
IMAGING:
CXR: Acute infective change in the right lower lobe with right
basal effusion superimposed on multifocal pulmonary opacities
consistent with areas of infection.
EKG: SR 94 nml axis, rSr' in V1, 1mm J point elevation in V2. No
significant change compared to [**1-17**].
ECHO ([**7-/2126**]): Global, diffuse HK; EF 35%
TTE [**2128-2-5**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with mild basal
inferior wall hypokinesis. The remaining segments contract
normally (LVEF = 50%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2126-8-6**],
overall biventricular systolic function has substantially
improved, but regionality of LV dysfunction is now appreciated.
The other findings are similar.
2 view CXR [**2128-2-6**]:
PA AND LATERAL CHEST, [**2-6**]
HISTORY: Multifocal pneumonia. Hypoxemia.
IMPRESSION: AP chest compared to [**1-25**] through [**2-4**].
Moderate interstitial pulmonary edema is stable since [**2-4**]. Moderate
right and small left pleural effusion have increased. Right
middle lobe
consolidation most likely pneumonia. Moderate cardiomegaly
stable. Tip of
the left PIC catheter projects over the superior cavoatrial
junction.
Interval improvement in left suprahilar consolidation suggests
that this
second region of pneumonia is improving.
Brief Hospital Course:
AP: 47 yo M with IDDM, recent multifocal, MRSA pneumonia, now
with hypoxia at rehab
#. Hypoxia: The patient had a recent/resolving multifocal, MRSA
pneumonia, and his symptoms (cough, sputum production) have been
resolving, although there does appear to be a new RLL infiltrate
and he has completed > 14 days now of vanc and zosyn. He had no
crackles on exam, but there was mild bilateral ankle edema,
grossly elevated BNP, and pt has history of systolic dysfunction
which could point to heart failure as a cause of his hypoxia.
Also in favor of heart failure is the improvement he had with
diuresis at rehab prior to transfer. Finally, diabetic
gastroparesis may predispose to aspiration as well as his
impaired oropharyngeal swallow seen on recent S & S, which, with
his new RLL infiltrate and acuity of event, seems most likely
explanation.
Patient underwent IV lasix diuresis and was discharged on his
normal lasix 20 mg po qd regimen. The patient may require
further diuresis to optimize his pulmonary status per discretion
of the physicians at [**Hospital1 **].
He was treated with cefepime (day 1 [**2-4**]), renally dosed for an
8-day course days given his likely aspiration; He was continued
on vanc(8 more days)& flagyl.
#. CAD risks: Given the patient's acute hypoxia and cardiac risk
factors such as DM and a low EF. Serial enzymes were checked to
rule out ischemia. He was continued on ASA and a B-blocker. A
TTE showed EF 50%, mild regional left ventricular systolic
dysfunction, c/w CAD, mild mitral regurgitation, mild pulmonary
hypertension.
#. IDDM: He was continued on glargine 12 units at bedtime and
HISS with meals.
#. C diff: The patient was diagnosed recently with C.diff and
was continued to be treated with flagyl x14 past end of other
antibiotics.
#. Thrombocytosis: likely due to his recent, serious infection.
#. Depression: The patient was continued on his outpatient
medication regmien.
#. HTN: Patinet's metoprolol was continued.
#. CKD, Stage 3: current Cr of 2.2 is below recent values of
[**3-25**].
#. Chronic pain syndrome: The patient continued to experience
low back pain. He was continued on fentanyl patches, lidocaine,
neurontin per his outpatient regimen and given break through
pain control with morphine 5mg oral liquid.
#. Anemia: The patient has anemia likely secondary to CKD. He
was continued on epo (formulary exchange for darbepoetin).
#. FEN: The patient's most recent S & S recs were pills whole or
with purees, thin liquids and pureed diet and he was continued
on this regimen.
#. CODE: FULL
Medications on Admission:
MEDS at Rehab
amlodipine 5mg [**Hospital1 **]
aspirin 325mg daily
escitalopram 20mg daily
darbepoetin alfa 100mcg qFriday
colace
fentanyl 150mcg patch q72hrs--last on [**2-4**]
lidocaine patch topical (lumbar region)
lasix 20mg daily
metoprolol 25mg QID
neurontin 300mg tid
heparin 5000 units [**Hospital1 **]
insulin glargine 12 units qhs and lispro sliding scale
omeprazole 20mg [**Hospital1 **]
sucralfate 1gm QID
vancomycin Q48hrs
flagyl 500mg tid
klonopin 0.5mg tid prn
morphine 3mg po q2h prn
compazine 10mg IV q6h prn
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
5. Morphine 10 mg/mL Solution Sig: Two (2) mg Intravenous every
four (4) hours as needed for pain.
6. Fentanyl 75 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
8. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
QACHS: Administer per sliding scale.
9. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Darbepoetin Alfa In Polysorbat 100 mcg/0.5 mL Pen Injector
Sig: One Hundred (100) mcg Subcutaneous every Friday.
14. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day as needed for heartburn.
15. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for low back pain: on for 12 hours, remove for 12 hours.
18. Vancomycin 1,000 mg Recon Soln Sig: One (1) mg Intravenous
every twenty-four(24) hours for 4 days.
19. Cefepime 2 gram Recon Soln Sig: Two (2) gm Intravenous every
twenty-four(24) hours for 4 days.
20. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 18 days: Continue for 14 days beyond the end of vanc and
cefepime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
MRSA Multifocal Pneumonia
Systolic Heart Failure, Acute
Hypoxemia
ARF on CKD stage 4
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return to the ED if you having high fevers, difficulty
breathing, hypotension, confusion, uncontrollable blood sugars
not responding to medical management, severe abdominal pain.
Followup Instructions:
Patient to schedule f/u with his PCP [**Name9 (PRE) 28955**] [**Name9 (PRE) **],[**Name9 (PRE) **]
[**Telephone/Fax (1) **] in [**1-23**] weeks.
|
[
"482.42",
"357.2",
"008.45",
"585.4",
"338.29",
"428.0",
"428.21",
"300.4",
"536.3",
"238.71",
"250.63",
"403.10",
"285.21",
"584.9",
"518.81",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9893, 9972
|
4867, 7434
|
347, 353
|
10100, 10120
|
2314, 4844
|
10347, 10494
|
1765, 1835
|
8009, 9870
|
9993, 10079
|
7460, 7986
|
10144, 10324
|
1850, 2295
|
273, 309
|
381, 1200
|
1222, 1380
|
1396, 1749
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,207
| 108,198
|
7175
|
Discharge summary
|
report
|
Admission Date: [**2199-5-10**] Discharge Date: [**2199-5-11**]
Date of Birth: [**2126-3-7**] Sex: M
Service: SURGERY
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
septic shock
toxic c. diff s/p subtotal colectomy
Major Surgical or Invasive Procedure:
invasive monitoring
History of Present Illness:
Pt is 73yo male who was recently diagnosed with lyme myelitis
and was hospitalized. He was treated with Ceftriaxone and
discharged home. At home, he developed watery diarrhea for
several weeks and became severely dehydrated. He presented to
OSH and was found to have C diff toxic megacolon. On [**5-10**],
he was taken to the OR by an outside surgeon and underwent
subtotal colectomy and end ileostomy. Pt's postop condition was
moribund, with oliguria, in septic shock, and he was transferred
to [**Hospital1 18**] for further management.
Past Medical History:
spinal stenosis
CAD, s/p CABG & RCA stent
Recurrent 3 vessel coronary disease
hypercholesterolemia
htxn
prostate CA, s/p XRT
hx of pancreatitis [**9-/2198**]
Barrett's esophagus / gastritis
Social History:
unable to obtain from patient
Family History:
unable to obtain from patient
Physical Exam:
VS unstable, while on pressors
Intubated, sedated
PERRL, nonicteric sclera
supple neck
RR S1 S2 tachycardic
course breath sounds bilaterally with ronchi in lower lobes
soft mildly distended, no guarding or rebound, pink ostomy right
lower quadrant, retention sutures and staples, no significant
drainage, no erythema
ext with bilateral 2+ pitting edema, mottled to thigh
bilaterally
Pertinent Results:
[**2199-5-10**] 03:48PM WBC-32.1*# RBC-3.23* HGB-9.9* HCT-30.3*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.9
[**2199-5-10**] 03:48PM PLT SMR-VERY LOW PLT COUNT-53*#
[**2199-5-10**] 03:48PM PT-14.1* PTT-59.2* INR(PT)-1.3
[**2199-5-10**] 03:48PM FIBRINOGE-596*
[**2199-5-10**] 03:48PM GLUCOSE-138* UREA N-37* CREAT-2.3*#
SODIUM-139 POTASSIUM-4.9 CHLORIDE-116* TOTAL CO2-16* ANION
GAP-12
[**2199-5-10**] 03:48PM ALT(SGPT)-72* AST(SGOT)-208* LD(LDH)-812*
CK(CPK)-2376* ALK PHOS-61 AMYLASE-79 TOT BILI-0.2
[**2199-5-10**] 03:48PM LIPASE-17
[**2199-5-10**] 03:48PM CK-MB-38* MB INDX-1.6 cTropnT-0.15*
[**2199-5-10**] 03:48PM ALBUMIN-1.1* CALCIUM-6.1* PHOSPHATE-5.4*
MAGNESIUM-1.7
[**2199-5-10**] 04:15PM TYPE-ART PO2-68* PCO2-43 PH-7.15* TOTAL
CO2-16* BASE XS--13
[**2199-5-10**] 04:15PM LACTATE-3.0*
Brief Hospital Course:
Mr. [**Known lastname 26644**] arrived on a ventilator and was aggressively
resuscitated using invasive monitoring. He was given intravenous
boluses, transfused blood products and was placed on four
pressors: Levophed, Neo-Synephrine, Dobutamine, and Pitressin.
(Later, pt was also placed on epinephrine gtt as well.) Pt
arrived with a Swan [**Last Name (un) 26645**] catheter, and cardiac parameters were
hyperdynamic.
Given the pt's cardiac hx and mildly elevated cardiac enzyme, a
STAT cardiology consult was obtained. STAT TTE showed preserved
EF and no grossly abnormal wall motions. There was no
pericardial effusion. All these findings essentially ruled out
cardiogenic shock.
Pt arrived anuric to [**Hospital1 18**]. Pt was acidodic as well. Pt was
started on sodium bicarbonate gtt. Nephrology consult was
obtained. L femoral dialysis line was placed, and pt was
initiated on CVVH.
LFT's began to rise, indicating likely shock liver.
Presuming septic shock, pt was given broad spectrum IV
antibiotics. Given the severity of the shock, he was also
started on activated Protein C gtt.
Despite all these measures, pt required increasingly higher
doses of all the pressors to maintain bp. Serum lactic acid
level peaked to > 10. Ventilation was difficult, requiring FiO2
of 1.0 and high PEEP.
Family members were present and understood the critical state of
pt's multi-organ failure. When pt's blood pressure could not be
maintained, family members decided to make the pt DNR. Slowly,
pt became bradycardic and hypotensive. Cardiac arrest ensued. Pt
was pronounced deceased 4:45am, [**2199-5-11**]. Cause of death
was cardiopulmonary arrest due to septic shock.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
C.Diff collitis
s/p subtotal colectomy, ileostomy
acute renal failure
acute respiratory failure
post operative anemia
liver failure
hypokelimia
hypocalcemia
hypomagnesimia
CAD
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2199-5-11**]
|
[
"V45.82",
"995.92",
"V45.81",
"V10.46",
"572.8",
"518.81",
"401.9",
"008.45",
"276.4",
"285.9",
"272.0",
"584.9",
"785.52",
"285.1",
"276.8",
"038.9",
"275.41",
"275.2",
"V45.72",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"00.11",
"00.17",
"96.71",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4197, 4206
|
2471, 4145
|
325, 346
|
4426, 4435
|
1640, 2448
|
4491, 4530
|
1191, 1222
|
4168, 4174
|
4227, 4405
|
4459, 4468
|
1237, 1621
|
236, 287
|
374, 915
|
937, 1128
|
1144, 1175
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,845
| 116,749
|
55016
|
Discharge summary
|
report
|
Admission Date: [**2200-5-28**] Discharge Date: [**2200-5-29**]
Date of Birth: [**2181-3-30**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory failure, unresponsive
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Pt, initally listed as an EU critical is a 21F w/ AMS [**1-9**] EtOH
with no signs of trauma. In the ED, it was felt she was unable
to protect her airway [**1-9**] vomiting, and so intubated. She came
to the [**Hospital Ward Name 332**] MICU on propofol for sedation. She was found by
her friend down, [**Name2 (NI) 112323**].
Talking to [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **], [**First Name3 (LF) 4051**], patient was identified as
[**Known firstname **] [**Known lastname **]. Pt and friend were in a limo with 12 other
friends when she got to [**Name (NI) 86**] Red [**Name (NI) 112324**] game after drinking
heavily (amount unknown) and then vomiting several times (red
wine vomit). She then walked out of the limo at Gate B, at
around 6:30PM, at wich point she just "dropped to the ground".
She as not seen seizing. EMS was called and she was taken to
[**Hospital1 18**] Emergency Department.
ED Course (labs, imaging, interventions, consults):
Diagnosis: ams, alcohol intoxication, intubated
- Initial Vitals/Trigger: unresponsive
-Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
-UA Negative
- pH 7.34 pCO2-46 pO2-141 HCO3 26
- Post intubation pH-7.37 pCO2-37 pO2-374 HCO3-22
- Lactate 2.5 -> 1.9
- PT: 11.1 PTT: 29.1 INR: 1.0
- WBC 6.5 HGB 13.3 HCT 38.5 PLT 280
- HEAD CT - negative
- EKG: Sinus tachycardia.
On arrival to the MICU, patient's VS: HR 72, BP 95/52, RR 17,
100% on CMV with TV 500cc, RR 12, PEEP 5, 100% FiO2.
Past Medical History:
depression (unconfirmed)
Social History:
Student at [**Hospital1 40198**] CC. EtOH use, unable to obtain further
substance use Hx.
Family History:
unknown
Physical Exam:
Admission exam:
General: Intubated, mildly responsive, especially to a paging
beeper.
HEENT: Sclera anicteric,
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities spontaneously.
Discharge exam:
General: Awake, alert, oriented, conversng appropriately.
Extubated.
HEENT: Sclera anicteric,
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities spontaneously.
Pertinent Results:
[**2200-5-28**] 09:01PM TYPE-ART RATES-16/ TIDAL VOL-400 PEEP-5
O2-100 PO2-374* PCO2-37 PH-7.37 TOTAL CO2-22 BASE XS--3
AADO2-312 REQ O2-57 -ASSIST/CON INTUBATED-INTUBATED
[**2200-5-28**] 09:01PM LACTATE-1.9
[**2200-5-28**] 09:01PM O2 SAT-99
[**2200-5-28**] 08:45PM URINE HOURS-RANDOM
[**2200-5-28**] 08:45PM URINE UCG-NEGATIVE
[**2200-5-28**] 08:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2200-5-28**] 08:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2200-5-28**] 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2200-5-28**] 08:20PM TYPE-ART PO2-141* PCO2-46* PH-7.34* TOTAL
CO2-26 BASE XS--1 COMMENTS-GREEN-TOP
[**2200-5-28**] 08:20PM GLUCOSE-96 LACTATE-2.5* NA+-147* K+-3.3
CL--106
[**2200-5-28**] 08:20PM freeCa-1.17
[**2200-5-28**] 08:15PM UREA N-8 CREAT-0.9
[**2200-5-28**] 08:15PM estGFR-Using this
[**2200-5-28**] 08:15PM LIPASE-21
[**2200-5-28**] 08:15PM ASA-NEG ETHANOL-295* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2200-5-28**] 08:15PM WBC-6.5 RBC-4.13* HGB-13.3 HCT-38.5 MCV-93
MCH-32.1* MCHC-34.5 RDW-12.3
[**2200-5-28**] 08:15PM PLT COUNT-280
[**2200-5-28**] 08:15PM PT-11.1 PTT-29.1 INR(PT)-1.0
[**2200-5-28**] 08:15PM FIBRINOGE-315
CT head: No acute intracranial process.
CXR
ET and NG tubes positioned appropriately. Diffuse mild
ground-glass opacity within the lungs, possibly indicative of
pulmonary edema.
Brief Hospital Course:
21 year old woman with unknown past medical history, found down
by friend. Was not protecting airway in the [**Last Name (LF) **], [**First Name3 (LF) **] was
intubated.
#Unresponsiveness/EtOH intoxication - Pt did not have any
evidence of infectious process, CT head was unremarkable. She
did not have any other toxidromes and serum tox was only + for
EtOH. Pt was weaned off of propofol in ICU and extubated
without complication. She was monitored overnight and her
mental status improved. She tolerated a normal diet, had
negative orthostatics and was able to ambulate normally at time
of discharge. Issues and dangers of acute alcohol intoxication
were discussed with the patient prior to discharge. At time of
discharge, a friend drove her home.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2)
Tablet PO every eight (8) hours as needed for headache.
2. ibuprofen 200 mg Tablet Sig: 2-3 Tablets PO Q8H (every 8
hours) as needed for headache.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ethanol intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It has been a pleasure taking care of you here at [**Hospital1 771**].
You were admitted to the hospital because you were very sedated.
You were found to have a high alcohol level. A breathing tube
was used briefly to protect your airway because you were so
sleepy. When you were more awake, the breathing tube was
removed. We encourage you to abstain from alcohol in the future
and to stay well-hydrated at home.
We made the following changes to your medications:
- You may take acetamnophen (Tylenol) 1g (2 extra-strength)
three times a day as needed for headache. You can use ibuprofen
(advil or Motrin) 400-600mg (2-3 tablets) every 8 hours in
between as needed.
Please continue all other medications as previosuly prescribed.
Followup Instructions:
Please follow up with your primary care doctor or student health
clinic in the next 1-2 weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"787.03",
"305.00",
"276.0",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07"
] |
icd9pcs
|
[
[
[]
]
] |
5700, 5706
|
4654, 5414
|
320, 345
|
5780, 5780
|
3123, 4448
|
6719, 6943
|
2028, 2037
|
5469, 5677
|
5727, 5759
|
5440, 5446
|
5931, 6397
|
2052, 2578
|
2594, 3104
|
6426, 6696
|
247, 282
|
373, 1856
|
4457, 4631
|
5795, 5907
|
1878, 1904
|
1920, 2012
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,133
| 157,871
|
27382
|
Discharge summary
|
report
|
Admission Date: [**2169-7-22**] Discharge Date: [**2169-7-28**]
Date of Birth: [**2108-2-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
CC: Abdominal pain, fevers, delerium
Major Surgical or Invasive Procedure:
IR guided drain placement to infected RLQ lymphocele with
drainage of pus
History of Present Illness:
This is a 61 year-old man with the history below who presented
to [**Hospital1 **] [**Location (un) 620**] [**7-19**] c/o three days of severe rlq abdominal pain.
He was found to have fever to 102. CT and MR of abdomen and
pelvis unrevealing excepting rlq lymphocele, stable from a prior
study. He spiked fevers over two days, and was persistently
tachycardic. The following consultations were obtained: ID,
urology, and surgery. ID recommended vanc, zosyn, and
doxycycline for broad empiric coverage. Surgery felt his issues
were urologic. Urology felt that his lymphatocele may be
contributing and recommended consideration of IR drainage of it,
but wanted to exclude nephrolithiasis. He is transfered to [**Hospital1 **]
for possible IR procedure, urologic evaluation, and ongoing
care. He was also noted to have ? LL atelectasis v. pneumonia
on a cxr. A l/s plain XR was done for back pain without
evidence fx.
Past Medical History:
CAD, s/p MI [**5-30**] with stent [**1-30**], HTN, NIDDM, Bipolar disorder,
PUD, Hepatitis (at age 5), hypercholesterolemia, h/o CN VII
lesion (dx [**7-29**])
PSHx: Rectal fissure repair, T&A, Appy, b/l inguinal hernia
Social History:
No smoking; social drinker; no drugs. He is a real estate
developer.
Family History:
M died age 62 due to MI
F died age 72 due to old age (no prior h/o CAD)
1 brother - no hx known
1 sister - alive and well
Physical Exam:
99.8 axillary. 142/78 101 18 94 on 3 L nc
.
General Appearance: confused, trying to walk to bathroom,
incontinent of large volume of loose stool
Eyes: : PERLL, at 3 mm bt, EOMI, no conjuctival injection,
anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions, no supraclavicular or cervical lymphadenopathy, no JVD,
no carotid bruits, no thyromegaly or palpable thyroid nodules;
poor dentition
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: tachy, S1 and S2 wnl, no murmurs, rubs or
gallops appreciated
Gastrointestinal: nd, +b/s, soft, exquisitely ttp RLQ, no
palpable masses or hepatosplenomegaly - well healed suprapubic
surgical scar.
Musculoskeletal/extremities: no cyanosis, clubbing or edema
Skin/nails: warm, no rashes/no jaundice/no splinter hemmorhages
Neurological: Alert. Oriented only to person and year. Cn
II-XII intact. 5/5 strength throughout. No sensory deficits to
light touch appreciated. Fluent speech, face symmetric.
Psychiatric: somnolent but arrousable. Delerious.
Heme/Lymph: no cervical or supraclavicular lymphadenopathy
GU: foley catheter in place.
Pertinent Results:
[**2169-7-23**] 3:00 pm ABSCESS RLQ ABSCESS.
GRAM STAIN (Final [**2169-7-23**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
ANAEROBIC CULTURE (Preliminary):
Brief Hospital Course:
61 y/o with hx. prostate cancer, bipolar disorder, and CAD s/p
stent, DM2, HTN, HCL, who is transfered here from [**Hospital1 **] [**Location (un) 620**] for
ongoing workup and care for approx one week of severe abdominal
pain and fever
.
Antibiotics were continued from OSH (vanc, zosyn), however,
doxycycline was held as no clear indication for this. Repeat
blood and stool cultures were sent. ASA held in anticipation of
possible procedure. CT head obtained given mentas status change
was normal. Psychiatry consulted given agitation, hx. of
bipolar disorder recommended risperidol prn for agitation, and
felt delerium due to infection. Urology was consulted abd rec.
non-contrast CT r/o neprolithiasis. This done, no stone, but
lymphocele now with clear evidence inflammation/stranding.
Surgery consulted, rec. IR drain of this. In procedure, pus
drained, and pt. transiently tachycardic, with agitation,
rigors, and with rash described as 'levido reticularis' on legs
transiently at this point. Given concern for early sepsis, pt.
sent to ICU. 2 U NS bolused, and abx continued. Pt. did well,
drainage cleared. ASA and statin restarted. Called out to
floor. Culture data grew MSSA and patient was started on
naficillin with continued clinical improvement with resolution
of his delirium. Patient did have an increase in WBC count and
CT scan was repeated which showed improvement of infected
lymphocele. However, evidence of possible blood clot in right
common femoral vein was noted. Patient then underwent U/S that
showed evidence of a clot in R common femoral vein that was
superior to the portion of the vein able to be assessed by
ultrasound. The patient was then started on coumdain with a
lovenox bridge and was switched to cefazolin for ease if dosing
in the outpatient setting.
Medications on Admission:
NovoLog sliding scale; Depakote 1 g p.o. b.i.d.; Toprol XL 25 mg
daily; Zosyn 4.5 g IV q.6 hours; vancomycin 1 g IV q.12 hours;
doxycycline 100 mg p.o. b.i.d.; IV fluids - D-5 [**1-25**]-normal
saline at 100 mL/hour; Colace 100 mg p.o. b.i.d.; morphine 2 mg
IV q.3 hours p.r.n.; Tylenol 650 mg q.6 hours p.r.n.
Discharge Medications:
1. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*qs ML(s)* Refills:*0*
9. PICC line care per NEHT protocol- saline and heparin flushes
10. Cefazolin 1 gram Recon Soln Sig: Two (2) grams Intravenous
every eight (8) hours for 9 days: Medication to be discontinued
after 8th day ([**8-5**]).
Disp:*qs qs* Refills:*0*
11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
12. Outpatient [**Name (NI) **] Work
PT/PTT/INR on Tuesday, [**2174-8-1**]. Lovenox 100 mg/mL Syringe Sig: One (1) syringe Subcutaneous
twice a day: Until INR therapeutic.
Disp:*10 qs* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Health Services
Discharge Diagnosis:
1)RLQ abscessed lymphocele
2)Methicillin sensitive staph aureus infection
3)Urinary tract infection, bacterial
4)Delerium
Discharge Condition:
Good
Discharge Instructions:
Take all medications as prescribed. Return to the [**Hospital1 18**]
Emergency Department for: fevers, abdominal pain, confusion
Followup Instructions:
1) You have an appointment scheduled with: [**Last Name (LF) **],[**First Name3 (LF) 278**]
[**Telephone/Fax (1) 3070**] on Friday [**8-4**] at 10:15am in [**Location (un) **]. Please
call her office if you need to reschedule.
2) You have an appointment with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] have the drain
removed on Wed [**2169-8-2**] at 3pm in [**Hospital Ward Name 23**] 3. Ph: ([**Telephone/Fax (1) 4376**]
3) Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2169-8-10**] 9:00
|
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"V13.01",
"272.4",
"995.91",
"250.00",
"V45.82",
"293.0",
"401.9",
"599.0",
"453.41",
"296.80",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6935, 7010
|
3433, 5244
|
351, 426
|
7176, 7183
|
3019, 3295
|
7362, 7959
|
1725, 1848
|
5606, 6912
|
7031, 7155
|
5270, 5583
|
7207, 7339
|
1863, 3000
|
275, 313
|
3330, 3375
|
454, 1379
|
3410, 3410
|
1401, 1622
|
1638, 1709
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,079
| 100,234
|
39938
|
Discharge summary
|
report
|
Admission Date: [**2118-10-23**] Discharge Date: [**2118-11-5**]
Date of Birth: [**2035-3-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Shortness of breath, hypoxia
Major Surgical or Invasive Procedure:
Central Venous Catheterization
Radial Arterial Catheterization
Endotracheal Intubation
History of Present Illness:
On admission to medical floor:
This is a 83 yo M with HTN, HLD, AAA 5.7cm and recent
hospitalization for diverticulosis initially presenting with
cough and SOB. On [**10-21**], patient experienced significant DOE,
even when walking across the room. He went to [**Hospital **] Hospital
on [**10-23**] for evaluation where a V/Q scan showed poor perfusion
in the RLL and CXR suggested RLL PNA. He received azithro, CTX,
and some lasix and was sent to [**Hospital1 18**]. Upon presentation, he had
no focal lung sounds, was talking in full sentences, but was
tired out by moving. Bedside echo showed no effusion or
ventricular collapse. An EKG showed TWI V1, V3, unchanged from
previous. A repeat CXR was unimpressive and not suggestive of
PNA. Trop was elevated to 0.16, creatinine was 3.6 (unknown
baseline). He was started on a heparin drip and received vanco
1g to supplement OSH Abx. CT w/o contrast was performed showing
hyperdense material in the right main pulmonary artery extending
in the segmental branches, concerning for large pulmonary
embolus with mild enlargement of right cardiac [**Doctor Last Name 1754**] raising
concern for possible right heart strain. No TPA was
administered. LENIs showed extensive RLE DVT and thrombus in
the posterior tibial vein in the LLE. Echo showed moderately
dilated RV with free wall hypokinesis. Retrievable IVC filter
was placed on [**10-24**]. Patient's creatinine rose on [**10-25**] with
concern for low UOP and patient was bolused.
.
Patient reports no recent immobilization or travel, no
malignancy, and no history of clots in his family. He has had
no previous clots that he knows of.
.
Currently, patient reports improved dyspnea, no chest pain, no
current cough, no fever or chills. He successfully got up to
the chair to eat lunch today. He reports no leg pain and has
noted no swelling.
.
ROS: as above, no dysuria, no diarrhea, no PND, no orthopnea, no
productive cough, no joint pains, no numbness or weakness, no
sinus tenderness.
Past Medical History:
Diverticulosis
Glaucoma
HTN
Dyslipidemia
AAA 5.6 cm, scheduled for surgery at OSH during the time of
admission
Chronic kidney disease
Social History:
[**11-27**] PPD from WW2 until [**2077**]. Rare etoh. Was in the service in
WW2, likely asbestos exposure, thereafter had a regional
manager's position at a paper company. Married to his wife, who
is relatively healthy. Family very involved and supportive.
Family History:
No clots. Father was a smoker and had throat cancer. Mother
died during childbirth.
Physical Exam:
On admission:
VS: Temp: 97.6 BP:138/87 / HR:90's RR: 24 O2sat 100% on NRB
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout. slight crackles
on the left
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e. Right leg is [**Hospital1 2824**] than the left. No palpable
cords. negative [**Last Name (un) **] sign
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL: negative per ED
Pertinent Results:
Labs on admission:
[**2118-10-23**] 05:30PM BLOOD WBC-10.9 RBC-3.14* Hgb-10.3* Hct-31.2*
MCV-99* MCH-33.0* MCHC-33.2 RDW-14.5 Plt Ct-229
[**2118-10-23**] 05:30PM BLOOD Neuts-78.8* Lymphs-13.1* Monos-6.8
Eos-0.9 Baso-0.3
[**2118-10-23**] 05:30PM BLOOD PT-15.7* PTT-20.0* INR(PT)-1.4*
[**2118-10-23**] 05:30PM BLOOD Glucose-100 UreaN-43* Creat-3.6* Na-145
K-4.9 Cl-113* HCO3-19* AnGap-18
[**2118-10-23**] 05:30PM BLOOD cTropnT-0.16*
[**2118-10-23**] 05:30PM BLOOD Albumin-4.2
[**2118-10-23**] 05:30PM BLOOD D-Dimer-6229*
[**2118-10-23**] 05:51PM BLOOD Lactate-1.7
[**2118-10-26**] 12:24PM BLOOD FACTOR V LEIDEN-PND
STOOL [**11-2**]
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2118-11-3**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 4:30A [**2118-11-3**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Labs on discharge:
Micro studies:
Blood cultures [**2118-10-23**]: negative x 2
MRSA screen [**10-23**]: negative
Ancillary tests:
CXR on admission [**10-23**]:
Mild bibasilar atelectasis. Cardiomegaly. Otherwise,
unremarkable study.
.
CT chest w/o contrast [**10-23**]:
1. Hyperdense material in the right main pulmonary artery
extending in the
segmental branches, concerning for large pulmonary embolus with
mild
enlargement of right cardiac [**Doctor Last Name 1754**] raising concern for
possible right heart strain. Findings were urgently discussed
with Dr. [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **] 10 p.m. on [**2118-10-23**], by Dr.
[**Last Name (STitle) 10304**].
2. Emphysema.
3. Bilateral lower lobe bronchiectasis, with subtle ground-glass
opacities at the lower lobes and area of ground glass opacity in
lingula, could suggest incipient atelectasis; however, cannot
exclude infectious disease involving lower airways.
4. Several subcentimeter pulmonary nodules. Followup CT chest in
6 to 12
months is recommended to document stability, if clinically
warranted.
5. Atherosclerotic changes at the SMA, with proximal dilatation
of SMA which indirectly could suggest stenosis at the origin of
SMA although suboptimal evaluation due to lack of IV contrast.
.
TTE [**2118-10-24**]:
Moderately dilated right ventricle with free wall hypokinesis.
Mild left ventricular hypertrophy with normal regional and
global systolic function (LVEF 55-60%). Dilated ascending aorta.
.
Bilateral lower extremity U/S [**2118-10-24**]:
Extensive right lower extremity deep venous thrombosis as above
and thrombus also seen in the posterior tibial vein on the left.
.
CXR [**2118-10-26**]:
In comparison with the study of [**10-23**], there is probably little
overall change. Again there is enlargement of the cardiac
silhouette with
opacification at the left base consistent with atelectasis and
effusion. The overall appearance is somewhat worsened due to the
low lung volumes. No
evidence of vascular congestion or pleural effusion. Blunting of
the right
costophrenic angle persists.
CXR postintubation [**11-4**]
there has been interval placement of an endotracheal tube ending
4.5 cm above the carina. A nasogastric tube is new with the tip
in the
stomach. A right internal jugular catheter projects over the mid
SVC. Right
pleural effusion is stable. Increased opacification at the left
lung base
represents worsening atelectasis and effusion. There is no
pneumothorax. The cardiac and mediastinal silhouette and hilar
contours are stable.
TTE [**11-4**]
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF 70%). The right ventricular cavity is dilated with
borderline normal free wall function. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. The tricuspid valve leaflets are mildly thickened.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2118-10-24**], the right ventriclre is less dilated and
less hypocontractile.
Pan CT [**2118-11-5**]
1. Diffuse panproctocolonic wall thickening with pericolonic
edema concerning for a pancolitis. Differential includes
infectious, inflammatory, or ischemic etiologies. Per discussion
with Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 1833**], the patient currently has a
Clostridium difficile infection and these findings are in
keeping withthis diagnosis.
2. Increased left basilar consolidation, concerning for interval
development of pneumonia.
3. Abdominal ascites particularly adjacent to the spleen, liver
and paracolic gutters.
4. Large infrarenal abdominal aortic aneurysm.
Brief Hospital Course:
Mr. [**Known lastname 87816**] was an 83 year old man with hypertension,
dyslipidemia and a 5.7cm AAA who, in the week prior to his
planned AAA repair had a diverticular bleed and shortly
thereafter developed a large PE in his right PA that caused
hypoxia and right heart strain. He was diagnosed and monitored
in the MICU on heparin, slowly transitioning from NRB to nasal
canula for oxygen. He did well and while his right heart strain
improved, he developed severe, complicated c.difficile colitis
with recalcitrant shock and ventillatory needs that required
intubation. He ultimately passed on [**11-4**].
.
#. Acute pulmonary embolus/bilateral deep venous thromboses -
patient was admitted to [**Hospital1 18**] after transfer from an outside
hospital for hypoxia and a V/Q scan that illustrated a right
lung filling defect. After admission, noncontrast CT was
obtained and showed a large pulmonary embolus in the right lung
vasculature. Patient was started on a heparin drip, with
warfarin shortly afterwards. IV heparin was stopped 24 hours
after therapeutic INR was achieved. Bilateral ultrasounds of
the lower extremities were performed and showed. Upon reaching
the medicine floor, the patient remained on 6 liters of O2 by
nasal cannula, on one occasion requiring a face mask for
desaturation below 90%, from which he quickly recovered.
.
# Hypoxia: patient was consistently hypoxic during his time on
the medical floor, with likely contributing factors being his
clot burden and underlying emphysema. Before being transferred
to the medical floor from the ICU, the patient was taken off a
non-rebreather mask and placed on nasal cannula. Patient was
provided albuterol inhalers and nebulizer treatments, as well as
ipratropium inhalers around the clock to optimize respiratory
status. Albuterol treatments were discontinued after the
patient developed an episode of atrial fibrillation. He worked
with physical therapy and slowly improved for a period of time
from an oxygenation standpoint. On [**2118-11-3**], patient was noted
to be tachypneic to the 30s-low 40s, with oxygen saturations
dropping from low 90s to 87-89% on 6 liter of O2. A trigger was
called. Physical exam showed rales present, mostly in the left
lung. A dose of Lasix was administered due to concern for fluid
overload after continuous IV fluid administration due to the
patient's elevated creatinine at the time. A non-rebreather was
placed with improvement in oxygen saturations to the mid-90s and
improvement in respiratory rate. Patient was given nebulizer
treatment and 20 mg IV Lasix. ABG was performed with pH 7.45,
pCO2 30, pO2 61 on 6 liters of oxygen. Chest X-ray was ordered
and showed no evidence of pulmonary vascular congestion or
pneumonia, but had signs of worsened atelectasis and pleural
effusion as compared to a previous X-ray on [**11-2**], when the
patient first developed a leukocytosis. Urine and blood
cultures were ordered after the patient spiked a fever to 101 F,
and the patient was started on IV cefepime and vancomycin
empirically. He was transferred to the MICU.
.
#. Clostridium difficile colitis: on [**2118-11-2**], patient began
developing numerous episodes of diarrhea along with
leukocytosis, and testing for Clostridium difficile was ordered.
A positive result returned on [**2118-11-3**] and the patient was begun
on PO flagyl for treatment. Later on that day, it was decided to
switch the patient's treatment to IV flagyl as well as PO
vancomycin for likely severe C. difficile infection. Despite
antibiotic therapy, the patient continued to fare poorly with
this infection. He went into septic shock. On [**11-5**] a
central line and arterial line were placed for rescusitation.
Vasopressors were begun. Unable to keep up with the work of
breathing, Mr. [**Known lastname 87816**] was intubated on the AM of [**11-4**]. He was
transfused one unit of pRBCs to preserve oxygenation but
remained on large doses of vasopressors. In the early AM of
[**11-5**], his blood pressure became untenable on neosynephrine and
he became increasingly dependent on 3 pressors. A CT torso was
obtained that showed severe colitis with few other positive
findings. His family was called to the bedside and he passed at
6am on [**11-5**].
.
#. Acute kidney injury on chronic kidney disease: given an
equivocal results of FEUrea, likely etiology was prerenal
failure with progression to acute tubular necrosis. Urinalysis
was performed and was non-revealing. The patient's baseline
creatinine was 3. Nephrotoxins were avoided and patient's
medications were renally dosed. Patient was kept at even fluid
balance. On [**2118-11-3**], his creatinine began to rise in
conjunction with the numerous episodes of diarrhea that the
patient began to experience found to be due to Clostridium
difficile infection. IV fluids were administered until the time
of hypoxia leading to his MICU transfer.
.
#. Urinary retention: the patient developed urinary retention
during his hospitalization which was thought to possibly be due
to the addition of trazodone to help with sleep, or from some
constipation that the patient developed during his hospital
course. There was no known history of prostate disease, and
rectal exam performed on the medical floor revealed no
nodularity or enlargement of the prostate, and patient was
guaiac negative. A Foley catheter had to be placed due to
urinary retention and trazodone was discontinued, but urine
retention did not resolve at the time of transfer to the MICU.
.
# Atrial fibrillation: patient was noted to be in atrial
fibrillation on [**2118-10-29**], with possible precipitants being his
pulmonary process, perhaps mild dehydration and the result of
his beta-blocker being held. Patient was started on metoprolol
for rate control which was uptitrated until regular rate was
achieved. He was already on anticoagulation for his pulmonary
embolism and deep venous thromboses. The patient was monitored
on telemetry throughout the rest of his time on the hospital
floor, and was maintained in sinus rhythm.
.
#. Anemia: Patient was anemic upon presentation with guaiac
negative stools. Active type and screen with crossmatched units
of blood were maintained. Vitamin B12 and folate were checked,
with a noted low vitamin B12 level. The patient was started on
intramuscular cyanocobalamin. Hematocrit was trended throughout
hospitalization.
.
#. Hypertension: patient's blood pressure was controlled while
off medication during admission. His enalapril was held given
acute kidney injury, and his HCTZ, nadolol and amlodipine was
held due the patient's normotensive status. Metoprolol was
started when the patient developed an episode of atrial
fibrillation while on the medical floor.
.
#. Abdominal aortic aneurysm: the patient was scheduled to
undergo elective repair of AAA at an outside hospital while he
was admitted to [**Hospital1 18**]. Blood pressures were checked often, with
a plan to obtain a stat echocardiogram if he became hypotensive.
.
#. Dyslipidemia: the patient was continued on his home statin
medication while he was admitted.
.
#. Glaucoma: the patient was continued on his glaucoma
medications during admission.
Medications on Admission:
HCTZ 25 mg MWF
Nadolol 80 mg every third day
Enalapril 5mg
Amlodipine 10 mg
Lipitor 80 mg
Tricor 145 mg
Fiorinal
Timolol .5% [**Hospital1 **]
Alphagan .1% [**Hospital1 **]
Pilocarpine 4% QID
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Submassive Pulmonary Embolism
Severe C.Difficile Colitis
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2118-11-6**]
|
[
"038.9",
"415.19",
"008.45",
"285.9",
"441.4",
"272.4",
"453.42",
"518.81",
"403.90",
"788.20",
"427.31",
"584.5",
"266.2",
"V15.84",
"785.52",
"995.92",
"365.9",
"585.9",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"96.71",
"38.93",
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
16286, 16295
|
8802, 16012
|
333, 421
|
16395, 16405
|
3821, 3826
|
16462, 16501
|
2909, 2996
|
16253, 16263
|
16316, 16374
|
16038, 16230
|
16429, 16439
|
3011, 3011
|
265, 295
|
4741, 8779
|
449, 2460
|
3841, 4721
|
2482, 2617
|
2633, 2893
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,303
| 111,223
|
37476
|
Discharge summary
|
report
|
Admission Date: [**2147-12-31**] Discharge Date: [**2148-1-1**]
Date of Birth: [**2126-2-2**] Sex: M
Service: NEUROLOGY
Allergies:
Vancomycin / Levaquin / Erythromycin
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Seizure in the setting of apparent head trauma
Major Surgical or Invasive Procedure:
* Pt arrived intubated
History of Present Illness:
Per Admitting Resident:
Patient is a 21 yo man (handedness unknown) s/p renal
transplant currently on Prograf, prednisone and mycophenolate,
who is incarcerated for battery and assault who fell off the top
bunk and was found seizing per guard this morning. Per guard,
patient was stiff and having shaking of all limbs with eyes open
but deviated upwards. This shaking abated on its own in less
than 1 minute but upon transfer to [**Hospital6 302**], patient
had more generalized seizures requiring Ativan IV total of 10mg
and Versed 4mg IV x2. In the midst of all this, he was intubated
and was loaded with Dilantin. Given that patient has no hx of
prior seizures, patient underwent LP (WBC 6, RBC 1356, Glucose
121 and Protein of 40) and given empiric ABX including
ceftriaxone and ampicillin plus Decadron for unclear reason then
transferred here for further care.
Patient remains intubated but upon turning off sedation, patient
awoke soon and appeared to move all limbs with good resistance.
ROS unknown.
Patient normally treated at [**Hospital1 3278**] but brought here because there
is no bed at [**Hospital1 3278**] per report. No details known about his renal
transplant hx.
Past Medical History:
Polycystic Kidney Disease, s/p renal transplant ([**2138**])
HTN
Depression
Social History:
- currently in a correcctional facility for assault and battery
Family History:
- unkown
Physical Exam:
ON ADMISSION:
T 99 BP 164/113 HR 76 RR 13 O2Sat 98% intubated
Gen: Lying in bed, intubated.
HEENT: Hard cervical collar.
CV: RRR, no murmurs/gallops/rubs
Lung: Clear
Abd: +BS, soft - well healed kidney transplant scars and bulge
present.
Ext: No edema
.
Neurologic examination:
Mental status: Intubated - initially did not open eyes to verbal
or sternal rub but then began moving both arms purposefully as
sedation turned off. Does not follow commands.
.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Positive Doll's eyes and corneal's present in both
eyes. Face appears symmetric.
.
Motor:
Normal bulk and tone bilaterally. No observed myoclonus or
tremor. Moves all extremities well with resistance. Although
unable to test individual muscle groups, appear full strength
and
without lateralization.
.
Sensory: Intact to noxious stim.
.
Reflexes: +2 and symmetric throughout. Toes downgoing
bilaterally
Pertinent Results:
[**2147-12-31**] WBC-15.5* RBC-3.02* HGB-8.7* HCT-26.3* MCV-87 PLT- 182
[**2147-12-31**] UREA N-47* CREAT-3.3*
[**2147-12-31**] GLUCOSE-147* LACTATE-1.5 NA+-139 K+-4.3 CL--107 TCO2-25
[**2147-12-31**] ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
.
[**2147-12-31**] URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2147-12-31**] URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-TR
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
.
[**2147-12-31**] tacroFK-5.0
.
[**2147-12-31**] 12:40PM PHENYTOIN-8.4*
[**2147-12-31**] 08:53PM PHENYTOIN-10.3
.
CT C-Spine without Contrast ([**2147-12-31**]):
FINDINGS: There is no fracture. Loss of cervical lordosis is
presumed
related to the hard cervical collar. There is no prevertebral
hemorrhage or edema, though the evaluation may be limited by the
presence of nasogastric and endotracheal tubes. The limited
included lung apices are unremarkable. Regional soft tissue
structures of the neck are unremarkable, and intracranial
contents are better characterized on the concurrent dedicated
head CT.
IMPRESSION: No fracture or traumatic malalignment.
.
CT Head without Contrast ([**2147-12-31**]):
FINDINGS: There is no intracranial hemorrhage, edema, mass
effect, or
vascular territorial infarction. The ventricles and sulci are
normal in size and configuration. There is no fracture.
Paranasal sinuses and mastoid air cells are clear. Small amount
of secretions layering dependently in the nasopharynx and the
posterior nasal cavity are presumed secondary to intubation.
IMPRESSION: No acute intracranial abnormality.
.
MRI Head without Contrast ([**2147-12-31**]):
formal interpretation is pending at discharge (please see brief
summary of hospital course for our interpretation)
.
Chest X-ray ([**2147-12-31**]):
IMPRESSION: ETT tip at 4.0 cm above the carina. No acute
intrathoracic
process.
.
Echocardiogram ([**2148-1-1**]):
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The estimated cardiac index is normal (>=2.5L/min/m2).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. The estimated
pulmonary artery systolic pressure is normal. There is a small
circumferential pericardial effusion without echocardiographic
signs of tamponade.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
No valvular pathology or pathologic flow identified. Small
circumferential pericardial effusion without evidence of
hemodynamic compromise.
Brief Hospital Course:
Mr. [**Known lastname **] is a 21 year-old (handedness unknown) man with a
past medical history including PCKD, s/p renal transplant, and
hypertension who initially presented to [**Hospital3 **] [**2147-12-31**]
following an apparent GTC in the setting of head trauma.
Following the administration of ativan, versed, a dilantin load,
and decadron, the performance of an LP, treatment with empiric
antibiotics, and the process of intubation, the patient was
transferred to the [**Hospital1 18**] for further evaluation and care. He
was admitted to the Neurology/ICU Service from [**2147-12-31**] to
[**2148-1-1**].
.
NEURO:
To evaluate for hemorrhage and other contributory abnormalities,
a non-contrast CT of the head was performed. The study was
negative for intracranial pathology. An MRI was also done to
look for evidence of PRES in the context of hypertension and the
use of prograf. The MRI revealed bioccipito-parietal (edema)
and right > left frontal cortically-based T2 lesions. The
findings could be consistent with PRES. Alternatively, the
results could reflect contusions sustained during the patient's
reported fall from a top bunk bed.
.
To provide seizure prophylaxis, dilantin 100 mg IV q 8h was
initiated. Following admission, the patient was thought to
experience an additional GTC lasting approximately five minutes.
In addition to ativan 2 mg IV, he was given phenytoin 1 gram IV
x 1. In the course of the evening, the patient's nurse thought
she witnessed approximately four further episodes lasting less
than one minute; the events were described as bilateral upper
and lower extremity shaking without clear head or gaze
deviation. In the setting of persistent events, ativan 1 mg IV
q 8h was started. The patient had one more event at about 6am;
the neurology resident who witnessed the event was uncertain as
to whether it represented epileptic activity; however, the
patient received ativan 2 mg IV x 1. There were no further
clinical events.
.
The most recent dilantin level was found to be 14.3 (corrected
to 23 with albumin of 2.7). As the level was considered
supratherapeitic, the 12 pm dose of dilantin was held [**2148-1-1**].
.
RESP
The patient arrived intubated; he remained intubated at
discharge.
.
CVS
The patient was monitored by telemetry. Nifedipine, clonidine,
and atenolol were continued.
.
FEK
The renal transplant surgical team was consulted. At their
recommendation, Mr. [**Known lastname **]' outpatient tacrolimus dosing was
continued and a morning level was drawn (7.5).
.
ID
The ampicillin and ceftriaxone started at [**Hospital3 **] were
continued at the time of admission to the [**Hospital1 18**]. The
ceftriaxone was ultimately transitioned to ceftazidime for
partial nocardia coverage. Acyclovir was initiated to
empirically treat HSV. Pyramethamine, clindamycin, and folinic
acid were started in case of a toxo infection. At the [**Hospital1 18**],
blood and fungal cultures were drawn (results pending at the
time of discharge). The team also called the lab at [**Hospital3 **]
([**Telephone/Fax (1) 84205**]; [**Telephone/Fax (1) 84206**] [**Doctor First Name **]) to ask the lab to
add on CMV, HSV, cryptococcus, nocardia, toxo, and fungal
assays. The urinalysis and chest x-ray were unrevealing.
.
PPX:
For prophylaxis, famotidine and sc heparin were adminsitered.
.
CODE: Full presumed.
Medications on Admission:
MEDICATIONS ON ADMISSION
Prograf 3mg [**Hospital1 **]
Trazodone 100mg bedtime
Venlafaxine 75mg daily
Atenolol 100mg daily
Clonidine 0.1mg [**Hospital1 **]
Nifedipine SR 90 daily
Mycophenolate 500mg
Prednisone 2mg [**Hospital1 **]
.
ALLERGIES: reaction unknown
Vancomycin
Levaquin
E-Mycin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for T>100.4 or pain.
2. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours).
3. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
Sig: One (1) PO BID (2 times a day): total of 500 mg.
4. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO DAILY (Daily).
5. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO daily ().
8. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
12. Propofol 10 mg/mL Emulsion Sig: One (1) Intravenous TITRATE
TO (titrate to desired clinical effect (please specify)).
13. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP>160.
14. Dextrose 50% in Water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
15. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours).
16. Acyclovir Sodium 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours): total of 700 mg .
17. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours).
18. Phenytoin Sodium 50 mg/mL Solution Sig: One (1) Intravenous
Q8H (every 8 hours).
19. Lorazepam 2 mg/mL Syringe Sig: [**12-23**] Injection Q2H (every 2
hours) as needed for seizures > 5 minutes.
20. Ceftazidime 1 gram Recon Soln Sig: One (1) Intravenous Q12H
(every 12 hours).
21. Lorazepam 2 mg/mL Syringe Sig: 0.5 Injection Q8H (every 8
hours).
22. Clindamycin Phosphate 150 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) for 1 days: total of 600 mg.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Seizure secondary to PRES vs Head Trauma
Discharge Condition:
On Day of Discharge:
Tmax 96.3; Tc 95.6; bp 1teens-140s/60-105; hr 70s-80s; O2 sat
100% on CPAP/PSV Fio2 40%, [**4-24**].
GEN: intubated, sedated
HEENT: apparent soft tissue swelling in lateral aspects of head
bilaterally
PULM: CTAB anteriorly
CVS: Regular rate, normal S1 and S2
ABD: round, + bs, soft, nt, nd
EXT: RLE more externally rotated than LLE
NEUROLOGICAL EXAMINATION:
Mental Status: sedated
CN: PERRL, + corneals bilaterally, + nasal tickle response
Motor: increased tone in LE, withdraws UE, LE to noxious
bilaterally, sustained clonus in LE bilaterally
Reflexes: brisk at biceps, patella bilaterally; plantar
responses flexor bilaterally
Discharge Instructions:
FOR THE NEXT CARE TEAM:
NEURO
* Please perform an EEG
* Please follow the corrected dilantin level (last corrected
level was 23 on [**2147-12-31**]); a free level had not yet been drawn at
the [**Hospital1 18**].
* Please follow the formal interpretation of the MRI
FEK
* Please connect with the patient's nephrologist
ID
* Please consider an infectious disease consult
* Please follow the results of pending CSF cultures ([**Hospital3 15402**]
drawn [**2147-12-31**])
* Please follow the results of blood cultures ([**Hospital1 18**] drawn
[**2147-12-31**])
FOR THE PATIENT:
You were initially brought to [**Hospital3 **] following a seizure in
the setting of head trauma. You were given medication to help
prevent further seizures. A procedure called a lumbar puncture
was done to look for evidence of infections. You were then
given antibiotics to treat potential infections pending the
results of the assays. You were then transferred to the [**Hospital1 18**]
for further evaluation and care. A CT of the head showed no
evidence of bleeding. An MRI of the brain did show some
abnormalities that likely represent swelling or bruising. The
seizures are thought to be related to the head trauma (from
falling out of your bunk bed) or a condition referred to as PRES
which can be associated with high blood pressures and some of
the medications you take.
Followup Instructions:
* Please coordinate follow-up care per your physicians at [**Hospital1 3278**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"E884.4",
"959.01",
"401.9",
"311",
"780.39",
"V42.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11938, 11953
|
6029, 9398
|
343, 367
|
12038, 12417
|
2775, 6006
|
14101, 14275
|
1783, 1793
|
9738, 11915
|
11974, 12017
|
9424, 9715
|
12714, 14078
|
1808, 1808
|
257, 305
|
395, 1586
|
2280, 2756
|
1822, 2062
|
12432, 12690
|
2086, 2086
|
1608, 1686
|
1702, 1767
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,326
| 158,556
|
46076
|
Discharge summary
|
report
|
Admission Date: [**2168-2-17**] Discharge Date: [**2168-3-17**]
Date of Birth: [**2103-6-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Latex / Morphine / Red Dye
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain and Shortness of Breath
Major Surgical or Invasive Procedure:
[**2168-2-23**] Cardiac Cath
[**2168-3-3**] Coronary artery bypass graft x 3 (LIMA to LAD, SVG to
Diag, SVG to PLV), Mitral Valve Replacment (31mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**]
bioprosthesis)
[**2168-3-15**] Insertion right IJ PermCath
History of Present Illness:
64-year-old woman presented with chest pain and shortness of
breath. She had recently been discharged s/p MI. Transferred
for cardiac evaluation and treatment.
Past Medical History:
Coronary Artery Disease s/p PTCA, Heart Failure,
Hypercholesterolemia, Hypertension, Diabetes Mellitus,
Hypothyroidism, Chronic Lymphocytic Leukemia, Chronic renal
insufficiency baseline Cr 2.5-3, Gastroesopahgeal Reflux
Disease, Obstructive sleep apnea with CPAP, Chronic Obstructive
pulmonary disease, Paroxysmal SVT, Spinal stenosis,
Fibromyalgia, Anxiety
Social History:
Married, Denies Tobacco or ETOH use
Family History:
mother had diabetes
Father CAD
Physical Exam:
Vitals:T 96.2, BP 143/75, HR 98, RR 30, O2 sat 98% on BIPAP set
at 10/8 with 80% oxygen.
General: obese female with face mask for BIPAP in place.
HEENT: anicteric sclera, MMM, PERRL, plethoric neck, unable to
assess JVD given body habitus
CV: RRR nl S1 S2, no m/r/g but distant heart sounds
LUNGS: diffusely rhonchorous, crackles half way up bilateral
lung fields R>L
ABDOMEN: +BS, obese, soft NTND, no HSM appreciated
EXT: 1+ edema bilateral LE
Pertinent Results:
[**2168-3-16**] CXR: There is consolidation/atelectasis in the left lower
lobe. Interval decrease in size of left pleural effusions, which
is small. There is no evidence of CHF. The lungs are better
aerated especially in the upper lobes. Cardiac contour is
obscured by the left consolidation and pleural effusion.
Mediastinal wires are intact. Right internal jugular catheter
with tip in right atrium, unchanged from prior study. There is
no pneumothorax.
[**2168-3-3**] Echo: POST CPB: Normal RV systolic function. Left
ventricular views are very limited. Can not rule out a focal
wall motion abnormality. Limited transgastric views suggest an
EF around 40%. A bioprosthesis is noted in the mitral position.
It is well seated with normal leaflet function. There is trace
valvular MR with a MVA of 2 cm2. No other changes from pre CPB.
[**2168-2-23**] Cardiac Cath: 1. Selective coronary angiography in this
right dominant patient revealed three vessel native coronary
artery disease. The LMCA was angiographically normal. The LCX
was mid occluded with faint collaterals to an OM from the LAD.
The LAD had a proximal 80% lesion, diffuse mid disease to 80-90%
involving a large diagonal which had an origin 70% lesion. The
RCA was totally occluded proximally with robust left to right
collaterals from the LAD to PDA. 2. Limited hemodynamics
revealed low systemic blood pressure at 83/49 with mild
pulmonary diastolic hypertension at 21mmHG. 3. Due to severity
of CAD with mitral regurgitation, intubated status with recent
ultrafiltration and clinical picture consistent with cardiogenic
shock and intra aortic balloon pump (Arrow 30cc) was placed.
[**2-24**] CNIS/Vein Mapping: 1. Patent bilateral greater saphenous
veins, that on the right below the knee was not assessed due to
an overlying boot. 2. Limited carotid study demonstrating
patency of the left ICA and CCA only. The right system could not
be assessed due to a central line.
[**2168-3-17**] 07:45AM BLOOD WBC-13.8* RBC-3.04* Hgb-9.5* Hct-28.3*
MCV-93 MCH-31.3 MCHC-33.6 RDW-18.7* Plt Ct-210
[**2168-3-16**] 12:15PM BLOOD WBC-15.3* RBC-3.45* Hgb-10.5* Hct-32.2*
MCV-93 MCH-30.3 MCHC-32.5 RDW-18.5* Plt Ct-259
[**2168-3-17**] 07:45AM BLOOD PT-17.6* PTT-33.9 INR(PT)-1.6*
[**2168-3-17**] 07:45AM BLOOD Plt Ct-210
[**2168-3-17**] 07:45AM BLOOD Glucose-94 UreaN-34* Creat-3.9* Na-145
K-4.2 Cl-103 HCO3-30 AnGap-16
[**2168-3-16**] 12:15PM BLOOD Glucose-105 UreaN-30* Creat-3.4* Na-144
K-3.7 Cl-101 HCO3-32 AnGap-15
Brief Hospital Course:
64 yo F with known CAD and reversible inferolateral defect, CRI
with Cr baseline 2-2.5, and DM who has been having increasing
angina and evidence of NSTEMI at OSH last week. This was
medically managed and now she returns with decompensated left
ventricular systolic heart failure. She was treated with
ceftriaxone, azithromycin &, flagyl for question of pneumonia.
She was changed to vancomycine and meropenum per infectius
diseases after having fevers. She remained intubated on CVVH on
multiple pressors until she was taken to the operating room on
[**2168-3-3**] where she underwent a CABG x 3/MVR ([**First Name8 (NamePattern2) 7163**] [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 9041**] Porcine Valve). She was transferred to the ICU in
critical but stable condition on milrinone, levophed, propofol,
and insulin. She continued on CVVH, remained intubated for
respiratory failure and question of ARDS, continued on
vancomycin and meropenum for sepsis of unclear etiology, and
remained on her vasoactive drips. She was transfused multiple
times, her HCT was followed closesly and she was started on a
PPI for coffee ground appearing NGT output. On POD #4 her
milrinone was weaned to off. She was started on tube feeds. The
remainder of her drips were weaned to off by POD #5. She was
seen by general surgery for HD access placement. She was
extubated that on POD #6. She was seen by speech and swallow
several times who ultimately recommended thin liquids, soft
solids and supervised feeds and aspiration precautions. CVVH was
stopped on POD #8, diuresis was unsuccessful with lasix and she
was started on HD. She was transferred to the floor on POD #11.
She continued to do well from a surgical perspective, finished
her antibiotics but was deconditioned and was ready for rehab on
POD #14. She was dialyzed in the morning on [**2168-3-17**].
Medications on Admission:
Imdur 60mg qam, Levaquin 250mg QOD, Nexium 40mg daily, Mucinex
1200mg [**Hospital1 **], Motrin 150mg qam, Cardizem 240mg in am, 180mg in pm,
Plavix 75mg daily, Trileptal 300mg [**Hospital1 **], Synthroid 25mcg [**Hospital1 **]-Fri
and 50mcg on sat&sun, Singular 10mg qam, lipitor 20mg daily,
lasix 20mg daily, zinc sulfater 2 capsules daily, ASA 81mg
daily, cozaar 100mg daily, Insulin NPH, Serax 10mg daily, Colace
100mg [**Hospital1 **], Tylenol prn, Nitrostat prn, Zetia 10mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO [**Last Name (LF) **], [**First Name3 (LF) **],
WED, [**Doctor First Name **], FRI ().
3. Levothyroxine 50 mcg Tablet [**Doctor First Name **]: One (1) Tablet PO SAT, SUN
().
4. Metoprolol Tartrate 25 mg Tablet [**Doctor First Name **]: 0.5 Tablet PO BID (2
times a day).
5. Senna 8.6 mg Tablet [**Doctor First Name **]: One (1) Tablet PO BID (2 times a
day).
6. Simvastatin 40 mg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY
(Daily).
7. Montelukast 10 mg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY
(Daily).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Bacitracin Zinc 500 unit/g Ointment [**Last Name (STitle) **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Disp:*QS 1 month* Refills:*0*
10. Haloperidol 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO at bedtime.
11. Amiodarone 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO once a day:
400 daily x 1 week, then 200 daily until dc'd by cardiologist.
12. Hydromorphone 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
13. Lantus 100 unit/mL Cartridge [**Hospital1 **]: Twenty (20) units
Subcutaneous at bedtime.
14. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Hospital1 **]: per
sliding scale units Subcutaneous every six (6) hours.
15. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 685**] [**Doctor Last Name **] hospital
Discharge Diagnosis:
Coronary artery disease (s/p acute myocardial infarction) s/p
Coronary artery bypass graft x 3
Mitral Regurgitation s/p Mitral Valve Replacment
Congestive heart failure requiring intubation and mechanical
ventilatory support
Chronic renal failure on continuous hemodialysis s/p Right IJ
PermCath placement
Pneumonia
Sacral Pressure Ulcer
PMH: Coronary Artery Disease s/p PTCA, Heart Failure,
Hypercholesterolemia, Hypertension, Diabetes Mellitus,
Hypothyroidism, Chronic Lymphocytic Leukemia, Chronic renal
insufficiency baseline Cr 2.5-3, Gastroesopahgeal Reflux
Disease, Obstructive sleep apnea with CPAP, Chronic Obstructive
pulmonary disease, Paroxysmal SVT, Spinal stenosis,
Fibromyalgia, Anxiety
Discharge Condition:
Good.
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in [**3-12**] weeks
Dr. [**Last Name (STitle) 3390**] [**Last Name (NamePattern4) **] [**2-9**] weeks
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2168-7-21**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2168-5-2**] 2:00
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2168-7-21**] 10:40
Completed by:[**2168-3-17**]
|
[
"244.9",
"585.6",
"204.10",
"403.91",
"530.81",
"518.81",
"428.22",
"496",
"424.0",
"729.1",
"250.00",
"410.71",
"707.03",
"285.21",
"486",
"272.0",
"428.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"36.15",
"89.64",
"96.6",
"99.04",
"96.04",
"39.61",
"36.12",
"37.22",
"35.24",
"88.56",
"37.61",
"96.72",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
8399, 8478
|
4293, 6164
|
350, 634
|
9223, 9230
|
1789, 2266
|
9548, 10152
|
1276, 1308
|
6699, 8376
|
8499, 9202
|
6190, 6676
|
9254, 9525
|
1323, 1770
|
276, 312
|
662, 825
|
847, 1207
|
1223, 1260
|
2276, 4270
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,361
| 127,631
|
3288
|
Discharge summary
|
report
|
Admission Date: [**2180-11-19**] Discharge Date: [**2180-11-22**]
Service: MEDICINE
Allergies:
Tricyclic Compounds / Nsaids / Requip
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Syncope and hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a [**Age over 90 **]yo female with PMH Parkinson's and recent
hospitalization on [**2180-9-8**] and [**2180-11-10**] for syncope and
hypotension associated with urinary tract infections who
presents today with similar episode. Per nursing home, patient
was found by the staff at [**Hospital3 537**] slumped over in her
chair while eating breakfast and was difficult to arouse. The
patient does not remember the episode and does not recall losing
conciousness. Denies fall out of the chair.
.
The patient came to the ED and was found to have rectal temp of
100.8. Her heart rate was in the 80's and BP was initially in
the 80's and per report transiently dropped as low as the 70's.
She was given fluids (3.5L) and her SBP came up to the 100's.
She was also given 1 g vancomycin and 4.5 g zosyn.
.
In the ICU, initial vs were: T:96.4 BP:137/70 HR:73 RR:15 O2
100% 2L. The patient reports that she has had a cough for the
past several weeks but this has been stable. She also has
questionable episode of "vomiting" that may have preceded her
cough. Pt denied any fever, chills. She states she has noticed
mild dysuria for "a few days."
Past Medical History:
- Parkinson's disease
- Chronic lower extremity pain/neuropathy
- Cervical spine osteoarthritis and degenerative joint disease
- Hypothyroidism
- Admission to [**Hospital1 18**] [**9-/2179**] for suspected UGIB, although
subsequent NGT and EGD were unrevealing
- CBD stone impaction s/p ERCP [**10/2179**]
- Recurrent UTIs in past, no resistant organisms in our system
- AAA 3.3 cm
- Hypercholesterolemia
- Restless leg syndrome
- Glaucoma/cataracts
- Depression
.
PSH: Tongue surgery for premalignant lesion [**2146**]; right hip fx
s/p repair2002; bladder suspension surgery [**02**] years ago; ERCP
[**10-22**]; cataract surgery bilaterally; right knee arthroscopy for
torn meniscus [**2172**]
Social History:
Lives with her husband of 65 years in [**Hospital3 15335**] apartment with 24 hour care. Not ambulatory but gets out
of bed to chair daily. Local daughter ([**Name (NI) 636**] [**Name (NI) 15331**]), two other
children. No tobacco use. Rare past wine consumption. Never
worked.
Family History:
Parents died in their 70s with CAD.
Physical Exam:
PE: T:98.4 BP:143/75 HR:85 RR:16 O2 94%RA
Gen: NAD/ Comfortable/ pleasant/ appears fatigued
HEENT: AT/NC, PERRLA, EOMI, anicteric, no conjuctival pallor,
MMM, clear oropharynx, no erythema, no exudates no rhinorrhea/
discharge, no sinus tenderness
NECK: supple, trachea midline, no LAD
LUNG: bibasilar crackles, no rales or rhonchi
CV: S1&S2, RRR, II/VI SEM at LSB
Carotid: no buits
ABD: Soft/+BS/ NT/ ND/no rebound/ no guarding.
EXT: No C/C/E
+2 pulses radial, DP, b/l & symetrical
NEURO: AAOx2 (pt confused about the date)
CN II-XII grossly intact and non-focal b/l
4/5 strength in upper ext
[**4-19**] lower ext b/l
Sensation to pain, temp, position intact b/l
Reflexes [**3-20**] brachioradialis, biceps, patellar, Achilles
Pertinent Results:
[**2180-11-20**] 04:56AM BLOOD WBC-7.8 RBC-3.51* Hgb-11.8* Hct-33.7*
MCV-96 MCH-33.6* MCHC-35.0 RDW-12.7 Plt Ct-299
[**2180-11-20**] 04:56AM BLOOD Neuts-66.4 Lymphs-18.6 Monos-9.8 Eos-5.0*
Baso-0.3
[**2180-11-19**] 09:50AM BLOOD PT-12.8 PTT-24.4 INR(PT)-1.1
[**2180-11-20**] 04:56AM BLOOD Glucose-83 UreaN-10 Creat-0.7 Na-139
K-3.9 Cl-103 HCO3-26 AnGap-14
[**2180-11-19**] 09:50AM BLOOD ALT-5 AST-22 CK(CPK)-70 AlkPhos-64
TotBili-0.3
[**2180-11-19**] 09:50AM BLOOD cTropnT-0.02*
[**2180-11-19**] 06:12PM BLOOD CK-MB-4 cTropnT-<0.01
[**2180-11-20**] 04:56AM BLOOD CK-MB-4 cTropnT-0.02*
[**2180-11-20**] 04:56AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.9
[**2180-11-19**] 10:12AM BLOOD Lactate-2.8*
UA:
[**2180-11-19**]:
Color Appear Sp [**Last Name (un) **]
Yellow Hazy 1.013
Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
LG NEG NEG NEG TR NEG NEG 6.5 MOD
RBC WBC Bacteri Yeast Epi
[**4-19**]* >50 MOD NONE 0-2
[**2180-11-19**] Blood Cx: PENDING
[**2180-11-19**] Urine Cx: PENDING
IMAGING:
CT HEAD [**2180-11-19**]
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect, or shift of normally midline structures. There is
moderate-to-severe cerebral atrophy with associated prominence
of the sulci and ventricles. There is extensive low density in
the white matter of the cerebral hemispheres, consistent with
chronic small vessel ischemic disease in a patient of this age.
Internal carotid arterial calcifications are again noted. The
imaged bones appear unremarkable.
IMPRESSION: No evidence of acute intracranial abnormalities.
Brief Hospital Course:
A/P: Pt is a [**Age over 90 **] yo female with pmhx parkinson's disease here
with syncopal event and hypotension.
.
# Hypotension/ Syncope:
The patient came to the ED and was found to have rectal temp of
100.8. Her heart rate was in the 80's and BP was initially in
the 80's and per report transiently dropped as low as the 70's.
She was given fluids (3.5L) and her SBP came up to the 100's.
She was also given 1 g vancomycin and 4.5 g zosyn. Her UA was
positive and cultures were pending. CT of her head was
negative. In the ICU, initial vs were: T:96.4 BP:137/70 HR:73
RR:15 O2 100% 2L. She was orthostatic supine: 144/85 HR: 73,
sitting: 130/70 HR:76. The patient remained stable throughout
the night and did not require additional fluids and no
additional episodes of hypotension/ snycope. Pt was empircally
started on Zosyn given previous urine cx data from previous
admission in [**Month (only) **].
Likely combination of infection given positive ua that was
untreated during last admission and hypovolemia, mildly
orthostatic on initial exam and BP responded to fluids (3.5L in
ED). Pt presented in a similar manner on previous admissions.
Additionally, autonomic dysfunction from Parkinsons and/or
vasovagal episode while eating breakfast could have contributed.
The patients troponins mildly elevated initially, but flat CK
and 2nd set negative. no ekg changes on admission --> unlikely
cardiac. No evidence of pna on CXR and BC pending.
-treat UTI with zosyn based on urine cx during last admission
- f/u on urine cx & sensitivities and blood cx
-bolus with IVF prn, does not need maintenance fluids at this
time
-monitor bp, keep map > 65
-f/u CXR this AM
-complete romi --> 3rd set pending
-monitor on tele
.
# UTI: Based on last urine cx, will treat with zosyn given
previous resistance & sensitivity data.
-f/u urine cx and sensitivies and adjust antibiotics accordingly
.
# Change in Mental Status: Pt was confused and disoriented
overnight. However, she was able to be reoriented. Most likely
patient was sundowning. Pt with baseline dementia 2/2 per
daughter.
.
# Parkinsons: stable cont home dose of sinemet
.
# Chronic pain/neuropathy: cont neurontin renally dosed
.
# HTN: hold toprol given hypotension, may add back tomorrow in
short-acting form if stable.
.
# Glaucoma: cont xalatan, betaxolol, pilocarpine eye gtts
.
# Hypothyroidism: cont levothyroxine, recent tsh in [**Month (only) **] at same
dose.
.
# FEN: no maintenance fluids, cardiac diet, confirmed with her
aide that she eats solids and thin liquids fine, replete lytes
prn.
.
# PPx: protonix, subq heparin, bowel reg
.
# Access: PIV
.
# Code: DNR/I confirmed with her HCP ([**Doctor Last Name **]) daughter
.
# comm: daughter [**First Name8 (NamePattern2) **] [**Known lastname **] [**Numeric Identifier 15339**]
.
# Dispo: Will discuss with CM regarding IV antibiotic treatment
at [**Hospital3 537**] and discharging directly from ICU. However, pt
would need to be placed at SNIF level of care which would delay
her discharge an additional day. Will d/w CM.
Medications on Admission:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime).
6. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
5X/DAY (5 Times a Day).
7. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO QHS (once a day (at bedtime)).
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY AT
1500 ().
10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. Pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic QHS
(once a day (at bedtime)).
12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for foot pain.
13. Multivitamin 1 tablet PO daily
14. Toprol XL 25mg SR one half tablet daily
15. Calcium 500+D 500- 1 tablet [**Hospital1 **]
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig:
One (1) Tablet Sustained Release PO once a day.
3. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Cholecalciferol (Vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 2 weeks.
12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Pilocarpine HCl 4 % Drops Sig: One (1) Drop Ophthalmic QHS
(once a day (at bedtime)).
15. Trazodone 50 mg Tablet Sig: 0.25 tablets Tablet PO at
bedtime as needed for insomnia: 12.5 mg total.
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
UTI with Sepsis
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"995.91",
"599.0",
"355.9",
"332.0",
"244.9",
"272.0",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10634, 10730
|
4906, 6817
|
271, 277
|
10790, 10795
|
3286, 4883
|
10846, 10852
|
2485, 2522
|
9187, 10611
|
10751, 10769
|
7994, 9164
|
10819, 10823
|
2537, 3267
|
208, 233
|
305, 1452
|
6832, 7968
|
1474, 2172
|
2188, 2469
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,574
| 109,934
|
3704
|
Discharge summary
|
report
|
Admission Date: [**2180-8-28**] Discharge Date: [**2180-8-31**]
Date of Birth: [**2106-4-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
1. Esophogealduodenoscopy (EGD)
2. Flexable Sigmoidoscopy
History of Present Illness:
74 year old man with CAD, valvular disease, GERD, PVD, and
recent admission for rectal bleeding from radiation proctitis,
presents with BRBPR for weeks. He reports some amount of GI
bleeding since the radiation treatment one year ago, but states
this was worsened since he was started on blood thinners for a
planned vascular surgery. Per his last discharge summary, he had
BRBPR requiring 2u+1u PRBC after being started on heparin gtt
for graft instability on [**8-6**]. During that admission, he had a
colonoscopy that showed radiation changes. She had bleeders
cauterized and was discharged. Since then, he had some mild
continued bleeding. His PCP sent him in for his low Hct of 25
from Hct 32 on [**8-17**].
In the ED, initial vs were: 97.4 51 137/70 18 99. He was alert
but ashen. He was seen by GI. He was started on one unit of PRBC
and had an 18G and 16G placed. He complained of some mild chest
dyscomfort and had an EKG that was "at baseline", and CE sent
for chest dyscomfort. Prior to transfer, BP 142/41 and HR 53.
Currently, he feels normal. Denies weakness or dizziness.
Past Medical History:
1. HTN
2. Hyperlipidemia (pt denies)
3. GERD (pt denies)
4. PVD s/p L CFA to DP bypass graft, s/p R CFA to peroneal
bypass for popliteal artery aneurysm, s/p redo R CFA to peroneal
bypass using nonreversed R basilic/cephalic veins, s/p B/L LE
angio ([**7-2**]), s/p LLE angio ([**8-3**])
5. CAD, s/p DES to LCX/OM1 in [**2168**]. On [**2180-8-10**] cath: LAD 50%
stenosis, D1 80% ostial stenosis, Cx had a 90% stenosis, RCA 70%
stenosis, lateral 80% stenosis in the med region of the vessel
and a subbranch of the PL had a 70% stenosis at its origin.
6. DM (pt denies)
7. Prostate cancer s/p radiation therapy
8. Aortic stenosis (0.8-1.19cm2)
9. CKD, baseline Cr 1.3
10. Anemia, baseline Hct upper 20s-low 30s
Social History:
Spanish speaking. He is married and lives with his wife. [**Name (NI) **]
continues to smoke [**4-30**] cigs/day, h/o 1ppd since age 15. Denies
EtOH for years, but history of heavy drinking. No drug use.
Family History:
Brother died of colon CA at age 70. No sudden cardiac death.
Physical Exam:
On MICU Admission
Vitals: 97 56 136/47 18 96%/RA
General: Alert, pale, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
loudest at base
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Rectal: in ED, small BRB G+
Pertinent Results:
ON ADMISSION:
[**2180-8-28**] 11:10AM BLOOD WBC-7.2 RBC-2.53*# Hgb-6.8*# Hct-22.3*#
MCV-88 MCH-26.9* MCHC-30.6* RDW-16.3* Plt Ct-404
[**2180-8-28**] 11:10AM BLOOD Glucose-114* UreaN-30* Creat-1.3* Na-139
K-4.5 Cl-102 HCO3-28 AnGap-14
[**2180-8-29**] 03:02AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.4
HCT TREND
[**2180-8-28**] 09:00PM Hct-25.1*
[**2180-8-29**] 03:02AM Hct-27.3*
[**2180-8-29**] 01:56PM Hct-27.8*
[**2180-8-29**] 09:00PM Hct-29.8*
[**2180-8-30**] 05:30AM Hct-30.0*
[**2180-8-30**] 05:30AM Hct-30.4*
ROMI
[**2180-8-28**] 11:10AM BLOOD CK(CPK)-31* cTropnT-<0.01
[**2180-8-28**] 09:00PM BLOOD CK(CPK)-28* CK-MB-NotDone cTropnT-<0.01
[**2180-8-29**] 03:02AM BLOOD CK(CPK)-32* CK-MB-NotDone cTropnT-<0.01
[**2180-8-29**] 01:56PM BLOOD CK(CPK)-32* CK-MB-NotDone cTropnT-<0.01
IRON STUDIES
[**2180-8-28**] 11:10AM BLOOD Iron-25* calTIBC-267 Hapto-261*
Ferritn-24* TRF-205
Brief Hospital Course:
74yo male with history of radiation proctitis with 1 year hx of
BRBPR with recent LGIB during pre-op hospitalization, GERD, PVD,
and severe aortic stenosis who presents with drop in Hct and
BRBPR.
.
# GI Bleed: Patient describes chronic, low-level bleeding that
is likely from angioectasias from radiation proctitis. Low
suspicion for upper GI bleed given slow nature, history, and
absence of nausea/vomiting. In the emergency room, he was
transfused 1 unit PRBCs and 2 large bore IV's placed. Due to
active GI bleed, he was admitted directly to the MICU. In the
ICU, he was given 3 units packed red blood cells. He maintained
hemodynamic stability. The patient does have a drug eluding
stent, but given he was one year out from stent placement, his
aspirin and beta-blocker were held in setting of his bleed.
Patient has a history of iron deficiency, he was loaded with
iron with his blood transfusions. Given his hemodynamic
stability, he was transferred to the floor for ongoing medical
managment and planned scopes by GI. He arrived to the floor
with stable hemodynamics and aysmptommatic. He still had BRBPR,
but per pt and nursing reports, it was greatly decreased from
admission. He was followed with serial hematocrits, and aspirin
was held. Outpatient iron replacement regimen was held as to
not mask melena. Due to GI bleed, DVT prophylaxis consisted of
ambulation. The GI consult team planned for a flex
sigmoidocscopy and EGD on day 2 of the floor and patient was
prepped with 2L Go-lytely for his procedures. Flex
sigmoidoscopy identified a large rectal ulcer at site of
previous cautery with no active bleeding to explain patient's
drop in hematocrit. EGD showed z-line abnormality and biopsy
was taken, otherwise unremarkable. Small bowel imaging was
planned in the outpatient setting. The patient continued to be
hemodynamically stable on the floor with a stable hematocrit x48
hours priors to discharge. The patient was to have his
hematocrit checked by VNA and faxed to his PCP on day 1 and 4
after discharge.
.
# CAD: Due to active GI bleed, Mr. [**Known lastname 16709**] aspirin and beta
blocker were held on admission and throught is hospital stay.
Due to patient > 1 year out from DES, low risk for in-stent
thrombosis. His statin was continued. Patient was instructed
to follow-up with his PCP after discharge to re-evaluate the
reintroduction of these medications.
.
# Hypertension: Due to active bleeding on admission, Mr.
[**Known lastname 16709**] anti-hypertensive medications were discontinued.
After becoming hemodynamically stable and transfer to the floor,
the patient was kept NPO in preparation for GI procedures. Mr.
[**Known lastname **] was normotensive for most of his admission, with his
Lisinopril and Nifedipine resstarted prior to discharge. He was
instructed to follow-up with the arranged PCP appointment for
blood pressure evaluation.
.
# Anemia: Iron studies, hypochromia, and microcytosis consistent
with iron deficiency. Mr. [**Known lastname **] was iron loaded in the ICU
with his transfusions and instructed to follow-up with PCP [**Last Name (NamePattern4) **]:
future iron replacement.
.
# FEN: No IVF, replete electrolytes, regular diet
.
# Code: Full
.
# Communication: Patient (spanish speaking, some english)
Medications on Admission:
Aspirin 325 mg PO daily
Clonazepam 1 mg PO QHS
Hydrochlorothiazide 25 mg PO daily
Lisinopril 20 mg PO daily
Nifedipine 90 mg PO daily
Pantoprazole 40 mg PO Q24H
Hydrocortisone Acetate 25 mg suppository
Atorvastatin 80 mg PO daily
Citalopram 10 mg PO daily
Ferrous Sulfate 325 mg PO daily
Metoprolol Succinate 50 mg PO daily
Discharge Medications:
1. Hydrocortisone Acetate 25 mg Suppository Sig: One (1)
Suppository Rectal DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia for 10 days.
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
8. Outpatient Lab Work
Please Check CBC on [**Last Name (NamePattern4) 2974**] [**2180-9-1**] and fax results to PCP.
[**Name10 (NameIs) 357**] check CBC on Monday [**2180-9-4**] and fax results to PCP
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Rectal Ulcer
2. Lower GI Bleed
Secondary:
1. Hypertension
3. Radiation Proctitis
Discharge Condition:
Stable. Vitals stable.
Discharge Instructions:
You were admitted to the hospital for active bleeding and a drop
in your blood levels. You were admitted to the Intensive Care
unit to monitor your closely until you were stabilized. You
revieved a total of 5 blood transfusions during your admission.
During your admission, your blood pressure medication was
stopped since you were losing blood. You also had a a
sigmoidoscopy sigmoid colon and and EGD to look at your
esophagus, stomach and part of your duodenum.
Medication changes:
1. Stop Hydrochlorothiazide
2. Stop Metoprolol
3. Stop Aspirin
4. Stop Ferrous sulfate
5. Pantoprazole now 40 mg every 12 hours
3. Take all other medications as prevoiusly prescribed
If you experience increased bleeding per rectum please contact
your PCP or go to the Emergency Room or call 911. Additionally,
if you get a Temperature > 102, light headedness, chest pain,
severe headache, decreased urine output, fainting or any other
syptom that concerns you please call you PCP or visit an
emergency room.
Followup Instructions:
PCP [**Last Name (NamePattern4) **]:
MD: Mr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**]
Specialty: PCP
Date and time: [**Last Name (LF) 2974**], [**9-8**] at 9:20AM
Location: [**Hospital 16710**] HEALTH CARE, INC., [**Street Address(2) 16711**], [**Location (un) **],[**Numeric Identifier 6809**]
Phone number: [**Telephone/Fax (1) 1792**]
Capsule Endoscopy:
Provider: [**First Name8 (NamePattern2) 20**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2180-9-6**] 11:30
Gastroenterology [**Name8 (MD) **]
MD: [**Doctor First Name 4370**] [**Doctor Last Name **]
Date/Time: [**2180-9-19**] 2:00pm
Location: [**Hospital1 18**] [**Hospital Ward Name **], RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX), [**Location (un) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"211.3",
"E879.2",
"185",
"414.01",
"272.4",
"424.1",
"585.9",
"280.9",
"556.2",
"412",
"569.85",
"403.90",
"569.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.16",
"45.42"
] |
icd9pcs
|
[
[
[]
]
] |
8560, 8617
|
4015, 7303
|
322, 382
|
8746, 8771
|
3116, 3116
|
9818, 10782
|
2473, 2535
|
7677, 8537
|
8638, 8725
|
7329, 7654
|
8795, 9264
|
2550, 3097
|
9284, 9795
|
274, 284
|
410, 1501
|
3130, 3992
|
1523, 2235
|
2251, 2456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,980
| 113,870
|
3026
|
Discharge summary
|
report
|
Admission Date: [**2104-10-27**] Discharge Date: [**2104-11-3**]
Service: MEDICINE
Allergies:
Sulfonamides / Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
83 yo female with a history of HTN, hyperlipidemia, diastolic
CHF, ESRD on HD, h/o CVA, and Alzheimers dementia presents from
dialysis with a wide complex tachycardia. Patient denies any
chest pain, shortness of breath, or other complaints. On the
day of admission, she presented for her routine dialysis
appointment. During the visit she was noted to look unwell and
not herself. On arrival of EMS, BP 77/50, HR 121, RR 16, O2
95%. Patient was brought to [**Hospital1 18**] ED for eval.
.
On arrival, HR 135, BP 90/60, RR 16 O2 90%. On exam, irregular
rhythym, no JVD, guaiac negative. ECG revealed a wide complex
tachycardia at rate of 140bpm. Patient was given Amio and
Calcium gluconate. Then spontaneously converted to NSR at [**Street Address(2) 14412**] elevations inferiorly in II, III, aVF (III > II)
also with reciprocal depression in I, aVL, V6, V5. Labs with CK
379, MB 43, MBI 11.3, TnT 13.4. The patient was given Aspirin,
heparin, intergrillin (couldn't swallow plavix) and taken to the
cath lab.
.
Left Heart Cardiac Catheterization demonstrated;
1. CTO of RCA
2. LMCA: Distal taper with moderate calcification
3. LAD: Proximal 50% w/ heavy calcification, D1 80% lesion.
4. LCx: Non-dominant w/ distal flow from l-r collaterals
5. Unable to cross CTO of RCA though unlikely acute.
.
Patient was then transferred to the CCU for management.
.
On review of symptoms, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CRI secondary to HTN.
2. HTN
3. CVA of posterolateral medulla in [**2095**]. Pt previously on
coumadin, but recently held by PCP due to concern about falls.
4. Hypercholesterolemia
5. Polio at age 18 with residual left lower extremity weakness
6. Aortic insufficiency
7. TR/MR [**First Name (Titles) **] [**Last Name (Titles) **] 12'[**95**]
8. s/p bilateral cataracts surgery
9. s/p TAH secondary to uterine fibroids
10. CHF - Diastolic Dysfunction
11. cognitive impairment
Social History:
The patient lives alone in the [**Location (un) **] of [**Location (un) 86**]. She is
completely independent in her ADL and IADLS - she cooks, cleans,
washes, dresses, herself. She is a retired nursing assistant.
She has no children and family is not involved, however pt has
friends who are involved in her life and care.Pt quit drinking
alcohol 50 years ago. Pt admits to smoking 0.3 pack/day for 3
years but also quit 50 years ago. Pt denies ever using illicit
drugs use.
Family History:
Noncontributory
Physical Exam:
VS: T 94.1, BP 148/89 , HR 73, RR 25 , O2 100 % on 4L NC
Gen: Elderly woman in NAD, resp or otherwise. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 1+ without bruit; 1+
palpable DP on R, dopplerable PT.
Left: Carotid 2+ without bruit; Femoral 1+ without bruit;
Dopplerable on Right but extremely faint.
Neuro: AOx3, "[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]" is president, US "not" at war and
"Red Sox" won world series.
Pertinent Results:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed 2 vessel coronary artery disease. The LMCA tapered
distally and
was noted to have moderate calcification. The LAD had a
proximal 50%
stenosis with heavy calcification. The D1 had an 80% stenosis
at the
origin. The LCx was a non-dominant vessel without critical
lesions. The
RCA had a total occlusion with distal flow from left-to-right
collaterals.
2. Resting hemodynamics revealed moderate-severe systemic
arterial
systolic hypertension with an SBP of 172 mmHg.
3. Supravalvular aortography revealed no evidence of AI and a
normal
ascending aortic diameter. The aortogram confirmed the total
occlusion
of the RCA.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate to severe systemic arterial systolic hypertension.
3. Acute inferior myocardial infarction, managed by medical
therapy with
failed PTCA of complete total occlusion of RCA.
Cardiac Echo:
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. There is mild regional left ventricular
systolic dysfunction with inferior hypokinesis. The right
ventricular cavity is dilated. Right ventricular systolic
function appears depressed. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is mild functional mitral stenosis
(mean gradient 5 mmHg) due to mitral annular calcification.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
[**2104-10-27**] 12:25PM WBC-14.5*# RBC-3.21* HGB-9.8* HCT-31.2*
MCV-97 MCH-30.6 MCHC-31.5 RDW-16.8*
[**2104-10-27**] 12:25PM CALCIUM-9.5 PHOSPHATE-6.4*# MAGNESIUM-2.3
[**2104-10-27**] 12:25PM CK-MB-43* MB INDX-11.3* cTropnT-13.4*
[**2104-10-27**] 12:25PM CK(CPK)-379*
[**2104-10-27**] 12:32PM GLUCOSE-116* NA+-138 K+-5.7* CL--95* TCO2-23
Abdominal USD:
IMPRESSION:
1. No gallstones or intra- or extra-hepatic biliary ductal
dilatation.
2. Focal mild dilation of infrarenal aorta with nonocclusive
mural thrombus, not meeting size criteria for aneurysm.
3. Small kidneys consistent with end-stage renal disease.
4. Possible small cyst at the head of the pancreas; reevaluation
for stability is recommended in one year's time.
Brief Hospital Course:
Brief Hospital Course:
.
#CAD: Patient was admitted to the CCU post-cath for management.
Was continued on ASA 325mg, Plavix 75mg daily (with anticipated
duration of one month). Metoprolol was started and titrated to
a dose of 37.5mg [**Hospital1 **]. Patient was started on captopril at low
dose (to be held pre-dialysis). Additionally, lipitor 80mg qd
was initiated. Patient was transfered to the floor post-cath
day 1 without event. Echo demonstrated LV diastolic dysfunction
with preserved EF, RV dilated with depressed systolic function.
Echo demonstrated mild aortic stenosis. Recommend outpatient
evaluation.
.
#V.Tach: Patient was monitored on telemetry in the CCU and later
on the floor. During that time she had no significant runs of
NSVT and no recurrence of her VTach. It was felt that her
initial presenting VT was likely due to the metabolic
derrangements (hyperkalemia) on presentation and decision was
made not to pursue an EP study at this time.
.
#ESRD: Patient was dialyzed on presentation. Was mildly
hypotensive post-dialysis and BP meds were held. Patient was
then returned to her usual M/W/F dialysis regimen. No further
events.
.
#Dementia/Social Work: Impression on admission was for mild
baseline dementia. Attempts to discuss patient's care revealed
that she did not clearly have capacity. After discussion with
the patient, social work, and administration it was decided that
patient's friend [**Name (NI) **] [**Name (NI) 3401**] ([**Telephone/Fax (1) 14413**] would serve as
healthcare proxy in the future. Social work arranged
designation prior to discharge.
.
#Abd pain: patient complained of intermittent abdominal during
her hospitalization. Abdominal exam was non-revealing with
intermittent RUQ tenderness. LFT's were normal for post-MI
setting and patient was followed clinically. RUQ USD
demonstrated no significant biliary pathology. A small cyst in
the head of the pancreas was noted which was recommended to be
reevaluated in 1-year's time.
.
#PT/OT: Rec'd--> discharge to rehab.
.
#Nutrition: Poor PO intake during her hospital stay thought to
be contributing to hypotension post-dialysis. Nutrition
recommending renal diet, with encouraging PO intake when
possible.
.
#Follow-Up Plan: As per discharge plans.
.
Remainder of her hospitalization was uneventful.
Medications on Admission:
Pantoprazole 40 mg daily
Toprol XL 25 mg daily
Atorvastatin 5 mg daily
Aspirin 325 mg daily
Donepezil 5 mg qhs
BComplex-Vitamin C-Folic Acid 1mg PO daily
nephrocaps
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Epoetin Alfa Injection
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Inc.
Discharge Diagnosis:
New diagnoses:
STEMI - inferior
Mild Aortic Stenosis (diagnosed by echo on recent admit)
.
End Stage Renal Disease, Dementia, Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for evaluation for low blood
pressure. On arrival, it was found that you had an abnormal
heart rhythm and a previous heart attack. You were taken to the
cardiac catheterization lab or an evaulation of the blood
vessels that supply your heart. It was found that you have
coronary artery disease. You were then admitted to the ICU for
observation and management.
.
Please continue to take all medications as directed upon leaving
the hospital. The following medications have been added to your
medical regimen:
1. Plavix 75mg daily - please continue to take for at least one
month.
2. Lisinopril 2.5mg daily - please do not take on mornings of
dialysis.
3. Atorvastatin 40mg daily
4. Toprol 37.5mg [**Hospital1 **]
.
Please call your doctor or return to the emergency department
should you experience any sudden chest pain or shortness of
breath.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 250**], please call for an appointment
in the next one month.
[**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2104-11-19**] 10:30
Dr. [**Last Name (STitle) **], Cardiology, [**Hospital Ward Name 23**] Building of [**Hospital3 **] [**Hospital Ward Name 5074**], [**Location (un) 436**], ([**Telephone/Fax (1) 11176**], Tuesday [**11-11**] at 1:40pm.
.
Repeat evaluation of pancreatic cyst in one-year's time for
interval change.
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64,873
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45924+58871
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Discharge summary
|
report+addendum
|
Admission Date: [**2135-4-15**] Discharge Date: [**2135-4-20**]
Date of Birth: [**2091-1-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Increased lower extremity edema
Major Surgical or Invasive Procedure:
Tunneled catheter placement
Hemodialysis x 3 sessions
History of Present Illness:
This is a 44 yo F h/o DMI, CKD, HTN who presented to the [**Hospital1 18**]
ED with anasarca, worsening LE swelling, malaise,fatigue and RUQ
abdominal pain. In the ED she was found to be hypertensive with
SBPs in the 200's. A nitro gtt was initiated and BP was reduced
quickly to 140, which resulted in patient experiencing
lightheadedness. Patient also found to have a Cr of 9.3, her
last OMR value was 3 in [**6-22**]. Patient received IV lasix in the
ED and was seen by renal who felt she would likely require
initiation of dialysis. Patient was admitted to the MICU for
management of her hypertension.
In the MICU, patient was weaned off her nitro gtt and restarted
on her outpatient regimen of labetolol and amlodipine. She was
also continued on IV lasix for diuresis goal of one to two
liters given her volume overload. She was followed by the renal
team who suggested tunnelled line for HD on Mon and lab
testing/vein mapping in anticipation of fistula placement.
At time of transfer to floor, patient had no complaints.
Past Medical History:
1. Type I DM - with retinopathy, nephropathy (Stage III). Is
followed at the [**Last Name (un) **] by Dr [**First Name (STitle) **]/ [**Doctor Last Name 3617**] and Dr [**Last Name (STitle) 4090**]
(nephrology)
2. HTN
3. Depression and anxiety
4. Hyperlipidemia
5. s/p D&C, tubal ligation,C-section
6. Anemia (on IV iron)
7. Hyperparathyroidism
Social History:
Never smoked, No ETOH, No IV drugs. Lives with children. Not
working.
Family History:
Mother: DM; hypertension; DM nephropathy
2 Sisters with [**Name (NI) 59282**]
Physical Exam:
VITAL SIGNS: T 97.5 BP 118/60 HR 82 RR 15 O2 100 RA
GENERAL: Pleasant, well appearing in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No elevation in JVP
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. II/VI
systolic ejection murmur heard best at right upper sternal
border
LUNGS: CTAB, good air movement bilaterally.
ABDOMEN: Midline abdominal scar. NABS. Soft, non-tender,
non-distended.
BACK: no flank pain
EXTREMITIES: 2+ pitting edema to knees, 2+ distal pulses
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-17**]+ reflexes
SKIN: venous stasis changes on L shin with both areas of
hyperpigmentation and hypopigmentation
Pertinent Results:
ADMISSION LABS:
CBC:
[**2135-4-15**] 12:30PM BLOOD WBC-9.5 RBC-3.31*# Hgb-9.8*# Hct-29.3*#
MCV-89 MCH-29.5 MCHC-33.3 RDW-15.9* Plt Ct-379
[**2135-4-15**] 12:30PM BLOOD Neuts-76.7* Lymphs-15.3* Monos-6.4
Eos-1.3 Baso-0.3
CHEMISTRIES:
[**2135-4-15**] 12:30PM BLOOD Glucose-120* UreaN-95* Creat-9.3*# Na-136
K-4.6 Cl-103 HCO3-17* AnGap-21*
[**2135-4-15**] 12:30PM BLOOD Calcium-7.7* Phos-5.9*# Mg-2.1 Iron-80
CARDIAC ENZYMES:
[**2135-4-15**] 12:30PM BLOOD cTropnT-0.15*
[**2135-4-16**] 04:30AM BLOOD CK-MB-11* MB Indx-1.4 cTropnT-0.12*
OTHER:
[**2135-4-16**] 05:00AM BLOOD %HbA1c-5.8
[**2135-4-16**] 04:30AM BLOOD Triglyc-300* HDL-38 CHOL/HD-4.3
LDLcalc-67
[**2135-4-15**] 12:30PM BLOOD PTH-451*
[**2135-4-15**] 12:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
=========================
DISCHARGE LABS:
CBC:
[**2135-4-20**] 07:10AM BLOOD WBC-8.2 RBC-2.34* Hgb-6.8* Hct-20.1*
MCV-86 MCH-29.1 MCHC-33.9 RDW-15.7* Plt Ct-292
CHEMISTRIES:
[**2135-4-20**] 07:10AM BLOOD Glucose-88 UreaN-36* Creat-5.7*# Na-135
K-3.8 Cl-101 HCO3-26 AnGap-12
[**2135-4-20**] 07:10AM BLOOD Albumin-2.9* Calcium-8.1* Phos-4.1
Mg-1.5*
OTHER:
[**2135-4-16**] 04:30AM BLOOD PEP-NO SPECIFI IgG-926 IgA-160 IgM-193
IFE-NO MONOCLO
===========================
ECG [**2135-4-15**]:
Sinus rhythm. Poor R wave progression which is non-diagnostic.
Diffuse T wave changes which are non-specific. Compared to the
previous tracing of [**2133-11-19**] no significant diagnostic change.
CXR [**2135-4-15**]: No acute cardiopulmonary process.
RENAL U/S [**2135-4-16**]:
1. Bilateral echogenic kidneys, similar in appearance.
2. No evidence of hydronephrosis.
3. Small amount of fluid between liver and right kidney and
spleen and left
kidney.
Transthoracic echocardiogram [**2135-4-18**]:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The 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. Moderate (2+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
severe pulmonary artery systolic hypertension. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
This is a 44 year old female with history of DM1, CKD, HTN who
now presents with lower extremity edema and was found to have
significantly worsened renal function requiring initiation of
HD. Patient initially admitted to the medical ICU given
hypertension on admission and was then transferred to floor
medical service.
#. End Stage Renal Disease: On admission Cr noted to be 9.8 up
from 3 ([**5-23**]). Thi was felt to be advanced chronic kidney
disease rather than due to an acute process. Patient followed by
the renal consult team who recommended tunneled line placement
for initiation of dialysis. Patient tolerated her first three
dialysis sessions without any complications. She underwent
ultrasound vein mapping in anticipation of fistula surgery.
Patient seen by dialysis social worker who helped coordinate
outpatient dialysis. Patient discharged with prescriptions for
nephrocaps and sevelamer carbonate
.
#. HTN: In the emergency department patient found to be
hypertensive with SBPs to the 200's. She was started on a
nitroglycerin gtt and admitted to the MICU for management of her
hypertension. Nitro gtt was titrated off and patient was
restarted on her outpatient regimen of amlodipine and labetolol.
Patient had no further episodes of hypertension during this
hospital course. Prior to discharge she was started on
lisinopril 5 mg daily and amlodipine was reduced to 5mg daily
from 10 mg daily. She also remains on labetolol 300 mg daily.
# Volume overload: Prior to admission patient noticed increasing
lower extremity edema. On admission she did not have any
evidence of pulmonary edema or elevated jugular venous pressure.
Lower extremity edema improved slightly with intravenous lasix
and patient felt more comfortable ambulating prior to discharge.
Notably, a transthoracic echocardiogram showed mild LVH, severe
pulm HTN and 2+ mitral regurgitation.
# Pulmonary Hypertension: ECHO demonstrated severe pulmonary
hypertension. There were no studies for comparison. The etiology
of PH is unclear. [**Name2 (NI) 227**] the patient does not have significant
left heart disease would suggest further work-up such as PFTs
and polysomnography. [**Month (only) 116**] also want to recheck ECHO within the
next fews weeks to assess whether improved hemodynamics in
setting of HD initiation has an effect.
#. Diabetes, type 1: Blood sugars remain well controlled.
Patient scheduled to follow up with Dr. [**Last Name (STitle) 3617**] at [**Last Name (un) **].
#. Hyperlipidemia: Patient continued on simvastatin.
#. Anemia: Hematocrit slowly trended down over hospital course.
This was felt to be secondary to chronic kidney disease. Patient
transfused 2 units of packed red blood cells prior to discharge.
She was also started on epogen and intravenous iron with HD.
Patient was a FULL code during this admission.
Medications on Admission:
labetalol 300 [**Hospital1 **]
calcitriol 0.25 mg daily
iron [**Hospital1 **]
ASA 81 daily
Insulin
Lasix 40 mg [**Hospital1 **]
amlodipine 10 mg daily
zocor 20 mg daily
Discharge Medications:
1. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 * Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Insulin Glargine 100 unit/mL Solution Sig: 6 units
Subcutaneous at bedtime.
Disp:*qs mL* Refills:*2*
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Sevelamer Carbonate 800 mg Tablet Sig: 0.5 Tablet PO three
times a day.
Disp:*45 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: End Stage Renal Disease, Hypertension
Secondary: Type I Diabetes Mellitus
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital because you noticed increased swelling
in your legs. We determined that you had significantly worsened
kidney disease which was likely contributing to the fluid in
your legs. You were followed by the kidney doctors who
recommended [**Name5 (PTitle) **] begin dialysis. You had a dialysis catheter
placed and have begun dialysis. You tolerated your first three
sessions well.
.
New medications:
Nephrocaps: this is a vitamin B supplement that you need to take
daily
Lisinopril: this is a medication for controlling blood pressure
Sevelamer Carbonate 400 mg by mouth three times a day with
meals.This medication binds extra phosphorous.
.
Medication Changes:
Lantus reduced from 8 units at bedtime to 6 units at bedtime
Amlodipine reduced from 10 mg daily to 5mg daily
.
If you experience lightheadedness, chest pain, shortness of
breath or any other concerning symptom please contact your
primary care physician or come to the emergency department for
evaluation.
Followup Instructions:
The dialysis social worker [**Name (NI) 12906**] [**Name (NI) 97793**] will contact you
tomorrow regarding when and where you will be starting dialysis.
Her phone number is ([**Telephone/Fax (1) 16147**].
Primary Care Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2135-4-28**] 2:00pm,
[**Hospital Ward Name 23**] Building [**Location (un) **].
Diabetologist: You have an appointment with Dr. [**Last Name (STitle) 3617**] on [**2135-4-26**]
at 9:00am at the [**Last Name (un) **] Diabetes Center.
Completed by:[**2135-4-25**] Name: [**Known lastname 10167**],[**Known firstname **] Unit No: [**Numeric Identifier 15610**]
Admission Date: [**2135-4-15**] Discharge Date: [**2135-4-20**]
Date of Birth: [**2091-1-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 128**]
Addendum:
# Elevated Troponins/ECG Changes: On admission patient found to
have troponins of 0.15-->0.12 and non-specific T wave changes on
ECG. Given no complaints of chest pain we had low suspicion for
ACS and no further inpatient work-up pursued. However, would
suggest that patient have outpatient stress test.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 131**] MD [**Last Name (un) 132**]
Completed by:[**2135-4-25**]
|
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icd9pcs
|
[
[
[]
]
] |
11601, 11764
|
5358, 8194
|
347, 403
|
9247, 9256
|
2831, 2831
|
10292, 11578
|
1933, 2012
|
8414, 9091
|
9141, 9226
|
8220, 8391
|
9280, 9942
|
3648, 5335
|
2027, 2812
|
3257, 3631
|
9962, 10269
|
276, 309
|
431, 1462
|
2848, 3240
|
1484, 1830
|
1846, 1917
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,271
| 188,841
|
6428
|
Discharge summary
|
report
|
Admission Date: [**2192-10-8**] Discharge Date: [**2192-10-17**]
Date of Birth: [**2149-1-1**] Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Shellfish
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
pt admitted for TIPS procedure, complication of TIPS; concern
for puncture of liver capsule
Major Surgical or Invasive Procedure:
transjugular intrahepatic porto-systemic shunt (TIPS)
History of Present Illness:
43 yo M with HCV cirrhosis and refractory ascites, on transplant
list, who underwent TIPS procedure for refractory ascites that
was apparently complicated by puncture of liver capsule. During
the procedure, paracentesis for 3L of ascites was performed.
First bottle was collected prior to the TIPS procedure and was
pink in color. The second and third liters were more bloody
concerning for puncture of liver capsule. During and after the
procedure, the patient remained HD stable. His Hct was 32 prior
to procedure and 28 after the procedure but this is also in the
setting of receiving 2 units FFP, one bag of platelets and 2
liters LR.
.
The patient was initially admitted to medicine service on [**10-8**]
when he presented with general malaise, nausea x 3-4 days, one
episode of vomiting. He was also noted to have signs of
worsening encephalopathy, difficulties with balance, slurred
speech. He was recently hospitalized for hyponatremia and was
just discharged on [**2192-10-3**], 4 days prior to his current
admission, with the plans to return for TIPS on [**2192-10-11**]. The
patient reported a 5 lbs weight gain on admission. In the ED
paracentesis was performed and 5.3 L were drained with
peri-procedural albumin. WBC 175 (1% polys) no organisms.
.
The patient currently c/o feeling tired. He denies any
fevers/chills. No dysphagia. No SOB/CP. No abdominal pain except
for mild RUQ tenderness and sore neck. His vital signs are all
stable. In the PACU, he has received 2 liters LR, 2 units FFP,
and a bag of platelets.
Past Medical History:
HCV cirrhosis - failed IFN treatments, c/b ascites.
hemorrhoids
anal fissure
h/o EtOH abuse - remote
Social History:
Pt is married with three children. No tobacco, no current EtOH.
h/o EtOH abuse (quit in [**2172**]) and IVDA. Has a tattoo.
Family History:
Uncle had EtOH abuse induced liver cirrhosis.
Physical Exam:
Vitals: 97.2; 141/69; 88; 13; 99% on 2L
Gen: lying in bed in NAD; tired appearing
HEENT: NC, AT, OP clear, MMM, anicteric sclera
Neck: supple, no LAD
CVS: regular, S4 gallop, soft 1-2/6 systolic murmur best heard
at LSB.
Lung: CTA bilaterally no wheezes
Abd: +BS, Soft, NT, ND, non tender in the RLQ, bruit heard
intermittently in the RUQ
Ext: trace LE edema; well perfused.
Rectal: good tone, guiac negative per ED report.
Neuro: no asterixis. A&O x 3, non-focal exam
Pertinent Results:
REPORTS:
CXR [**2192-9-8**]: No evidence of pleural effusion on this portable
projection. Findings consistent with ascites.
.
ECHO [**3-/2192**]: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal.
.
TIPS Operative Note ([**2192-9-9**], summarized): The right portal
vein was punctured using the TIPS needle system. This required
four punctures before successful access was achieved. One of the
needle punctures traversed beyond the liver capsule... As the
ascites fluid became more bloody during the course of the
procedure related to puncture through the liver capsule, we
discussed the case with the gastroenterology service and we
elected to monitor the patient in an ICU setting with careful
monitoring of his vital signs and hematocrit. Two units of
fresh-frozen plasma were given prior to the procedure. The
patient was transferred to the PACU intubated. IMPRESSION:
Successful placement of a transjugular intrahepatic
portosystemic shunt extending from the main portal vein to the
right hepatic vein by way of the right portal vein. A 10 mm x
6.8 cm Wallstent was utilized. This was dilated to a 9-mm
diameter. The portal-systemic gradient was 6 mmHg post-
procedure.
.
Investigation of transfusion rxn [**2192-10-10**]: This patient has
experienced
a self-limited (transient, cutaneously-restricted) urticarial
transfusion reaction within 45 minutes of his first transfusion
with pRBC. Following the disappearance of his [**2-10**] wheals, he has
been transfused with an additional 3u pRBC, 4u SD platelets, and
8u FFP over the following 24 hour period without any resemblant
untoward effects. (He has, however, been pre-medicated with
Benadryl by the medical service as a precautionary measure.)
Urticarial transfusion reactions represent the most minor of
allergic transfusion reactions on a spectrum, and are typically
due to
donor-specific allergens to which the patient has previously
been sensitized, rather than universally-present plasma proteins
to which the patient would be destined to consistently react
with. As such, there is not yet a need to be vigilant with
pre-transfusion antihistamine prophylaxis after such a first,
singular, minor urticarial episode. If repeat urticarial
reactions occur, then the patient may benefit from premedication
with an antihistamine.
.
Abd doppler ultrasound [**2192-10-10**]: Baseline TIPS study. The studies
are compatible with normal functioning TIPS. Unusual grayscale
imaging appearance of TIPS, likely artifactual.
.
Repeat Abd U/S [**2192-10-17**]:
IMPRESSION:
1. Patent TIPS with normal flow velocities.
2 No interval change in the appearance of the ascites adjacent
to the liver.
.
CXR [**2192-10-16**]:
IMPRESSION: Bilateral small pleural effusion and atelectasis in
both lower lobes. No pneumothorax.
LABS:
[**2192-10-17**] 05:45AM BLOOD WBC-4.2 RBC-2.99* Hgb-10.6* Hct-30.2*
MCV-101* MCH-35.6* MCHC-35.2* RDW-16.9* Plt Ct-51*
[**2192-10-14**] 06:10AM BLOOD WBC-3.2* RBC-2.85* Hgb-10.3* Hct-28.7*
MCV-101* MCH-36.0* MCHC-35.8* RDW-17.7* Plt Ct-67*
[**2192-10-12**] 04:38PM BLOOD Hct-32.5* Plt Ct-87*
[**2192-10-11**] 08:15PM BLOOD WBC-4.9 RBC-3.12* Hgb-10.8* Hct-30.4*
MCV-98 MCH-34.6* MCHC-35.5* RDW-18.7* Plt Ct-64*
[**2192-10-11**] 08:21AM BLOOD Hct-28.3* Plt Ct-83*
[**2192-10-10**] 04:57PM BLOOD WBC-3.1* RBC-2.74* Hgb-9.9* Hct-28.0*
MCV-102* MCH-36.1* MCHC-35.4* RDW-15.5 Plt Ct-45*
[**2192-10-9**] 12:15PM BLOOD WBC-4.3 RBC-3.12* Hgb-11.4* Hct-31.7*
MCV-101* MCH-36.5* MCHC-36.0* RDW-15.6* Plt Ct-50*
[**2192-10-9**] 05:20AM BLOOD WBC-3.4* RBC-2.97* Hgb-10.9* Hct-30.3*
MCV-102* MCH-36.8* MCHC-36.1* RDW-15.7* Plt Ct-47*
[**2192-10-8**] 08:50AM BLOOD WBC-5.8 RBC-3.40* Hgb-12.8* Hct-35.7*
MCV-105* MCH-37.6* MCHC-35.7* RDW-15.5 Plt Ct-74*
[**2192-10-10**] 04:57PM BLOOD Neuts-75.9* Lymphs-17.6* Monos-4.4
Eos-1.8 Baso-0.4
[**2192-10-8**] 08:50AM BLOOD Neuts-74.9* Lymphs-16.8* Monos-6.0
Eos-1.9 Baso-0.4
[**2192-10-17**] 05:45AM BLOOD Plt Ct-51*
[**2192-10-17**] 05:45AM BLOOD PT-17.5* PTT-49.9* INR(PT)-2.1
[**2192-10-15**] 05:05AM BLOOD PT-16.1* INR(PT)-1.8
[**2192-10-14**] 06:10AM BLOOD PT-16.1* INR(PT)-1.8
[**2192-10-11**] 04:50PM BLOOD PT-15.0* INR(PT)-1.5
[**2192-10-11**] 04:01AM BLOOD PT-15.7* PTT-94.0* INR(PT)-1.7
[**2192-10-8**] 08:50AM BLOOD PT-15.4* PTT-43.1* INR(PT)-1.6
[**2192-10-12**] 02:10AM BLOOD Fibrino-221
[**2192-10-11**] 04:01AM BLOOD Fibrino-181 Thrombn-150*
[**2192-10-17**] 05:45AM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-134 K-4.0
Cl-103 HCO3-27 AnGap-8
[**2192-10-16**] 05:35AM BLOOD Glucose-80 UreaN-6 Creat-0.6 Na-135 K-3.8
Cl-101 HCO3-27 AnGap-11
[**2192-10-15**] 05:05AM BLOOD Glucose-76 UreaN-9 Creat-0.5 Na-132*
K-3.7 Cl-100 HCO3-26 AnGap-10
[**2192-10-12**] 02:10AM BLOOD Glucose-71 UreaN-23* Creat-0.8 Na-134
K-3.9 Cl-103 HCO3-25 AnGap-10
[**2192-10-8**] 08:50AM BLOOD Glucose-102 UreaN-19 Creat-0.8 Na-129*
K-4.5 Cl-99 HCO3-21* AnGap-14
[**2192-10-17**] 05:45AM BLOOD ALT-46* AST-72* LD(LDH)-206 AlkPhos-78
TotBili-3.7*
[**2192-10-9**] 05:20AM BLOOD ALT-61* AST-80* LD(LDH)-193 AlkPhos-71
Amylase-62 TotBili-2.8*
[**2192-10-8**] 08:50AM BLOOD ALT-76* AST-98* AlkPhos-95 Amylase-85
TotBili-2.9*
[**2192-10-11**] 04:01AM BLOOD Lipase-29
[**2192-10-10**] 04:45AM BLOOD Lipase-52
[**2192-10-17**] 05:45AM BLOOD Albumin-2.6* Calcium-8.0* Phos-3.0 Mg-1.8
[**2192-10-16**] 05:35AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.9 Mg-1.7
[**2192-10-14**] 06:10AM BLOOD Albumin-2.4*
[**2192-10-9**] 05:20AM BLOOD Albumin-2.9* Calcium-8.5 Phos-3.4 Mg-1.8
[**2192-10-8**] 08:50AM BLOOD Ammonia-90*
[**2192-10-8**] 09:00AM BLOOD Lactate-2.5*
Brief Hospital Course:
Pt is a 43yoM w/ HCV cirrhosis with refractory ascites
transferred to MICU after TIPS procedure for close observation
due to a concern for liver capsure perforation.
.
1. ? Liver capsule perforation s/p TIPS. Pt. was transfused
with 2U FFP, 1 bag of platelets, 2L of LR, and 2U pRBCs. Pt.
remained hemodynamically stable while in the MICU; his Hct was
checked Q4H. He was initally kept NPO, but his diet was
advanced as tolerated. He was treated with morphine PRN for
pain control. Intraperitoneal pressure (as measured via foley)
remained stable. Pt. became mildly jaundiced likely as a result
of the blood products he received. Pt. followed by hepatology
and transplant. Pt was then transferred to the floor, given
his hct remained stable. Pt became extremely fluid overloaded
during the remainder of the admission, and complained of tense
edema in his legs. There was concern for a blockage of the
TIPS, however an ultrasound showed that the TIPS was patent.
The pt was diuresed with increased doses of Lasix (80mg PO) and
spironolactone (100mg), and his edema improved significantly.
He was discharged on these doses of diuretics. The day before
discharge, the pt also c/o calf pain and some minor inspiratory
chest pain, however a LE ultrasound was negative and the pt's
pain resolved spontaneously.
.
2. Cirrhosis - secondary to HCV; no signs of encephalopathy; no
asterixis; on transplant list.
- lactulose prn (has not needed any)
- continued, docusate, senna
- followed LFTs
- continued Cipro for SBP ppx
.
3. Encephalopathy - pt with originally documented asterixis upon
arrival to ED. NH3 90. Ascitic fluid analysis did not show SBP.
- continued prophylactic Cipro qTuesday.
- avoided sedating meds
.
4. Hyponatremia. Baseline Na 125. During admission, pt's
hyponatremia improved with 1.5 L free water restriction, and
then stabilized in the low 130's.
- Lasix was held at the beginning of the admission, however it
was re-started after pt became fluid overloaded.
.
5. Osteopenia. Continued Vitamin D and Calcium suppliments
.
6. FEN - Advanced diet as tolerated s/p TIPS procedure.
.
5. PPX - pneumoboots, ambulation, PPI
.
6. Code - Full
.
7. Communication - wife [**Name (NI) 553**] [**Name (NI) 3175**] cell [**Telephone/Fax (1) 24745**] and
home [**Telephone/Fax (1) 24746**].
Medications on Admission:
1. Cholecalciferol (Vitamin D3) 400 unit daily
2. CaCO3 500 mg PO BID
3. Furosemide 40 mg qd
4. Quinine Sulfate 325 mg qhs
5. Cipro 750 qTuesday PO
6. Protonix 40 QD PO
7. Lactulose 10 g/15 mL Syrup 30 ML PO Q2-3H prn
Discharge Medications:
1. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO QTUESDAY
().
Disp:*12 Tablet(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO daily ().
4. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO every [**5-16**]
hours: Take if not having [**12-11**] BM a day as needed.
Disp:*1 bottle* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
12. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
hepatic encephalopathy
Liver capsule Bleed
ascites
s/p TIPS
Discharge Condition:
stable. Pt is feeling well, ambulating, eating, and hematocrit
is stable.
Discharge Instructions:
Please seek medical attention immediately if you experience
fever, chills, nausea, vomiting, chest pain, shortness of
breath, dizziness, abdominal pain, or increased edema.
Please take all medications as prescribed.
Weigh yourself every day. If your weight increases by 2 lbs,
please call Dr.[**Name (NI) 948**] office.
2 gram per day sodium restriction
1500 ml per day fluid restriction
Please attend all follow-up appointments.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 497**] in one week on Wednesday or
Thursday. His number is [**Telephone/Fax (1) 673**]; please call tomorrow.
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 6164**] ([**Telephone/Fax (1) 24747**] for follow up in
the next 2 weeks.
You will have your blood drawn on Friday, [**10-19**] at Dr. [**Name (NI) 8390**] office. You already have the prescription for that.
Completed by:[**2192-10-21**]
|
[
"571.5",
"E879.8",
"999.8",
"572.2",
"789.5",
"V49.83",
"285.1",
"E878.8",
"070.54",
"276.1",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05",
"54.91",
"99.07",
"39.1"
] |
icd9pcs
|
[
[
[]
]
] |
12321, 12327
|
8529, 10838
|
381, 436
|
12431, 12507
|
2842, 8506
|
12988, 13465
|
2283, 2330
|
11106, 12298
|
12348, 12410
|
10864, 11083
|
12531, 12965
|
2345, 2823
|
250, 343
|
464, 2000
|
2022, 2125
|
2141, 2267
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,603
| 141,773
|
33249
|
Discharge summary
|
report
|
Admission Date: [**2181-8-4**] Discharge Date: [**2181-8-20**]
Date of Birth: [**2117-12-12**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
VP shunt removal [**2181-8-7**]
Endotracheal intubation [**2181-8-6**]
History of Present Illness:
63 y/o M w/ non-small cell lung cancer metastatic to the brain
with VP shunt placed for obstructive hydrocephalus who p/w
abdominal pain to OSH. Prior to his presentation, he reportedly
had not had any fevers, chills, nausea, vomiting, or altered
mental status. He did not have fever or leukocytosis. He was
treated with levofloxacin and metronidazole, followed by
ceftriaxone and vancomycin. Mental status was waxing and [**Doctor Last Name 688**],
which was attributed to narcotic therapy used for severe
abdominal pain. An abdominal CT showed a 3 cm RUQ fluid
collection at the distal tip of the VP shunt. He underwent
ultrasound-guided aspiration of this fluid collection on [**2181-8-4**]
with drainage of purulent material. A RUQ drain was left in
place. He was transferred to [**Hospital1 18**] for neurosurgical evaluation
given the concern for VP shunt infection.
Past Medical History:
NSCLC met to brain - diagnosed [**11-18**]; s/p whole brain XRT,
avastin, taxol, carboplatin completed [**5-20**]); s/p resection
parietal lesion c/b obstructive hydrocephalus w/ VP shunt
placement
COPD
BPH
diverticulosis
SBO s/p ex-lap (childhood)
s/p tonsillectomy
Social History:
Married, lives with wife. [**Name (NI) **] children. Occupation: former auto
parts salesman
Drugs: denies
Tobacco: smoked 1 ppd x 20 yrs; quit one year ago
Alcohol: formerly drank approx 6 beers/night; drank [**2-13**]
beers/night up until cancer diagnosis in [**2179**]
Family History:
Mother died of pancreatic cancer; two uncles died of lung
cancer; one brother died of esophageal cancer; another brother
died of head/neck cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
V/S T 97.3 HR 99 RR 23 O2sat 97%
General: lying in bed with eyes closed and intermittently
moaning
HEENT: no scleral icterus, dry mucous membranes
Neck: supple, no cervical/supraclavicular lymphadenopathy
Chest: scattered rhonchi and loud upper airway sounds
CV: regular rate/rhythm, normal s1s2, no murmurs
Abdomen: soft, mildly distended, no guarding but significantly
tender to palpation especially on right side; (+) rebound
tenderness; normal bowel sounds; (+) upper right flank drain
with whitish liquid drainage
Extremities: warm, no edema, 2+ PT pulses
Skin: no jaundice or rashes
Neurologic: alert, disoriented and inattentive, intermittently
following commands; CN 2-12 intact, though exam limited by poor
attentiveness/cooperation; 4/5 strength in bilateral deltoids,
biceps, triceps, wrist extensors, hip flexors/extensors, ankle
flexors/extensors; 2+ biceps reflexes bilaterally; unable to
elicit patellar reflexes
Pertinent Results:
7/28/098 MRI HEAD W/ CONRAST
There are changes from a right frontal and left parietal
craniotomy. There is
slight decrease in the soft tissue swelling overlying the left
parietal
craniotomy. The soft tissue overlying the right frontal
cranitomy is stable.
There is a right frontal ventricular catheter with its tip just
past the left
frontal [**Doctor Last Name 534**].
There is a postoperative cavity in the left parietal lobe with
blood products
within it, which appears to be relatively stable in terms of
size and mild
associated enhancement. Enhancing lesion in the right cerebellum
appears to
be stable. No new enhancing foci are seen.
Previously noted subdural fluid collections and dural
enhancement have
decreased to a large degree.
There has been progression of confluent periventricular
hyperintensity, which
may reflect post-treatment sequela. The ventricles are mildly
enlarged
compared to the prior study.
The post-gadolinium enhancing volume of the right cerebellar
lesion measures
1.16 cm3. In the right cerebellum, the FLAIR volume measures
239.9 mm3 .
IMPRESSION:
Postoperative changes, no new enhancing foci are seen. Stable
enhancement in the right cerebellum and in the left parietal
operative bed. Progression of white matter hyperintensity which
may reflect radiation sequela.
.
[**2181-8-4**] CXR There are low lung volumes. There is no pneumothorax
or pleural effusion.
There is atelectasis in the right base. Ill-defined opacity in
the right apex
is consistent with patient's known lung cancer.
Cardiomediastinal contours
are unremarkable.
IMPRESSION: No evidence of acute cardiopulmonary abnormalities.
.
[**2181-8-6**]
CT CHEST:
1. Negative examination for pulmonary embolism.
2. Increase in size of the previously described spiculated
lesion in the
right upper lobe, now extending to the pleura.
3. New lung nodules as described above.
4. Atelectasis of the right lower lobe, associated with
effusion; no pleural nodule.
5. Bronchomalacia of the right main bronchus and intermedius
bronchus,
evoked by expiration.
[**2181-8-6**] NON-CONTRAST HEAD CT
1. No evidence of intracranial abscess or VP shunt infection.
However, CT has significantly limited sensitivity in this
regard, compared to MRI.
2. Known enhancement in the left cerebellum and at the left
parietal surgical site, seen on the [**2181-7-9**] MRI, is not
appreciated due to differences in technique.
3. Increased hemispheric white matter hypodensity without mass
effect, likely related to radiation therapy. Further evaluation
of tumor burden may be performed by MRI.
.
[**2181-8-8**] NON-CONTRAST HEAD CT
The patient is status post right VP shunt removal with a small
locule of air
noted non-dependently within the left frontal [**Doctor Last Name 534**] in addition
to a trace
amount of likely post-surgical intraventricular hemorrhage noted
dependently
within the left occipital [**Doctor Last Name 534**]. Examination is otherwise
unchanged from
[**8-6**]. There is stable appearance to the left parietal
surgical resection
bed. Small extra-axial fluid collections are unchanged.
Subcutaneous
emphysema and a mild amount of edema is noted along the external
old VP shunt
site. Mild mucosal thickening within the ethmoid air cells and
sphenoid sinus
is stable as is partial opacification of the mastoid air cells
bilaterally.
IMPRESSION:
1. Trace amount of blood within the left occipital [**Doctor Last Name 534**],
otherwise no
significant interval change status post VP shunt removal.
.
[**2181-8-12**]
R Humerus Xray:
Two views. There is an oblique fracture of the proximal shaft of
the humerus. There is callus formation at the fracture site,
although the fracture line is partially visible. Fracture
fragments are not significantly displaced. Bones are osteopenic.
There is no evidence of dislocation. Mild degenerative arthritic
change is present in the shoulder joint. A PICC line is present.
IMPRESSION: Healing fracture proximal humerus.
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2181-8-17**] 05:40AM 11.0 3.00* 10.7* 31.7* 106* 35.5*
33.6 16.5* 135*
[**2181-8-16**] 05:55AM 12.5* 3.07* 11.3* 32.7* 107* 36.8*
34.5 16.6* 132*
DIFF ADDED [**8-16**] @ 12:08
[**2181-8-15**] 05:20AM 12.8* 3.12* 11.1* 32.8* 105* 35.6*
33.9 16.5* 139*
[**2181-8-14**] 04:59AM 9.3 2.92* 10.5* 30.2* 103* 36.1*
34.9 16.4* 141*
Source: Line-picc
[**2181-8-13**] 05:30AM 8.8 2.77* 10.1* 29.5* 106* 36.5*
34.3 15.9* 126*
Source: Line-PICC
[**2181-8-12**] 04:39AM 9.8 2.58* 9.5* 26.9* 105* 36.9*
35.3* 16.2* 133*
Source: Line-PICC
[**2181-8-11**] 02:40AM 10.8 2.58* 9.4* 27.6* 107* 36.6*
34.3 16.1* 127*
Source: Line-Right PICC
[**2181-8-10**] 03:07AM 8.8 2.77* 10.3* 29.4* 106* 37.1*
35.0 16.3* 122*
Source: Line-piv
[**2181-8-9**] 04:00AM 9.7 2.99* 11.0* 32.1* 107* 36.9*
34.4 16.1* 118*
Source: Line-piv
[**2181-8-8**] 03:07AM 7.1 2.93* 10.5* 30.5* 104* 35.9*
34.4 16.2* 121*
[**2181-8-7**] 02:52AM 6.1 2.79* 10.0* 29.6* 106* 35.9*
33.9 16.4* 122*
[**2181-8-6**] 08:40PM 5.3 2.74* 10.0* 28.5* 104* 36.5*
35.1* 16.3* 115*
[**2181-8-6**] 02:32AM 7.7 2.81* 10.3* 29.5* 105* 36.5*
34.9 16.0* 129*
[**2181-8-5**] 05:27AM 11.1* 2.95* 10.5* 31.0* 105* 35.8*
34.0 16.5* 143*
[**2181-8-4**] 09:36PM 10.2 2.97* 10.9* 32.1* 108* 36.8*
34.0 16.4* 175#
.
ANTIBIOTICS Vanco trough
[**2181-8-9**] 04:00AM 17.5
.
[**2181-8-7**] 7:52 pm FOREIGN BODY
VALVE AND VENTRICULAR CATHETER OF VP SHUNT.
**FINAL REPORT [**2181-8-13**]**
WOUND CULTURE (Final [**2181-8-13**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
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
PENICILLIN G---------- =>0.5 R
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**2181-8-7**] 7:51 pm FOREIGN BODY VP SHUNT ABDOMINAL CATHETER.
**FINAL REPORT [**2181-8-11**]**
WOUND CULTURE (Final [**2181-8-11**]):
LACTOBACILLUS SPECIES.
.
[**2181-8-16**] 2:44 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2181-8-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
Brief Hospital Course:
#Hypercapnic respiratory failure - Secondary to COPD
exacerbation in the setting of narcotic analgesia and aspiration
pneumonitis. Treated with mechanical ventilation followed by
noninvasive ventilation, high-dose corticosteroid taper,
nebulized bronchodilators, incentive spirometry, and antibiotics
as above. Ambulatory oxygenation improved with physical therapy.
O2sat mid-high 90s on RA prior to discharge.
.
#VP shunt infection - Given changes in mental status with an
indwelling catheter, the patient was continued on broad-spectrum
ABX and the VP shunt was removed [**2181-8-7**]. Culture grew MSSA. He
was continued on vancomycin for CNS penetration to complete a 14
day course via right brachial PICC beginning on the day of shunt
removal. Mental status progressively improved and the patient
did not have any signs or symptoms of residual neurological
deficit.
.
#RUQ fluid collection - Ultrasound-guided drainage of this
collection at the OSH reportedly revealed purulent material,
most likely an infected pseudocyst which formed at the distal
site of the VP catheter. A drain placed at the OSH was removed
prior to discharge. Peritoneal fluid was not consistent with
peritonitis and culture grew lactobacillus. The patient was
treated with ceftriaxone and flagyl to complete a 14 day course
per ID recommendations. His abdominal symptoms and exam
progressively improved prior to discharge.
.
#Metastatic NSCLC - Most recent MRI [**2181-7-9**] showed stable
metastatic disease in the cerebellum. Seen in consultation by
the palliative care service who provided information to the
patient and his wife regarding end of life care. The patient has
scheduled follow-up with his oncologist 2 weeks after discharge,
at which time he is due for a repeat MRI.
.
#HTN - The patient did not carry the diagnosis of hypertension
prior to admission but had BP 160-180/80-100 in the setting of
corticosteroid therapy. Was started on amlodipine which was
uptitrated to 10 mg daily with improvement in BP. Blood pressure
should be closely monitored during steroid taper, and amlodipine
may be decreased or discontinued accordingly.
.
#Prophylaxis - Given pneumoboots for DVT PPX, and PPI and ISS
while on steroids.
Medications on Admission:
Medications on transfer:
Hydromorphone 2mg IM/SC q4h prn
Ondansetron 4 mg IV q4h prn
Heparin SC 5000 units TID
Ceftriaxone [**2172**] mg IV q12h ([**8-3**] - )
Vancomycin 1000 mg IV q12h ([**8-3**] - )
Home medications:
Fluticasone/salmeterol 250/50 1 puff [**Hospital1 **]
Fluticasone nasal 50 mcg [**Hospital1 **]
Esomeprazole 40 mg daily
Multivitamin once daily
Calcium citrate once daily
Folic acid 1 mg daily
Thiamine 100 mg daily
Levetiracetam 1000 mg [**Hospital1 **]
Polyethylene glycol once daily
Metoclopromide 10 mg four times daily
Megace 625 mg daily
Prochlorperazine 10 mg prn (rarely takes)
Lorazepam 1 mg prn (very rarely takes)
Loratadine/pseudoephedrine prn
Tiotropium 1 puff daily
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for sbp<100, hr<55.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) INH
Inhalation Q6H (every 6 hours).
5. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) INH Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 days.
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days: [**Date range (1) 14790**].
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
13. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
14. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
1) Hypercapnic respiratory failure
2) Ventriculoperitoneal shunt infection s/p shunt removal
3) Chronic obstructive pulmonary disease
4) Non-small-cell lung cancer
Discharge Condition:
asymptomatic with stable vital signs.
Discharge Instructions:
You were admitted to the hospital with an infection of your
ventriculoperitoneal shunt. Your infection was successfully
treated with antibiotics.
You also had a COPD flare treated with mechanical ventilation,
nebulizer breathing treatments and a course of steroids which is
scheduled to be completed on Wednesday [**8-22**].
Please call the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 5835**] to
arrange a follow-up appointment in [**12-13**] weeks.
Please attend your MRI appointment on Monday [**9-3**] at
1:15 PM prior to your appointment with Dr. [**Last Name (STitle) 4253**] at 3:00 PM.
Please call your physician or return to the Emergency Department
if you experience fever, chills, sweats, dizziness,
lightheadedness, headache, confusion, aversion to light, changes
in vision, chest pain, cough, shortness of breath, back pain,
abdominal pain, vomiting, bloody or dark stools, leg pain or
swelling, numbness, weakness, tingling, or falls.
Followup Instructions:
Please call the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 5835**] to
arrange a follow-up appointment in [**12-13**] weeks.
Please attend your MRI appointment on Monday [**9-3**] at
1:15 PM prior to your appointment with Dr. [**Last Name (STitle) 4253**] at 3:00 PM.
Completed by:[**2181-8-20**]
|
[
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"518.0",
"682.2",
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"997.02",
"507.0",
"491.21",
"996.63",
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"041.11",
"518.81",
"287.5",
"401.9",
"562.10",
"432.1",
"E878.1",
"600.00",
"041.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91",
"96.04",
"02.43",
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] |
icd9pcs
|
[
[
[]
]
] |
14635, 14718
|
10182, 12393
|
284, 357
|
14926, 14966
|
3005, 10043
|
16027, 16388
|
1858, 2006
|
13167, 14612
|
14739, 14905
|
12419, 12419
|
14990, 16004
|
2021, 2986
|
12648, 13144
|
10159, 10159
|
230, 246
|
385, 1260
|
10127, 10127
|
12445, 12629
|
1282, 1550
|
1566, 1842
|
10075, 10090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,013
| 108,996
|
43016
|
Discharge summary
|
report
|
Admission Date: [**2147-8-25**] Discharge Date: [**2147-8-30**]
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Fall, with a left facial droop, neglect the left hemispace, and
right gaze deviation
Major Surgical or Invasive Procedure:
Intubation and extubation
Angiography - with an unsuccessful attempt to use the penumbra
clot retrieval device and ultimate treatment with local IA t-PA
History of Present Illness:
Mrs [**Known lastname **] is an 89 RHF with complex PMH including PVD, CAD,
HTN, DMII, hypercholesterolemia, and afib on coumadin who fell
at home at 2:45. She was feeling well and was on the telephone
prior to the fall. She bent down to write something that was
being told to her on the phone. She fell out of her chair and
found herself unable to get up. She was able to call for help
from the front desk at her [**Hospital3 **] facility. She was
brought in by EMS. Initial finger stick was 123. On arrival
here the patient was noted to have a left facial droop, neglect
the left hemispace, and have right gaze deviation.
Code stroke called at 3:26. Her initial NIHSS was deferred for
head imaging given the patient's anticoagulation and suspected
hemorrhage. NIHSS:Total score 10.
Past Medical History:
CHF
Hypothyroid
Afib on coumadin s/p ablation.
HTN
DMII
Hyperlipidemia
CAD
Spinal stenosis
Uterine CA
PNA
PVD
GERD
Social History:
Widowed, recently moved to an [**Hospital3 **] facility.
Non-smoker.
Family History:
Non-contributory.
Physical Exam:
BP: 152/78; HR: 64 (sinus on tele); RR: 12; SaO2: 98%RA
Gen: Alert, oriented. Sclerae anicteric. MMM.
No meningismus.
No carotid bruits auscultated.
Lungs clear bilaterally.
Heart regular in rate.
Abd soft, nontender, nondistended. Bowel sounds heard
throughout.
Initial Neurological Examination:
>>MS??????Alert. Oriented to self, location, date. Apt historian
(watched vice presidential debate last night; worried about
economy and aware of impending legislation in Congress). Speech
fluent, but labially dysarthric. No paraphasic errors.
Registration, repetition, recall intact.
>>CN??????Fundi w/ sharp discs. PERRL. Does not blink to threat on
LEFT. No ptosis. Forced right gaze deviation but w/ coaching is
able to briefly cross left of midline voluntarily. Facial
sensation and pterygoid strength intact. Moderate central LEFT
facial weakness. Hearing intact to finger rub. Palate elevates
midline. SCMs intact. Tongue protrudes midline.
>>Motor??????R UE [**3-27**] prox and distally. R LE [**3-27**] prox and distally.
L UE [**3-27**] prox and distally. L LE 5-/5 proximally but [**3-27**]
distally. L leg drift.
>>Sensory??????Decreased sensation to touch/nox on left side. Visual
and tactile extinction.
>>DTRs??????L/R: bic [**11-22**], br tr/tr, tri 0/0; pat 0/0; Ach 0/0. LEFT
plantars extensor.
>>Coord/Gait??????No dysmetria by FTN and HTS. Did not ambulate.
1a LOC =0
1b Orientation =0
1c Commands =0
2 Gaze =2
3 Visual Fields =2
4 Facial Paresis =2
5a Motor Function R UE =0
5b Motor Function L UE=0
6a Motor Function R LE=0
6b Motor Function L LE=0
7 Limb Ataxia =0
8 Sensory perception =1
9 Language =0
10 Dysarthria = 1
11 Extinction/Inattention =2
TOTAL = 10
Pertinent Results:
Cardiology Report ECG Study Date of [**2147-8-25**] 3:20:54 PM
Sinus rhythm. First degree A-V block. Borderline left axis
deviation with
probable left anterior fascicular block. Lateral ST-T wave
changes. Cannot
rule out myocardial ischemia.
CXR [**2147-8-26**]
Ill-defined opacities worse in the bases and more so in the left
side are worrisome for aspiration given the provided clinical
history,
although there are no prior studies available for comparison to
assess its
chronicity. There is no pneumothorax or large pleural effusions.
There is
mild cardiomegaly.
Pelvis AP X-Ray [**2147-8-26**]
There are no fractures. Mild degenerative changes are in the
right hip joint. Moderate degenerative changes are in the lower
lumbar spine. Right femoral catheter is in place. Surgical clips
are in the left pelvis. Contrast material is in the bladder and
partially obscures the sacrum.
Left Wrist X-ray [**2147-8-28**]
Three radiographs of the left wrist demonstrate diffuse
demineralization.
There is moderate-to-severe subchondral sclerosis, joint space
narrowing, and marginal osteophyte formation about the first CMC
joint. Chondrocalcinosis about the radiocarpal and intercarpal
joint spaces is present. No discrete fracture is identified. The
regional soft tissues are unremarkable.
CThead/CTA/CT perfusion [**2147-8-25**]
1. Acute distal M1 occlusion of the right middle cerebral artery
with large at risk region of ischemic penumbra.
2. Calcified atherosclerotic plaque involving the carotid
arteries
bilaterally with 50% stenosis at the origin of the left internal
carotid
artery and 20% at the right. Heavy calcified atherosclerotic
plaques are
present within bilateral carotid siphons.
3. Atheromatous ulcerations within the aortic arch only
partially evaluated on this study.
4. Diffuse interstitial abnormality within the lung apices .
Dedicated CT of the chest may be warranted as clinically
indicated.
MRI of the head [**2147-8-26**]
Areas of small infarcts in the distribution of right middle
cerebral artery without evidence of mass effect, midline shift,
hydrocephalus
or signs of hemorrhage.
MRA of the head [**2147-8-26**]
Motion limited study demonstrating flow signal in both middle
cerebral arteries without evidence of occlusion.
ECHO (TTE) [**2147-8-29**]
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic valve
leaflets (3) are moderately thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild symmetric left ventricular
hypertrophy with preserved global and regional systolic
function. Mild right ventricular dilation with preserved
systolic function. Mild mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
[**2147-8-28**] VIDEO OROPHARYNGEAL SWALLOW
The study was performed in collaboration with the speech and
swallow service. In brief, the oral phase was unremarkable with
the exception of mild pre-spillage of thin liquids. Pharyngeal
phase was notable for episodes of flash penetration with sips of
thin liquid that
cleared with swallowing. No episodes of aspiration were seen.
IMPRESSION: Pre-spillage and flash penetration with thin
liquids. No episodes of aspiration.
Lab results
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2147-8-30**] 06:20AM 9.6 4.43 13.1 38.8 88 29.5 33.7 16.2*
341
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2147-8-30**] 06:20AM 341
[**2147-8-30**] 06:20AM 40.0* 40.7* 4.3*
MISCELLANEOUS HEMATOLOGY ESR
[**2147-8-28**] 12:55PM 95*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2147-8-30**] 06:20AM 138* 24* 1.1 136 4.4 104 24 12
[**2143-8-26**] 8.2%
Brief Hospital Course:
Mrs [**Known lastname **] was admitted on the [**8-25**], she had a right
MCA syndrome that was confirmed by a CT brain perfusion study.
Her initial NIHSS was 10. Her INR precluded IV TPA. She
therefore received intra-arterial 5 mg TPA. She was intubated
for the procedure and successfully extubated. Her neurological
examination significantly improved prior to discharge: language
was normal, and she had a very mild right sided hemiparesis, and
was able to walk with a walker.
Hospital course is reviewed by the following problem list:
Neurology
Her Coumadin dose on [**8-30**] was held due to the INR (4.3), her
level needs checking, and she should be restarted on an
appropriate dose.
Cardiology
Her Imdur 30 mg was kept on hold after the stroke. Digoxin was
stopped due to symptomatic pauses>3s and bradycardias of 30-40s.
Her cardiologist from [**Hospital1 **] - Dr [**Last Name (STitle) **] [**Name (STitle) 2257**] 1 [**Telephone/Fax (1) 92828**]/1 [**Telephone/Fax (1) 92829**] was updated about the hospital course. Her
PCP from [**Hospital1 92830**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] 1 [**Telephone/Fax (1) 92831**], was
[**Name (NI) 653**], and messages were left for her to get in touch with
the stroke Neurology service at [**Hospital1 18**].
Musculoskeletal
Due to her diffuse muscular pains, an ESR was checked which was
elevated. It will need repeating because it may be elevated in
the context of a stroke. She may have polymyalgia rheumatica, if
these muscular pains continue. Incidentally, her CK was not
elevated.
Her X-Rays of the pelvis and hand suggested osteopenia, and she
would benefit from an outpatient DEXA scan and bisphosphonates
if appropriate. The calcium and vitamin D are on hold, as these
interact with thyroxine to reduce the absorption.
Respiratory
She has orthopnea, and she has been restarted on Lasix (half of
her usual dose).
GI/Nutrition
VIDEO OROPHARYNGEAL SWALLOW ([**2147-8-28**]): In brief, the oral phase
was unremarkable with the exception of mild pre-spillage of thin
liquids. Pharyngeal phase was
notable for episodes of flash penetration with sips of thin
liquid that
cleared with swallowing. No episodes of aspiration were seen.
Endocrine
Her TSH was 13, therefore her dose of thyroxine was increased.
She was on an insulin sliding scale in the hospital, and
restarted on Januvia prior to discharge.
Dispo
Niece [**First Name5 (NamePattern1) **] [**Name (NI) 92832**]) contact details 1-[**Telephone/Fax (1) 92833**].
Medications on Admission:
Aspirin 81 daily
Calcium carbonate 1250mg daily
Digoxin 0.125mg daily
Ferrous sulfate 325mg daily
Lasix 40mg daily
Imdur - 30mg daily
Januvia 25mg daily
levothyroxine 50mcg daily
Toprol XL 50mg daily
Omeprazole 20mg [**Hospital1 **]
Simvastatin 80mg daily
Vitamin D 400 units daily
Coumadin variable to goal.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours).
9. Januvia 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
11. Coumadin Oral
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 533**] Centre for Extended Care
Discharge Diagnosis:
Right middle cerebral artery infarct status post intraarterial
tPA
Atrial fibrillation
Hyperlipidemia
Diabetes mellitus
Hypothyroidism
Mild symmetric left ventricular hypertrophy with preserved
global and regional systolic function.
Mild right ventricular dilation with preserved systolic
function. Mild mitral regurgitation.
Moderate tricuspid regurgitation.
Moderate pulmonary hypertension.
Discharge Condition:
Improved: Language is fluent with intact naming and repetition
and without dysarthria. She has a mild right UMN hemiparesis.
She is able to ambulate with assistance and a walker.
Discharge Instructions:
You have been admitted to the hospital with a stroke. You
received clot-busting medications and have improved
significantly, but will still need rehabilitation.
Take all medications as prescribed, and follow up with your
doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**]. You will need to have your coumadin levels
(INR) checked frequently and your dose adjusted as needed. One
dose of Coumadin has been held due to your elevated INR, please
get your INR checked tomorrow. Your INR needs to be between 2.5
to 3.
Seek medical attention for any new weakness, numbness, tingling,
change in responsiveness or thinking, difficulty speaking, gait
abnormalities, bleeding, chest pain, difficulty breathing, any
signs of bleeding or spontaneous bruising, or any other new or
worsened symptoms.
Followup Instructions:
Call your primary care physician (Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]) on discharge
from rehabilitation.
Follow up in neurology clinic with Drs. [**Last Name (STitle) 78537**] and [**Name5 (PTitle) **], on
[**10-4**] at 1:30pm
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2147-8-30**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
11468, 11547
|
7616, 8143
|
301, 456
|
11984, 12165
|
3304, 7593
|
13017, 13421
|
1516, 1535
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|
12189, 12994
|
1550, 3285
|
177, 263
|
484, 1275
|
8157, 10129
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1297, 1414
|
1430, 1500
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,919
| 132,862
|
13039
|
Discharge summary
|
report
|
Admission Date: [**2183-9-12**] Discharge Date: [**2183-9-24**]
Date of Birth: [**2112-11-19**] Sex: M
Service: MEDICINE
Allergies:
Rocephin / Ceftriaxone
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
Intubation; Cholecystostomy x 2; paracentesis x 3
History of Present Illness:
Mr. [**Known lastname 16495**] is a 70 yo male with pmh of dCHF, cirrhosis, CRI,
CAD, prostate cancer, and DM who presented to [**Hospital3 17031**]
today with increasing RUQ abdominal pain, nausea, vomiting, and
change in mental status. At the OSH his family gave a history of
questionable bloody emesis so he underwent an NG lavage which
was negative. He was felt to be dry on exam and given 2 L of
IVF. He was started on a PPI and given levofloxacin, zosyn, and
morphine for pain. LFTS WNL except for a Tbili of 2.9 which was
within his baseline. A CT abd/pelvis showed ascites and a
dilated gallbladder with a thickened wall which was changed from
previous studies.
.
In the ED at [**Hospital1 18**], vs were: afebrile P 99 BP 111/61 RR 23 O2
sat 94% on 2L. Patient was given 1.8 L NS. Surgery was consulted
and recommended an abdominal ultrasound which preliminarily
showed gallbladder wall thickening with nonmobile sludge at the
neck. The read stated that the thickening could be related to
liver disease, but was concerning for acute cholecystitis.
Surgery did not feel he was a surgical candidiate. HIDA scan was
recommended for further workup and a cholecystostomy tube could
be placed if he is confirmed to have cholecystitis. In the ED he
also had a diagnostic paracentesis which showed 24k WBC and 21k
RBC with 88% polys.
.
Of note the family has been discussing hospice. His daughter is
his health care proxy.
.
He was hospitalized last week for unclear reasons and is
frequently hospitalized. Had a recent UTI and is still taking
nitrofurantoin for another 4 days. Last bowel movement was
yesterday afternoon. Has been having urinary retension for the
last few days. His abdominal pain started on Sunday suddenly. He
states the pain is crampy and throughout his abdomen. It is [**7-21**]
and doesn't radiate. Is constant. Had associated nausea and
vomiting x 5. Denies vomiting of blood.
Past Medical History:
1. dCHF
2. Htn
3. CAD s/p cath in [**2170**], and a second cath per cards note in
[**Last Name (LF) **], [**First Name3 (LF) **] 60% (per old DC from [**2180**])
4. Cirrhosis secondary to NASH, followed at NVMC. Complicated by
hepatic encephalopathy and depemend on lactulose. Denies
knowledge of varices.
5. history of left hemisphere TIA
6. carotid artery disease s/p left carotid endartectomy [**2181-7-12**]
7. DMII
8. Hypothyroidism
9. DJD s/p left knee arthroscopies,s/p RT. TKR x2 Hx of infected
knee prosthesis
10. Prostate Ca s/p resection complicated by incontinence, had
been recieved hormonal therapy
11. Histroy of + heparin antibody (listed in previous DC summ in
[**2180**], was sent in [**2180**] here and was negative)
12. OSA
13. GERD
Social History:
Lives with his wife. Uses a walker. Denies tobacco, alcohol, or
drug use. Is retired. Had worked as an electrician.
Family History:
NC
Physical Exam:
Vitals: T 96.6 P 99 BP 126/69 RR 24 Sat 91% on 2 L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, no JVD appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi. Decreased air movement throughout
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, obese with a positive fluid wave. Diffusely
tender to palpation throughout. No rebound or guarding.
GU: foley present with dark urine
Ext: warm, well perfused, 1+ DP pulses, no clubbing, cyanosis or
edema
Neuro: Alert and oriented to person, place, and month/year but
not day. CN II-XII grossly intact. sensation to light touch
intact.
Skin: Right arm with dry skin with pigmented skin changes
Pertinent Results:
Admission Labs:
[**2183-9-12**] 10:19PM TYPE-ART PO2-73* PCO2-35 PH-7.41 TOTAL CO2-23
BASE XS--1
[**2183-9-12**] 10:19PM LACTATE-5.0*
[**2183-9-12**] 08:31PM GLUCOSE-423* UREA N-43* CREAT-1.5*
SODIUM-129* POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-24 ANION GAP-12
[**2183-9-12**] 08:31PM CALCIUM-6.8* PHOSPHATE-3.5 MAGNESIUM-1.8
[**2183-9-12**] 08:31PM PLT COUNT-39*
[**2183-9-12**] 03:43PM WBC-6.8 RBC-3.04* HGB-10.2*# HCT-31.4*
MCV-103* MCH-33.7* MCHC-32.6 RDW-15.0
[**2183-9-12**] 03:43PM PT-23.6* PTT-40.7* INR(PT)-2.2*
[**2183-9-12**] 01:56PM LACTATE-6.5*
[**2183-9-12**] 01:56PM O2 SAT-73
[**2183-9-12**] 01:31PM ALT(SGPT)-25 AST(SGOT)-48* LD(LDH)-147 ALK
PHOS-68 TOT BILI-3.5*
Labs On Day of Expiration:
[**2183-9-24**] 03:07AM BLOOD WBC-11.9* RBC-2.34* Hgb-8.1* Hct-24.0*
MCV-103* MCH-34.6* MCHC-33.7 RDW-19.3* Plt Ct-73*
[**2183-9-24**] 03:48PM BLOOD PT-26.9* PTT-34.6 INR(PT)-2.6*
[**2183-9-24**] 03:48PM BLOOD FDP-320-640*
[**2183-9-24**] 03:48PM BLOOD Fibrino-84*
[**2183-9-24**] 03:07AM BLOOD Glucose-110* UreaN-167* Creat-5.2*#
Na-142 K-5.3* Cl-105 HCO3-20* AnGap-22*
[**2183-9-24**] 03:07AM BLOOD ALT-54* AST-226* AlkPhos-66 TotBili-18.6*
[**2183-9-23**] 04:13PM BLOOD D-Dimer-GREATER TH
Radiology:
CXR: IMPRESSION: [**2183-9-24**] 1:21 PM
1. ET tube at 5.8 cm above carina.
2. NG tube traced to upper stomach; however, tip not visualized.
If needed, a radiograph obtained with abdominal technique would
better display the tip of the NG tube.
3. Unchanged bibasilar atelectasis and pleural effusions.
Brief Hospital Course:
Patient is a 70 yo male with pmh of dCHF, cirrhosis, CRI, CAD,
prostate cancer, and DM who presented to an OSH ED today with
increasing RUQ abdominal pain, nausea, vomiting, and change in
mental status concerning for acute cholecystitis.
.
# Sepsis secondary to cholecystitis: The patient presented with
RUQ pain and imaging which was consistent with cholecystitis.
Per surgery he was not a surgical candidiate. A HIDA scan was
performed which was consistent with cholecystitis. IR placed a
cholecystostomy tube to allow drainage of his infected
gallbladder. He was placed on vanc and zosyn initially.
Intially, culture data grew GNR's; he intially started on cipro
and zosyn. Initally, the cultures grew E. coli and cipro and
vanc were d/c'd. He was continued on zosyn. As more culture data
came back, he also grew E. coli that was intermediately
sensitive to zosyn. He was switched to meropenem after this.
Unfortunately, the patient continued to spike temps and his
hepatic enzymes continued to rise. Through the course of his
dressing changes around his cholecystostomy tube, his tube fell
out. IR replaced the tube and adequate billous drainage appeared
again. Even after this intervention, the patient continued to
have increased hepatic enzymes and worsening sepsis. Patient
was also found to have an anion gap acidosis, likely related to
elevated lactate in the setting of hypotension and sepsis.
On [**9-14**], the patient was intubated due to significantly
increased work of breathing. It was felt intubation would
improve patient's respiratory status it would help relieve the
tremendous pressures on his chest and abdomen from his
significant ascites. He abdomen was tapped three times during
his course to help improve his respiratory status but little
effect. He was unable to be weaned off of the vent, due to high
pleural pressures in the setting of the high abdominal pressures
pressing on the chest wall.
After a prolonged course in the ICU that ended in multisystem
organ failure, during a family meeting on [**9-23**], he was made DNR
by his family. Shortly there after he was found to be in DIC,
and on [**9-24**], the patient was made CMO due to the unlikelihood
of recovering from the multi-organ failure and DIC. He was made
comfortable, extubated and expired with his family present.
# Acute on chronic renal insufficiency: Initially thought to be
due to ATN, also with a component of abdominal compartment
syndrome, due the extremely large volume of ascites and high
bladder pressures. His creatinine would transiently improve
post paracentesis, but as the fluid would rapidly reaccumulate,
his renal function would again worsen. As his course progressed
and his liver disease worsened, his kidney function acutely
worsened, which was attributed to possible hepatorenal syndrome.
He was started on albumin and octreotide, while on vasopressin
with no effect. He was not an appropriate candidate for CVVH,
which contributed to the family's decision to make the patient
CMO.
.
# Cirrhosis secondary to NASH: The patient has known cirrhosis
complicated by encephalopathy requiring lactulose. On admission
he was noted to have some baseline synthetic dysfunction with a
mildly elevated INR, additionally it was thought that he had a
component of hepatic encephalopathy despite the lactulose. With
his continued infection and worsening sepsis his liver function
continued to decline, with worsening coagulopathy ultimately
with him developing DIC.
# Change in mental status: Per report from the ED, his family
thought he had change in mental status. In the setting of his
acute illness and decreased bowel movements most likely his
change in mental status was due to hepatic encephalopathy, but
also likely a component of sepsis. After the patient was
intubated, he was sedated for some time. He sedation was weaned
down, but unfortunately, the patient did not wake up. Through
the course of this unresponsiveness, the patient's kidney
function deterioriated further causing an marked increased in
his BUN, also with his worsening liver function, there was
concern that he was unable to clear the sedating medications
from his system.
.
# Atrial Fibrillation with RVR: Initially occurred post
intubation, however in the setting of his hypotension, beta
blockers and calcium channel blockers were unable to be used, so
he was started on amiodarone. The loading dose and IV infusion
controlled his rate well.
.
# DMII: blood sugars intially well controlled on HISS and
glargine. As his infection worsened, he was requiring more
insulin. He was placed on an insulin gtt due to his labile blood
sugars.
Medications on Admission:
Lasix 20 mg daily
Zocor 40 mg daily
Lactulose 4-5x/day
Nadolol 20 mg daily
Aldactone 50 mg daily
Tolterodine 4 mg po daily
Donepezil 10 mg po daily
Citalopram 40 mg po daily
Levothyroxine 100 mcg po daily
Magnesium oxide 500 mg po daily
Nitrofurantoin 100 mg po qid
Ambien 2.5 mg po qhs prn
Glargine 22 units SQ daily - vs glargine 40 [**Hospital1 **] ?
Lispro SSI
Prilosec 20 mg po daily
Hormonal prostate cancer therapy
Discharge Medications:
None
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Respiratory Failure secondary to sepsis and mulitorgan failure
Discharge Condition:
Death
Discharge Instructions:
Death
Followup Instructions:
None
|
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"51.01",
"54.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10725, 10734
|
5571, 9065
|
293, 344
|
10849, 10856
|
4013, 4013
|
10910, 10917
|
3203, 3208
|
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|
10755, 10828
|
10233, 10657
|
10880, 10887
|
3223, 3994
|
245, 255
|
372, 2277
|
4030, 5548
|
9080, 10207
|
2299, 3054
|
3070, 3187
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,632
| 175,860
|
44825
|
Discharge summary
|
report
|
Admission Date: [**2126-10-20**] Discharge Date: [**2126-11-1**]
Date of Birth: [**2061-5-2**] Sex: M
Service: [**Company 191**] East
CHIEF COMPLAINT: Severe abdominal pain, nausea, and vomiting.
HISTORY OF PRESENT ILLNESS: This is a 65-year-old male with
a history of diabetes, hypertension, and a past episode of
pancreatitis in [**2126-1-25**] who presents with severe [**10-3**]
abdominal pain which awoke him from sleep, lasting approximately
25 minutes. The pain was constant, not intermittent, not
radiating with change in position. Nausea and vomiting times
three. He denies recent alcohol intake, medication changes,
abdominal trauma, history of gallstones, or flu-like symptoms.
PAST MEDICAL HISTORY:
1. Diabetes.
3. Pancreatitis in [**2126-1-25**].
4. Hand surgery for carpal tunnel syndrome.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Propranolol 40 mg p.o. b.i.d.
2. Naproxen 375 mg p.o. b.i.d. as needed.
3. Glipizide 5 mg p.o. b.i.d.
4. Metformin 850 mg p.o. q.a.m. and 1700 mg p.o. q.p.m.
5. Moexipril 7.5 mg p.o. q.d.
6. Mysoline 250 mg p.o. t.i.d. as needed.
SOCIAL HISTORY: The patient is single. He lives with a friend
in [**Name (NI) 669**]. No alcohol use since [**2096**].
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 98.6,
blood pressure was 176/85, heart rate was 83, respiratory
rate was 30, oxygen saturation was 99% on 2 liters. In
general, this patient was a moderately obese male,
intermittently moaning in pain. Head, eyes, ears, nose, and
throat examination revealed sclerae were anicteric.
Conjunctivae were clear. Extraocular movements were intact.
Pupils were equal, round, and reactive to light and
accommodation. The oropharynx was clear and moist, no
icterus. Neck was supple. Skin with no lesions.
Cardiovascular examination revealed normal first heart sound
and second heart sound. No murmurs, rubs, or gallops. No
bruits. Point of maximal impulse at 2 cm at left
midclavicular line. Respiratory examination was clear to
auscultation bilaterally. Abdominal examination was firm,
diffuse epigastric tenderness to palpation. Bowel sounds
were present. No guarding tenderness or rebound. Negative
[**Doctor Last Name **] sign. No Cullen sign. No [**Doctor Last Name **] sign. Extremities
revealed no clubbing, cyanosis, or edema. Pulses were 2+
bilaterally. Neurologic examination revealed alert and
oriented times three. Cranial nerves II through XII were
intact. No focal deficits.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
revealed white blood cell count was 9.7, hematocrit was 44.2,
platelets were 262. Sodium was 135, potassium was 4.2,
chloride was 100, bicarbonate was 24, blood urea nitrogen was
14, creatinine was 1, and blood glucose was 262. Creatine
kinase was 12, MB fraction was 3, troponin I was less
than 0.3. Calcium was 10, magnesium was 2.5, phosphorous
was 4.9. ALT was 514, AST was 298, amylase was 4976, lipase
was 14,300, total bilirubin was 3, albumin was 4.5, alkaline
phosphatase was 122, LDH was 1176. Hemoglobin A1c was 8.3.
Urinalysis revealed clear yellow, specific gravity was 1015,
and glucose was 250.
RADIOLOGY/IMAGING: Electrocardiogram revealed a normal sinus
rhythm with normal axis and 1-mm ST elevations in V2 and V3,
normal R wave progression, and normal intervals.
A right upper quadrant ultrasound revealed multiple
gallstones in the gallbladder, gallbladder wall 7-mm
thickness with edema. No pericholecystic fluid. No
son[**Name (NI) 493**] [**Name (NI) **] sign. Consider acute cholecystitis in
appropriate clinical setting.
A CT of the abdomen and pelvis revealed moderate inflammatory
changes associated with pancreatitis.
HOSPITAL COURSE:
1. PANCREATITIS: Acute pancreatitis meeting four [**Last Name (un) **]
criteria. The patient was made nothing by mouth with aggressive
intravenous fluid hydration and noted on hospital day two to have
an acute elevation of his total bilirubin.
He was taken emergently to endoscopic retrograde
cholangiopancreatography. They performed a sphincterotomy with
stone fragment and sludge extraction. Imipenem was empirically
started at 500 mg intravenously q.6h., and the patient was
transferred to the Intensive Care Unit for hypoxia.
A CT of the abdomen and pelvis revealed poor uptake of contrast
suggestive of a necrotic pancreatitis. Serial liver function
tests revealed downtrending levels of amylase and lipase. A
nasojejunal tube was placed on hospital day four for low-level
feeds.
Surgery was consulted to evaluate whether emergent
cholecystectomy was indicated, and they suggested that this would
be performed as an outpatient six weeks after hospital discharge.
The patient had a fever curve which gradually throughout his
hospital stay. A pancreatic biopsy was deferred secondary to
resolving temperatures and improving clinical examination.
On hospital day six, the patient was found to have a nasogastric
tube and nasojejunal tube displaced and was subsequently pulled.
Total parenteral nutrition was initially started at this point.
His diet was advanced slowly, and he was tolerating this well.
At the time of this dictation, the patient was tolerating a low-
residue and low-fat and non-lactose diet without complications.
He was to have a repeat CT of the abdomen and pelvis in
approximately three weeks for further evaluation. He was to
follow up with Dr. [**Last Name (STitle) 8499**] (his primary care physician) in
three weeks as well and with Dr. [**Last Name (STitle) **] for a cholecystectomy
in approximately four to six weeks.
2. HEMATOLOGY: The patient was noted on CT scan to have
superior mesenteric vein thrombosis. Due to the recent
sphincterotomy, it was felt that anticoagulation would be held
until the pancreatitis issue is resolved. Also of note is that
his hematocrit was slowly downtrending throughout his hospital
course. Hemolysis laboratories were unremarkable, and his stool
was guaiac-negative.
It was presumed that his pancreas may be oozing slowly, but given
that he would not be an ideal candidate for surgery, he was
conservatively managed. At the time of this dictation, his
hematocrit was 25.3 which has been stable over the last 24 hours
to 48 hours, and he was not transfused during this admission.
3. DIABETES: His metformin and glipizide were held throughout
his admission with the addition of tube feeds/total parenteral
nutrition. He was placed on a sliding-scale and had increasing
amounts of insulin in his total parenteral nutrition. He was
restarted with half dose of glipizide and will need to be managed
accordingly.
4. HYPERTENSION: The patient was hemodynamically stable, and
his blood pressure medications were slowly restarted. He was
tolerating his ACE inhibitor without complications. At this
time, we did not restart the propranolol, and he will need
further management of his hypertension.
5. INFECTIOUS DISEASE: Imipenem will be continued for a total
of three weeks. A peripherally inserted central catheter line
was inserted for this course. Multiple blood and urine cultures
were obtained without any growth.
6. PULMONARY SYSTEM: Noted hypoxia in the Intensive Care Unit
with a chest x-ray revealing bibasilar infiltrates. He was
subsequently saturating well and was encouraged to use incentive
spirometry.
7. FLUIDS/ELECTROLYTES/NUTRITION: He was to continue a soft,
low-residue, low-fat, and non-lactose diet until cholecystectomy.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to Centennial [**Hospital6 **].
DISCHARGE FOLLOWUP:
1. To follow up with Dr. [**Last Name (STitle) 8499**] in three weeks and with
Dr. [**Last Name (STitle) **] in four to six weeks for a cholecystectomy.
2. He was to have a CT of the abdomen and pelvis on [**11-22**]
at 10 a.m. to further evaluate his pancreas.
MEDICATIONS ON DISCHARGE:
1. Oxycodone 5 mg to 10 mg p.o. q.4-6h. as needed.
2. Moexipril 7.5 mg p.o. q.d.
3. Imipenem 500 mg intravenously q.6h. (times 12 days).
4. Glipizide 2.5 mg p.o. q.d.
5. Ambien 5 mg p.o. q.h.s.
DISCHARGE DIAGNOSES:
1. Acute pancreatitis.
2. Status post sphincterotomy and sludge removal.
3. Hypertension.
4. Diabetes.
5. Anemia; rule out hemolysis of unknown etiology.
6. Gallstones.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1302**], M.D.
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2126-11-1**] 14:23
T: [**2126-11-2**] 06:18
JOB#: [**Job Number 43004**]
|
[
"285.9",
"401.9",
"276.0",
"574.50",
"577.0",
"250.00",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"51.85",
"51.88"
] |
icd9pcs
|
[
[
[]
]
] |
8168, 8583
|
7947, 8147
|
895, 1135
|
3752, 7510
|
7525, 7636
|
168, 214
|
7656, 7921
|
243, 712
|
734, 869
|
1152, 3734
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,577
| 179,531
|
18946
|
Discharge summary
|
report
|
Admission Date: [**2145-9-28**] Discharge Date: [**2145-10-12**]
Date of Birth: [**2092-8-6**] Sex: M
Service: MEDICINE
Allergies:
Zestril / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
hypoglycemia/uremic encephalopathy
Major Surgical or Invasive Procedure:
Transfusion of 5 units packed red blood cells.
Tunnel line placement-Hemo-ultrfiltration.
Initiation of hemodialysis.
Thoracentesis for pleural effusion.
Right knee joint aspiration.
Bone marrow biopsy.
History of Present Illness:
53M with multiple medical problems including chronic renal
insufficiency and coronary artery disease recently underwent
pre-[**First Name3 (LF) **] kidney evaluation requiring elective cardiac
cath. The cath revealed 3 vessel coronary artery disease and he
underwent CABG [**2145-9-15**]. Two weeks later, he now presented to his
PCP's office (Dr. [**Last Name (STitle) 43109**] with SOB, edema and, possible
pneumonia. He was transported from PCP's office to [**Hospital1 18**] ER for
further evaluation and management.
Past Medical History:
CAD, s/p stent ([**12-19**] at [**Hospital1 1774**]), s/p CABG [**2145-9-15**] ongoing angina
Hypertension, h/o hypertensive urgency
Respiratory arrest [**2-/2145**] with resuscitation
Chronic diastolic heart failure
Chronic renal failure, secondary to ATN and diabetes
Angina pectoris
Diabetes
Obesity, s/p laparoscopic banding ([**Doctor Last Name **], [**12-25**]), with
subsequent removal of band after prolonged hospitalization in
[**10/2144**]
Hypercholesterolemia
OSA; has not used CPAP/BIPAP for years but does use 2L NC at
night
Psoriasis; Psoriatic arthritis
Chronic anemia
h/o TIA without residual symptoms
Motorcycle trauma ([**2144-11-8**]) with BL open Monteggia fractures,
R
knee degloving injury, hypotension, facial laceration s/p
ex-lap, and s/p cervical fusion with bone graft. ORIF R and L
elbows with hardware still in place, trach and peg
h/o hypernatremia
Social History:
Lives with wife, 3 children. On disability, former truck driver.
Tobacco: Former smoker, quit [**9-/2143**] after 80 pack-year history.
ETOH: Former heavy drinker, currently only has one drink on
occasion. Illicits: does endorse very remote history of cocaine
use, no history of any drug use in many years.
Family History:
Father - Leukemia, [**Name2 (NI) 32071**] heart disease
Mother - Diabetes [**Name2 (NI) **] type 2
Sister - Diabetes [**Name2 (NI) **] type 2
Physical Exam:
On admission, vital signs were: blood pressure 110/50, pulse 69,
respiratory rate 18, and oxygen saturation 86% on 2L by nasal
cannulae. Mr. [**Known lastname **] was rather sleepy, easily arousable and
answered questions, but his wife provided most of the
information. She reported that her husband had not done well
since his discharge to home. He has had generalized weakness,
lack of appetite, increasing edema, shortness of [**Known lastname 1440**], chills
but no fever, diarrhea or emesis. Skin was dry with psoriatic
changes of nails. Sternal wound
moist not well approx at distal pole with yellow eschar- no
drainage- 3cm in length. Neck exam notable for trach scar.
Abdomen was firm and obese with a healed mid-abd incision,
psoriatic lesions, and 2 ventral hernias. It was soft and
nontender on exam. Extremities were warm and well perfused with
hard pitting edema from thighs to feet bilaterally. No
varicosities. There were early venous stasis changes
bilaterally. Left leg SVG harvest site-open and weeeping-
erythema or purulent drainage.
Pulse exam was as follows:
Femoral Right: +1 Left: 1+
DP Right: Left:
PT [**Name (NI) 167**]: Left: pedal pulses not palpable [**3-22**] edema
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits appreciated
The remainder of the exam, including cardiac, neurologic and
respiratory components, was normal.
Pertinent Results:
LABS AT ADMISSION:
[**2145-9-28**] 02:02PM BLOOD WBC-11.3* RBC-2.93* Hgb-8.4* Hct-25.7*
MCV-88 MCH-28.8 MCHC-32.8 RDW-15.0 Plt Ct-388#
[**2145-10-1**] 06:18AM BLOOD WBC-10.7 RBC-2.78* Hgb-7.9* Hct-24.6*
MCV-88 MCH-28.4 MCHC-32.1 RDW-15.7* Plt Ct-345
[**2145-9-28**] 02:02PM BLOOD PT-18.1* PTT-34.4 INR(PT)-1.6*
[**2145-9-29**] 03:12AM BLOOD PT-18.2* PTT-34.6 INR(PT)-1.6*
[**2145-9-28**] 02:02PM BLOOD Glucose-60* UreaN-169* Creat-5.8*#
Na-132* K-4.5 Cl-87* HCO3-26 AnGap-24*
[**2145-10-1**] 06:18AM BLOOD Glucose-91 UreaN-85* Creat-3.1* Na-139
K-3.9 Cl-95* HCO3-30 AnGap-18
[**2145-9-28**] 02:02PM BLOOD ALT-68* AST-60* LD(LDH)-336* CK(CPK)-515*
AlkPhos-578* Amylase-36 TotBili-0.3
[**2145-9-29**] 03:12AM BLOOD ALT-58* AST-47* AlkPhos-470* Amylase-70
TotBili-0.2
LABS AT DISCHARGE:
[**2145-10-12**]: CBC: WBC 6.0; Hct 24.4; Plt 299
Chemistires: Na 143 / L 4.3 / Cl 104 / bicarb 31 / BUN 47 / Cr
2.5 / Glu 128; Ca 8.8; Phos 3.4; Mg 1.8
MICROBIOLOGY:
[**2145-9-28**] Blood Culture #1:No Growth.
[**2145-9-28**] Blood Culture #2:No Growth.
[**2145-9-28**] Blood Culture #3:No Growth.
[**2145-9-28**] Urine Culture #1: <10,000 organisms/ml.
[**2145-9-28**] Urine Culture #2: No Growth.
[**2145-9-29**] MRSA Screen: neg
[**2145-9-30**] Sputum Culture: GRAM STAIN (Final [**2145-9-30**]): >25 PMNs
and <10 epithelial cells/100X field. 1+ GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE: RARE GROWTH OROPHARYNGEAL FLORA.
[**2145-10-3**] Blood Culture #1:No Growth.
[**2145-10-3**] Blood Culture #2:No Growth.
[**2145-10-3**] Blood Culture #3:No Growth.
[**2145-10-3**] Sputum Culture: GRAM STAIN <10 PMNs and >10 epithelial
cells/100X field. Gram stain indicates extensive contamination
with upper respiratory secretions. Bacterial culture results are
invalid.
[**2145-10-3**] Urine Culture:No Growth.
[**2145-10-4**] Blood Culture #1: No growth.
[**2145-10-4**] Blood Culture #2: No growth.
[**2145-10-4**] Catheter Tip Culture:No significant growth.
[**2145-10-5**] Sputum Culture:GRAM STAIN >25 PMNs and >10 epithelial
cells/100X field. Gram stain indicates extensive contamination
with upper respiratory secretions. Bacterial culture results are
invalid.
[**2145-10-5**] Pleural Fluid: 4+ (>10 per 1000X FIELD)
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. Fluid: no
growth. Anaerobic: no growth.
[**2145-10-7**] Urine Culture:NO GROWTH.
[**2145-10-8**] Joint Fluid:2+ (1-5 per 1000X FIELD) POLYMORPHONUCLEAR
LEUKOCYTES. NO MICROORGANISMS SEEN. Fluid: no growth.
LABS PENDING AT DISCHAGE:
[**2145-10-11**]: Blood culture: pending - please follow up at your
kidney doctor appointment
STUDIES:
[**2145-10-7**]: Knee XR: RIGHT KNEE: Images are somewhat limited due to
underpenetration. There is some prepatellar soft tissue
swelling, which is unchanged. There is persistent spurring of
the superior aspect of the patella. There is a suprapatellar
knee joint effusion. No acute fractures or dislocations are
seen. The joint spaces are relatively preserved. There are
surgical grafts. THE LEFT KNEE: Surgical clips are seen within
the medial soft tissues. Joint spaces are relatively preserved.
There is some minimal spurring of the superior aspect of the
patella as well as prepatellar soft tissue swelling. There is
also a small joint effusion.
[**2145-10-5**]: CXR: In comparison with the study of [**10-4**], there has
been some decrease in the left pleural effusion with residual
atelectasis at the base. No evidence of pneumothorax.
[**2145-10-5**]: CT Chest and Pelvis: 1. Postoperative changes in the
anterior mediastinum, without focal fluid collection. 2.
Moderate simple left pleural effusion with compressive
atelectasis of the left lower lobe. 3. Extensive atherosclerotic
calcification. 4. Diffuse subcutaneous edema consistent with
third spacing.
[**2145-10-4**]: CXR: IMPRESSION: AP chest compared to [**9-20**] through
[**10-3**].
Large scale opacification of the left lower lobe accompanied by
a least
moderate left pleural effusion may not be due to atelectasis
since there is slight rightward mediastinal shift. Findings are
concerning for infection either in the pleural space or
pericardial mediastinum, and the possibility of left lower lobe
pneumonia needs to be excluded as well. Right lung is grossly
clear. Overall size of the postoperative cardiomediastinal
silhouette is stable, increased compared to the preoperative
appearance. Right lung is grossly clear. A left-sided central
line ends alongside a supraclavicular dual channel right
internal jugular line at the junction of the brachiocephalic
veins. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**] and I discussed these findings.
[**2145-9-30**]: ECHO: The left atrium is mildly dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. with normal free wall contractility. The ascending
aorta is mildly dilated. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is no pericardial effusion.
IMPRESSION: Symmetric LVH with preserved global systolic
function. Very limited study. Compared with the prior study
(images reviewed) of [**2145-9-14**], findings are probably similar.
Both studies are limited. If more definitive information about
wall motion is desired, consider repeating the study with echo
contrast.
[**2145-9-29**]: Tunneled cath insertion: IMPRESSION: Successful
placement of a tunneled right internal jugular dual-lumen
hemodialysis catheter, with ultrasound and fluoro guidance
measuring 27 cm tip- to- cuff and with the tip now terminating
in the right atrium. The line is ready to use.
[**2145-9-29**]: LENIs: No evidence of deep venous thrombosis in the
left lower extremity. The study and the report were reviewed by
the staff radiologist.
[**2145-9-28**]: Liver/Gallbladder ultrasound: 1. Normal study without
evidence of acute cholecystitis or cholelithiasis. 2. Small
right pleural effusion is incidentally noted.
[**2145-9-28**]: CXR: Limited study with decreased penetration in the
retrocardiac
region, an infection/consolidation in this region can not be
excluded.
Otherwise unremarkable, no pulmonary edema.
[**2145-9-28**]: EKG: Sinus rhythm with prolonged P-R interval.
Intraventricular conduction delay. Non-specific septal and
lateral ST-T wave changes. Compared to the previous tracing of
[**2145-9-17**] the QRS duration has shortened and the ST-T waves have
changed in the lateral leads. Clinical correlation is suggested.
Brief Hospital Course:
A/P: 53M with HTN, HL, DMt2, ESRD on newly initiated HD and on
renal tx list, OSA and dCHF on home O2, CAD s/p arrest in [**2-/2145**]
s/p CABG on [**2145-9-15**] admitted with worsening renal failure,
initiated on hemodialysis.
Mr [**Known lastname **] was readmitted after CABG weeks PTA now with
increasing lethargy, failure to thrive, and increasing shortness
of [**Known lastname 1440**]. Work up revealed hypoglycemia, uremic
encephalopathy-acute on chronic renal failure, left lower
extremity erythema, and question of pneumonia status post off
pump coronary artery bypass grafting x 3 on [**9-15**] requiring
transfer to CVICU for close monitoring. Dextrose infusion,
Ultrasound of left lower extremity which ruled out deep vein
thrombosis, trans thoracic echo showed global systolic function
(LVEF>55%) and no pericardial effusion. Renal was consulted and
hemodialysis was initiated. Hospital Day #1 elective intubation
was performed for respiratory support/airway management during
tunnel line placement. Mr. [**Known lastname **] was extubated in a timely
fashion with hemodynamic stability and neurologically intact.
Antibiotics were initiated empirically for possible
pneumonia/bacteremia on admission. Pan culture was negative. On
D#2 he was transferred to the step down unit for further
monitoring.
While in the step-down unit, he was nearly anuric, on dialysis,
and on the renal [**Known lastname **] list. He continued to require
supplemental oxygen and was found to have a significant L sided
pleural effusion. He underwent thoracentesis on [**10-6**] and
1.4 L of fluid was removed. He reported symptomatic relief but
remains on supplemental oxygen (2L). He also several days of
unexplained fevers up to 103, for which he received zosyn ([**9-28**]
- [**10-5**]) and a single dose of vancoymycin. Panculture was
negative and fevers resolved around [**10-5**]. Fevers resolved
about three days prior to transfer and were thought to be due to
gout. Patient did develop worsening joint pain (h/o serious MVA
in [**2144**] and significant known arthritis) in the setting of
decreasing his pain medication regimen, and a right knee joint
aspirate was showed needle shaped negatively birefringent
crystals consistent with gout. Of note, patient has had a
persistent anemia that has not responded to multiple
transfusions (5 u pRBC), and a bone marrow biopsy on [**10-8**]
was still pending on discharge to be followed up at his
outpatient hematology appointment.
Given multiple medical problems was transferred to medical
service on [**10-8**] for further management.
His medical issues at discharge are summarized below:
ESRD: He had tunnelled cath placed on [**9-29**] and hemodialysis was
begun on a Monday, Wednesday, and Friday schedule, which should
be maintained on an outpatient basis. Will require follow-up
with Renal as an outpatient as he is a new dialysis patient. He
is also on the renal transplatn list. He should continue his
sevelamer, Epo, and nephrocaps as well.
Possible line infection vs. skin infection: Patient developed
erythema and tenderness at the HD line site (R chest) on
[**2145-10-10**]. On the day of discharge, there was no pain but some
pruritis. He has had low grade fevers, most likely explained by
gout, and a normal WBC count. Blood cultures were drawn on
[**2145-10-11**], which will be followed up by the renal clinic (Dr.
[**Last Name (STitle) 4090**]. If the patient develops any fever, increased redness at
the hemodialysis line site, please check BCx from the line, and
consider starting empiric antibiotics for this.
Diastolic heart failure: Pleural effusion presumed secondary to
fluids from surgery in setting of dCHF and renal failure
requiring HD. Patient is now status post L thoracentesis on
[**10-5**] with no growth on culture. Pulmonary exam clear to
auscultation bilaterally at discharge and patient with 1L oxygen
requirement by nasal cannulae.
Anemia: Patient has had multiple tranfusions (has received 5
units of blood since [**10-3**]) during this admission without
response. A bone marrow biopsy was done on [**10-8**] with results
pending, to rule out myelodysplastic syndrome. This will
require outpatient follow-up with hematology.
Fevers of unknown origin: Fevers have resolved; patient now with
low grade temperatures (~99.1), no leukocytosis, and no
localizing symptoms; the fevers were most likely secondary to
gout. Pt with pain at HD cath site but does not appear infected
at this time. Urine and pleural fluid did not grow out any
microbiology.
Gout: Pain improved with 1 dose of colchicine. NSAIDs, steroids
and further colchicine were avoided in the setting of renal
failure and status post surgery (due to infection risk). Will
require outpatient follow-up for subsequent management of
flares; opioids for pain relief may be considered in the interim
if pain worsens.
Coronary artery disease: Patient is status post recent CABG on
[**2145-9-15**] and PCI in past. No evidence of ACS at this time. He
should continue his home medications of ASA 81, atorvastatin
80, zetia 10mg PO daily, metoprolol 50 [**Hospital1 **], plavix 77. He has
not tolerated Zestril in the past. Will defer on implementing
[**Last Name (un) **] as he is a new dialysis patient; we have discussed with
Renal and will defer this to the outpatient setting.
Type II Diabetes [**Last Name (un) **]: Blood sugars have been under fair
control on current regimen; will require continued outpatient
management to optimize glucose control.
Abnormal thyroid tests: TSH:6.2 Free-T4:0.81. Most consistent
with known primary hypothyroidism, but given borderline TSH,
there may be a component of sick euthyroid. Patient to continue
levothyroxine.
Obstructive sleep apnea: Does not tolerate CPAP. Outpatient
follow-up recommended.
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 1Tablet(s) by mouth DAILY (Daily)
ATORVASTATIN [LIPITOR] - 80 mgTablet - 1 Tablet(s) by mouth
once
a day
CALCITRIOL - 0.25 mcg Capsule 1 Capsule(s) by mouth once a day
CITALOPRAM - 20 mg Tablet - 1Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - 75 mgTablet - 1 Tablet(s) by mouth once a
day
DILTIAZEM HCL - 360 mg Capsule Sustained Release - 1 Capsule(s)
by mouth at bedtime
DOXAZOSIN - 4 mg Tablet - 1 Tablet(s) by mouth
EPOETIN ALFA [EPOGEN] - 40,000unit/mL Solution - 1 shot per
week if needed prn
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule -
1
Capsule(s) by mouth once aweek
ETANERCEPT [ENBREL] - 50 mg/mL(0.98 mL) Syringe - 1 shot q week
weekly
EZETIMIBE [ZETIA] - 10 mgTablet - 1 Tablet(s) by mouth once a
day
FAMOTIDINE - 20 mg Tablet - 1Tablet(s) by mouth twice a day
FUROSEMIDE - 80 mg Tablet - 1Tablet(s) by mouth twice a day
GEMFIBROZIL - 600 mg Tablet - 1Tablet(s) by mouth twice a day
GLIMEPIRIDE - 4 mg Tablet - 1/2Tablet(s) by mouth twice a day
HYDRALAZINE - 25 mg Tablet -TWO Tablet(s) by mouth three times
a day
ISOSORBIDE MONONITRATE - 60 mgTablet Sustained Release 24 hr -
1
Tablet(s) by mouth once a day
L-THYROXINE - - 0.05 once [**Last Name (un) 5490**]
LOSARTAN [COZAAR] - 25mgTablet - 2 Tablet(s) by mouth ONCE a
day
METOLAZONE - 2.5 mg Tablet - 1Tablet(s) by mouth q12
OXYCODONE-ACETAMINOPHEN [ENDOCET] - 5 mg-325 mg Tablet - 1
Tablet(s) by mouth every six (6) hours as needed for pain
Medications - OTC
ASPIRIN [ENTERIC COATED ASPIRIN] - - 81 mg Tablet, Delayed
Release (E.C.) - oneTablet(s) by mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCARB 600 WITH VITAMIN D] -
(Prescribed by Other Provider) - 600 mg (1,500 mg)-400 unit
Tablet - 1 Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D3) [VITAMIN D] - 400 unit Capsule - 1
Capsule(s) by mouth once a day
FERROUS SULFATE - 325 mg (65 mgIron) Tablet - 1 Tablet(s) by
mouth twice a day
INSULIN NPH HUMAN RECOMB [NOVOLIN N] - 100 unit/mL Suspension -
per sliding scale
INSULIN REGULAR HUMAN [NOVOLIN R INNOLET] - 300 unit/3 mL
Insulin
Pen - as directed Insulin(s)
four times a day Sliding Scale: 61-120 mg/dL 0 Units
121-140
mg/dL 4 Units 141-160 mg/dL 6 Units 161-180 mg/dL 8
Units 181-200 mg/dL 10 Units 201-220 mg/dL 12 Units
mg/dL 18 Units 281-300 mg/dL 20 Units 301-320 mg/dL 22
Units 321-340 mg/dL 24 Units 341-360 mg/dL 26 Units
361-380 mg/dL 28 Units 381-400 mg/dL 30 Units > 400
mg/dL 32 Units
MULTIVITAMINS WITH MINERALS - (OTC) - Tablet - 1 Tablet(s) by
mouth twice a day Recommended once per day for Lap Band
THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth once a day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6
hours).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-19**] Sprays Nasal
TID (3 times a day) as needed for xeronasia.
12. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Epoetin Alfa 4,000 unit/mL Solution Sig: Three (3) doses
Injection 3 times per week (Monday, Wednesday, Friday).
14. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
18. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
19. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
20. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
21. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
22. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
23. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
unit dwell Injection PRN (as needed) as needed for line flush:
Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
.
24. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
25. Insulin Glargine 100 unit/mL Solution Sig: 14 units in the
AM, 18 units at bedtime units subcutaneously Subcutaneous twice
a day.
26. Insulin Lispro 100 unit/mL Solution Sig: Administer per
insulin sliding scale units Subcutaneous four times a day:
Insulin sliding scale attached.
27. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
28. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
29. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Primary Diagnosis:
End stage renal disease requring initiation of hemodialysis
Secondary Diagnoses:
- acute gout flare
- anemia
- coronary artery disease
- angina pectoris
- hypertension
- chronic diastolic heart failure
- diabetes
- chronic kidney disease
- rheumatoid arthritis
- hypercholesterolemia
Discharge Condition:
Stable, with low grade temperatures and stable gout, on
hemodialysis, with good oxygen saturation on 1L NC.
Discharge Instructions:
You were admitted to the hospital with shortness of [**Hospital3 1440**] and
increased swelling in your legs. You were found to have
worsening renal function. A tunnelled line was placed and
hemodialysis was initiated during your hospitalization, and you
are currently on the renal [**Hospital3 **] list. In addition, you
developed a pleural effusion while in the hospital, which was
tapped and drained (thoracentesis). You also developed some
fevers and an episode of gout, which was diagnosed by joint
aspiration of your right knee. You were treated with
antibiotics for eight days given fevers of unknown origin, which
are now thought to be due to your gout flare. In addition, you
were transfused 5 units of packed red blood cells while in the
hospital but your blood count did not rise as would expected. A
bone marrow biopsy was performed, and the results were still
pending upon your discharge.
Please continue to take your home medications, with the
following changes: We discontinued many of your blood pressure
and diuretic medications now that you are on hemodialysis
- please discontinue: amlodipine, calcitriol, diltiazem,
etanercept, furosemide, gemfibrozil, glimepiride, hydralazine,
isosorbide mononitrate, losartan, metolazone, and
oxycodone-acetaminophen. Please follow-up with your Renal and
Cardiology doctors [**First Name (Titles) **] [**Last Name (Titles) 51790**] your blood pressure control and
to consider restarting your Losartan.
- please reduce your doxazosin dose to 1mg (1 tablet) by mouth
at bedtime
- please take metoprolol 50mg by mouth twice a day
- please take sevelamer 800mg (2 tablets) by mouth three times a
day, with meals
- please also take the following as prescribed: Vitamin
B/C/Folate supplement, Colace, and subcutaneous heparin.
In addition, please do the following:
- adhere to 2 gm sodium diet
- shower daily including washing incisions
- do not swim or take baths
- monitor your wounds for infection. If you notice increased
redness, drainage, pain, or if you develop fevers, please notify
your doctor, as you may require antibiotics.
- report any fever greater than 101
- report any weight gain of greater than 2 pounds in 24 hours or
5 pounds in a week
- do not use creams, lotions, powders, or ointments to incisions
- do not drive for approximately one month, or while taking
narcotics
- do not lift more than 10 pounds for the next 10 weeks
If you develop shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] increase in leg swelling,
increased joint pain, or any other symptoms that concern you,
please contact your primary care physician or return to the
hospital.
Followup Instructions:
Hematology will contact you by phone to schedule a follow-up
appointment. Please follow-up on the results of your bone marrow
biopsy at this time. If you don't hear from them within 1 week,
call ([**Telephone/Fax (1) 14703**] to make an appointment.
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43109**] (primary care) in [**3-23**]
weeks. Please have your rehabilitation facility schedule this
appointment. [**Last Name (LF) **],[**First Name3 (LF) **] S [**Telephone/Fax (1) 51791**]
Please follow up wtih Dr. [**Last Name (STitle) 4090**] [**Telephone/Fax (1) 2378**] (Renal). Please
have chemistries drawn for this appointment. The renal nurses
will call you at rehab to schedule a the appointment. At this
appointment, you need to follow up on the blood culture taken
from your hemodialysis line.
Please also follow-up with the following healthcare providers:
- [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-10-21**] 8:00
- [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-10-21**] 8:30
- [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 24317**], MD Phone:[**Telephone/Fax (1) 6429**] Date/Time:[**2145-12-7**] 1:00
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|
2003, 2313
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,000
| 150,032
|
50948+59265
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-8-24**] Discharge Date: [**2123-8-29**]
Date of Birth: [**2082-10-26**] Sex: F
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: The patient's chief complaint was
dyspnea on exertion and syncopal episode. She was found to
have aortic insufficiency and aortic stenosis after having
serial echoes each year. Syncope a month prior to admission
with increasing dyspnea on exertion ultimately led to
preoperative evaluation for probable valve replacement.
Cardiac cath on [**2123-7-28**] revealed an EF of 54%, moderate AS,
mild coronary artery disease, 2+ MR. She had a 20% left main
stenosis. Cardiac echo in [**2123-1-22**] showed mild LVH, EF
greater than 55%, normal aortic root, moderate AS, 2+ MR, 2+
AI, 1+ TR.
PAST MEDICAL AND SURGICAL HISTORY: Hodgkin's disease, status
post XRT and lymphadenectomy. History of hypothyroidism.
History of obesity. History of restrictive pericarditis.
Status post median sternotomy, T&A as a child. She had a
left mastectomy with reconstruction for cancer back in
[**Month (only) 404**] [**2121**]. Thyroidectomy was performed this year in
[**2122**].
MEDICATIONS ON ADMISSION:
1) Zestril 5 mg q.day.
2) Synthroid 112 mcg q.d.
ALLERGIES: No known drug allergies.
[**Last Name (STitle) 105876**]tal exam - has her own teeth. She had a normal exam
last month prior to admission by Dr. [**First Name8 (NamePattern2) 5279**] [**Last Name (NamePattern1) **]. The
report was pending and to be faxed to Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**]
office.
FAMILY HISTORY: Mother is alive, does have lung cancer.
Father died of MI in his 30s.
SOCIAL HISTORY: Occupation: She is an administrator. She
lives with a significant other. She never smoked. She has
occasional ETOH utilization. No cocaine or I.V. drug abuse.
REVIEW OF SYSTEMS: No recent weight changes in the past 3 to
6 months. Skin exam negative. HEENT was normal.
Respiratory exam was negative for asthma, COPD, bronchitis,
pneumonia. Cardiac: Positive syncopal episodes times two
with palpitations. Positive paroxysmal nocturnal dyspnea.
No orthopnea. GI: No recent nausea, vomiting or
constipation. No GI bleed. No liver disease. GU/renal: No
history of renal insufficiency or calculi. Musculoskeletal:
No osteoarthritis or other orthopedic problem to speak of.
Peripheral vascular revealed no claudication. Neuro: No
CVA, no TIA. No history of diabetes. No bleeding diathesis.
She does have hypothyroidism.
PHYSICAL EXAMINATION: Heart rate 88, respiratory rate of 12,
satting at 98% on room air. Blood pressure 112/75 on the
right arm, 105/68 on the left. Weight was 180 pounds, height
5 feet 4 inches. Well-nourished, well-developed, African
American female. Skin was unremarkable. Buccal mucosa
moist. No thyroid noted. Old transverse cervical incision,
well-healed. No cervical bruits. No JVD. There was
radiation of a murmur to the bilateral carotids from the
chest. The chest was clear to auscultation. She had a well
healed median sternotomy incision. Heart had a normal S1 and
S2 with a 3/6 systolic ejection murmur. Abdomen was soft,
nontender, no pulsatile liver, no hepatosplenomegaly. There
are well-healed abdominal scars noted. No varicosities.
Lower extremities were warm with palpable pulses and brisk
capillary refill. Neurologic was nonfocal. Cranial nerves
II - XII intact. Pulses were palpable throughout.
She was slated for surgery and consented. She underwent a
St. [**Male First Name (un) 923**] #19 aortic valve repair on [**2123-8-24**]. She left the
operating room off cardiopulmonary bypass with EF noted to be
greater than 55%, mean arterial pressure was 70. She had a
CVP of 12, PAD was 26. She was on nitro and Propofol. She
left with a right radial line and right IJ Swan-Ganz
catheter, two ventricular leads, two atrial leads, two
mediastinal chest tubes. Her pericardium was left open.
Postoperatively she was sent to the CSRU where she
resuscitated. Intermittently she was on Neo-Synephrine for
blood pressure management, but thereafter when off this she
became relatively hypotensive after she recovered from
bypass. She was on a Nipride drip and nitroglycerin drip for
blood pressure control. She was extubated on the night of
surgery. She was given a liter of Hespan and a liter bolus
of crystalloid to assist her with her relative hypotension.
Thereafter, her tachycardia and low PADs resolved.
She was 100.8 on post-op day #1, status post surgery.
Pressures were stable on Nipride and nitro. Hematocrit was
23.2 postoperatively, BUN and creatinine were 8 and 0.5.
Exam was otherwise unremarkable. She was transfused a unit
of packed cells for the hematocrit of 23, started on Coumadin
for her valve. On postoperative day #2, she was doing well.
She was on the floor. Her Foley was DC'd. Her Coumadin was
dosed. She was out of bed, ambulating with physical therapy
and otherwise doing well. Over the next three days, the
patient continued to ambulate and work with physical therapy.
She received pulmonary hygiene and her Coumadin dose serially
was 5 mg. By postoperative day #5, she was deemed
appropriate and stable for discharge with a T-max of 100.1,
vital signs were otherwise stable. She was satting at 95% on
one liter by nasal cannula. She was alert and oriented,
feeling well. She had no JVD, no carotid bruits. Lungs were
clear, decreased at the bases. Heart was regular with no
murmur. Abdomen was soft, nontender, nondistended.
Extremities were nonedematous, warm. Brisk capillary refill.
Neurologically she was nonfocal and intact.
She was discharged on a Coumadin dose to be specified at the
time of discharge; please see page one for details.
Additionally, she will require PT/INR check approximately
48 hours from the time of discharge with results to be
managed by her primary care provider, [**Name10 (NameIs) 1023**] is Dr. [**First Name8 (NamePattern2) 122**]
[**Last Name (NamePattern1) 4104**], her cardiologist. She was discharged on:
1) Percocet one or two tabs p.o. q.[**2-27**] p.r.n.
2) Colace 100 mg p.o. b.i.d.
3) Dulcolax p.o. 10 mg b.i.d. p.r.n.
4) She will continue her Zestril 5 mg q.d.
5) Continue Synthroid at 112 mcg q.d.
6) She will be on a low-dose beta blocker to be specified at
the time of discharge which she will continue during the
perioperative period, which can ultimately be removed at the
time of followup.
In[**Last Name (STitle) **]ions for her to follow up with Dr. [**Last Name (Prefixes) **] in the
outpatient clinic, at which time her staples can be DC'd from
her sternum. She will leave the wound open to air. She can
shower, pat the wound dry. Otherwise doing fine. Discharge
INR was pending, but the previous day on post-op day #4, INR
was 1.5.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2123-8-28**] 09:42
T: [**2123-8-28**] 09:54
JOB#: [**Job Number 58044**]
Name: [**Known lastname **], [**Known firstname 850**] Unit No: [**Numeric Identifier 17129**]
Admission Date: [**2123-8-24**] Discharge Date: [**2123-8-31**]
Date of Birth: [**2082-10-26**] Sex: F
Service:
Please see the previously dictated discharge summary for
detail.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in
approximately four weeks.
2. The patient is to followup with a cardiologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1426**] in approximately 3-4 weeks.
3. The patient is to followup with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17130**] in approximately 1-2 weeks.
4. The patient is to continue on Coumadin. She is to
followup in the [**Hospital 1209**] Clinic. She needs to have her
coagulation laboratories drawn on [**2123-9-2**] and sent to her
primary care physician, [**Name10 (NameIs) 3308**] will be following her Coumadin
levels as well as Dr. [**Last Name (STitle) 1426**] in the [**Hospital 1209**] Clinic.
DISCHARGE MEDICATIONS:
1. Coumadin 3 mg to be given on [**2123-9-1**], none to be given on
[**2123-8-31**]. Coumadin levels to be followed in the [**Hospital 1209**]
Clinic.
2. Colace 100 mg po bid.
3. Enteric coated aspirin 325 mg po q day.
4. Synthroid 112 mcg po q day.
5. Levofloxacin 500 mg po q day x3 days.
6. Dilaudid 2 mg po q4 hours prn pain.
7. Lasix 20 mg po bid x7 days.
8. Lopressor 50 mg po bid.
9. Potassium chloride 20 mEq po bid x7 days.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Last Name (NamePattern1) 1388**]
MEDQUIST36
D: [**2123-8-31**] 10:06
T: [**2123-8-31**] 10:18
JOB#: [**Job Number 17131**]
|
[
"V10.3",
"V10.72",
"424.1",
"244.9",
"997.3",
"518.0",
"458.2",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"89.61",
"35.22",
"39.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
1580, 1651
|
8206, 8900
|
1167, 1563
|
7395, 8183
|
2526, 7371
|
1852, 2504
|
168, 1141
|
1667, 1832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,827
| 199,336
|
15704
|
Discharge summary
|
report
|
Admission Date: [**2106-6-8**] Discharge Date: [**2106-6-11**]
Date of Birth: [**2038-4-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
68 y.o.m. with T4 paraplegia, CAD, CHF, sacral decubitus ulcers,
UTIs, PE w/p IVC filter on anticoagulation who presents.
Presents from [**Hospital **] rehab with 5 days intermittent SSCP on
right side, abdominal discomfort, decreased appetite, nausea,
?emesis. Also with shortness of breath over last couple of days
and increasing cough over last couple of weeks. Abdominal pain
is chronic and has been present for years. No fevers, chills.
EMS stated SBPs were 70s, responded to NS bolus.
.
In the ED vitals were 98, 92, 91/63, 28, 100% 2L. BP decreased
to a low of 89/64, blood cultures and lactate drawn and given
vanc IV 1gm and zosyn IV 1 gm and 1LNS. Guaiac negative.
Impression was for abdominal source [**3-13**] to sacral decub -> CT
Abd/Pelvis showed large infra sacral decub fluid collection with
possible abscess formation and associated rectal thickening.
.
Of note, that patient has had multiple admissions in the past,
the most recent from [**Date range (1) 45260**] for hypotension requiring
pressors. Etiology unclear but felt to be either line vs. UTI
vs. sacral decub. He was treated with meropenem, vancomycin,
flagyl, and ciprofloxacin, PICC removed, foley changed. Plastic
surgery evaluated sacral decubs and did not feel they were the
source of his sepsis. Influenza negative. Plan was to receive
two week course of meropenem and vancomycin given no clear
source of infection (completed [**5-27**]). Discharge summary states
that pt should have serial blood and urine cultures, as well as
wound evaluation by plastic surgery, prior to initiating further
antibiotics as repeted episodes of hypotension with no culture
data to guide antibiotic therapy. Prior discharge was after
admission for code stroke [**4-21**]--[**4-27**] which at the end, it was
thought to be a seizure episode. Prior to that, admitted
[**2106-4-6**]- [**2106-4-15**] for fever and hypotension treated for UTI and
wound infection with Vanc/Zosyn completed on [**4-21**].
Past Medical History:
1. Inflammatory disease of the spinal cord of uncertain
etiology. MRA [**10-16**] negative for vascular malformation. Initial
CSF analysis showed elevated protein (82) without oligoclonal
bands. NMO blood titer negative, RPR negative, Lyme serology
negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal,
neuromyelitis IgG negative, ESR 70, CRP 66.8. Ultimately
treated with broad spectrum antibiotics, corticosteroids (two
weeks of Solu-Medrol followed by a prednisone taper), and 5 days
of mannitol without improvement. He is followed by neurology
for a dense paraplegia (T4) with neuropathic pain, restrictive
shoulder arthropathy, and a neurogenic bladder requiring a
chronic indwelling foley.
2. Chronic sacral decubitus ulcer, previously treated with a VAC
Dressing
3. Multiple UTI (including Pseudomonas)
4. Pulmonary embolus [**11-15**] s/p IVC filter placement
5. Asthma
6. Two-vessel coronary artery disease s/p CABG 4-5 years ago
7. Systolic CHF (EF 25-30% on [**2-15**] TTE)
8. Repaired liver laceration
9. Chronic back pain
10. Vitiligo
11. Feeding tube
12. Depression
13. MRSA from sacral swab and sputum
14. Prior transient episodes of leg paralysis
15. Right frontal lobe brain lesion biopsied [**11-15**] and c/w
gliosis; resolved on repeat imaging
16. Abnormal visual evoked potentials
Social History:
He moved here from [**Country 3594**] (after living in many different
countries) in the [**2068**]. He is retired from a job in the
maritime industry. Divorced 24 years ago. Three children.
Quit smoking [**2076**]. Quit drinking [**2080**]. No history of illicit
drug use or abuse.
Family History:
No stroke, aneurysm, no seizure, no AAA.
Physical Exam:
General Appearance: Well nourished, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4,
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Rhonchorous: throughout)
Abdominal: Soft, Tender: RUQ, Obese, no rebound or guarding
Extremities: Right: Trace, Left: Trace, mutlipidous boots
Skin: Warm, No(t) Rash: , No(t) Jaundice, stage III-IV sacral
decubs bilateral ischial tuberosities, gluteal clefts
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not
assessed
Pertinent Results:
IMPRESSION:
1. Tree-in-[**Male First Name (un) 239**] opacities in the right lower lobe concerning for
infectious process. Given the presence of copious secretions in
the airways aspiration should also be considered.
2. Large infra-sacral decubitus ulcer with possible abscess
formation. Associated rectal thickening could be representing
reactive changes or infectious involvement.
3. Left renal cyst.
4. IVC filter.
5. Cholelithiasis without cholecystitis.
--------------
URINE CULTURE (Final [**2106-6-9**]):
ACINETOBACTER BAUMANNII COMPLEX. >100,000
ORGANISMS/ML..
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
|
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- =>16 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
Brief Hospital Course:
68-year-old man with severe shock (source most likely decub, but
UTI and PICC line also in DDx) on a background history of T4
paraplegia (?myelitis) complicated by decubiti, neurogenic
bladder, PEs and UTIs.
.
# Hypotension
History autonomic dysfunction with component likely urosepsis
with acinetobacter sensitive to tobramycin, patient completed 7
day course. Patient also was treated with a course of vancomycin
and cefepime to treat suspected underlying pneumonic process
given tree and [**Male First Name (un) 239**] opacities at right lower lobe on CTA chest.
MRI to evaluate for osteo prior to discharge to assess for
change in osteo was unrevealing. Cortstym test was appropriate.
PICC line was kept in place. Foley changed on admission. Patient
was off pressors with stable blood pressure, he was alert and
oriented and UOP was appropriate at the time of discharge.
.
# Decubitus ulcers
Evaluated by both plastic and general surgery who did not think
wound was actively infected. Stage IV documented sacral decubiti
ulcers which underwent debridement per surgery. MRI did not show
any evidence of new infection and did not warrant further
treatment with antibiotics.
.
# PE s/p IVC filter
Hold warfarin today; goal INR 2 ?????? 3. Monitor closely. If he
does not continue his rapid improvement, convert to heparin and
hold warfarin. Multiple abx on board likely affecting level.
.
# CAD/CHF (systolic, chronic)
No evidence of volume overload. Hold antihypertensives;
continue aspirin.
His troponin is elevated, but appears to be chronically so (for
unclear reasons) ?????? does not appear to be ACS/unstable plaque.
Ruled out for ACS with 3 negative enzymes
.
Medications on Admission:
Keppra 500mg [**Hospital1 **]
Gabapentin 300mg [**Hospital1 **]
Citalopram 30mg daily
Baclofen 5mg PO TID
Lisinopril 2.5 mg daily
Carvedilol 3.25mg [**Hospital1 **]
Advair 250/50 [**Hospital1 **]
Albuterol 2 puffs Q6H
Ipratroprium 2 puffs Q6H
Aspirin 81 mg daily
Ursodiol 300mg PO BID
Vit D 800 daily
Vit B12 1000 daily
Calcium carb 500mg TID
Pantoprazole 40
Folic acid 1mg daily
Oxycodone 5mg Q6H prn
Warfarin 2mg daily
Meropenem (stopped [**5-27**])
Vancomycin (stopped [**5-27**])
Flagyl (stopped [**6-3**])
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
15. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
18. Tobramycin Sulfate 40 mg/mL Solution Sig: Three Hundred
Forty (340) mg Injection Q24H (every 24 hours) for 4 days.
19. PICC line care per protocol
20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours.
Discharge Disposition:
Expired
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
UTI
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with hypoxia. This resolved quickly and we
found a urinary tract infection, for which we are treating you
with intravenous antibiotics through your PICC line. We got an
MRI to make sure there is no bone infection. You will need to
have this followed up with your PCP.
.
Please return to the emergency room if you develop any fevers or
any other concerning symptoms.
.
Follow up as indicated below and take all of your medications as
directed.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 250**] within
the next two weeks to follow up your MRI results.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD Phone:[**Telephone/Fax (1) 5434**]
Date/Time:[**2106-7-16**] 9:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2106-11-3**] 9:40
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2106-11-3**]
11:00
|
[
"995.92",
"493.90",
"707.03",
"707.04",
"V45.81",
"E928.9",
"507.0",
"038.9",
"428.22",
"785.52",
"428.0",
"345.90",
"344.1",
"596.54",
"599.0",
"530.81",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
10164, 10223
|
6208, 7888
|
325, 331
|
10270, 10278
|
4951, 6185
|
10790, 11426
|
4045, 4087
|
8470, 10141
|
10244, 10249
|
7914, 8447
|
10302, 10767
|
4102, 4932
|
274, 287
|
359, 2344
|
2366, 3724
|
3740, 4029
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,493
| 187,382
|
12991
|
Discharge summary
|
report
|
Admission Date: [**2143-12-26**] Discharge Date: [**2143-12-27**]
Date of Birth: [**2098-9-9**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin Hcl / Epinephrine / Pentothal / Flagyl / Fentanyl
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 48-year-old woman with a past medical history of CAD,
HTN, HL, chronic abdominal pain, headaches and fibromyalgia who
presented to ED with nausea. She reports nausea started
approximately one week ago and was concerned it was related to
restarting reglan. She called the covering gastroenterologist
and was referred to the ED. Of note, verapamail was also
recently started and uptitrated by neurology for headaches. She
had brief "twinge" of chest pain which she associated with
feeling anxious in ED and did not require nitro but resolved on
its own. It did not radiate nor was it associated with symptoms
other than nausea.
.
In ED, initial VS: 98.8 107/78 87 18 100%RA. There was concern
for ECG changes (ST depressions III and AVF) so she had two sets
trops which were both negative. She received Ativan 1mg IV x 2
and zofran 4mg IV. BP 110/78 prior to ativan and 80s/50s after
ativan. She subsewquently received 5L NS for hypotension as she
remained in the 80s. She was guaiac negative. Labs significant
for WBC 11.5, HCt at baseline, normal lactate, normal LFTS and
negative UA. Surgery was consulted for abdominal pain and did
not recommend any further workup. Ct A/P unremarkable. ED TTE
with no effusion. VS prior to transfer: 95/63 61 98%RA.
.
On arrival to the unit, she reports her usual chronic headache
and nausea but denies CP, SOB, palpitations, LE edema, fevers,
chills, dysuria, abdominal pain, weight loss.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Chronic fatigue
4. Chronic headaches
5. Fibromyalgia
6. Depression/Anxiety
7. Talus fracture
8. Cervical cancer
9. GERD
10. Hydronephrosis
11. Mild COPD
14. Chronic mesenteric ischemia - known occlusion of SMA and
celiac, [**Female First Name (un) 899**] was re-implanted in [**2140-6-3**] by vascular surgery
[**48**]. Recent admission [**7-10**] for ? TIA - foudn to have
microvascular infarcts on MRI and HTN.
16. Admission for GI bleeding, antral ulcers
Social History:
History of heavy alcohol, stopped in [**2136**]. 20 pack year smoking
history, still smokes 1-2 packs/day. Works as proofreader. No
drug use.
Family History:
Mother and aunt with coronary artery disease and carotid
disease. Both parents died of lung cancer, mother at age 73,
father at age 68.
Physical Exam:
GEN: pleasant, comfortable, NAD, sitting up in bed, eating
dinner
HEENT: PERRL, EOMI, mild periorbital edema, anicteric, MMM, op
without lesions, no supraclavicular or cervical lymphadenopathy,
no jvd, no carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout and faint
bibasilar crackles
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.
Pertinent Results:
[**2143-12-26**] 05:55PM cTropnT-<0.01
[**2143-12-26**] 05:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-12-26**] 04:16PM HGB-12.6 calcHCT-38
[**2143-12-26**] 01:03PM LACTATE-0.8
[**2143-12-26**] 11:27AM GLUCOSE-104* UREA N-7 CREAT-0.9 SODIUM-134
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-13
[**2143-12-26**] 11:27AM estGFR-Using this
[**2143-12-26**] 11:27AM ALT(SGPT)-10 AST(SGOT)-21 ALK PHOS-98
AMYLASE-90 TOT BILI-0.2
[**2143-12-26**] 11:27AM LIPASE-49
[**2143-12-26**] 11:27AM cTropnT-<0.01
[**2143-12-26**] 11:27AM ALBUMIN-4.2
[**2143-12-26**] 11:27AM CORTISOL-5.6
[**2143-12-26**] 11:27AM URINE HOURS-RANDOM
[**2143-12-26**] 11:27AM URINE HOURS-RANDOM
[**2143-12-26**] 11:27AM URINE UCG-NEG
[**2143-12-26**] 11:27AM URINE GR HOLD-HOLD
[**2143-12-26**] 11:27AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2143-12-26**] 11:27AM WBC-11.5* RBC-3.99* HGB-13.0 HCT-38.6 MCV-97
MCH-32.6* MCHC-33.8 RDW-13.6
[**2143-12-26**] 11:27AM NEUTS-60.2 LYMPHS-32.4 MONOS-4.7 EOS-1.3
BASOS-1.4
[**2143-12-26**] 11:27AM PLT COUNT-335
[**2143-12-26**] 11:27AM PT-11.4 PTT-23.1 INR(PT)-0.9
[**2143-12-26**] 11:27AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2143-12-26**] 11:27AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
This is a 45-year-old woman with CAD, fibromyalgia, chronic
migraines who presents to ED the with nausea, who subsequently
developed hypotension in the setting of multiple medications.
HYPOTENSION: Likely in the context of receiving ativan in the
ED and recently starting verapamil. Although sepsis,
hypovolemia, and adrenal insufficiency were in the differential,
Ms. [**Known lastname 39729**] did not have any signs/symptoms to suggest these
etiologies. The patient received a total of 5L of fluid in the
emergency department and her pressures normalized. A CXR was
not suggestive of an acute process, and blood and urine cultures
are negative to date. Verapamil, ACE, and other sedating
medications were held. On day one of hospital admission,
patient was normotensive. Her blood pressure was 130/80 on
discharge without further intervention. Her ACE was restarted
but she was instructed to hold the Verapamil until further
discussion with her PCP and neurologist.
CAD: Although Ms. [**Known lastname 39729**] had initially complained of a "twinge"
of chest pain in the ED, she gave a more concerning story for
unstable angina while in the unit. Ms. [**Known lastname 39729**] stated that she
has persistent angina, even at rest. An EKG performed in the ED
was significant for ST depressions in inferior leads during
episodes of chest pain. She was ruled-out for MI by enzymes.
Patient was seen by cardiology in the ICU and it was recommended
that she have a persantine stress test either during admission
(over the weekend) or very early next week. Due to the holiday,
patient requested to go home. Cardiology was in agreement with
this plan. An email was sent to stress lab director inquiring
about scheduling stres test for early next week. Patient was
continued on statin, ASA, and ACE. She is not on metoprolol due
to hypotension with this drug in the past.
DEPRESSION: Patient was ontinued on fluoxetine and
amitriptyline.
GERD: PPI continued.
ABDOMINAL PAIN: Unclear etiology. LFTs, lipase, and CT were
unremarkable. Could be attributed to ferrous sulfate or reglan.
Patient is encouraged to discuss this with her PCP at next
visit. Her symptoms subsided throughout admission and she
tolerated a normal diet.
MIGRAINES: Verapamil was held in context of hypotension. She
was given tylenol as needed for headaches.
Medications on Admission:
Clopidogrel 75 daily
Aspirin 325 daily
Clonazepam 1mg Po TID prn
Simvastatin 20 mg PO daily
Ferrous Sulfate 325mg PO daily
Fluoxetine 40mg Po daily
Omeprazole EC 40 [**Hospital1 **]
Amitriptyline 25 qhs
Dicyclomine 10mg PO TID
Acetaminophen 325 prn
Lisinopril 2.5mg Po daily
Folic Acid 1mg PO daily
Verapamil 240mg PO daily
percocet prn
Reglan 10mg PO daily prn
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
10. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
11. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. Reglan 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Hypotension related to medications.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 39729**],
It was a pleasure taking care of you on this admission. You
were admitted to the ICU with low blood pressures which were
likely related to medications you received including ativan and
your home verapamil. Your blood pressure was improved when you
arrived to the ICU. You also had nausea, which resolved. We
also did lab work that showed you did not have a heart attack.
There were some changes on your EKG and in light of your history
of heart disease, the cardiologists would like you to go for a
stress test on Monday [**12-30**]. You will be contact[**Name (NI) **] for
further information about this test.
We made the following changes to your medications
1. Please STOP Verapamil for now. This can lower your blood
pressure. Please ask your PCP or neurologist when it is safe to
restart this medication.
It is very important that you quit smoking.
Please follow up with your doctors as below.
Return to the emergency department if you experience chest pain,
shortness of breath, palpitations, nausea, vomiting, diarrhea,
fevers, chills, or any other concerning signs or symptoms.
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: TUESDAY [**2144-1-7**] at 10:10 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1579**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: NEUROLOGY
When: MONDAY [**2144-1-27**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: TUESDAY [**2144-4-14**] at 8:00 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"276.51",
"411.1",
"272.4",
"557.1",
"530.81",
"789.07",
"414.01",
"311",
"401.9",
"E942.4",
"E939.4",
"496",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8525, 8531
|
4671, 7026
|
344, 351
|
8629, 8629
|
3224, 4648
|
9937, 10851
|
2518, 2656
|
7438, 8502
|
8552, 8552
|
7052, 7415
|
8779, 9914
|
2671, 3205
|
293, 306
|
379, 1816
|
8571, 8608
|
8644, 8755
|
1838, 2343
|
2359, 2502
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,872
| 158,544
|
13730
|
Discharge summary
|
report
|
Admission Date: [**2144-9-19**] Discharge Date: [**2144-10-9**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Aspirin / Heparin Agents /
Shellfish
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Status post fall.
Reason for MICU admission: tachycardia, falling hematocrit.
Major Surgical or Invasive Procedure:
Left femur intramedullary nail.
History of Present Illness:
[**Age over 90 **] year old female with history of hypertension, asthma, CVA in
[**2140**] on anticoagulation, MRSA left hip infection in [**2142**] (on
life long doxycycline), transferred status post fall in commode
at OSH on [**2144-9-19**], while being treated for a UTI. At the OSH,
patient found to have a right humeral and left distal femur
fracture. There was no venous insufficiency, distally.
Preliminary reads at the OSH revealed no abnormalities on head
CT or cervical spine. Patient's abdomen/pelvis were reported as
normal.
.
On presentation, found to have HR 120 BP 120's and O2 sat 100%
on 2L. EKG revealed sinus tachycardia. Pain was controlled
with morphine and tachycardia treated with metoprolol.
Ceftriaxone was continued for patient's UTI. Shortly after
admission to orthopedics service, for impending surgery,
patient's hematocrit decreased from 31 to 25.6 in 6 hours. Ct
was negative for hip bleed. Right groin line was placed. As
patient's blood pressure decreased to the 70's, responding to 2
liters IVF to the 90's, and O2 saturations that were in the
80's, but only returned to [**Location 213**] with 10L supplemental oxygen,
she was transferred to the medical ICU. She spiked a fever to
100.0F, so vancomycin 1gm given for presumed line infection.
Her blood pressure remained tenuous, so she received a total of
4 units of packed red blood cells and 2 units of fresh frozen
plasma during these first several days.
While in the MICU, patient was noted to have NSTEMI, with
cardiac ECHO noted to reveal new global hypokinesis. Troponins
elevated to 1.28, but subsequently trended downwards. Following
surgery, she was noted to develop new-onset atrial fibrillation,
but she remained hemodynamically stable. Patient was started on
metoprolol and lovenox and transferred to medicine floor for
medical management.
Past Medical History:
1) Hypertension
2) GERD
3) CVA [**2140**] (residual short-term memory loss and diminished
vision bilaterally)
4) Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-8**]:
complicated by infected prosthesis with enterobacter and MRSA.
Removal of Hardware in [**1-9**].
5) Hypothyroidism
6) Asthma
7) Vertebral compression
8) hysterectomy
9) appendectomy
10) vertebroplasty: L1 and T12
11) MRSA/diskitis/epidural abscess
Social History:
No Tob/EtOH. Independent prior to 1st hip fracture.
Daughters [**Name (NI) **] (Healthcare proxy) and [**Name (NI) **] and son.
Family History:
Non-contributory.
Physical Exam:
On admission:
VS Tc 99.0, P 100-115, BP 105/46, resp 18, 95% on 10 L face
tent.
Gen: elderly, chronically-ill appearing female, collar in place.
Head: NCAT
Mouth: MM dry
Cardiac: Tachycardic, regular no M/R/G
Pulm: Diffuse expiratory wheezes and scattered rhonchi
Abd: NABS, soft, NT/ND
Ext: In traction L hip, cast in place at R arm.
Pulses dopplerable on L, palpable on R no edema.
Pertinent Results:
Chest Xray ([**10-4**]): Allowing for the differences in rotation and
technique, there likely has been no major change in the
appearance of the bilateral pleural effusions, left basilar
atelectasis/airspace disease and mild pulmonary vascular
congestion.
.
Chest Xray ([**9-19**]): Slightly more pronounced perihilar markings
and hazy opacity right upper zone most likely reflects early
CHF.
.
CT head ([**9-30**]): 1. No acute intracranial hemorrhage identified.
2. Multiple chronic large and small vessel infarctions.
.
Cardiac ECHO ([**9-22**]): Symmetric LVH with mild regional left
ventricular systolic dysfunction. Mild aortic stenosis. Moderate
mitral regurgitation. Moderate pulmonary hypertension. Compared
with the prior study (images reviewed on tape) of [**2142-8-3**],
septal hypokinesis is new, and mild aortic stenosis is now
identified. The other findings appear similar.
.
Xray ([**9-19**]): Humerus fracture. No evidence of associated elbow
dislocation. There is a fracture of the distal left femur,
which is not completely imaged on this study. There has been
placement of a traction pin through the distal left femur, with
slight posterior displacement and minimal anterior angulation of
the distal fracture fragment.
.
Speech and Swallow ([**10-6**]): PO diet of nectar thick liquids and
pureed solids when fully awake and seated upright. Continue
with tube feeds for supplemental nutrition and hydration.
.
.
[**2144-10-7**] 06:01AM BLOOD WBC-11.3* RBC-3.14* Hgb-9.9* Hct-29.4*
MCV-94 MCH-31.6 MCHC-33.8 RDW-17.6* Plt Ct-282
[**2144-10-2**] 07:15AM BLOOD WBC-20.0*# RBC-3.47* Hgb-10.9* Hct-32.4*
MCV-94 MCH-31.4 MCHC-33.5 RDW-16.5* Plt Ct-354
[**2144-9-24**] 04:22AM BLOOD WBC-20.7* RBC-3.46* Hgb-10.8* Hct-31.5*
MCV-91 MCH-31.2 MCHC-34.2 RDW-16.3* Plt Ct-237
[**2144-9-20**] 05:36PM BLOOD WBC-15.0* RBC-3.46* Hgb-10.9* Hct-31.5*
MCV-91 MCH-31.6 MCHC-34.7 RDW-14.4 Plt Ct-172
[**2144-9-19**] 05:10AM BLOOD WBC-11.1* RBC-3.13* Hgb-9.7* Hct-28.6*
MCV-91 MCH-31.0 MCHC-34.0 RDW-13.7 Plt Ct-265
[**2144-10-7**] 06:01AM BLOOD PT-12.9 PTT-43.4* INR(PT)-1.1
[**2144-9-19**] 05:10AM BLOOD PT-25.5* PTT-53.8* INR(PT)-2.6*
[**2144-10-7**] 06:01AM BLOOD Glucose-112* UreaN-23* Creat-0.6 Na-132*
K-3.8 Cl-93* HCO3-34* AnGap-9
[**2144-9-19**] 05:10AM BLOOD Glucose-148* UreaN-23* Creat-0.8 Na-140
K-3.5 Cl-104 HCO3-27 AnGap-13
[**2144-10-6**] 05:57AM BLOOD CK-MB-3 cTropnT-<0.01
[**2144-9-23**] 04:52PM BLOOD CK-MB-NotDone cTropnT-1.28*
[**2144-9-21**] 11:21AM BLOOD CK-MB-NotDone cTropnT-1.12*
[**2144-9-20**] 03:17PM BLOOD CK-MB-21* MB Indx-11.2* cTropnT-1.13*
[**2144-10-7**] 06:01AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.7
[**2144-9-19**] 09:46PM BLOOD Calcium-8.2* Phos-2.9 Mg-1.5*
[**2144-10-5**] 08:16AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2144-9-22**] 04:40PM BLOOD Type-ART pO2-98 pCO2-35 pH-7.38
calTCO2-22 Base XS--3 Intubat-INTUBATED Vent-CONTROLLED
[**2144-10-9**] 06:22AM BLOOD WBC-9.9 RBC-2.77* Hgb-9.0* Hct-26.0*
MCV-94 MCH-32.5* MCHC-34.7 RDW-18.5* Plt Ct-286
[**2144-10-9**] 06:22AM BLOOD Glucose-91 UreaN-20 Creat-0.7 Na-133
K-3.9 Cl-95* HCO3-32 AnGap-10
[**2144-10-9**] 06:22AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.9
Brief Hospital Course:
A/P:
[**Age over 90 **] year old woman with HTN, asthma, osteoarthritis, and GERD who
presented with L femur and R humeral fracture status post fall.
Admitted to MICU for tachycardia, periods of hypotension and
hypoxemia, and falling hematocrit. Tachycardia improved with
volume resuscitation and with pain control. On hospital day 3,
the patient underwent ORIF of her L femur fracture and reduction
of R humeral fracture. Her post-operative course was
complicated by new onset atrial fibrillation which was
controlled with diltiazem and for which prophylaxis was started
with lovenox. In addition, the patient had an NSTEMI with
evidence of new septal hypokinesis on cardiac ECHO. Her MICU
course was also complicated by [**Age over 90 **] UTI.
Transferred to the medical service for medical management of
pulmonary edema. Developed a pseudomonas bacteremia, for which
patient was treated with vancomycin, gentamicin, and
ciprofloxacin.
.
1) Humeral and femur fracture:
Right humeral and left humeral fracture. Right humerus in cast
and left intramedullary nail in place. Pain managed with
hydromorphone. As patient developed transient decreases in
blood pressure when administered IV, better results achived when
administered SC. Previous enterobacter (necessitating hardware
removal in [**1-9**]) and MRSA required lifelong doxycycline
treatment. Enoxaparin 60mg q12hr used for DVT prophylaxis and
to anticoagulate. Lower extremity pulses auscultated by
Doppler, with right greater than left dorsalis pedis pulses.
Left upper thigh wound slightly erythematous during
hospitalization. Culture revealed pseudomonas. Orthopedics
team opted to not remove hardware. Will treat with life-long
antibiotics course of doxycycline and ciprofloxacin. A two week
course of IV gentamicin will continue following discharge.
Encourage patient out of bed with assistance. Patient able
to sit in chair without pain.
.
2) Bacteremia/Lower extremity cellulitis:
Blood cultures on [**10-1**] positive for pseudomonas. History of
blood infections (MRSA and enterobacter) in [**2142**]. On [**10-2**],
elevated white count to 20 and fever to 100.3. Infectious
disease team consulted and recommended changing linezolid to
vancomycin on [**10-2**], but then switched to ceftazidime and
levofloxacin. Once sensitivites achieved, switched to
ciprofloxacin 400 IV q12, as ceftaz resistant. Continued
vancomycin. Added gentamicin 90 IV qd on [**10-4**]. Lower extremity
cellulitis improving.
White count has continued to trend downwards since [**10-2**].
Doses for vancomycin and gentamicin adjusted for therapeutic
goals. At no point did sputum cultures reveal pseudomonas.
On discharge, patient will remain on gentamycin for 2 weeks,
until [**10-18**]. She will remain on doxycycline and
ciprofloxacin for the remainder of her life. If she develops a
temperature when discharged, she will need to have blood
cultures drawn immediately. In there are gram negative rods
found in the culture, she will need to be transported
IMMEDIATELY back to [**Hospital1 69**] for IV
antibiotic treatment.
.
3) Hypoxemia:
Upon transfer from MICU, patient required supplemental oxygen.
Evidence of edema on previous chest films. Following surgery,
patient probably developed stunned myocardium and her net fluid
balance had been positive for several days. Initially goal was
to gently diurese patient, with IV lasix doses given on PRN
basis. On [**10-4**], she developed flash pulmonary edema, that was
relieved with lasix 20mg IV x2 and one dose of 40mg IVx1.
Subsequent to event, patient was continued on IV lasix with
diuresis continued. On [**10-6**], patient able to achieve 93% oxygen
saturation on ambient air. Will continue PO lasix upon
discharge.
.
4) UTI:
On admission, patient's UTI treated with ceftriaxone.
Sensitivities revealed [**Last Name (LF) **], [**First Name3 (LF) **] patient started on linezolid, but
changed to vancomycin on [**10-2**]. Foley was changed on [**10-2**], and
urine cultures from [**10-2**] negative to date.
.
5) NSTEMI/Atrial Fibrillation:
Following surgical repair of fracture, post-operatively,
patient developed new onset of atrial fibrillation. Thought to
be likely to increased intravascular volume. Also, during
surgery, patient may have developed demand ischemia, as
manifested by new septal hypokinesis on ECHO. The ischemia was
most likely transient. Rate control achieved through metoprolol
and diltiazem. Anticoagulation achieved through enoxaparin.
Will be discharged on atenolol and lisinopril, in place of
metoprolol and captopril.
On [**10-4**], patient developed ten beats of polymorphic VT. Blood
pressure remained stable. Troponin was 0.02, but returned to
<0.01. No acute EKG changes noted. Monitored electrolytes to
ensure that K>4.0 and Mg>2.0.
.
6) Mental Status:
Patient has history of CVA in [**2140**] that resulted in short term
memory loss. During admission, patient oriented only to self
and place. As hospital stay lengthened, patient became more
interactive. The team tried to continually find a balance
between pain relief and decreased mentation from pain
medications.
As there was concern, initially, that mental status was not
improving, head CT performed on [**9-30**]. It revealed no
intracranial hemorrhage, but multiple chronic large and small
vessel infarctions. An MRI of the head was not obtained.
.
7) Hypotension:
Initially etiology for hypotension unclear. Considered
potential infectious, versus acute bleeding episode. Patient
responded well to fluid and blood transfusions after initial
episode of hypotension. Bleeding resolved following hematocrit
drop before surgery. Antibiotics started. No further episodes
of hypotension during hospitalization.
.
8) Hypertension:
Continued patient on lisinopril, atenolol, and diltiazem.
.
9) Anemia:
Following surgery on [**9-22**], patient required 2 units of packed
red blood cells. Hematocrit has remained stable in the low 30's
since this event.
.
10) Hypothyroid:
Patient was continued on levothyroxine during hospitalization.
.
11) FEN:
NGT placed during recovery from surgery. With altered mental
status, patient aspiration risk. On [**10-6**], patient passed speech
and swallow test to drink nectars and dysphagia solids. Will
remove NGT once PICC line placed. Discharged taking adequate PO
intake.
.
12) Asthma:
During admission, continued ibratropium nebulizers, as needed.
.
13) Prophylaxis:
Patient placed on enoxaparin SC and a proton pump inhibitor
for GERD.
.
14) Access:
Difficult to achieve access in patient. Peripheral IVs were
tenuous. Central IJ removed once PICC in place.
.
15) Dispo:
DNR/DNI.
Daughters actively involved in care. [**Doctor Last Name **] is healthcare proxy
([**Telephone/Fax (1) **]). Will be placed in rehabilitation facility
following hospital stay.
Medications on Admission:
1. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QSUN
(every Sunday).
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation DAILY (Daily).
3. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
12. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic daily
14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
18. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
20. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed.
All: PCN/Sulfa/ASA/Heparin/Shellfish
Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
11. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
12. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
13. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q6H
(every 6 hours) as needed for pain.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO TID (3 times a day).
16. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO ONCE
(Once) for 1 doses.
17. Gentamicin 90 mg IV Q24H
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every other
day: Please alternate each day with 60 mg PO lasix.
19. Lasix 20 mg Tablet Sig: Three (3) Tablet PO every other day:
Please alternate with 40 mg every other day.
20. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
21. Atenolol 100 mg Tablet Sig: Three (3) Tablet PO once a day.
22. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
23. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
24. Outpatient Lab Work
Please draw weekly CBC, BUN, Cr, Gentamicin trough and peak
values and fax to Dr. [**Last Name (STitle) 3394**] at [**Telephone/Fax (1) 41334**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Primary:
-Left femur fracture
-Bacteremia
-Hypertension
-Atrial Fibrillation
.
Secondary:
-GERD
-CVA in [**2140**] (residual short-term memory loss and diminished
vision bilaterally)
-Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-8**]
-Hypothyroidism
-Asthma
Discharge Condition:
Stable.
Discharge Instructions:
**You were admitted for a femur and humeral fracture. You
developed atrial fibrillation and then developed difficulty
breathing without supplemental oxygen. In addition, you
developed an infection in your blood.
**During your stay, your leg fracture was operated upon and you
were treated for your blood and urine infections.
**You will be discharged home on a variety of medications, some
of which are new. You should continue to take all your
medications that are ordered at discharge.
**You will need to remain on gentamycin for 2 weeks, until
[**10-18**]. You will remain on doxycycline and ciprofloxacin
for the remainder of your life. If you develop a temperature,
you need to have blood cultures drawn immediately. In there are
gram negative rods found in the culture, you need to be
transported IMMEDIATELY back to [**Hospital1 1170**] for IV antibiotic treatment.
**You no longer will take coumadin.
**If you develop chest pain, shortness of breath, or any other
concerning symptoms, you need to call your doctor or go to the
ED immediately.
**You will need to have weekly blood work faxed to Dr. [**Last Name (STitle) 3394**] at
[**Telephone/Fax (1) **] (CBC, Cr, BUN, gentamicin peak and trough).
Followup Instructions:
**You need to follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 30642**] [**Name (STitle) **] ([**Telephone/Fax (1) **]) on Friday [**2144-10-23**] at 2:00pm. [**Street Address(2) 41335**], [**Location (un) 620**], MA.
**You need to follow-up with your orthopedic surgeon, Dr.
[**Last Name (STitle) **] on [**2144-11-5**] at 10:00am ([**Location (un) **], [**Location (un) 551**]
[**Hospital Ward Name 23**] Building). Phone number is [**Telephone/Fax (1) **].
**You need to follow-up with Dr. [**Last Name (STitle) 3394**] in the Infectious Disease
Clinic on [**10-27**] at 11am.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"812.40",
"427.1",
"821.01",
"790.29",
"593.9",
"599.0",
"428.0",
"E884.6",
"530.81",
"401.9",
"244.9",
"790.7",
"998.59",
"427.31",
"410.71",
"285.1",
"682.6",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.6",
"38.93",
"99.07",
"78.55",
"79.01",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
17402, 17486
|
6519, 11354
|
359, 393
|
17817, 17827
|
3343, 6496
|
19089, 19826
|
2903, 2922
|
15324, 17379
|
17507, 17796
|
13439, 15301
|
17851, 19066
|
2937, 2937
|
241, 321
|
421, 2276
|
2951, 3324
|
11371, 13413
|
2298, 2741
|
2757, 2887
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,186
| 111,646
|
35180
|
Discharge summary
|
report
|
Admission Date: [**2123-4-4**] Discharge Date: [**2123-4-22**]
Date of Birth: [**2054-12-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hurricaine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Severe tricuspid regurgitation.
Major Surgical or Invasive Procedure:
[**2123-4-6**]: Removal of right ventricular dual coil
pace-sense-defibrillator lead, right atrial pacing lead, right
ventricular pacing lead, right atrial pacing lead.
[**2123-4-16**]: Redo Redo sternotomy 29 mm [**Company 1543**] Mosaic Porcine
Tricuspid Valve Replacement, Epicardial Lead Placement + PPM +
AICD placement
History of Present Illness:
Mr. [**Known lastname 80287**] is a 68 year-old male with complex cardiac history
yearly exam with his PCP who ordered an echocardiogram which
showed increased tricuspid regurgitation with possible
constrictive physiology. He's had a 5 pound weight gain over
the past 5 days but denies DOE, orthopnea, Occasional PND,
increased
abdominal girth with mild nausea and decreased appetite.
Cardiac surgery was consulted for evaluation and recommendations
for possible constricture pericarditis physiology and increased
TR.
Past Medical History:
Past Cardiac History
Atrial tachycardia [**2117**]
Tricuspid vegetation 0,03,05
CHB s/p DDD [**Company **] [**2114**]
Past Medical History
Diabetes Mellitus Type 2
Hypertension/Hyperlipidemia
COPD
Asthma exercise induced
GERD
Mild Carotid stenosis [**2120**]
Peripheral Vascular disease
Past Surgical History
Cardiac Surgery:
[**2121**]: atrial flutter ablation
[**2121-1-20**]: placement of 2 LV Epicardial pacing wires via Left
anterior thoracotomy. Evacuation of hematoma.
[**2121**]: ICD [**Name8 (MD) 1543**] CRT ICD left pectoral region with removal of
right sided DDM
[**2118**]: Left atrial papillary elastofibroma resection
[**2114**]: s/p device explanted and re-implant, infection [**2-3**] trauma
[**2106**]: s/p mechanical AVR ([**Company **] [**Doctor Last Name **])/Ao root prosthesis c/b
CHB
PFO, moderate atrial septal aneurysm s/p closure
Left Rotator cuff surgery
Tonsillectomy
Back surgery (disc herniation)
Social History:
Race: Caucasian
Last Dental Exam: several teeth removed 2 mos ago h/o gingivitis
Lives with:wife
Occupation: retired construction
Tobacco:35 pack year, quit [**2102**]
ETOH: none for over 1 year.
Family History:
Brother died age 29 DM & heart failure. Mother CA
Physical Exam:
Pulse: 72-73 SR Resp: 16 O2 sat: 97% RA
B/P Right: 128/82 Left:
Height:5;11 Weight: 99.6 kg
General:
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 Good Click
Abdomen: Soft [x] distended [] non-tender [x] bowel sounds + []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
[x]
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit radiating AVR Right: 2+ Left: 2+
Pertinent Results:
[**2123-4-21**] 04:40AM BLOOD WBC-9.8 RBC-3.00* Hgb-9.3* Hct-27.0*
MCV-90 MCH-30.9 MCHC-34.3 RDW-16.1* Plt Ct-180
[**2123-4-20**] 04:35AM BLOOD WBC-8.6 RBC-2.92* Hgb-8.8* Hct-25.9*
MCV-89 MCH-30.1 MCHC-34.0 RDW-16.7* Plt Ct-157
[**2123-4-21**] 04:40AM BLOOD PT-15.0* INR(PT)-1.3*
[**2123-4-18**] 01:35AM BLOOD PT-15.6* PTT-27.9 INR(PT)-1.4*
[**2123-4-21**] 04:40AM BLOOD Glucose-49* UreaN-42* Creat-1.4* Na-135
K-4.1 Cl-96 HCO3-28 AnGap-15
[**2123-4-20**] 04:35AM BLOOD Glucose-110* UreaN-40* Creat-1.5* Na-136
K-3.7 Cl-97 HCO3-29 AnGap-14
[**2123-4-21**]
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is dilated with mild global free wall hypokinesis. There
is abnormal septal motion/position. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Trace aortic regurgitation is seen. [The amount of
regurgitation present is normal for this prosthetic aortic
valve.] The mitral valve leaflets are mildly thickened. A
bioprosthetic tricuspid valve is present. The tricuspid
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients. There is no pericardial effusion.
IMPRESSION: Normally functioning tricuspid valve replacement.
Dilated and hypokinetic right ventricle. There is abnormal
septal motion present, likely due to a combination of conduction
abnormality and pressure/volume overload. Normally functioning
aortic prosthesis, normal regional and global left ventricular
systolic function.
Compared with the prior study (images reviewed) of [**2123-4-9**], a
tricuspid valve prosthesis is now present. No tricuspid
regurgitation is seen. Pulmonary artery pressures cannot be
measured. The right ventricle is probably slightly smaller and
is hypokinetic on the current study. Dysfunction of the right
ventricle may have been masked by the degree of tricuspid
regurgitation on prior.
Brief Hospital Course:
Mr. [**Known lastname 80287**] was admitted on [**2123-4-4**] for a heparin bridge before
extraction of his RV lead and tricuspid valve replacement. His
lead was extracted and a new generator was implanted on [**2123-4-6**].
A perctoral hematoma formed which resolved with evaculation and
a pressure dressing. On [**2123-4-16**] he underwent a redo, redo
sternotomy, TV replacement (29mm porcine), epicardial lead
placement and PPM/AICD placement with Dr. [**Last Name (STitle) **]. Please see
the operative note for details. He tolerated this procedure well
and was transferred in critical but stable condition to the
surgical intensive care unit. He was extubated by the following
day. His pacer was interrogated and his epicardial wires were
removed. He was transferred to the surgical step down floor and
started on coumadin. By post-operative day six he was ready for
discharge to home with coumadin follow-up. All appointments
were advised.
Medications on Admission:
Dofetilide 250 mcg every 12 hours
Losartan 25 mg daily
Metoprolol 50 mg [**Hospital1 **]
ASA 81 mg daily
Spironolactone 25 mg daily
Furosemide 20 mg daily
Simvastatin 40 mg daily
Coumadin 5 mg M/W/F/7.5 mg Tu/[**Last Name (un) **]/Sat/Sun
Glyburide 10 mg [**Hospital1 **]
Metformin 1000 mg [**Hospital1 **]
Januvia 100 mg daily
Omeprazole 40 mg [**Hospital1 **]
Ranitidine 150 mg daily
Docusate 100 mg [**Hospital1 **]
Acetminophen prn
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-3**] inhalations Inhalation Q4H (every 4 hours)
as needed for sob, wheezing.
6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
10. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. potassium chloride 20 mEq Packet Sig: One (1) Packet PO
DAILY (Daily) for 14 days: take 20meq for 14 days, then
discontinue.
Disp:*14 Packet(s)* Refills:*2*
13. glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
16. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
17. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day for 14
days: take 40mg daily for 14 days, then decrease to 20mg daily
ongoing.
Disp:*28 Tablet(s)* Refills:*2*
18. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal [**2-4**] for afib. First INR to be drawn on [**4-23**] with results to
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]-[**Doctor First Name 10588**] Phone: [**Telephone/Fax (1) 11254**]
.
Disp:*30 Tablet(s)* Refills:*2*
19. Outpatient Lab Work
INR goal [**2-4**] for afib. First INR to be drawn on [**4-23**] with
results to Dr. [**Last Name (STitle) **],[**First Name3 (LF) **]-[**Doctor First Name 10588**] Phone: [**Telephone/Fax (1) 11254**]
20. Outpatient Lab Work
BUN/Creatinine/Potassium check one week from discharge
Discharge Disposition:
Home With Service
Facility:
community health and hospice
Discharge Diagnosis:
1. Severe tricuspid regurgitation.
2. Status post biventricular implantable cardioverter
defibrillator [**2121**].
3. Status post unused previously implanted right atrial and
right
ventricular pacing leads [**2114**].
4. Status post aortic valve replacement
5. Congestive heart failure.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
1+ LE 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:
You are scheduled for the following appointments:
Wound Check [**4-28**] at 10:30
Surgeon: Dr [**Last Name (STitle) **] on [**5-13**] at 1:15 PM
ICD check 1 week with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 11250**], please call to
arrange
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 11250**] ([**Telephone/Fax (1) 59543**] at [**5-27**] at 11:45 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 Atrial fibrillation
Goal INR 2.0-2.5
First draw [**2123-4-23**]
Results to phone Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 11250**] [**Telephone/Fax (1) 11254**]
Completed by:[**2123-4-22**]
|
[
"998.12",
"250.40",
"425.4",
"V58.67",
"428.0",
"424.2",
"583.81",
"427.32",
"530.81",
"362.33",
"443.9",
"E878.1",
"416.8",
"V43.3",
"493.20",
"V53.32",
"428.23",
"789.59",
"573.0",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.79",
"39.61",
"37.78",
"35.27",
"37.77",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
9083, 9142
|
5126, 6082
|
309, 636
|
9481, 9652
|
3089, 5103
|
10492, 11425
|
2370, 2422
|
6569, 9060
|
9163, 9460
|
6108, 6546
|
9676, 10469
|
2437, 3070
|
238, 271
|
664, 1185
|
1207, 2140
|
2156, 2354
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,110
| 130,087
|
50083
|
Discharge summary
|
report
|
Admission Date: [**2153-9-15**] Discharge Date: [**2153-9-17**]
Date of Birth: [**2092-12-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13891**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60M with history of CCY in [**2150**] followed by recurrent CBD stones
requiring ERCP x5 including sphincterotomy and potential for
balloon dilitation (although not yet performed), transferred
from [**Hospital3 **] Hospital for ERCP.
Over past week, has had RUQ pain that has resolved
spontaneously. Has actually had, typically, early morning,
transient spasmotic pain. However, yesterday, patient developed
sharp and unremitting RUQ pain, radiating to the back, worse
than 10 out of 10 pain, accompanied by nausea although no frank
vomiting and has subsequently avoided taking any POs. Has not
noticed any fevers.
In the ED, initial VS were:
97.7 51 156/97 20 97%
In the ED today, patient received 3L NS. Laboratory studies in
the ED were notable for normal chem 7, normal PT/PTT/INR at
11.9/31/1.1, no leukocytosis at 10.6, hematocrit of 44.8, and
lactate 1.0. Repeat lactate at 6PM was 2.6, but had dropped to
0.8 by 8PM after fluid resuscitation. LFTs were also wnl with
ALT 31, AST 37, AP 65, Tbili 1.3. Lipase was 26. Troponin x1 <
0.01. Blood culture, Urine culture were sent.
CXR was performed, which was benign, with clear lung fields,
normal cardiomediastinal silhouette, and normal osseus and soft
tissue structures. CT abdomen was also performed, with wet read
suggesting small pneumobilia (suggesting instrumentation), no
intrahepatic bile, and CBD diltation to 14 mm (which can be seen
after cholecystectomy). Finally, RUQ US was performed, with wet
read suggesting hepatic steatosis (due to echogenic liver),
prominence of CBD without intrahepatic biliary dilitation c/w
post-CCY status.
In addition, the patient required pain control dilaudid 5 mg
over the course of the first hour. Then was found to have heart
rate dropping to 30s (transiently) and also with respiratory
depression. Patient also with nausea/vomiting, diaphoresis, and
worsening pain. Received Narcan 0.4 and then 0.2 to total of
0.6 mg. Patient improved, and on transfer, was found to be
lying comfortably in bed without any need for additional
narcotics.
On transfer from the ED, VS were:
98.0 54 150/95 10 99%
On arrival to the MICU, patient's VS.
98.2 54 159/95 12 96% RA
Pain currently is in same location in RUQ. Pain is [**7-8**], sharp
in character. Says HR tends to run in 50s.
Past Medical History:
Hypertension
Cholecystectomy [**7-7**]
Recurrent CBD stones requiring repeated ERCP
Social History:
[**Doctor Last Name **] x30 yrs
Has son & daughter (going to college this yr, wants to be a
nurse) with ex-wife
Lives with significant other, [**Name (NI) **] (who is HCP)
Denies smoking ever & currently
Drinks 20-25 beers per week
No illicit drug use
Family History:
Cardiac disease hx in grandparents
Son has lymphoma, now in remission, cared for at [**Company 2860**]
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Soft, non-distended, bowel sounds present, no
organomegaly. Tender to palpation in RLQ > RUQ. No rebound or
guarding. No [**Doctor Last Name **] sign.
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.
Exam on day of discharge:
Afebrile, vital signs stable
HEENT: No scleral icterus
Lungs: Clear B/L on auscultation
CV: RRR, S1S2 present
Abd: Soft, non tender, non distended. No rebound or guarding
EXT: NO edema
Pertinent Results:
Chest XR [**9-15**]:
FINDINGS: Single portable view of the chest is compared to
previous exam from earlier the same day at 12:44 p.m. The lungs
remain clear. Cardiomediastinal silhouette is stable as are the
osseous and soft tissue structures. No visualized free air is
seen below the diaphragm. IMPRESSION: No significant interval
change since prior, no visualized air below the diaphragm.
CT Abd [**9-15**]:
IMPRESSION:
1. No liver abscess or CT evidence of cholangitis. Normal
appendix.
2. Left hepatic lobe pneumobilia with air in the CBD compatibel
with prior
spincterotomy. CBD dilation to 13 mm is likely
post-cholecystectomy.
3. Probably focally dilated duct in hepatic segment V versus
portal venous
thrombosis. Mildly enlarged porta hepatic lymph nodes. If not
already
performed, MRCP is recommended for further evaluation.
4. Left renal lower pole 1-cm exophytic hyperdense lesion with
peripheral
hyperdensity. Renal ultrasound is recommended for further
evaluation.
MRCP [**2153-9-16**]:
No CBD stones, normal caliber bile duct, normal caliber
pancreatic duct.
Cysts seen in kidneys- simple cyst
Iron deposition in the liver concerning for hemochromatosis.
RUQ U/S [**9-15**]:
1. Mildly echogenic liver, likely due to technical factors.
2. Mild prominence of the CBD likely relates to the
post-cholecystectomy
status. No intrahepatic biliary dilatation
[**2153-9-15**] 03:15PM BLOOD WBC-10.6 RBC-4.94 Hgb-15.0 Hct-44.8
MCV-91 MCH-30.5 MCHC-33.6 RDW-12.7 Plt Ct-175
[**2153-9-15**] 03:15PM BLOOD PT-11.9 PTT-31.0 INR(PT)-1.1
[**2153-9-15**] 03:15PM BLOOD Glucose-97 UreaN-16 Creat-0.8 Na-139
K-4.1 Cl-106 HCO3-22 AnGap-15
[**2153-9-15**] 03:15PM BLOOD ALT-31 AST-40 AlkPhos-68 TotBili-1.1
[**2153-9-17**] 06:05AM BLOOD WBC-5.4 RBC-4.82 Hgb-14.7 Hct-42.5 MCV-88
MCH-30.5 MCHC-34.6 RDW-12.4 Plt Ct-179
[**2153-9-17**] 06:05AM BLOOD Glucose-86 UreaN-9 Creat-0.9 Na-140 K-4.1
Cl-104 HCO3-29 AnGap-11
[**2153-9-17**] 06:05AM BLOOD ALT-23 AST-22 LD(LDH)-140 AlkPhos-66
TotBili-1.1
[**2153-9-15**] 07:55PM BLOOD Lipase-26
[**2153-9-17**] 06:05AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
Brief Hospital Course:
This is a 60 y/o M with history of cholecystectomy in [**2150**] with
recurrent CBD stones requiring ERCP x5 in past presented with
RUQ abdominal pain.
# RUQ PAIN: Patient's RUQ pain was attributed likely [**3-1**] biliary
obstruction vs. cholangitis. There was low suspicion for
cholangitis with normal LFTs, normal bili, lack of fever, or
jaundice. The patient was treated conservatively with IVF and
initally bowel rest. He underwent CT of the abdomen, ultrasound
and MRCP. The CT scan showed common bile duct dilitation
compatable with prior cholecystectomy. Ultrasound showed the
same. The patient also underwent MRCP which showed no stones in
the CBD or pancreatic duct. There were concerns for iron
deposition in the liver concerning for hemochromatotis. The
patient was not treated with antibiotic therapy as there was no
evidence of active infection. The patient's pain resolved
without inetervention, he was able to tolerate a regular diet
prior to discharge. The case was discussed with the ERCP team
here who felt there was no need for acute intervention given
resolution of symptoms.
# BRADYCARDIC EPISODE: Patient with bradycardic episode in ED.
This was though to be secondary to dilaudid, combination with
exaggerated vagal activity with nausea/vomiting. Patient had no
further episodes.
# BENIGN HYPERTENSION:
- on lisinopril and aspirin.
#RENAL CYSTS:
- the patient had evidence of renal cysts on his CT-- these were
characterized as cysts on MRI. These should be followed as an
outpatient.
Transitional care issues to be followed as outpatient:
- Renal Cysts
- Iron deposition in liver concerning for hemochromatosis
Medications on Admission:
Lisinopril 20 mg qDaily
Aspirin 81 mg qDaily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted from [**Hospital3 **] hospital with abdominal pain.
While you were in the emergency department you were found to
have a low heart rate. You were monitored in the ICU overnight
and your heart rate normalized. You underwent an MRCP (MRI of
the area around your gallbladder ducts and pancreas)which did
not show any gallbladder stones. You were seen by surgery and
your case was discussed with the ERCP team here who recommended
outpatient follow up. Your pain resolved witout intervention and
you were able to tolerate a regular diet prior to discharge.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 275**] N.
Location: [**Hospital3 **] INTERNAL MEDICINE
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 58635**]
Phone: [**Telephone/Fax (1) 31938**]
Appt: Tuesday, [**9-25**] at 8:30am
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Address: ONE LYNXHOLM COURT, [**Location (un) **],[**Numeric Identifier 33731**]
Phone: [**Telephone/Fax (1) 104569**]
Appt: Tuesday, [**10-9**] at 1:45pm
[**Name6 (MD) 3130**] JUPITER MD [**MD Number(2) 13893**]
Completed by:[**2153-9-17**]
|
[
"789.01",
"275.03",
"576.8",
"401.1",
"427.89",
"593.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7967, 7973
|
6148, 7791
|
321, 327
|
8032, 8032
|
4018, 6125
|
8777, 9409
|
3040, 3145
|
7887, 7944
|
7994, 8011
|
7817, 7864
|
8183, 8754
|
3160, 3999
|
267, 283
|
355, 2646
|
8047, 8159
|
2668, 2754
|
2770, 3024
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,292
| 192,506
|
46590
|
Discharge summary
|
report
|
Admission Date: [**2167-11-18**] Discharge Date: [**2167-11-24**]
Service: MEDICINE
Allergies:
Crestor / Ciprofloxacin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 88-year-old gentleman with a history of CAD s/p LAD
stent, heart block s/p PPM, Parkinson's who presents with
shortness of breath, cough.
Dr. [**Known lastname **] states that 3 days PTA he noted the onset of sore
throat, rhinorrhea, productive cough with yellow/green
expectorant. He went to see his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**] who diagnosed
him with bronchitis and prescribed a course of Amoxicillin given
his allergy to Fluoroquinolones. Unfortunately he noted an
increase in cough and SOB. As such, he presented to the ED.
Patient denies any fevers, chills, nausea, vomiting, sick
contacts. [**Name (NI) **] received the influenza vaccine but not the H1N1. He
has had decreased PO intake over the past few days secondary to
not feeling well. Dr. [**Known lastname **] denies history of aspiration and eats
a normal diet.
Patient was taken to the ED where his initial vitals were noted
to be T97.7, HR 81, BP 143/62, RR 26, Sat 100% on 5L facemask.
He was triggered in the ED for a RR in the 40s and documented to
have a fever of 102.1 [**Name8 (MD) **] MD note. Tachypnea seemed to improve
with nebulizer treatment.
Labs were notable for a WBC of 9.6 with a left shift. Creatinine
of 1.4 (prior Creatinine 1.0-1.4). A chest x-ray was obtained
which showed only minimal left basilar atelectasis. Given the
level of his respiratory distress and unremarkable CXR he
underwent a CTA, which showed no evidence of PE but did show
small bilateral pleural effusions small on left and trace on
right. Possible atelectasis vs infection on left base. He
received some symptomatic relief with Combivent, he was also
started on Zosyn and Vanc for CAP.
Prior to transfer vital signs were HR 74, 114/67, RR 25, Sat
100% on NRB. In the ICU he was noted to be mildly tachypneic in
the 20s, saturating 99% on 3 LPM nasal cannula.
Past Medical History:
Hyperlipidemia
Glaucoma
CAD s/p cath [**2158**] s/p LAD stent
Bradycardia
Prostate Cancer s/p XRT ([**2152**])
HTN
Basal Cell Carcinoma
GERD
Parkinson's Disease
Mobitz Type I block s/p PPM placement
Pernicious Anemia
Hematuria
Left nephrolithotomy ([**2127**])
Social History:
Pt is a retired FP physician, [**Name10 (NameIs) 9116**] lives at home with his
wife. [**Name (NI) **] does have a history of tobacco use 2ppd x
26years, but he quit 44 years ago. Denies any Etoh use or IVDU.
Family History:
Non-contributory.
Physical Exam:
T=97.8, BP=79-85, HR=133-136/46-51, RR=23-25, O2= 99% on 3 LPM
nasal cannula.
GENERAL: Elderly Caucasian Male with intention tremors sitting
up in bed with mild tachypnea.
HEENT: EOMI, PERRL, mucous membranes tacky.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Crackles noted in the LLL otherwise CTA. noted to be
mildly tachypneic (20s), no accessory muscle use.
ABDOMEN: NABS. Soft, NT, ND. No HSM
Back: No CV tenderness.
EXTREMITIES: 2+ pitting edema b/l to knees.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN II-[**Last Name (LF) **],[**First Name3 (LF) 81**], XII intact on examination. Tremors
with tongue protrusion. Intentions tremors noted in upper
extremities.
Pertinent Results:
CXR [**11-17**]:
UPRIGHT AP VIEW OF THE CHEST: Left side dual-chamber pacemaker
leads
terminating in the right atrium and right ventricle is again
demonstrated. The cardiac silhouette is unchanged in size and
within normal limits. The aortic knob is calcified. While there
is mild prominence of the pulmonary vascular markings, no overt
pulmonary edema is noted. There is minimal linear atelectasis
within the left lung base. Otherwise, the lungs are clear
without focal consolidation, pleural effusion or pneumothorax.
No acute skeletal abnormalities are visualized.
IMPRESSION: Minimal left basilar atelectasis. No acute
cardiopulmonary
abnormality.
[**2167-11-18**] 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2167-11-18**] 07:45PM URINE RBC-<1 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2167-11-18**] 07:00PM GLUCOSE-127* UREA N-26* CREAT-1.4* SODIUM-139
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2167-11-18**] 07:00PM ALT(SGPT)-20 AST(SGOT)-23 CK(CPK)-199* ALK
PHOS-71 TOT BILI-0.6
[**2167-11-18**] 07:00PM LIPASE-57
[**2167-11-18**] 07:00PM CK-MB-5 cTropnT-0.02* proBNP-550
[**2167-11-18**] 07:00PM WBC-9.6 RBC-4.23* HGB-12.0* HCT-36.9* MCV-87
MCH-28.4 MCHC-32.6 RDW-15.0
[**2167-11-18**] 07:00PM NEUTS-79.6* LYMPHS-13.7* MONOS-3.6 EOS-2.9
BASOS-0.2
[**2167-11-19**] 02:28AM BLOOD WBC-7.3 RBC-3.63* Hgb-10.3* Hct-31.0*
MCV-85 MCH-28.5 MCHC-33.3 RDW-14.7 Plt Ct-147*
[**2167-11-20**] 05:30AM BLOOD WBC-6.2 RBC-3.45* Hgb-9.9* Hct-29.1*
MCV-84 MCH-28.8 MCHC-34.1 RDW-14.8 Plt Ct-169
[**2167-11-21**] 06:55AM BLOOD WBC-6.0 RBC-3.38* Hgb-9.6* Hct-28.6*
MCV-85 MCH-28.5 MCHC-33.7 RDW-14.9 Plt Ct-169
[**2167-11-22**] 06:55AM BLOOD WBC-5.2 RBC-3.54* Hgb-10.0* Hct-29.7*
MCV-84 MCH-28.3 MCHC-33.7 RDW-14.5 Plt Ct-168
[**2167-11-22**] 06:55AM BLOOD Glucose-95 UreaN-22* Creat-1.2 Na-139
K-4.3 Cl-106 HCO3-23 AnGap-14
[**2167-11-22**] 06:55AM BLOOD LD(LDH)-186 TotBili-0.5
[**2167-11-22**] 06:55AM BLOOD Hapto-275*
MRSA SCREEN (Final [**2167-11-21**]): No MRSA isolated.
BCx x 2 12/3/0/09 No growth
UCx [**2167-11-18**] No growth
Urinary Legionella Antigen, Influenza A & B testing all
negative.
ECHO [**2167-11-24**]: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 60%). 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 tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
ICU Summary:
This is an 88-year-old gentleman with CAD s/p stent to LAD, h.o.
Wenkebach s/p PPM, Parkinson's disease who presents with cough
suggestive of bronchitis vs. PNA.
.
##. DYSPNEA: Patient with cough, small effusions on CT of chest.
This was felt to be pneumonia, and he produced sputum at time,
but improved with antibiotics. Patient has no history of
hospitalization, no aspiration history (denies), and did receive
influenza vaccine this year. Flu swab and urine legionella are
both negative. CXR and physical exam did not suggestive of
volume overload. As such, we felt it appropriate to treat as a
community acquired pneumonia. Patient received one dose of
zosyn/vanc in ED, but this was switched to ceftriaxone on the
floor. (Antibiotic choices are limited due to floroquinolone
allegy; moreover, pharmacy warned about the concurrent
administration of azithromycin and amiodarone). Patient was
given albuterol/ipratropium nebs as needed. He developed a rash
which went away despite continuation of the antibiotic. He
continued to improved from respiratory standpoint and Oxygen was
weaned. He will complete 7 day course Ceftriaxone on [**2167-11-25**].
.
##. ELEVATED TROPONINS: Pt noted to have increased Troponin of
0.02, CK 199 with negative CKMBs in the setting of renal
failure. EKG shows no gross ST segment changes but difficult to
interpret [**12-22**] paced rhythm. Suspect elevated troponins are due
to renal failure. Second set of cardiac enzymes show CK down to
163 with MB of 4. An ECHO showed no depressed EF.
##. ELEVATED CREATININE: Pt noted to have borderline pre-renal
azotemia with BUN/Creatinine of 26/1.4. Unfortunately pt has no
recent lab data for an accurate baseline, in the past he has had
Creatinine of 1.3-1.8 (though in the setting of treatment for
prostate cancer). Mr. [**Known lastname **] also received dye for CTA, which is
another explaination for elevated creatinine. We continued to
monitor his urine output and trended creatinine. On discharge
his Cr was 1.2, which represents chronic kidney disease. His
Lasix was decreased to 20mg daily and can be titrated by his
PCP.
.
##. LOWER EXTREMITY EDEMA: Pt states his edema is baseline and
attributed to venous insufficiency; we have no ECHO to determine
diastolic function. In light of dry mucous membranes, increased
creatinine, and exposure to IV contrast furosemide was held.
I's and O's and daily weights were monitored as was the edema,
and lasix given [**2167-11-23**] when he was more wheezy, had increased
edema and not responding to nebs. He has moderate pulm HTN by
echo which may be contributing. Lasix will be given on
discharge at 20mg orally daily, [**11-21**] former dose.
## DIASTOLIC DYSFUNCTION: On [**2167-11-23**] after several days without
lasix, was more wheezy and not resoponsive to nebs, but was to
IV lasix. ECHO done [**2167-11-24**] prior to discharge, and verbal
communication indicated no depressed EF or gross abnormalities.
Likely diastolic dysfunction. His PCP is aware and will follow
up the report.
.
##. PARKINSON'S DISEASE: Continued home regimen of sinemet.
.
##. GERD: Omeprazole was continued. Home dose is 10mg, but
patient was started on 20mg here as 10mg is not formulary.
.
##. AFIB: Patient was continued on amiodarone. He is not
anticoagulated.
.
##. CAD S/P STENT TO LAD: ASA was continued. Patient is on
home regimen of 30mg ISDN ER; this was not available during
admission, so ISDN 10mg TID was started. He is not on
betablocker presumably because of COPD
.
## Rash: Possibly medication related. It went away on its own
without removal of mes.
.
Electrolytes were repleted. Dr. [**Known lastname **] was kept on a cardiac
diet, made soft b/c of gum pain and difficulty eating with
dentures. Ensure Plus at meals was given per nutrition consult.
He was given heparin SQ TID and maintained on a PPI. He had
peripheral access. He is full code. Emergency contact is wife
[**Name (NI) **] [**Name (NI) **] (Wife) [**Telephone/Fax (1) 1408**].
Medications on Admission:
Aspirin 81mg daily
Amiodarone 50mg qHS
Isosorbide Dinitrate ER 30mg daily
Furosemide 40mg daily
Sinemet CR 50-200 mg qHS
MVI daily
Omeprazole 10mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: 0.25 Tablet PO QHS (once a day
(at bedtime)).
3. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO QHS (once a day (at bedtime)).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for wheezing.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic one
drop in each eye once/day ().
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours).
9. Isosorbide Dinitrate 30 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Community Acquired Pneumonia
Chronic Anemia
CKD
Acute Diastolic Congestive heart failure
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
found to have pneumonia. This has been treated with IV
antibiotics and you will continue a full 7 day course, through
[**2167-11-25**]. You developed a rash which then subsided. Your blood
count was noted to be low after admission, but is stable, and
likely represents a chronic anemia which can be addressed
further with your PCP who is aware. Physical therapy evaluated
you and you are being discharge to a rehab facility. You
received an echocardiogram which showed good pump function.
Your lasix dose was halved to 20mg daily.
Followup Instructions:
Call your PCP office to schedule a follow up appointment with
him within the next 2 weeks.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2168-2-15**]
2:00
|
[
"332.0",
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"V45.82",
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"486",
"585.9",
"518.0",
"530.81",
"799.02",
"428.0",
"285.9",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11527, 11593
|
6362, 10388
|
241, 247
|
11726, 11726
|
3474, 6339
|
12519, 12722
|
2678, 2697
|
10591, 11504
|
11614, 11705
|
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|
2712, 3455
|
194, 203
|
275, 2151
|
11740, 11872
|
2173, 2435
|
2451, 2662
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,666
| 186,325
|
3961
|
Discharge summary
|
report
|
Admission Date: [**2117-6-11**] Discharge Date: [**2117-6-18**]
Date of Birth: [**2053-5-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**2117-6-11**]
Left thoracotomy and left upper lobe and left lower lobe wedge
resection
History of Present Illness:
Ms [**Known lastname **] is a 64F with a h/o
stage IIIA NSCLC since [**2095**]. She received neoadjuvant chemo
followed by a right pneumonectomy then had post op XRT. She has
been followed by Dr [**Last Name (STitle) **] since [**2112**] for dyspnea/COPD and noted
worsened DOE 12/[**2115**]. She has declined the recommended O2 use.
A CXR [**3-/2117**] noted a new peripheral LUL opacity followed by a
Chest CT finding a 2x2.4cm sipculated LUL mass, a 2mm GG nodule
LLL and other GG lesions in left lung. The LUL mass had an FDG
uptake of 12.7 with the LLL lesion having low level avidity. She
presents today for surgical wedge resection.
placement.
Past Medical History:
PAST MEDICAL HISTORY:
stage IIIA nsclc, s/p pre op chemo, R pneumonectomy, post op XRT
[**2095**]
COPD
GERD
obesity
osteopenia
hypothyroidism
Social History:
Cigarettes: [ ] never [x ] ex-smoker [ ] current
Pack-yrs:_44___
quit: 1991______
ETOH: [ ] No [ ] Yes drinks/day: _____
Drugs:
Exposure: [x ] No [ ] Yes [ ] Radiation
[ ] Asbestos [ ] Other:
Occupation: former bank teller and waitress
Marital Status: [ ] Married [ ] Single
Lives: [x] Alone [ ] w/ family [ ] Other:
Other pertinent social history:
Travel history:
Family History:
Mother: alive w/ pacemaker
Father: died lung cancer, CAD
Siblings
Offspring
Other
Physical Exam:
BP: 139/66. Heart Rate: 99. Weight: 175.5. Height: 58.5. BMI:
36.1. Temperature: 98. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 96.
GENERAL [x] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [ ] abnormal findings:
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [ ] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[x] Abnormal findings: no BS on right chest
CARDIOVASCULAR [x] All findings normal
[ ] RRR [ ] No m/r/g [ ] No JVD [ ] PMI nl [ ] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [x] All findings normal
[ ] Soft [ ] NT [ ] ND [ ] No mass/HSM [ ] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [x] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [ ] Abnormal findings:
MS [x] All findings normal
[ ] No clubbing [ ] No cyanosis [ ] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [x] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC [x] All findings normal
[ ] Nl judgment/insight [ ] Nl memory [ ] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
[**2117-6-11**] 03:52PM WBC-9.0 RBC-4.95 HGB-13.0 HCT-40.4 MCV-82
MCH-26.2* MCHC-32.1 RDW-14.1
[**2117-6-11**] 03:52PM PLT COUNT-332
[**2117-6-11**] 03:52PM PT-11.0 PTT-26.3 INR(PT)-1.0
[**2117-6-11**] 03:52PM GLUCOSE-124* UREA N-11 CREAT-0.6 SODIUM-138
POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-20* ANION GAP-15
[**2117-6-11**] 03:52PM CALCIUM-8.2* PHOSPHATE-4.3 MAGNESIUM-1.8
[**2117-6-15**] CTA Chest :
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Status post left thoracotomy and left upper and lower lobe
wedge
resections with normal post surgical changes noted such as small
areas of
consolidation at the resection bed and loculated pleural
effusions with a
small gas component. Subcutaneous emphysema in the right is
also significant. Otherwise, no new focal consolidations or
ground-glass opacities are present in the left lung to suggest
new inflammatory process.
3. Chronic changes such as heavily calcified internal surface
of the right hemithorax with post-pneumonectomy fluid collection
and coronary artery calcifications are not significantly changed
compared with prior studies.
[**2117-6-16**] CXR :
Left lower lobe opacities have improved. Right pneumonectomy
and
calcification of the pleura on the right is again noted and
unchanged.
Cardiomediastinum is shifted towards the right as before.
Cardiac size cannot be evaluated. Peripheral opacities in the
left lung are consistent with postoperative changes with a small
amount of fluid collection surrounding cervical chains, better
seen in prior CT from [**6-15**]. There is no evidence of
pulmonary edema. Left chest wall subcutaneous emphysema has
decreased.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the hospital and taken to the
Operating Room where she underwent a left thoracotomy and left
upper lobe and left lower lobe wedge resection. She tolerated
the procedure well and returned to the PACU in stable condition.
She maintained stable hemodynamics and her pain was controlled
with an epidural catheter.
Following transfer to the Surgical floor she had multiple
episodes of dizziness, lightheadedness and nausea. She was not
orthostatic but her heart rate was in the 100 range. Her
symptoms were possibly from the epidural and she preferred to
have it removed and use oral medication. After removal of her
epidural catheter and chest tubes she felt better but remained
tachycardic. Her EKG was normal but her oxygen requirements
were high ( 4 liters @ 96%). She had a CTA of the chest which
ruled out PE and subsequently underwent vigorous pulmonary
toilet. She was also diuresed gently over 48 hours and her
oxygen saturations gradually improved.
Unfortunately due to her limited pulmonary reserve pre op, she
required oxygen both at rest and with activity. She worked with
the Physical Therapist and persistently desaturated with any
activity ( 2L/85% ). A pulmonary rehab program was recommended
so that she can eventually return home safely, possibly needing
oxygen indefinitely.
From a surgical standpoint her left thoracotomy incision was
healing well. Pathology is pending. She was tolerating a
regular diet though modestly and her pain was well controlled.
After a slow recovery she was discharged to rehab on [**2117-6-18**] to
help improve her respiratory function prior to returning home.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]
3. Sodium Chloride Nasal [**11-30**] SPRY NU TID:PRN stuffiness
4. Guaifenesin [**4-8**] mL PO Q6H:PRN congestion
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
6. Ibuprofen 400 mg PO Q8H:PRN pain
7. Pantoprazole 40 mg PO Q24H
8. Fexofenadine 60 mg PO BID
9. Loratadine *NF* 10 mg Oral daily congestion
10. albuterol sulfate *NF* 90 mcg Inhalation QID wheeziness
11. Levothyroxine Sodium 88 mcg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
3. Guaifenesin [**4-8**] mL PO Q6H:PRN congestion
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Vitamin D 1000 UNIT PO DAILY
7. Acetaminophen 1000 mg PO Q6H
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
9. Heparin 5000 UNIT SC BID
10. Ipratropium Bromide Neb 1 NEB IH Q6H
11. Milk of Magnesia 30 mL PO Q12H:PRN constipation
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*40
Tablet Refills:*0
14. Tiotropium Bromide 1 CAP IH DAILY
15. Sodium Chloride Nasal [**11-30**] SPRY NU TID:PRN stuffiness
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) **]
Discharge Diagnosis:
Left upper lobe and left lower lobe nodules.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotic.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 16996**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2117-7-1**] at 2:30 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinicla
center for a chest xray.
Completed by:[**2117-6-18**]
|
[
"244.9",
"793.19",
"V15.82",
"530.81",
"496",
"278.00",
"780.4",
"V10.11",
"V45.76"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"32.29"
] |
icd9pcs
|
[
[
[]
]
] |
8702, 8787
|
5478, 7141
|
313, 404
|
8876, 8876
|
3787, 5455
|
10354, 10843
|
1729, 1813
|
7844, 8679
|
8808, 8855
|
7167, 7821
|
9059, 10331
|
1828, 3768
|
270, 275
|
432, 1086
|
8891, 9035
|
1130, 1252
|
1695, 1713
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,122
| 138,769
|
47178
|
Discharge summary
|
report
|
Admission Date: [**2162-6-10**] Discharge Date: [**2162-6-16**]
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Reason for admission: Chest pain
Reason for transfer to the MICU: hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal intubation.
Arterial line placement.
History of Present Illness:
87 y/o woman with CAD, Afib, presents with shortness of breath
and chest pain since morning of admission. She felt that her
shortness of breath has improved since getting to the hospital.
She can't elaborate as to what the extent of her activity level
is, but she cannot walk up one flight of stairs. She denied any
orthopnea or PND. On the morning of admission she was doing
regular housework, when she developed substernal pressure, as if
someone was sitting on her chest. She took one SL nitro and
called her friend to take her to the [**Name (NI) **]. On interview, she
denies any CP. She also c/o of having visual hallucinations at
night, she thinks it prob in her dreams.
.
On review of systems, the patient denied any chest pain,
shortness of breath, fevers, chills, weight loss, night sweats,
fatigue, headaches, dizziness, blurred vision, sore throat,
nausea, vomiting, abdominal pain, any new rashes, denies
dysuria, hematuria, increased urgency, diarrhea, constipation,
hematochezia, melena, epistaxis. All other systems were reviewed
in detail and were negative except for what has been mentioned
above.
.
In the ED, VS T 98.2 HR 80 BP 147/73 Sat 94 on RA increased to
98 on 3:. ECG with subtle ST dep/TW flattening anterior leads.
She was given ASA 325mg, combivent neb, plavix 600mg and lasic
40mg iv times 1. CXR showed vascular congestion. She had a foley
placed.
.
On the floor, patient was agitated requiring large amounts of
zyprexa and also Haldol was used. 1 Am [**6-12**] patient was found
unresponsive. ABG was performed with PH 7.15 pCO2 112 pO2 105.
Pt was electively intubated. Moving all four extremities,
responding to sternal rub. Suction of brown material, question
of aspiration. Pt to CT scan to assess for bleed, CVA and then
to MICU for further work up and management.
Past Medical History:
1. Coronary artery disease, EF 45-50% in [**2157**].
2. Asthma.
3. Atrial fibrillation.
4. Hypertension.
5. Hepatosplenomegaly.
6. Anxiety.
7. Osteoarthritis.
8. Carpal tunnel syndrome.
9. Sciatica.
10. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
11. Status post lumpectomy
Social History:
Negative tobacco, occasional alcohol. Lives alone. Has two sons
and five grandchildren. Patient was born in Poland, Now lives
alone in [**Location (un) 583**] with daily care taker visits and [**1-23**]
times/week VNA.
Family History:
Father with heart problems.
Physical Exam:
On admission to MICU
VS: 95/57. 62, 99.1, 100% on AC 450, 18/5 100 fio2
Gen: intubated, agitated, moving all extremities.
HEENT: Pupils pinpoint, ET tube in place.
CV: irregularly irregular
Lung:course breath sounds bilaterall, no wheezes noted.
Abdomen: Distended, hypoactive bowel sounds, but soft.
Ext: 1+ peripheral edema bilaterally, no clubbing, cyanosis, no
calf pain, DP pulses are 2+ bilaterally
Neuro: moving all extremities, unable to follow commands. DTR 2+
throughout, Toes downgoing
Skin: pink, warm, no rashes
Pertinent Results:
Echocardiography: EF 45% The left atrium is elongated. The right
atrium is moderately dilated. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
There is mild global left ventricular hypokinesis. The right
ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The aortic valve leaflets appear structurally normal with good
leaflet excursion. No aortic stenosis is suggested. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-22**]+) mitral regurgitation
is seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2158-9-28**],
the estimated pulmonary artery systolic pressure is now lower.
The severity of mitral regurgitation is slightly increased. Left
ventricular systolic function is similar.
Brief Hospital Course:
This is an 87 y/o woman with CAD, atrial fibrillation, Asthma,
who presented with acute onset of substernal chest pain and
altered mental status. On [**6-12**] the floor she was found to be in
respiratory distress and found to be in hypercarbic respiratory
failure; this prompted emergent intubation and transfer to MICU.
The patient was noted to be frequently agitated as well. A
psychiatry consult was called and believed she had [**Last Name (un) **] body
dementia--notably the patient had received large dose.
The patient's hypercarbia resolved and the patient was extubated
on [**6-14**]. She was maintained on albuterol and atrovent
nebulizers. Post extubation the patient was markedly less
agitated and her respiratory status remained stable. She
passed a speech and swallow evaluation [**6-16**] and was subsequently
discharged.
.
In summary, this is an 87 year old woman with atrial
fibrillation, coronary artery disease and newly diagnosed with
[**Last Name (un) 309**] body dementia that was likely exacerbated by use of
antipsychotic medication. This in turn may have led to
oversedation, hypoventilation and subsequent hypercarbic
respiratory failure. She has been extubated for 48 h with nl
respiratory status and now appears again at her baseline mental
status.
Issues:
1) Reactive airway disease/respiratory failure, asthma vs. COPD
vs. sedative related hypoventilation.
-continue albuterol, atrovent nebulizers
-should get pulmonology followup with PFT's
-question component of aspiration, continue broad spectrum
antibiotics (vancomycin and zosyn) for two more days against
presumed hospital acquired pneumonia.
.
2) [**Last Name (un) 309**] Body dementia
-needs psychiatry and possibly neurology follow up
-avoid all antipsychotics
.
3) Atrial fibrillation, rate controlled without medications
-was on digoxin, but was bradycardic, would not continue digoxin
-continue coumadin, INR therapeutic.
.
4) CAD/chest pain
-continue aspirin.
-ruled out for MI
.
5) CHF, EF 40-45%
-held diuretics for low nl blood pressures
-diuresed cautiously, can restart PO lasix
.
6) Hyperglycemia, likely steroid related
-insulin sliding scale (humalog)
-consider A1c
.
FEN: Diabetic cardiac healthy diet. Speech and swallow
evaluation cleared.
.
Ppx: Included heparin SC, bowel regimen and PPI
.
Code: Full
.
Disposition: Rehabilitation facility
Medications on Admission:
Tylenol
Coumadin 4mg po daily
Nitro SL
Namenda 10mg [**Hospital1 **]
Spironolactone 25mg qdaily
Furosemide 20mg daily
Isordil 10mg TID
Glucophage 500mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
5. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed.
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
16. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours): last day is [**2162-6-18**].
20. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours): last day is [**2162-6-18**].
**got PRN lasix, consider restarting PO lasix, also was on
aldactone as outpatient
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
[**Last Name (un) 309**] Body Dementia
Reactive airway disease
Pneumonia
CAD
Discharge Condition:
Good, mentating at baseline, normal respiratory status on 2L
NC.
Discharge Instructions:
Please have patient follow up with psychiatry for her [**Last Name (un) 309**] Body
Dementia
Please avoid all antipsychotics
Continue antibiotics for two more days
Continue prednisone and inhalers.
Followup Instructions:
Please have pt follow up with [**Hospital1 18**] Psychiatry, also consider
follow up with [**Hospital1 18**] Neurology.
Please have pt follow up with Dr. [**Last Name (STitle) 3707**] of [**Hospital1 18**] APG
practice.
|
[
"E932.0",
"428.0",
"715.90",
"486",
"789.1",
"401.9",
"251.8",
"294.10",
"331.82",
"496",
"E939.3",
"300.00",
"414.01",
"518.81",
"354.0",
"427.31",
"396.0",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8857, 8928
|
4377, 6736
|
312, 363
|
9049, 9117
|
3370, 4354
|
9363, 9586
|
2780, 2809
|
6945, 8834
|
8949, 9028
|
6762, 6922
|
9141, 9340
|
2824, 3351
|
173, 274
|
391, 2196
|
2218, 2528
|
2544, 2764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,420
| 155,775
|
26905
|
Discharge summary
|
report
|
Admission Date: [**2200-2-20**] Discharge Date: [**2200-3-18**]
Date of Birth: [**2124-6-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine Sulfate / Codeine / Keflex / Sudafed
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fever/+BC w/ h/o MV endocarditis
Major Surgical or Invasive Procedure:
Mitral Valve Replacement with 31mm SJM Biocor Tissue valve/[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 1916**] resection on [**2200-3-11**]
History of Present Illness:
Mr. [**Known lastname **] is a 75 y/o man who has a PMHx significant for
Enterococcus mitral valve endocarditis which has been treated
since [**9-11**]. He has had 2 6 week courses of antibiotics with
recurrent bacteremia. He had a TEE on [**2200-1-14**] which revealed
thickened mitral leaflets with small vegetations on both
anterior and posterior leaflets with moderate to severe mitral
regurgitation. He has preserved LV systolic function with mild
TR and AR and LAE without abscess. He had a repeat TEE on [**2-11**]
which revealed 4+ MR. [**Name13 (STitle) **] was tranferred from MWMC (where he was
admitted on [**2-7**] with fevers and positive blood cultures) to IDMC
for further treatment and possibly MVR.
Past Medical History:
h/o Mitral Valve Endocarditis
Hypertension
h/o CVA
Spinal Stenosis s/p Lumbar Laminectomy x 3
Parkinson's disease
h/o paranoid delusions
MGUS vs MM
Social History:
Lives in nursing home. Quit smoking 3.5 years ago. Denies ETOH.
Family History:
Non-contributory
Physical Exam:
Preop
General: Elderly man in NAD, VSS
HEENT: NC/AT, PERRLA, EOMI, poor dentition
Neck: Supple, FROM, -thyromegaly, -lymphadenopathy, Carotids 2+
Bilat w/out bruits
Lungs: CTAB -w/r/r
Heart: RRR, +S1S2, [**2-10**] mumrmur
Abd: Soft NT/ND, +BS without masses or hepatomegaly/splenomegaly
Ext: Warm, dry -c/c/e, pulses 2+ throughout
Neuro: Non-focal, MAE
Skin: well-healed surgical scars on lower back
Discharge
Gen: NAD/VSS
Neuro: Alert, non focal exam
Pulm: CTA bilat
Card: RRR, sternum stable, incision clean and dry, no
erythema/drainage
Abdm: soft, NT/ND/NABS
Ext: warm well perfused, no C/C/E
Pertinent Results:
[**2200-2-20**] 07:30PM GLUCOSE-94 UREA N-21* CREAT-1.3* SODIUM-138
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
[**2200-2-20**] 07:30PM ALT(SGPT)-6 AST(SGOT)-20 LD(LDH)-255* ALK
PHOS-134* TOT BILI-0.4
[**2200-2-20**] 07:30PM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.3
[**2200-2-20**] 07:30PM WBC-4.9 RBC-4.27* HGB-11.3* HCT-35.1* MCV-82
MCH-26.4* MCHC-32.2 RDW-17.4*
[**2200-2-20**] 07:30PM NEUTS-66.3 LYMPHS-25.0 MONOS-5.7 EOS-0.1
BASOS-2.9*
[**2200-2-20**] 07:30PM PLT COUNT-187
[**2200-2-20**] 07:30PM PT-13.1 PTT-30.1 INR(PT)-1.1
[**2200-2-20**] 06:27PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2200-3-15**] 05:31AM BLOOD WBC-8.6 RBC-3.43* Hgb-9.9* Hct-28.7*
MCV-84 MCH-28.9 MCHC-34.5 RDW-17.8* Plt Ct-120*
[**2200-3-17**] 01:53AM BLOOD Glucose-95 UreaN-35* Creat-1.4* Na-136
K-4.9 Cl-105 HCO3-21* AnGap-15
[**2200-3-17**] 04:47PM BLOOD PT-14.1* PTT-29.4 INR(PT)-1.3*
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was transferred from MWMC to
[**Hospital1 18**] for ongoing care (?MVR). And Infectious disease consult
was immediately made. IV Daptomycin was continued via PICC line
which was inserted on [**2-12**] at MWMC.
Mr [**Known lastname **] had an extensive preop evaluation including cardiology,
infectious diseases, orthopedics, psychiatry and ethics
services.
He ultimately was brought to the operating room on [**3-11**]. At that
time he had a Mitral Valve replacement, aortoomy, and left
atrial appendage resection. His bypass time was 103
minutes/crossclamp 89 mins. Please see OR report for full
details. He tolerated the surgery well and was transferred from
the OR to the CSRU on Epinephrinne and Propofol infusions. He
did well in immediate postoperative period. Following surgery
his anesthesia was reversed, he was weaned from ventilator and
successfully extubated. His iv medications were also weaned to
off. On POD1 His PA line and chest tubes were removed, he was
also started on Beta blockers and diuretics. On POD2 the patient
remained hemodynamically stable and was transferred from the ICU
to F2 for continued postop care. Over the next several days with
the assisstance of the nursing staff and physical therapy the
patients activity level was advanced, he was transitioned to all
oral medications with the exception of his antibiotics.
On POD7 it was decided that the pt was stable and ready for
discharge to rehabilitation.
It should be noted that the patient did have episodes of
postoperative atrial fibrillation, he was seen by the
Electrophysiology service, started on Procainamide and Coumadin.
Medications on Admission:
Aricept 10mg qd, Aspirin 81mg qd, Folic acid, Gabapentin 200mg
tid, Lopressor 12.5mg [**Hospital1 **], Lisinopril 5mg qd, Daptomycin 420mg
IV qd, Protonix 40mg qd, Seroquel 50mg tid, Heparin 5000 units
SQ tid, Colace 100mg [**Hospital1 **], Lactulose 15mg [**Hospital1 **], Comtan 200mg qd,
Mirapex 1.5mg tid, Sinemet 50/200mg tid
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 2 weeks.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Entacapone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
8. Pramipexole 0.25 mg Tablet Sig: Six (6) Tablet PO TID (3
times a day).
9. Carbidopa-Levodopa 50-200 mg Tablet Sustained Release Sig:
One (1) Tablet PO TID (3 times a day).
10. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Procainamide 250 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours): x 6 weeks.
12. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
13. Warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily).
14. Daptomycin 500 mg Recon Soln Sig: Four [**Age over 90 11578**]y (480)
mg Intravenous Q24H (every 24 hours): thru [**4-24**].
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] Nursing Home
Discharge Diagnosis:
mitral valve endocarditis s/p MV replacement
HTN
s/p CVA
Spinal stenosis s/p Lumbar Laminectomy
Parkingson's
h/o paranoid delusions
MGUS vs MM
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] take shower. Wash incisions with warm water and gentle soap.
Do no take bath or swim. Do not apply lotions, creams, ointments
or powders to incision.
Do not drive for 1 month.
Do not lift more than 10 pounds for 2 months.
Please contact office if you develop a fever more than 101.5 or
notice drainage from chest incision.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**First Name (STitle) **] (PCP) in [**12-9**] weeks
Infectious disease Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-4-21**] 10:00
Completed by:[**2200-3-18**]
|
[
"V58.61",
"041.04",
"521.00",
"280.9",
"332.0",
"724.2",
"V12.59",
"790.7",
"331.0",
"427.31",
"401.9",
"294.10",
"421.0",
"273.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"88.56",
"23.19",
"37.23",
"88.72",
"39.63",
"39.61",
"37.11"
] |
icd9pcs
|
[
[
[]
]
] |
6458, 6567
|
3104, 4773
|
343, 494
|
6753, 6760
|
2159, 3081
|
7154, 7458
|
1508, 1526
|
5154, 6435
|
6588, 6732
|
4799, 5131
|
6784, 7131
|
1541, 2140
|
271, 305
|
522, 1240
|
1262, 1411
|
1427, 1492
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,497
| 190,934
|
991
|
Discharge summary
|
report
|
Admission Date: [**2154-11-28**] Discharge Date: [**2154-12-3**]
Date of Birth: [**2071-11-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 812**]
Chief Complaint:
Abdominal Pain, Diarrhea
Major Surgical or Invasive Procedure:
- Central Venous Line
- PICC Line
History of Present Illness:
83 yom with severe AS s/p AVR and [**2-1**]+ AR on most recent ECHO
from [**11-8**], atrial flutter, and h/o urinary retention with
chronic indwelling Foley who presents with fever. Per the
family, pt has been having diarrhea and decreased po intake for
the past week. He was not complaining of abdominal pain, nausea,
or vomiting. His stool was black but he is on iron. His daughter
took him to see his PCP where he had CBC, urine cx, and stool
cxs, all of which were negative. His diarrhea has not improved.
On Tuesday, VNA changed his Foley. The patient felt that it was
not in correctly. No hematuria. Then today, the patient's
grandson noted that the pt was warm to the touch. He had a
temperature of 101. The pt was noted to appear fatigued, have
malaise. No sick contacts.
.
In the ED, initial VS: 100 130 95/52 16 89RA. BP fell to 80s/40s
and patient was started on levophed. Exam was sig. for tender
lower abdomen. CT showed malpositioned foley catheter, may be in
prostate, and markedly distended bladder with associated
hydroureter and hydronephrosis. His Foley was advanced with
release of 1200 cc of urine. He received 3 L NS and
vanc/levaquin/flagyl. RIJ was placed and patient was started on
levophed, which is currently at 0.1 mcg/kg/hr with BP of 93/44,
HR 92. RR20. 95% RA. CVP 11.
Past Medical History:
- severe AS, s/p valvuloplasty [**3-8**], then AVR [**4-5**] (19 mm
[**Last Name (un) 3843**]-[**Known firstname **] bovine pericardial prosthesis), repair [**5-6**],
latest ECHO from [**11-8**] reported [**2-1**]+ AR.
- CHF [**3-4**] AS (no CAD) EF 55-60%
- atrial flutter/fib
- colon adenoCA s/p R colectomy [**3-8**]
- h/o urinary retention - chronic indwelling foley
- h/o manic depression/anxiety
- Iron deficiencyanemia--baseline 31-32%
- Zenkers diverticulum s/p surgical repair [**4-3**]
- h/o splenomegaly and thrombocytosis
- b/l inguinal hernia repair 35y ago, right inguinal hernia [**2146**]
- h/o esophageal stenosis
- pulmonary asbestosis diagnosed by CT scan in [**2142**]
- h/o jejunal microperforation diagnosed by barium swallow in
[**2144**]
- left rotator cuff partial tear
- hard of hearing
Social History:
Pt lives at home w/ wife who also has dementia. His family
brings him meals at night and his daughter [**Name (NI) **] [**Name (NI) **], his
healthcare proxy, is a nurse [**First Name (Titles) **] [**Name (NI) 2025**] and brings medications for
him. He has home VNA services helping him and his wife around
the house as well.
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM
- Tmax: 37.4 ??????C (99.3 ??????F)
- Tcurrent: 37.4 ??????C (99.3 ??????F)
- HR: 89 (89 - 90) bpm
- BP: 96/65(71) {93/42(55) - 96/65(71)} mmHg
- RR: 17 (13 - 22) insp/min
- SpO2: 98%
- General Appearance: No acute distress, Thin
-Eyes / Conjunctiva: No(t) PERRL, R pupil larger than L, both
reactive
- Head, Ears, Nose, Throat: Normocephalic, Edentulous
- Lymphatic: Cervical WNL, Supraclavicular WNL
- Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic,
Diastolic)
- Peripheral Vascular: (Right radial pulse: Present), (Left
radial pulse: Present), (Right DP pulse: Present), (Left DP
pulse: Present)
- Respiratory / Chest: (Breath Sounds: Crackles : bibasilar)
- Abdominal: Soft, Non-tender, Bowel sounds present,
non-Distended
- Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
- Musculoskeletal: Muscle wasting
- Skin: Not assessed
- Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, - Oriented (to): self, [**Hospital3 **], [**Month (only) **],
Movement: Purposeful, Tone: Not assessed
Pertinent Results:
Admission Labs:
[**2154-11-28**] 03:00PM WBC-11.1* RBC-3.88* HGB-11.8* HCT-34.5*
MCV-89 MCH-30.3 MCHC-34.1 RDW-16.6* NEUTS-81* BANDS-13*
LYMPHS-2* MONOS-3 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0
HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL
MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ SCHISTOCY-1+
TEARDROP-1+ BITE-OCCASIONAL PLT SMR-NORMAL PLT COUNT-385
[**2154-11-28**] 03:00PM PT-15.5* PTT-31.4 INR(PT)-1.4*
[**2154-11-28**] 03:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.009
BLOOD-LG NITRITE-NEG PROTEIN-75 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-MOD
[**2154-11-28**] 03:00PM cTropnT-0.05*
Imaging
- CT Abdomen: Malpositioned Foley catheter, likely lying within
the prostatic urethra, with the balloon possibly within the
penile urethra. Associated marked distension of the bladder, and
new mild-to-moderate hydronephrosis and hydroureters
bilaterally. Parenchymal opacity within the left lower lobe in
the lung, could reflect atelectasis. However, superimposed
consolidation cannot be excluded. Cholelithiasis without
secondary findings for cholecystitis. Diverticulosis.
- CXR: No acute cardiopulmonary abnormality.
Microbiology
Blood Culture Results
- KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
- E.COLI. PRELIMINARY SENSITIVITIES
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
A/P: 83 yom admitted with septic shock and GNR bacteremia, h/o
AS s/p AVR, A.flutter with variable block, chronic urine
retention (dynamic analysis showed bladder atony) w/ chronic
foley.
.
# Septic shock: Patient was treated with IVF, levophed (from
[**2175**] to 2230 on [**11-28**].), and empiric vanc/zosyn given a history
of MDR pathogens. Blood cultures 10/29 grew 2 species of GNR,
vancomycin discontinued. Urine was believed to be likely source
given chronic indwelling foley and past urine Cx's. Other
sources discussed included GI, hepatobilliary, peri-rectal.
Prostate exam was unremarkable, demonstrating no tenderness and
there was no evidence of colitis or hepatobilliary disease on CT
scan and no evidence of abscess on rectal. Of note, UCx drawn at
the time was contaminated with "fecal flora," so 1:1 correlation
cannot be established as source. On [**11-30**] antibiotics were
switched to Meropenem and Ciprofloxacin for double
anti-pseudomonal coverage. Antibiotics were then narrowed to
Meropenem only on [**12-1**] after sensitivities returned. Speciation
of ED blood Cx + for E.Coli and K.Pneumo x 2 sets with
sensitivities K.Pneumo (pan-sensitive) and E.Coli (sensitive to
only genatmicin and meropenem). Patient remained afebrile on
floor and his clinical picture drastically improved. He was
alert and oriented x 3 and was able to participate in regular
physical therapy sessions.
.
# UTI: chronic retention at baseline req. indewelling foley with
past urine Cx's showing same MDR E.Coli as current blood Cx.
There was initial concern for prostatitis in setting of
malpositioned foley catheter; however, rectal exam was
unremarkable. Patient was continued on Meropenem as discussed
above. He was referred to urology for further evaluation. Of
note, patient may benefit from a urinary diversion (ex:
appendicovescular shunt) to eliminate the issue of chronic
indwelling foley. This may improve his quality of life,
preventing recurrent UTI's and helping with ambulation.
.
# Anemia: HCT at admission 34.5 trended down to nidus of 25.4
now 29.4 without intervention. Baseline in high 20's based on
OMR and normal MCV. Believe large component may have been
dilutional [**3-4**] over resucitation, now resolving. With normal
MCV, chronic blood loss seems less likely. RDW slightly elevated
suggesting RBC production. Smear was not typical of any single
process. Patient had known diagnosis of Fe deficiency anemia
and this is likely mixed with anemia of chronic disease. Stools
were guiac'd and negative. His HCT remained stable.
.
# A. Flutter: patient initially presented with AFlutter with RVR
and variable block. Patient with A.Flutter at baseline and may
have had component of demand ischemia at initial presentation
[**3-4**] RVR and hypotension, TN's slightly elevated at admission but
stable. Patient was monitored for several days on telemtry and
was stable. Rate was well controlled without nodal agents.
Patient was maintained on daily aspirin.
.
# Dementia: patient reports feeling confused while in hospital
but remains A + O x 3. Component likely [**3-4**] to illness, hospital
stay. Objectively, patient was quite lucid inspite of his
subjective complaints. Patient was maintained on his home
donepezil dose. Nightly vitals were discontinued, visual cues
were increased and SCD's were discontinued to help with possible
delerium.
.
# Access: R. IJ was initialy placed in setting of septic shock
for pressor requirement. R. IJ was dc'd after PICC line placed
to complete 2 week course of IV antibiotics.
.
# Orthostasis: Patient was continued on home dose of
fludrocortisone.
.
# Diarrhea: Patient intially presented with c/o diarrhea x 1
week. While on the medicine floor, patient's stools remained
unremarkable. On the day prior to discharge, stool frequency
increased and sample was sent for C.Diff toxin and culture. At
the time of discharge C.Diff was neg. x 1.
.
# Dispo: patient was discharge to [**Hospital 100**] Rehab MACU for further
management. Follow up appoint to urology was made. PCP was
[**Name (NI) 653**] and agreed to contact patient's daughter with
appointment details.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Fludrocortisone 0.1 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Multivitamin PO DAILY
6. Aricept daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Fever, Pain.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
7. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 10 days: Complete 14 day
course ending on [**12-13**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Sepsis
Discharge Condition:
Good. Improved.
Discharge Instructions:
Mr [**Known lastname **],
You were admitted to the hospital for a blood infection which
likely came from your urine. This infection requires 14 days of
intravenous antibiotics. You will be discharged to a rehab
facility where you can regain your strength, improve your
nutrition and receive the full course of antibiotics.
Please call your primary care doctor or return to the emergency
department for any of the following:
- fevers, chills
- chest pain, difficulty breathing, feeling dizzy, passing out
- nausea with vomiting
- abdominal pain, continued or worsening diarrhea
- any other new or change in symptoms which concern you
Please note the following appointments we have made for you:
Urology:
- Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**] Date/Time:
[**2154-12-16**] 2:00
Primary care doctor's office will be calling your daughter
([**Name (NI) **]) [**Telephone/Fax (1) 6555**] to schedule follow-up appointment in 2
weeks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**]
Date/Time:[**2154-12-16**] 2:00
Primary care doctor's office will be calling daughter (health
care proxy) [**Telephone/Fax (1) 6555**] to schedule follow-up appointment in 2
weeks.
[**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, DMD [**MD Number(2) 821**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
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icd9pcs
|
[
[
[]
]
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11652, 11718
|
6622, 10758
|
350, 386
|
11769, 11787
|
4047, 4047
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2914, 2918
|
10975, 11629
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11739, 11748
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10784, 10952
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11811, 12832
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2933, 4028
|
286, 312
|
414, 1716
|
4063, 6599
|
1738, 2554
|
2570, 2898
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,834
| 103,473
|
47992+59049
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-11-14**] Discharge Date: [**2174-11-22**]
Date of Birth: [**2109-8-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex / Latex / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2174-11-14**] - Coronary artery bypass grafting x3 (Left internal
mammary artery sequential graft to the diagonal and left
anterior descending artery, Free right internal mammary artery
to the obtuse marginal artery)
History of Present Illness:
65 year old female who developed dyspnea on exertion in [**Month (only) 958**],
now with progression, occurring with less activity and more
frequently. She underwent a Dobutamine stress in [**Month (only) 216**] which
was negative, however due to ongoing symptoms she underwent an
Adenosine stress test where she reported DOE and developed 1mm
planar ST depressions inferior/laterally. Imaging revealed a
medium area of moderate stress induced ischemia. She was started
on Aspirin and beta blockers last week without any change in her
present symptoms. She was referred for cardiac catheterization
which found her to have severe two vessel coronary artery
disease. She was seen by Dr. [**Last Name (STitle) **] in [**Month (only) 359**] while an
inpatient and returns today for preadmission testing. Her
surgery is scheduled for Monday [**2174-11-14**]. She has had a recent
upper respiratory infection treated with azithromycin and
albuterol.
Past Medical History:
Hypertension
Diabetes
Mild PVD
Hypercholesterolemia
Right Breast CA in [**2166**] s/p lumpectomy and radiation therapy
with recurrence in [**2170**] s/p right breast mastectomy and
reconstruction
Left great toe to left shin cellulitis s/p Cephalexin and
Bactrim course completed 1-2 weeks ago with resolution. This is
an intermittent problem.
Depression
Restless leg syndrome
Hypothyroidism
DVTs in the past
s/p appendectomy
Social History:
Lives with:daughter
Occupation:retired meat manager at grocery store
Cigarettes: Smoked no [] yes [x] Hx:1ppd for 15 years and quit
25
to 30 years ago
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-17**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
non-contributory
Physical Exam:
Pulse:70 Resp:14 O2 sat:95/RA
B/P Right:no BP in right arm d/t mastectomy Left:155/64
Height:5'3" Weight:191 lbs
General:NAD, alert and cooperative
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] no Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] 1+ (B) LE Edema. Left
lower extremity with edema, venous stasis changes, shiny and
tense. It is nontender to touch and no significant erythema
noted. The calf muscle feels tight/knotted causing an abnormal
appearance of LE with a tense softball like calf and then an
abruptly thin LE distal to calf.
Right with venous stasis changes however not as significant as
left lower leg. Negative [**Last Name (un) **] signs bilaterally.
Varicosities: Multiple varicosities noted on bilateral lower
extremities particularly in thighs. Likely thrombosis of GSV vs
Superficial vein just above right knee and Left Lesser saphenous
vein.
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2174-11-14**] ECHO: PRE BYPASS 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. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest. 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. There are simple
atheroma in the descending thoracic aorta. 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 chordal systolic
anterior motion without systolic anterior motion of the mitral
valve leaflets. There is no left ventricular outlow tract
obstruction. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study.
POST BYPASS There is normal biventricular systolic function. No
change in valvular function. The left to right flow across the
interatrial septum at the foramen ovale is no longer seen. The
thoracic aorta is intact after decannulation. No other changes
from the pre bypass study.
.
[**2174-11-16**] CT Head: An ill-defined hypodensity involving the dorsal
aspect of the right thalamus, just lateral to the third
ventricle is noted. The chronicity of this finding cannot be
determined given the lack of prior imaging. In the setting of
high clinical suspicion for acute infarction, may consider MR
for further assessment if not contra-indicated or close followup
with CT if MRI cannot be obtained. No acute hemorrhage or mass
effect. Out of proportion dilation of the lateral and third
ventricles compared to cerebral sulci- while this can be due to
central volume loss, other etiologies such as normal pressure
hydrocephalus can look similar and need clinical correlation.
.
[**2174-11-18**] Head MRI: 1.Three small foci of high signal intensity
identified on the diffusion-weighted sequences, suggesting
acute/subacute thromboembolic ischemic event. There is no
evidence of hemorrhagic transformation. 2. Chronic microvascular
ischemic disease is identified. Small chronic lacunar infarct is
noted on the left cerebellar hemisphere.
3. Bilateral mucosal thickening noted on the maxillary sinuses
with air-fluid level on the left side, the possibility of an
ongoing inflammatory process is a consideration.
.
[**2174-11-20**] CXR: Postoperative widening of the cardiomediastinal
silhouette is slightly larger today than yesterday. Small left
pleural effusion is presumed. There is no pulmonary edema or
pneumothorax. Right jugular line ends at the junction of
brachiocephalic veins.
.
[**2174-11-14**] 02:15PM BLOOD WBC-7.5 RBC-3.65* Hgb-10.6* Hct-31.7*
MCV-87 MCH-29.1 MCHC-33.5 RDW-14.9 Plt Ct-100*
[**2174-11-20**] 06:51AM BLOOD WBC-9.6 RBC-3.79* Hgb-10.6* Hct-33.0*
MCV-87 MCH-28.1 MCHC-32.3 RDW-14.5 Plt Ct-236
[**2174-11-14**] 02:15PM BLOOD PT-13.6* PTT-32.9 INR(PT)-1.3*
[**2174-11-17**] 01:57AM BLOOD PT-14.5* PTT-23.8* INR(PT)-1.4*
[**2174-11-14**] 02:15PM BLOOD UreaN-25* Creat-0.9 Na-140 K-5.2* Cl-111*
HCO3-23 AnGap-11
[**2174-11-21**] 05:35AM BLOOD UreaN-34* Creat-0.9 Na-138 K-4.4 Cl-100
[**2174-11-18**] 01:49AM BLOOD ALT-57* AST-68* LD(LDH)-309* AlkPhos-92
Amylase-33 TotBili-0.5
[**2174-11-21**] 05:35AM BLOOD Albumin-PND Mg-2.3
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2174-11-14**] for surgical
management of her coronary artery disease. She was taken to the
operating room where she underwent coronary artery bypass
grafting to three vessels. Please see operative note for
details. Postoperatively she was taken to the intensive care
unit for monitoring. On postoperative day one she was extubated.
Neurologically she did not follow commands and her speech was
delayed. She was seen by neurology who felt she had a stroke
involving the left cerebral hemisphere - either deep or frontal.
The major finding was abulia - a lack of spontaneity, prolonged
latency in response and short terse replies with easy
distractibility. A CT scan was performed which showed an
ill-defined hypo density involving the dorsal aspect of the
right thalamus was noted. MRA done on [**11-18**] showed three small
foci of high signal intensity identified on the
diffusion-weighted sequences, suggesting acute/subacute
thromboembolic ischemic event. Neurology felt she had a Left PCA
embolic stroke. Her right-sided weakness improved. She was seen
by Speech and swallow who recommended regular diet with thin
liquids. Long and short acting insulin was continued to maintain
blood sugars < 150. Chest tubes and epicardial wires were
removed without complications. She was gently diuresed toward
her preoperative weight. Patient was transferred to the
step-down unit on post-op day 4 for further recovery. She
remained in sinus rhythm and hemodynamically stable. She was
followed by physical and occupational therapy for strength and
mobility. She was discharged to rehab - [**Hospital1 **] [**Location (un) **] on
post-op day seven with the appropriate medications and follow-up
appointments.
Medications on Admission:
CITALOPRAM 20mg daily
ERGOCALCIFEROL (VITAMIN D2) 50,000 unit [**Unit Number **] Capsule
weekly/saturday
INSULIN GLARGINE 110 units SQ at bedtime
INSULIN LISPRO SQ below with meals 56 units AM, 16 units a
lunch, and 60 units at dinner time
LEVOTHYROXINE 50 mcg daily
LOSARTAN-HYDROCHLOROTHIAZIDE 50 mg-12.5 mg Tablet daily
METFORMIN 500 mg 2 [**Hospital1 **]
METOPROLOL SUCCINATE 25 mg daily
OMEPRAZOLE 20 mg [**Hospital1 **]
PRAVASTATIN 40 mg 2 Tablets daily
ASPIRIN 325 mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
7. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
10. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation q2h as needed for
shortness of breath or wheezing.
12. Lantus 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous QBreakfast : home dose 110 units please continue to
titrate up to home dose based on BG .
13. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
14. Imdur 60 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day for 3 months.
15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO
qsaturday.
16. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. Insulin scale insulin
Humalog
10 units premeal plus sliding scale
100-140 - 4 units
141-180 - 8 units
181-210 - 12 units
211-240 - 14 units
241-280 - 16 units
281-320 - 18 units
18. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
TBD
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Left PCA embolic stroke
Hypertension
Diabetes Mellitus
Mild PVD
Hypercholesterolemia
Right Breast CA in [**2166**] s/p lumpectomy and radiation therapy
with recurrence in [**2170**] s/p right breast mastectomy and
reconstruction
Left great toe to left shin cellulitis s/p Cephalexin and
Bactrim course completed 1-2 weeks ago with resolution. This is
an intermittent problem.
Depression
Restless leg syndrome
Hypothyroidism
DVTs in the past
s/p appendectomy
Discharge Condition:
Alert and oriented x3 right arm weakness
Ambulating with assistance
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Edema: Trace bilateral lower extremities
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: [**Doctor Last Name **] [**Telephone/Fax (1) 170**] Date/Time: [**2174-12-21**] 1:30
Location: [**Hospital Unit Name **] [**Last Name (NamePattern1) **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 101253**] office will call with
appt.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (2) 6803**]in 4-5 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2174-11-21**] Name: [**Known lastname 16260**],[**Known firstname 1911**] Unit No: [**Numeric Identifier 16261**]
Admission Date: [**2174-11-14**] Discharge Date: [**2174-11-22**]
Date of Birth: [**2109-8-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex / Latex / Lipitor
Attending:[**First Name3 (LF) 741**]
Addendum:
Patient had episode of unresponsiveness in bathroom last pm.
Vitals signs stable with SBP 130's, BS 120 - episode thought to
be vasovagal. Vitals signs stable at the time of discharge.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2174-11-22**]
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63,922
| 125,776
|
4798
|
Discharge summary
|
report
|
Admission Date: [**2145-7-27**] Discharge Date: [**2145-8-7**]
Date of Birth: [**2068-5-10**] Sex: F
Service: MEDICINE
Allergies:
morphine / Codeine
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 77yo F with history of numerous recent
hospitalizations for aspiration pneumonia events presents with
hypoxia at her rehabiilitation center. Per nursing home/rehab
reports, she had been on a [**5-11**] day steady decline of respiratory
status and found to be hypoxic to 85% on 8L NC. She was
witnessed to choke on food while at rehab and became hypoxic.
She has a history of poor glossopharyngeal coordination.
.
In the ED, initial VS were 99.4, 130, 135/86, 26, 91%, 12L
Non-Rebreather. She received vancomycin, levaquin, flaygl for
pneumonia coverage and lorazepam for anxiety. CXR showed
bilateral infiltrates. Patient was admitted to medicine for
further workup. Vitals prior to transfer 98.0 aux (100 rectal),
93SR, 108/52, 23, 95 6L.
.
On the floor, she reported difficultly breathing and believes
she choked on some food but is not sure. She has a productive
cough. She denies current SOB, chest pain, fevers or chills. As
per records, she had recently been on levaquin since [**7-23**]. She
has also received increasing doses of benzodiazepines for last
week. Pt is [**Name8 (MD) **] RN, who notes that she does still eat, however
does get supplementation with TF. On ROS, also notes recent 30
lb weight loss and loss of appetite.
.
ROS: Denies fever, chills, rhinorrhea, congestion, sore throat,
current shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, dysuria, hematuria.
Past Medical History:
Torticollis (s/p Botox injections)
h/o numerous aspiration events s/p G-tube placement
tremor
stress-induced CM
HL
osteoporosis
vertebral fracture s/p vertebroplasty
vitamin b12 deficiency
hypothyroidism s/p surgery (Grave's in [**2097**]) - had thyroidectomy
panic attacks
MVP
IBS
Social History:
Lives at [**Hospital1 **] NH, 70py smoking history but no longer
smokes, occassional alcohol use, denies illicits. Former nurse,
has 3 children in the area very involved in her care.
Family History:
Brother died at 54 from MI, 2 others healthy. No major illnesses
in parents.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98/55, 88, 95% 6L NC
GENERAL: Thin, elderly, female with tremor in NAD.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MM slightly dry,
OP clear.
NECK: Supple, no thyromegaly, no JVD.
HEART: RRR, unable to appreciate m/r/g over breath sounds, nl
S1-S2.
LUNGS: Bilateral coarse breath sounds with rhonchi.
ABDOMEN: Soft/NT/ND, G-tube in place without erythema, 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 (knew year and month, not date), CNs II-XII
grossly intact, bilateral hand tremor
DISCHARGE PHYSICAL EXAM
VS: 97 139-146/70s, 99-110, 20, 95% 5L NC
GENERAL: Thin, elderly, female with tremor in NAD.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD.
HEART: RRR, no m/r/g over breath sounds, nl S1-S2.
LUNGS: Bilateral but R> L crackles, rhonchi much improved from
admission
ABDOMEN: Soft/NT/ND, G-tube in place without erythema, no masses
or HSM, no rebound/guarding.
EXTREMITIES: WWP, 2+ peripheral pulses, no edema
NEURO: Awake, Ao&x3, CNs II-XII grossly intact, head and
bilateral hand tremor unchanged from admission
Pertinent Results:
ADMISSION LABS
[**2145-7-27**] 05:57PM BLOOD WBC-10.4 RBC-3.73* Hgb-12.2 Hct-36.6
MCV-98 MCH-32.9* MCHC-33.5 RDW-16.1* Plt Ct-290
[**2145-7-27**] 05:57PM BLOOD Neuts-80.4* Lymphs-15.8* Monos-2.7
Eos-0.9 Baso-0.3
[**2145-7-27**] 05:57PM BLOOD PT-14.0* PTT-26.9 INR(PT)-1.2*
[**2145-7-27**] 05:57PM BLOOD Glucose-103* UreaN-27* Creat-0.6 Na-136
K-4.8 Cl-94* HCO3-34* AnGap-13
[**2145-7-28**] 07:05AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.8 Iron-PND
Discharge Labs:
[**2145-8-7**] 06:40AM BLOOD WBC-6.9 RBC-2.91* Hgb-9.7* Hct-29.8*
MCV-103* MCH-33.3* MCHC-32.5 RDW-16.0* Plt Ct-417
[**2145-8-1**] 04:10AM BLOOD PT-14.4* PTT-24.3 INR(PT)-1.2*
[**2145-8-7**] 06:40AM BLOOD Glucose-92 UreaN-14 Creat-0.4 Na-142
K-4.6 Cl-100 HCO3-37* AnGap-10
[**2145-8-4**] 06:35AM BLOOD Calcium-9.2 Phos-2.7 Mg-2.0
Cardiac Enzymes:
[**2145-7-31**] 07:30AM BLOOD CK(CPK)-12*
[**2145-7-31**] 05:18PM BLOOD CK(CPK)-10*
[**2145-8-1**] 04:10AM BLOOD CK(CPK)-11*
[**2145-8-2**] 05:17AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.1
[**2145-8-3**] 05:17PM BLOOD Calcium-9.1 Phos-2.6* Mg-2.0
Iron studies:
[**2145-7-28**] 07:05AM BLOOD calTIBC-152* VitB12-385 Folate-GREATER TH
Ferritn-791* TRF-117*
Thyroid studies:
[**2145-7-28**] 07:05AM BLOOD TSH-8.3*
[**2145-7-28**] 07:05AM BLOOD Free T4-1.0
Pending Neurologic studies at discharge:
[**2145-8-1**] 02:30PM BLOOD GQ1B IGG ANTIBODIES-PND
[**2145-8-1**] 02:30PM BLOOD ACETYLCHOLINE RECEPTOR ANTIBODY-Test
[**2145-8-1**] 02:30PM BLOOD GANGLIOSIDE AB PANEL, SERUM (GM1,
ASAILO-GM-1 AND GD1B)-PND
CXR [**2145-7-27**]
IMPRESSION: Hazy opacities in both lungs, which could represent
pulmonary
edema, but a superimposed infectious process is not excluded,
particularly
given the more focal opacities within the right upper lobe and
left lung base. Moderate-sized right pleural effusion. Given the
limited nature of the study, consider a followup PA and lateral
view when the patient is more cooperative.
CTA [**2144-7-28**]:
IMPRESSION:
1. No pulmonary embolism.
2. Confluent consolidation predominantly within the lung bases,
right greater
than left. in the right middle lobe and posterior segment of the
right upper
lobe . Findings are consistent with aspiration pneumonia and
large
atelectasis as described above.
3. Healed right anterior third rib fracture and sclerotic left
eighth and
ninth ribs, likely secondary to prior trauma.
CXR [**2145-7-31**]:
FINDINGS: Again seen is opacity obscuring the right
hemidiaphragm and right
heart border consistent with the known right lower lobe and
middle lobe
consolidation. Patchy areas of increased opacity in the right
upper lung and
left lower lung as well that are similar in appearance compared
to prior.
CT Head Noncontrast [**2145-8-5**]:
IMPRESSION: No acute intracranial process.
CXR [**2145-8-6**]:
The right PICC line tip is at the cavoatrial junction. There is
slightly
improved atelectasis of the right lower lobe, but there is still
present
pulmonary edema, asymmetric, right more than left associated
with bilateral
pleural effusions and with bibasilar atelectasis. Old fractures
of the left
humerus as well as vertebroplasty and percutaneous gastrostomy
are
demonstrated.
Brief Hospital Course:
Primary reason for hospitalization:
Ms. [**Known lastname **] is a 77yo F with history of numerous recent
hospitalizations for aspiration events who presented with
hypoxia at rehab, found to have pneumonia.
Active Diagnoses:
# Pneumonia: Likely due to aspiration event. CXR shows bilateral
infiltrates and diffuse rhonchi on exam. Given her recent
residence in a nursing home, treat for HCAP and aspiration with
Vanc/cefepime/metronidazole. Patient initially maintained
oxygen saturation around low 90s on 5-6L, but on HD3 triggered
for hypoxia to low 80s unresolved with nebulizers. She was
given oxygen by non-rebreather, diuresed and given chest
physical therapy, and sent to the ICU. In the ICU, she was
given high flow oxygen and her antibiotics were continued. She
was transferred back to the floor, where she has maintained O2
sats in the mid-90s on 5L. Pulmonary exam was much improved by
discharge, but still showed R>L crackles/rhonchi 2/3 up both
lung fields. She will need to complete 6 more days of
vancomycin, cefepime and flagyl after discharge.
# Dysphagia. Patient has decreased oropharyneal muscle tone and
trouble swallowing, causing her to aspirate. She has a g-tube
in place, which provides nutrition in the absence of swallowing,
but does not prevent aspiration. On a previous admission, she
failed speech and swallow study. Neurology team was consulted
to see if there is an underlying cause for her dysphagea. Motor
neuron disease was ruled out by EMG. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**] was
ruled out by EMG and antibody tests. MRI Cspine could not be
obtained as patient is unable to tolerate lying flat due to
aspiration risk. Family meeting was held to discuss the
irreversibility of dysphagea, and patient is allowed to take
small sips for comfort. Discussed with patient and family
unless they are willing to accept the aspiration risk she will
need to remain NPO.
# Tachycardia: Pt still frequently tachycardic with HR 105-110.
She reports feeling anxious, and benzodiazepines have
consistently decreased her HR, but make her more somnolent, and
hence more hypoxic. She has responded well to ativan 0.25mg.
# Depression/anxiety: She was written for ativan when she felt
acutely anxious. During her admission, the medical team tried
to balance benzos for anxiety with alertness for respiratory
status. When anxious, she was given Ativan po 0.25mg, but no
standing or prn orders were placed so the physician was always
aware when she received the medication. We continued remeron
and paroxetine for depression.
# Stage II pressure ulcer: Wound care provided dressing changes
and care.
Chronic Diagnoses:
# Anemia: Iron studies show anemia of chronic disease, stable
since baseline.
# Hypothyroidism: She was continue on her home levothyroxine.
Transitional issues:
#She should continue vanc, cefepime, flagyl for pneumonia for 6
more days.
#She should not receive the standing orders of Valium and Ativan
she was taking when she was admitted, as these make her
somnolent and compromise her respiratory status.
# CODE: DNR/DNI (confirmed with patient, daughter and sons)
# CONTACT: [**Name (NI) **], [**First Name3 (LF) **], [**Telephone/Fax (1) 20105**], [**Doctor First Name **]-[**Telephone/Fax (1) 20105**],
[**Telephone/Fax (1) 20106**], [**Female First Name (un) 20107**] [**Telephone/Fax (1) 20108**]
Medications on Admission:
Duonebs QID
Valium 2.5-5mg PO TID
Ativan 0.25 mg PO q8h prn anxiety/sleep
Levaquin 500mg daily (start [**7-23**])
Cefazolin 1 g IV q8h x 3 days
Acidopholus [**Hospital1 **]
Synthyroid 100mcg daily
Colace 100mg [**Hospital1 **]
Simvastatin 40mg daily
Paroxetine 20mg daily
Remeron 7.5mg daily
Lasix 40mg daily
Lisinopril 2.5mg daily
Aspirin 325 mg PO daily
Oscal 500 with vitamin D 1 tab POBID
Flexeril 5 mg PO daily
Dalteparin SQ [**Hospital1 **]
Jevity TF
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Acidophilus Capsule Sig: One (1) Capsule PO twice a day.
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. paroxetine HCl 10 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
6. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
9. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
10. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain/fever.
11. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
12. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q3H (every 3
hours) as needed for dyspnea, pain.
13. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours).
14. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
15. Vancomycin 750 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
PRIMARY [**Hospital **]
Healthcare associated pneumonia
SECONDARY DIAGNOSES
Dysphagea
Aspiration pneumonitis/pneumonia
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure taking care of you during your
hospitalization. You were admitted to [**Hospital1 18**] with shortness of
breath and found to have pneumonia. You were started on
antibiotics for your pneumonia and given nebulizer treatments
and oxygen to help your breathing. We realized that the cause
of your pneumonias is aspiration because of your trouble
swallowing (dysphagea). Our Neurology team came by and
evaluated you and feel that there is no underlying neurologic
cause of your dysphagia and no treatment options.
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS:
- Please CONTINUE to take your antibiotics (cefepime, flagyl,
vancomycin) as indicated below until your are re-evaluated by a
physician for improvement in your pneumonia
- Please DISCONTINUE the previous antibiotics (levoquin,
cefazolin) that you were taking before admission.
- Please DISCONTINUE taking standing doses of valium and ativan,
and only take small doses (0.25mg IV ativan works well) when
extremely anxious, as taking too many sedatives makes you sleepy
and your breathing more difficult.
Followup Instructions:
You will be discharged to a rehabilitation center. Please
follow-up with your outpatient primary care provider after
discharge from the rehabilitation center.
Completed by:[**2145-8-8**]
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"379.41",
"518.82",
"V15.88",
"333.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"93.08"
] |
icd9pcs
|
[
[
[]
]
] |
11837, 11973
|
6818, 7026
|
298, 304
|
12145, 12145
|
3648, 4090
|
13427, 13617
|
2314, 2392
|
10714, 11814
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11994, 12124
|
10232, 10691
|
12280, 12871
|
4106, 4437
|
2407, 3629
|
4944, 6795
|
9662, 10206
|
12900, 13404
|
4454, 4930
|
239, 260
|
332, 1791
|
12160, 12256
|
7044, 9641
|
1813, 2097
|
2113, 2298
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,776
| 139,951
|
1884
|
Discharge summary
|
report
|
Admission Date: [**2154-11-7**] Discharge Date: [**2154-11-23**]
Date of Birth: [**2075-4-21**] Sex: M
Service: NEUROLOGY
Allergies:
Erythromycin Base / Methyldopa
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Transferred for Intracranial hemorrhage
Major Surgical or Invasive Procedure:
Intubation
Continuous EEG monitoring
Tracheostomy
PEG
History of Present Illness:
79 year-old man with a history of hypertension, dyslipidemia,
TIAs s/p carotid endarterectomy, coronary artery disease s/p
myocardial infarction and CABG, v-fib arrest in [**2152**] s/p
pacemaker placement, and on Aspirin and Plavix who presents as a
transfer from [**Hospital **] Hospital for management of intracranial
hemorrhage.
The patient was reportedly "confused" at breakfast this morning.
Later, he was sitting and watching television; he had difficulty
getting up from a seated position at ~11:30 am. By 1 pm, he
apparently had further difficulty standing up, and emergency
services were notified. He was reportedly observed to have a
right facial droop and was "listing to the right" by one report.
He was taken to [**Hospital **] Hospital where he was a bit drowsy,
though GCS was reported as 14. His initial vitals at 3 pm
included a blood pressure 190/102, pulse 100, and SaO2 99.
Blood pressures rose to as high as 230s/140s range. CBC
reportedly showed a thrombocytopenia. Chemistry, and urinalysis
were unremarkable; INR was 1.1. EKG was ventricular-paced (rate
100), and chest x-ray clear. CT head will showed a left
thalamic bleed (4 x 3 cm), with third ventricular extension.
Mild prominence of the lateral and third ventricles was noted.
There was 7 mm of left-to-right shift. The patient was started
on Nipride to control blood pressure. He was given Zofran and
two units of platelets. The patient was med-flighted to [**Hospital1 18**]
for further management. En route, the patient was loaded with 1
gram of phenytoin. The patient reportedly "lost his airway"
upon landing on the roof, and was intubated on the spot.
Review of Systems: Unable to provide, given that he is intubated
and sedated.
Past Medical History:
-Hypertension
-Dyslipidemia
-TIAs s/p bilateral carotid endarterectomy (years apart)
-Coronary artery disease s/p myocardial infarction and CABG
-V-fib arrest in [**2152**] s/p pacemaker placement
-Anxiety
-An abdominal aortic aneurysm is noted on transfer paperwork
Social History:
By report, was previously a cigar smoker and drank alcohol
"earlier in life." Otherwise unknown at this time.
Family History:
Coronary artery disease by prior report, otherwise unknown
Physical Exam:
Vitals: T 99.6 F BP 155/63 P 75 RR 14 SaO2 100 on
ventilator
General: sedated
HEENT: NC/AT, sclerae anicteric, orally intubated
Neck: supple, no nuchal rigidity, no bruits
Lungs: clear, ventilated breath sounds
CV: regular rate and rhythm, no MMRG
Abdomen: soft, non-tender, non-distended
Ext: cool feet, no edema, pedal pulses appreciated
Skin: no rashes
Neurologic Examination:
Mental Status: Sedated on Propofol, unresponsive to voice or
sternal rub
Cranial Nerves: Could not visualize fundi; no blink to threat.
Pupils equally round and reactive to light, 3 and minimally
reactive bilaterally. Oculocephalic maneuver negative. Absent
corneals and nasal tickle bilaterally. Appears to gag on ETT.
Sensorimotor: Normal bulk and some mild increased tone in legs.
No tremor. Triple flexes to noxious in lower extremities, no
withdrawal noted in upper extremities.
Reflexes: Hyporeflexic throughout. Right toe spontaneously
upgoing, left toe mute.
Coordination and gait could not be performed.
Pertinent Results:
LABS:
[**2154-11-7**] 06:20PM BLOOD WBC-6.8 RBC-3.23* Hgb-10.6* Hct-30.7*
MCV-95 MCH-32.8* MCHC-34.5 RDW-12.7 Plt Ct-107*#
[**2154-11-22**] 09:00PM BLOOD WBC-8.9 RBC-1.65*# Hgb-5.3*# Hct-16.6*#
MCV-101* MCH-32.2* MCHC-31.9 RDW-12.8 Plt Ct-276
[**2154-11-22**] 10:09PM BLOOD WBC-10.7 RBC-2.04* Hgb-6.6* Hct-21.2*
MCV-104* MCH-32.5* MCHC-31.3 RDW-12.6 Plt Ct-263
[**2154-11-7**] 06:20PM BLOOD Neuts-90.1* Lymphs-7.4* Monos-2.3 Eos-0
Baso-0.1
[**2154-11-7**] 06:20PM BLOOD PT-15.3* PTT-34.7 INR(PT)-1.3*
[**2154-11-7**] 06:20PM BLOOD Glucose-156* UreaN-17 Creat-1.0 Na-141
K-4.1 Cl-110* HCO3-24 AnGap-11
[**2154-11-22**] 10:09PM BLOOD Glucose-75 UreaN-34* Creat-1.2 Na-140
K-6.9* Cl-113* HCO3-12* AnGap-22*
[**2154-11-7**] 06:20PM BLOOD ALT-9 AST-21 LD(LDH)-279* CK(CPK)-44
AlkPhos-51 TotBili-0.5
[**2154-11-8**] 01:33AM BLOOD CK(CPK)-42
[**2154-11-8**] 03:27AM BLOOD CK(CPK)-39
[**2154-11-12**] 02:00AM BLOOD CK(CPK)-214*
[**2154-11-12**] 09:52AM BLOOD CK(CPK)-271*
[**2154-11-17**] 10:48AM BLOOD CK(CPK)-74
[**2154-11-17**] 05:41PM BLOOD CK(CPK)-73
[**2154-11-17**] 11:34PM BLOOD CK(CPK)-60
[**2154-11-22**] 10:09PM BLOOD CK(CPK)-71
[**2154-11-7**] 06:20PM BLOOD cTropnT-<0.01
[**2154-11-8**] 01:33AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-11-8**] 03:27AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-11-11**] 08:41PM BLOOD CK-MB-3 cTropnT-0.05*
[**2154-11-12**] 02:00AM BLOOD CK-MB-4 cTropnT-0.05*
[**2154-11-12**] 09:52AM BLOOD CK-MB-4 cTropnT-0.05*
[**2154-11-17**] 10:48AM BLOOD CK-MB-2 cTropnT-0.03*
[**2154-11-17**] 05:41PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2154-11-17**] 11:34PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2154-11-22**] 10:09PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2154-11-7**] 06:20PM BLOOD Albumin-3.1* Calcium-6.9* Phos-3.0
Mg-1.5*
[**2154-11-22**] 10:09PM BLOOD Calcium-10.7* Phos-7.6*# Mg-2.8*
[**2154-11-7**] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2154-11-22**] 10:27PM BLOOD Lactate-10.1*
[**2154-11-15**] 02:05AM BLOOD Lipase-34
[**2154-11-7**] 06:20PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2154-11-7**] 06:20PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2154-11-7**] 06:20PM URINE RBC-[**1-23**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0
[**2154-11-8**] 03:27AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2154-11-21**] 11:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2154-11-21**] 11:25AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2154-11-21**] 11:25AM URINE RBC-[**1-23**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
MICRO:
Urine Cx ([**11-10**]): pansensitive E. coli
Urine Cx ([**11-13**], [**11-15**], [**11-17**], [**11-21**]): No growth
Blood cx: [**11-11**] No growth x2; [**11-13**]: no growth, [**11-15**] no growth
x2, [**11-17**] no growth x3
Sputum cx ([**11-13**]): No growth
Sputum cx ([**11-16**]) 1+ GNRs, culture showed no growth
C. diff cx ([**11-14**], [**11-17**], [**11-18**]): Negative
IMAGING:
ECG ([**11-7**]): Sinus rhythm at a rate of 68 with pseudo-fusion
ventricular pacing and fusion with atrial follow. Left
ventricular hypertrophy. Diffuse ST-T wave changes. Left atrial
enlargement. Since the previous tracing of [**2153-4-24**] pacemaker is
in place. Left ventricular hypertrophy and ST segment changes
persist.
CXR ([**11-7**]): IMPRESSION: ETT high at approximately 7.5 cm from
the carina at the thoracic inlet, can be advanced approximately
2 cm for standard positioning. No acute cardiopulmonary
abnormality.
CT Head ([**11-7**]): IMPRESSION: 3.5 x 2.6 cm intraparenchymal
hemorrhage centered in the left basal ganglia, with
intraventricular extension and mild ventriculomegaly.
Approximately 4 mm of rightward midline shift. No herniation.
Mixed density blood layering in the posterior lateral
ventricles.
CT Head ([**11-8**]): IMPRESSION:
1. Unchanged large left thalamic intraparenchymal hematoma and
intraventricular hemorrhage . Now evidence of extension/leaking
into the
subarachnoid space most evident in the left parietooccipital
region.
2. Persistent mass effect with an overall unchanged midline
shift. Also
persistent hydrocephalus.
EEG ([**11-12**]): IMPRESSION: This is an abnormal routine EEG due to
the presence of diffuse background slowing indicative of a
moderate encephalopathy. There is also intermittent right
central spike and slow wave activity and more rare left central
activity. This would indicate an area of cortical irritability.
However, there is no sustained rhythmic activity to indicate an
electrographic seizure.
TTE ([**11-12**]): The left atrium is elongated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is moderate regional left
ventricular systolic dysfunction with inferior/inferolateral
akinesis with hypokinesis elsewhere. Overall left ventricular
systolic function is moderately depressed (LVEF= 30 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2153-4-21**], the
left ventricle is now dilated and left ventricular systolic
function is now worse.
R Knee Film ([**11-13**]): IMPRESSION: Small area of lucency between
the tibial tray and the anterior proximal margin of the tibia is
doubtful to represent loosening, although no prior study is
available to assess for interval change. The remainder of the
cement-component and cement-osseous interfaces are normal.
Attention to this region on followup studies is recommended.
Knee joint effusion is not an unexpected finding in a patient
status post total knee arthroplasty.
Abdominal Ultrasound ([**11-15**]): IMPRESSION:
1. Cholelithiasis without evidence of cholecystitis.
2. Non-visualization of the pancreas and distal CBD.
3. Simple-appearing exophytic cyst arising from the right
kidney.
EEG ([**11-15**]): IMPRESSION: Markedly abnormal portable EEG due to
the slow and disorganized background, bursts of generalized
slowing, right frontal sharp features, and a dimunition of the
background over the left hemisphere especially in the temporal
region. Both abnormalities contribute to the diagnosis of a
widespread encephalopathy affecting both cortical and
subcortical structures. In addition, the lower voltage over the
left raises the possibility of widespread cortical dysfunction
or materal interposed between the brain and recording
electrodes, such as fluid. There were some sharp features in the
right frontal region, but there were no overtly epileptiform
abnormalities. Clinically abnormal left arm movements did not
correlate with EEG evidence of ongoing seizures although there
are some focal motor seizures that occur without EEG correlates.
Compared to the recording of three days earlier, the sharp
features in the right frontal area were somewhat less prominent
on current recording.
TEE ([**11-15**]): No mass/thrombus is seen in the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is
moderately depressed (LVEF~25-30 %). There are complex (>4mm)
atheroma in the descending thoracic aorta to 40 cm from the
incisors. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild to moderate ([**11-22**]+) mitral regurgitation is seen.
Right atrial and right ventricular pacing leads were visualized
without evidence of vegetation. A central catheter was also
seen, with its tip terminating in the right atrium, and free of
vegetations/thrombus. There is no pericardial effusion.
IMPRESSION: No vegetations seen on cardiac valves or
intracardiac hardware. Mild to moderate mitral regurgitation. At
least moderately depressed LV function.
EEG ([**11-17**]): IMPRESSION: This is an abnormal 24-hour video EEG
telemetry in the waking and sleeping states due to the slow and
disorganized background rhythm, the right centro-temporal
slowing and rare right posterior quadrant and rigth
centro-temporal sharp waves. These sharp waves are suggestive of
a potential focus of epileptogenesis while the slowing is
suggestive of subcortical dysfunction in this region. The slow
and disorganized background rhythm is suggestive of a mild to
moderate encephalopathy which may be seen with medication
effect, toxic/ metabolic abnormalities, or infection. There were
numerous pushbutton activations for episodes of left arm
shaking. While at times this seemed to correspond with right
centro-temporal 9 Hz sharp waves, there was no clear evolution
to the discharges and these did not necessarily correlate at all
times with these clinical events suggesting that these are not
likely electrographic seizures. However, simple motor seizures
such as these frequently do not have electrographic correlate
unless clinical correlation is recommended.
CXR ([**11-17**]): Nasogastric tube unchanged in position since
earlier today, would need to be advanced 5 cm to move all the
side ports beyond the gastroesophageal junction. ET tube,
right-sided central venous catheter, in standard placements. The
change in relative position of the transvenous right ventricular
pacer defibrillator lead with respect to the left ventricular
lead and left hemidiaphragm could be a function of patient
positioning or an indication that the right ventricular lead is
not anchored. Clinical correlation advised. Standard position of
the right atrial lead is stable. Lungs are clear, and there is
no pleural effusion. Moderate-to-severe cardiomegaly is stable
over the past several days but increased since [**11-13**].
EEG ([**11-18**]): IMPRESSION: This is an abnormal 24-hour video EEG
telemetry due to the slow and disorganized background with
bursts of multifocal slowing and bursts of frontally predominant
generalized slowing with a triphasic appearnce. These findings
suggest a moderate encephalopathy. The bifrontal slowing
suggests subcortical or deep midline dysfunction. There were six
pushbutton activations for high frequency left hand and arm
tremor which did not have any electrographic correlate. No clear
epileptiform discharges or electrographic seizures were seen.
EEG ([**11-19**]): IMPRESSION: This is an abnormal 24-hour video EEG
telemetry which captured one pushbutton activation for
intermittent high frequency left upper extremity tremor which
did not have any clear electrographic correlate. Throughout the
recording the background was slow and disorganized with bursts
of multifocal slowing and generalized, frontally predominant
slowing which had a triphasic appearance suggestive of a
moderate encephalopathy. No clear epileptiform discharges were
seen. No electrographic seizures were seen.
EEG ([**11-20**]): IMPRESSION: This is an abnormal video EEG telemetry
due to the slow and disorganized background with bursts of
multifocal and generalized slowing suggestive of a moderate
encephalopathy. The synchronous or independent bifrontal
slowing, R>L, is suggestive of subcortical or deep midline
dysfunction. No clear epileptiform discharges and no
electrographic seizures were seen.
ECG ([**11-22**]): Baseline artifact. Paced rhythm at a rate of 69.
Occasional ventricular premature beats. Compared to the previous
tracing of [**2154-11-21**] ventricular ectopy is new.
CXR ([**11-22**]): There has been no significant change since the prior
chest x-ray. The position of the various lines and tubes is
unchanged. Position of the tracheostomy tube is satisfactory. No
infiltrates or evidence of pneumonia or failure is seen.
Brief Hospital Course:
The patient was a 79 year-old man with a history of
hypertension, dyslipidemia, TIAs s/p carotid endarterectomy, CAD
s/p MI and CABG, v-fib arrest in [**2152**] s/p pacemaker placement,
and on Aspirin and Plavix who presented as a transfer from
[**Hospital **] Hospital for management of a left thalamic hemorrhage
with intraventricular extension. CT head on admission showed a
3.5 x 2.6 cm intraparenchymal hemorrhage centered in the left
basal ganglia, with intraventricular extension and mild
ventriculomegaly with approximately 4 mm of rightward midline
shift. His brainstem reflexes were largely absent on admission
(with the exception of minimally reactive pupils and a gag
reflex). He was thought to most likely have a hypertensive
hemorrhage. Urine and serum tox were negative on admission.
Repeat Head CTs showed unchanged large left thalamic
intraparenchymal hematoma and intraventricular hemorrhage, but
he did develop extension/leaking into the subarachnoid space
most evident in the left parietooccipital region and persistent
hydrocephalus. His ASA and Plavix were initially held, but his
ASA 81 daily was restarted on [**11-14**]. Upon repeat neurological
examinations, he would only withdraw his LUE to noxious
stimulation, and he developed intermittent rhythmic tremor of
his LUE thought to be epilepsia partialis continua. He was
initially on Dilantin, but had fevers and episodes of
hypotension (see below), so this was changed to Keppra 1000 [**Hospital1 **].
Initial EEG showed diffuse background slowing indicative of a
moderate encephalopathy, intermittent right central spike and
slow wave activity and more rare left central activity
indicating an area of cortical irritability. However, there was
no sustained rhythmic activity to indicate an electrographic
seizure. Continuous EEG monitoring showed moderate
encephalopathy, but the LUE tremor did not have electrographic
correlate.
He was initially on a nicardipine gtt for blood pressure
control, then was started on standing Metoprolol. Cardiology
interrogated his pacemaker on admission, which was functioning
appropriately. He would intermittently have episodes of
hypotension to SBP 70-80, especially when being turned in bed,
which would require a few hours of pressors which he would then
quickly wean off. His cardiac enzymes were negative but bumped
after the first of these episodes, which may have been demand
ischemia in the setting of hypotension. TTE showed mild
symmetric LVH with LVEF 30%, moderately dilated LV cavity,
moderate regional left ventricular systolic dysfunction with
inferior/inferolateral akinesis with hypokinesis elsewhere, mild
(1+) AI, and mild (1+) MR.
The patient persistently spiked temperatures during the
admission, which was determined to be central fever. His WBC on
admission was 6.8, which peaked at 16.2 on [**11-16**]. He was
initially on CTX 1 gm IV daily for a pan-sensitive E. coli UTI.
On [**11-13**], he was started on Vanc 1 gm IV q12 hr, Gentamicin 450
IV q36 hr, and Zosyn 4.5 gm IV q8 hr for possible ventilator
associated pneumonia (given that there were 1+ GNRs on a sputum
gram stain from [**11-16**], but the culture showed no growth). He
completed a 7 day course of these antibiotics. Multiple other
cultures showed no growth, CXR never showed a consolidation, and
TEE showed no vegetations on cardiac valves or intracardiac
hardware. Liver/gallbladder ultrasound showed cholelithiasis
without evidence of cholecystitis, non-visualization of the
pancreas and distal CBD, and simple-appearing exophytic cyst
arising from the right kidney.
Despite his stable appearing CT head and multiple normal
cultures and CXRs, the patient's neurological exam did not
improve. The team had 2 family meetings with his family, and the
family wanted to continue with all treatment.
Per the TSICU team, on [**11-22**] the patient had a tracheostomy and
PEG placed without complications or blood loss. He had had
labile blood pressures during the day, and required a persistent
amount of phenylephrine. Because of this, the team sent labs
which showed his Hct had dropped to 16.6 from 29.9 that morning.
He was continued on pressors and bolused crystalloid. His
telemetry then showed that his QRS widened to asystole, and ACLS
began. He received 2 rounds of epi, was in v-fib, was shocked,
then regained a perfusing rhythm. Repeat Hct was 22.5 after 2 U
PRBCs. The family decided to make him CMO, and the patient
passed away.
Medications on Admission:
-Plavix 75 mg daily
-Aspirin 81 mg daily
-Zocor 40 mg daily
-Toprol XL 100 mg daily
-Lasix 20 mg daily
-Folate 1 mg daily
-Ferrous sulfate 325 mg daily
-Ranitidine 150 mg daily
-Ativan 0.5 mg q 4 hours prn anxiety
-Tylenol 650 mg q 4 hours prn pain
-Trazodone 50 mg qhs prn sleep
-Nitro 0.3 mg prn chest pain
-Chlorpheniramine 0.4 mg q 4-6 hours prn allergy
-Desonide prn
-Nasonex prn
-Spiriva prn
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Left thalamic hemorrhage, likely hypertensive
Hypertension alternating with hypotension
Epilepsia partialis continua
E. coli UTI
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"331.4",
"V45.81",
"786.06",
"041.4",
"414.00",
"427.5",
"272.4",
"348.30",
"599.0",
"401.1",
"431",
"782.3",
"276.1",
"342.90",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"38.91",
"43.11",
"96.71",
"99.04",
"96.72",
"96.04",
"96.07",
"31.1",
"33.23",
"38.93",
"89.45",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
20743, 20752
|
15810, 20255
|
332, 387
|
20924, 20933
|
3693, 15787
|
20989, 21091
|
2584, 2645
|
20703, 20720
|
20773, 20903
|
20281, 20680
|
20957, 20966
|
2660, 3029
|
2088, 2148
|
253, 294
|
415, 2069
|
3143, 3674
|
3068, 3127
|
3053, 3053
|
2170, 2439
|
2455, 2568
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,386
| 147,531
|
10149
|
Discharge summary
|
report
|
Admission Date: [**2136-12-10**] Discharge Date: [**2136-12-25**]
Date of Birth: [**2072-5-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
.
Fevers
.
Major Surgical or Invasive Procedure:
mechanical ventilation
History of Present Illness:
.
Pt is 64 yo f with h/o mental retardation, DM2, epidural
abscesses with veterbral osteo, s/p recent T3-L3 fusion with
bone graft, s/p recent admission to [**Hospital1 18**] from [**Date range (1) 33891**], who
now presents with fever x 1 day. Of note, pt had temp 100.0 on
morning of discharge [**12-4**]. Today, pt was febrile at rehab to
103-104, found to have hct 22.3, and K 2.7. Blood, urine, and
sputum cx's were sent at rehab several days ago (? fever x past
several days). She was started on Bactrim on [**12-8**] and Linezolid
on [**12-7**] for positive sputum and urine cx's.
.
In the [**Name (NI) **], pt had temp of 101.1, but was hemodynamically stable.
She received 1L NS and vanc 1g. Her vent settings were set to
AC 14/500/5/30%.
.
Pt currently is alert, but is unable to verbalize any
complaints.
.
Past Medical History:
.
- h/o Osteomyelitis T6-T8 with cord compression: s/p T6-7
corpectomy with T5-8 strut graft/fusion on [**2136-10-19**], s/p T3-L3
fusion w/bone graft on [**2136-11-2**], on long-term nafcillin
- h/o MSSA epidural abscesses from L4-brain: s/p multiple
drainages during prior admissions
- h/o ATN requiring HD, now with CRI (recent baseline 1.2-1.4)
- anemia likley [**2-23**] ACD, on epo (recent baseline hct 26-28)
- h/o upper GIB (no recent scopes in OMR)
- COPD
- h/o transudative pleural effusion
- h/o sepsis
- h/o drug resistant acinetobacter from sputum cx (sensitive to
tobramycin)
- h/o VRE UTI
- h/o resp failure: s/p trach and PEG [**2136-11-9**], continues to
require vent at rehab
- persistent diarrhea (C.diff negative)
- Mental retardation
- DVT [**1-/2130**]
- NIDDM
- Obesity
- Sciatica
- Hypertension
- Hypercholesterolemia
- Anxiety
- Psoriasis
- Paroxysmal A. fib
- cholelithiasis
.
Social History:
Lives in apartment with 24 hour caregiver; has a long term
boyfriend. [**Name (NI) 1403**] part time. Guardian is [**Name (NI) 402**] [**Name (NI) 33801**]
[**Telephone/Fax (1) 33802**].
Family History:
Pt unable to provide
Physical Exam:
.
Vitals: T 100.0 BP 118/60 HR 102 RR 14 O2 99% on AC 14/500/5/30%
Gen: alert, NAD
HEENT: PERRL. Dysmorphic facial features
Neck: Thick neck. Trach in place.
Cardio: distant heart sounds
Resp: rhonchi BL anteriorly
Abd: soft, obese, mild epigastric tenderness, no
rebound/guarding, +BS.
Ext: 1+ BL LE edema.
Skin: Erythematous sacral decub. R heel ulcer.
Neuro: alert, answers questions but unclear if appropriate,
moves both lower ext, but did not move UE in response to
commands
.
Pertinent Results:
.
Culture Data from OSH:
[**12-5**] blood cx: no growth
[**12-5**] urine cx: alpha hemolytic strep, GNR
[**12-5**] sputum cx: GNR, acinetocbacter (sensitive only to Bactrim)
.
Culture Data from [**Hospital1 18**]:
[**12-10**] Blood cxs: [**1-25**] Coag Negative Staph (anaerobic bottle)
[**12-10**] Urine Cx: Enterobacter cloacae (sensitive to bactrim,
imipenem, cefipime but resistant to Ceftaz, Ceftriaxone, Cipro,
Levofloxacin, Gent, Nitrofurantoin, Piperacilin; Intermediate
sensitivity to Tobramycin)
[**12-12**] Sputum Cx: Gram Negative Rods
[**12-12**] Blood Cx: NGTD
[**12-13**] Stool Cx: Negative for C dif
.
Chest CT Scan, [**2136-12-13**]: Persistent left lower lobe
consolidations with moderate left pleural effusion. This may
represent atelectasis, but superimposed pneumonia cannot be
excluded. Small right lower lobe consolidation and effusion,
but no new airspace consolidations. Mild pulmonary edema.
.
CXR, [**12-10**]: 1. Persistent left retrocardiac opacity which
appears to have increased in comparison to the prior study.
This may represent atelectasis and/or consolidation. If this is
clinically feasible, further evaluation with dedicated PA and
lateral radiographs may be beneficial in characterizing this
further. 2. Interval placement of a right PICC, with the tip
not well visualized secondary to overlying metallic hardware.
.
LABS ON DISCHARGE:
[**2136-12-24**] 03:55AM BLOOD WBC-5.9 RBC-2.54* Hgb-8.0* Hct-24.4*
MCV-96 MCH-31.4 MCHC-32.7 RDW-19.1* Plt Ct-335
[**2136-12-24**] 03:55AM BLOOD Glucose-103 UreaN-34* Creat-0.9 Na-141
K-3.3 Cl-107 HCO3-25 AnGap-12
[**2136-12-24**] 03:55AM BLOOD Calcium-9.0 Phos-2.4* Mg-2.1
Brief Hospital Course:
.
A/P: 64 yo f with MMP, including spinal osteomyelitis, CRI, s/p
trach and PEG, recently discharged from [**Hospital1 18**], now with
recurrent fevers.
.
[**Hospital Unit Name 153**] Course: Patient was admitted to the [**Hospital Unit Name 153**] for recurrent
fevers. She had multiple possible sources for her infection
including UTI (has chronic foley), known osteomyelitis and
epidural abscesses, sacral decubitus ulcer, PICC line (placed on
[**2136-11-26**]), and possible PNA. The patient was continued on
Linezolid for the epidural abscess. She was seen by ID and was
then switched from Linezolid to Daptomycin [**2-23**] increased
rigidity on physical exam. She was also continued on Bactrim
for finding of Acinetobacter in her sputum from her previous
admission. Blood cultures were sent and [**1-25**] grew Coag negative
Staph (in anaerobic bottle, identification pending). This was
thought to likely represent a contaminant. Repeat surveillance
cultures from the PICC line were drawn and are currently no
growth to date. She was seen by ortho spine (who performed her
last spinal fusion) and felt there was no need for further
imaging or surgical intervention currently. She was continued
on her current ventilator settings as she is trached and
ventilator dependent. She has anemia of chronic disease and was
found to have a Hct upon admission 22.8 for which she was
transfused one unit PRBCs. Her Hct remained stable after this
transfusion. The patient has a history of eosinophilia of
unclear etiology. This was monitored and trended downwards
slightly during her [**Hospital Unit Name 153**] course - thought to lend evidence
toward a non-infectious etiology for her fevers.
.
.
#) Fever: The patient has been treated with multiple antibiotics
with persistent fevers. Likely not infectious source. Per ID -
continue to treat with Imipenem until [**2136-12-27**] at which point
will begin nafcillin 2gm IV q 4 hours. Per ID, may also start
rifampin at that time. Her med list was evaluated for
medications that could possibly cause a drug-fever and potential
offenders were discontinued. She actually defervesed and at the
time of her discharge she had not had fevers for 48 hours.
.
#) Resp failure: pt currently with trach, on vent. Had high RR
initially, but oxygenation remained good and these were
attributed to anxiety/agitation. She was liberated with PSV
trials of longer and longer duration, until switching directly
to a trach collar.
.
#) Abdominal tenderness: pt with hx of colonic thickening seen
on prior CT's. LFT's, amylase, lipase within normal limits.
Her abdominal exam was benign during her stay.
.
#) Vertebral osteo: Initially treated with linezolid, but this
was thought to be cause of patient's fever. This was changed to
Imipenem. A course was defined by ID to run until [**2136-12-27**]
.
#) CRI: Was thought to be pre-renal on presentation. Patient
reutrned to baseline with hydration and was discharged with Cr
of 0.9.
.
#) HTN: Restarted on antihypertensive metoprolol as her BP
tolerated.
.
#) DM 2: continued on RISS. Blood sugars remained in good
control.
Medications on Admission:
.
Ipratropium Bromide 2 puffs Q6H
Albuterol 1-2 Puffs Q6H (every 6 hours) prn
RISS
Tylenol 325-650 q4h prn
Motrin 400mg q4h prn
Miconazole Nitrate 2 % Powder Topical [**Hospital1 **] prn
Loperamide 2 mg QID prn
Epoetin Alfa 20,000 units QMOWEFR
Lamotrigine 25 mg [**Hospital1 **] (50mg [**Hospital1 **] from last d/c summary)
Olanzapine (rapid dissolve) 5 mg qd (from last d/c summary)
Heparin SC 5,000 units tid
Metoprolol Tartrate 25 mg [**Hospital1 **] (from last d/c summary)
Nafcillin 2 gm IV Q4H tx of osteomyelitis (per d/c summary, not
in rehab med record)
Linezolid 600mg IV bid (started on [**12-7**])
Bactrim DS 2 tabs [**Hospital1 **] (started on [**12-8**])
Fluconazole 100 mg IV Q24H x 1 wk (began [**12-3**], finished on
[**12-9**])
Hydromorphone 0.5 mg IV Q4H prn
Lorazepam 0.5-2 mg IV Q2-3H prn
Pantoprazole 40 mg IV Q12H
Levothyroxine 200 mcg per GT qd (50mcg IV from last d/c summary)
Metoclopramide 10 mg IV Q6H
Morphine Sulfate 2 mg IV Q2H:PRN pain (per last d/c summary)
.
Discharge Medications:
1. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
3. Levothyroxine 100 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
4. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
6. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day) as needed.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q6H
(every 6 hours) as needed.
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
10. Cyanocobalamin 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Imipenem-Cilastatin 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 3 days: last dose
[**12-27**]. Recon Soln(s)
12. Insulin Regular Human 100 unit/mL Solution [**Month (only) **]: One (1)
Injection ASDIR (AS DIRECTED).
13. Sodium Bicarbonate 650 mg Tablet [**Month (only) **]: One (1) Tablet PO BID
(2 times a day).
14. Nafcillin 2 g Recon Soln [**Month (only) **]: Two (2) g Intravenous every
four (4) hours: Please begin this medication on [**12-28**],
the day after her last dose of Imipenem. .
Discharge Disposition:
Extended Care
Facility:
Northeast Specialist
Discharge Diagnosis:
respiratory failure
vertebral osteomyelitis
metabolic acidosis
hypothyroidism
anemia
mental retardation
eosinophilia
hypertension
diabetes
Discharge Condition:
fair
Discharge Instructions:
Please continue antibiotics. She will need to be on impenem
until [**12-27**]. Please monitor blood cultures, CBC, and LFTs
in 4 days. Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3394**] at
[**Telephone/Fax (1) 1419**].
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2137-1-1**]
10:30
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13,944
| 190,660
|
54145
|
Discharge summary
|
report
|
Admission Date: [**2123-3-16**] Discharge Date: [**2123-3-24**]
Date of Birth: [**2065-9-20**] Sex: F
Service: MEDICINE
Allergies:
Morphine Sulfate / Metformin
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
ICU Admission
Endotracheal Intubation
Subclavian Central Line placement
History of Present Illness:
HPI: The pt was originally admitted on [**2123-3-16**] s/p fall. Pt felt
weak while walking, + dizziness, describes "knees going out from
under her." Usually walks with a cane, but, couldn't keep her
balance. She denied head injury. In the ED, her HCT was found to
be 25.9 with c/o black stools. She hwas found to be guiaiac +
stool. She had a traumatic NG lavage initially was positive for
dark clumps but cleared after 400ccs. She was also found to have
a + UA with c/o urinary frequency and was started on
ciprofloxacin.
.
She was transfused two units of PRBC's. GI was consulted and
upper and lower endoscopies done. EGD showed duodenitis and
erosive gastritis but normal mucosa in the second part of the
duodenum. Colonoscopy was normal to the cecum. Pt remained
hemodynamically stable and had stable hct after transfusion
ranging from 27 to 31. Also, notable this admission was renal
failure with Cr to 2.0 from baseline 1.0-1.3. Pt was noted to
have lethargy following colonoscopy. A head CT was done due to
fall hx but was normal. A trigger was called on the floor due to
the patients increasing lethargy. An ABG was 7.26/65/85/31 on 4
liters and she was noted to be hyperglycemica to 300s at the
time. At the time her temp was 101 and SBP 220.
She was transfered to the ICU for hypercarbic respiratory
failure in the context of toxic metabolic encephalopathy. The pt
was first tried on BiPAP, but did not tolerate it and then was
intubated for worsening hypercarbic respiratory failure. As the
pt continued to be febrile, and a CXR was suggestive of possible
RLL pneumonia, Ceftraixone and Metronidazole was given for PNA,
possible due to aspiration. The pt also had intermittent
hypotension thought to be due to decreased preload in the
context of intubation versus adrenal insufficiency versus SIRS.
Pt was empirically treated with steroids which were discontinued
as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was normal. Hypotension improved with fluid
boluses only. Pt improved rapidly and was able to be extubated
two days day after. She tolerated extubation well and was
maintained on O2 per NC. Repeat ABG did not show any
reaccumulation of CO2. The pt appears to be retaining CO2 at
baseline as CO2 was still elevated in the low 50s.
Past Medical History:
DM II
HTN
Anxiety
Depression
narcotic dependence
hypercholesterolemia
Social History:
lives alone in housing for disabled. goes to day program. no
smoking, no EtOH, no drugs.
Family History:
NC
Physical Exam:
PE: Tmax 100.6 (on [**3-21**]) afebrile since, Tc 99.1, NBP 88/46, ABG
92-142/44-62, O2sat 92-99 on 5L NC, I/O 2250/905
Gen: NAD, breathing comfortably
HEENT: PERRLA, EOMI, MMM
neck : JVP not assessible
Chest: CTAB. poor breath sounds crackles toward bases
CV: RRR, no m,r,g. NML s1, s2
ABD: + BS. obese, ND, NT, soft.
Msk/Sk: abrasion R knee
NEURO: CNII-XII intact, no focal neurologic deficits
Pertinent Results:
[**2123-3-15**] 03:35PM PLT COUNT-357
[**2123-3-15**] 03:35PM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-2+
[**2123-3-15**] 03:35PM NEUTS-66.7 LYMPHS-27.2 MONOS-2.9 EOS-2.7
BASOS-0.6
[**2123-3-15**] 03:35PM WBC-9.7 RBC-3.88* HGB-9.0* HCT-29.8* MCV-77*#
MCH-23.1*# MCHC-30.0* RDW-17.7*
[**2123-3-15**] 03:35PM LDL([**Last Name (un) **])-105
[**2123-3-15**] 03:35PM %HbA1c-8.0* [Hgb]-DONE [A1c]-DONE
[**2123-3-15**] 03:35PM FERRITIN-14
[**2123-3-15**] 03:35PM IRON-30
[**2123-3-15**] 03:35PM LIPASE-220*
[**2123-3-15**] 03:35PM ALT(SGPT)-16 AST(SGOT)-18 CK(CPK)-77 ALK
PHOS-105
[**2123-3-15**] 03:35PM UREA N-64* CREAT-2.1*# SODIUM-142
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-26 ANION GAP-19
[**2123-3-15**] 03:35PM GLUCOSE-291*
[**2123-3-16**] 12:05PM URINE HYALINE-[**11-1**]*
[**2123-3-16**] 12:05PM URINE RBC-0-2 WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2123-3-16**] 12:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2123-3-16**] 12:05PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2123-3-16**] 12:05PM URINE GR HOLD-HOLD
[**2123-3-16**] 12:05PM URINE HOURS-RANDOM
[**2123-3-16**] 02:55PM GLUCOSE-196* UREA N-69* CREAT-2.0* SODIUM-143
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-25 ANION GAP-18
[**2123-3-16**] 04:05PM RET AUT-1.3
[**2123-3-16**] 04:05PM PLT COUNT-257
[**2123-3-16**] 04:05PM HYPOCHROM-3+ ANISOCYT-1+ MICROCYT-2+
[**2123-3-16**] 04:05PM NEUTS-67.5 LYMPHS-25.6 MONOS-3.8 EOS-2.8
BASOS-0.2
[**2123-3-16**] 04:05PM WBC-6.2 RBC-3.34* HGB-7.9* HCT-25.9* MCV-78*
MCH-23.5* MCHC-30.3* RDW-17.8*
[**2123-3-16**] 05:40PM PT-10.5 PTT-19.1* INR(PT)-0.9
[**2123-3-16**] 05:40PM calTIBC-575* FERRITIN-15 TRF-442*
[**2123-3-16**] 05:40PM IRON-25*
[**2123-3-16**] 05:40PM ALT(SGPT)-15 AST(SGOT)-18 LD(LDH)-254* ALK
PHOS-110 TOT BILI-0.1
[**2123-3-23**] Echo:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular
wall motion is normal. Right ventricular chamber size and free
wall motion are
normal. The aortic valve leaflets (3) appear structurally normal
with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears
structurally normal with trivial mitral regurgitation. There is
no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be
determined. There is no pericardial effusion.
[**2123-3-17**] EGD/pathology of the Stomach and Duodenal Bx taken
DIAGNOSIS:
Gastrointestinal mucosal biopsies, two:
A. Stomach, antrum:
Chronic focally active gastritis.
Bacteria , morphologically consistent with H. pylori seen.
B. Duodenum:
No diagnostic abnormalities recognized
[**2123-3-17**] Colonoscopy:
Normal Study to Cecum
Brief Hospital Course:
57 yo obese female who was initially admitted after fall and was
found to be anemic due to erosive gastritis and duodenitis on
EGD secondary to NSAID overuse. Patient subsequently became
somnolent likely due to toxic metabolic encephalopathy in the
setting of sedative meds and possible OSA. Pt was subsequently
intubated 24 hours later for hypercarbic respiratory failure,
but improved rapidly and was able to be extubated 24 hours
thereafter on [**3-21**].
.
# Hypercarbic respiratory failure: Initially, most likely due to
oversedation after receiving medications during EGD and also her
scheduled trazadone, mirtazapine, klonopin and risperidone with
slightly worsening renal failure. There is also suspicion for
probable OSA contribution as well. Patient was transfered to
the unit for closer monitoring of her respiratory status. She
did not tolerate her noninvasive ventilation well and continued
to worsen with worsening hypercarbia. Patient subsequently
became febrile up to 102 and relatively hypotensive. Aspiration
was most likely culprit and she was subsequently intubated.
Repeat CXR showed new pneumonia in RLL due to presumed
aspiration. Patient was subsequently started on Ceftriaxone and
Flagyl to cover CAP and aspiration PNA pathogens. Patient
quickly improved in her mental status and was extubated 24 hours
later. Patient does have underlying OSA at baseline and has
recently been refered by her PCP for sleep study and further
evaluation. Pt does not have recent PFTs (last from [**2112**]
showing mild restricitive and obstructive component) and may
benefit from repeat PFTs once acute phase resolved. Continue
Antibiotic for 10 day course.
- montior respiratory and mental status (at rehab)
.
# Hypotension - Patient was hypotensive in the unit requiring
Levophed for 24 hours to keep her MAPs >65. She had a L SCL
tripple lumen catheter placed for pressor administration.
Patient quickly improved with initiation of antibiotic therapy
and her hypotension was presumed to be due to septic/SIRS
response to her RLL PNA. Patient also underwent [**Last Name (un) 104**] stim test
with appropriate response and thus no steroids were initiated.
Patient was also resuscitated with 4 L LR while in the unit
while maintaining excellent urine output and her renal function
remained at her baseline. She never had elevated lactate above
4.0. Since blood pressures were stable, and patient was
acutually HYPERTENSIVE, lisinopril was restarted to be titrated
as an outpatient.
.
# Toxic metabolic encephalopathy: likely due to sedation after
procedure. Rapid improvement consistent with this theory. OSA
might be contributing. Now resolved. Patient's psych
medications could be contributing to the patient's
oversedations. During the hospitalization Paxil and clonopin
was started. The patient's previous psych regimen was verified
with PCP, [**Name10 (NameIs) **] some medications were discontinued due to
oversedation. The patient has an outpatient psych appointment
scheduled in the near future. The outpatient psychiatrist is Dr.
[**Last Name (LF) 5639**], [**Name8 (MD) **] MD at ([**Telephone/Fax (1) 24780**], who could be contact[**Name (NI) **]
should an emergency arise while at rehab regarding psychiatric
issues. The patient was instructed to call and make appt with
psychiatry once discharged from rehab.
.
# Anemia/GiB: Baseline Fe def + acute bleed from GI source.
Patient required 1 U PRBCS on [**3-20**], her Hct > 25. Her Hct has
been stable last 48 hours around 27. She continues to have
guiac positive stools. Patient was started on iron replacement.
GI service was consulted before her transfer to the unit and
EGD result ( gastric erosions) were interpreted to be due to
NSAID overuse. Patient is to continue on [**Hospital1 **] PPI and avoid
further NSAID. However if her Hct does trend down below her
threshold of 25. She may require a more urgent scope rather
than the one planned in next 4-6 weeks as her anemia is not
resolving and continue to progress despite the avoidance of
NSAIDS. GI recommended a pill endoscopy if the hematocrit keeps
drifting in the next 6 weeks. PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] has been
informed about the aforementioned plan. Also, Dr. [**Last Name (STitle) **] was
informed that biopsy came back positive for H pylori and he will
tx as outpatient.
.
# Renal failure: unclear etiology, urine lytes not consistent
with hypovolemia or relative hypotension associated with GIB,
but pt improved with fluids. Pt with peripheral eosinophilia,
but AIN less likely given negative eosinophils. Also likely
contributor include diabetic vs hypertensive nephropathy.
Creatinine now back to baseline.
.
# GU: UTI (+UA). Urine cx spec negative. Repeat UA negative.
Patient is to complete a 7 day course (Levoflox for aspiration
pneumonia)
.
# Psych: pt has a complicated psych hx, including narcotic
dependence, depression and bipolar disorder. Currently on Paxil
and clonazepam. See the contact info for outpatient psychiatris
is above.
.
# DMII: holding PO hypoglycemics. They should be restrarted
once the patient leaves acute rehab facility. See discharge
meds. currently on NPH and regular insulin sliding scale, which
may need adjustment while the patient is at rehab. .
.
# FULL CODE
Medications on Admission:
ASPIRIN 325MG qd
ATENOLOL 25 MG--One tablet every day
ATORVASTATIN CALCIUM 40 MG--One by mouth every day CLONAZEPAM
500 MCG--One by mouth twice a day
DYAZIDE 25-37.5MG--One by mouth every day (reportedly held by
PCP, [**Name10 (NameIs) **] no note to document).
GLYBURIDE 5 MG--One by mouth daily for diabetes
IBUPROFEN 800 MG--One by mouth q8 as needed for with meals
LISINOPRIL 20MG--One by mouth every day for blood pressure
NPH (HUMAN) 100 UNITS/ML--Take 20 units sq in the morning, 16
units in the evening, adjust as directed
ONE TOUCH LANCETS --Use as directed to monitor blood sugar
ONE TOUCH ULTRA TEST STRIPS --Use as directed to check blood
sugar up to three times a day
PAXIL 20MG--3 by mouth every day
PIOGLITAZONE 45 MG--One by mouth every day
POTASSIUM CHLORIDE 10 MEQ--2 tabs every day
REMERON 15MG--One by mouth at bedtime
RISPERIDONE 1MG--[**Last Name (un) **] by mouth at bedtime
SYRINGE 1ML (INSULIN) 1 ML--Use as directed for insulin
Trazodone 50 mg--[**12-14**] tablet(s) by mouth qhs as needed for sleep.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Iron Deficiency Anemia
Gastritis and Duodenitis
Hypercarbic Respiratory Failure
Aspiration Pneumonia
Pickwickian Syndrome
Discharge Condition:
stable, afebrile, ambulatory, improved mental status.
Discharge Instructions:
-please take all your medications as directed
-please follow up all outpatient appointments
-please keep head of bed up when sleeping
-should you feel more lethartic or more short of breath, please
call your PCP or go to the ER immediately
-pleae follow up with your pscyhiatris to adjust your
psychiatric medications
Followup Instructions:
-PCP needs to [**Name Initial (PRE) **]/u endoscopic bx and hpylori testing
-needs iron supp on d/c
-pt needs outpatient sleep study
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2123-6-14**] 2:50
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2123-5-7**] 9:15
Provider: [**Name10 (NameIs) **] FERN, RNC Date/Time:[**2123-4-20**] 10:20
-please call Dr. [**Last Name (STitle) **] to schedule a follow up appointment
([**Telephone/Fax (1) 250**]) after you get discharged from [**Hospital3 **].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2123-3-24**]
|
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"507.0",
"535.41",
"599.0",
"401.9",
"296.7",
"038.9",
"285.1",
"995.91",
"349.82",
"518.81",
"535.60",
"584.9",
"E935.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"45.16",
"38.93",
"45.23",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12565, 12635
|
6174, 11487
|
298, 372
|
12801, 12857
|
3337, 6151
|
13223, 13975
|
2902, 2906
|
12656, 12780
|
11513, 12542
|
12881, 13200
|
2921, 3318
|
250, 260
|
400, 2687
|
2709, 2780
|
2796, 2886
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,068
| 136,640
|
9016
|
Discharge summary
|
report
|
Admission Date: [**2107-6-18**] Discharge Date: [**2107-7-8**]
Date of Birth: [**2054-1-24**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Transfer from [**Hospital 8125**] Hospital with partial small bowel obstruction
Major Surgical or Invasive Procedure:
Exploratory laporotomy and lysis of adheasions with delayed
closure
History of Present Illness:
Ms. [**Known lastname 5730**] is a 53 year old woman with recurrent stage IIIC
papillary serous ovarian cancer on Doxil presents as transfer
from outside hospital with partial small bowel obstruction.
Ms. [**Known lastname 5730**] was diagnosed with stage IIIB, grade 3 papillary
serous ovarian carcinoma in [**2103-1-18**] when she presented
with ascites. She underwent optimal debulking and is s/p
chemotherapy with taxol/carboplatin x one cycle, DoCaGem
(Taxoterene, Carboplatin, Gemcitabine) x one cycle (did not
tolerate due to low counts), s/p Taxol/carboplatin x 6 cycles
with clinical remission [**4-18**]. She is s/p consolidation with
Topotetacan x 6. Due to a rising CA-125, she began a Phase II
protocol of CP-547,632 an oral tyrosine kinase inhibitor of
VEGFR-2 in [**2105-10-17**]. She relapsed in [**11-19**] and received
axol/carboplatin x 6 cycles. She then started Arimidex, but
relapsed and completed 6 more cycles of [**Doctor Last Name **]/gemcitabine. She
received one cycle of GM-CSF
but her CA-125 progressed and she was started on Doxil [**3-22**].
Patient received her last dose of Doxil on [**2107-5-24**]. Her CA-125
continued to rise to 1013 and the plan was to start topotecan.
At her last clinic visit on [**6-8**] she complained of two episodes
of BRBPR associated with vagal symptoms. She was guiac positive
and her hct was 31 down from 35. She was scheduled for a
colonoscopy on [**6-17**]. She called clinic on [**6-15**] complaining of
nausea and bloating. She had not had a bowel movement in three
days despite colace and senna. She was having intermittant
crampy abdominal pain which was much worse than her baseline.
She was told to go to the local ED if she vomited or developed
temp > 100.5. She started vomiting dark fluid and developed a
temp of 100.7 and went to [**First Name4 (NamePattern1) 8125**] [**Last Name (NamePattern1) **]. KUB at [**Doctor First Name 8125**] showed a
parital small bowel obstruction. An NG tube was placed and
patient's symptoms improved considerably. Her KUB also showed
significant constipation. She received four soap suds enemas and
one tap water enema and has had several bowel movements, the
last one today was formed.
Currently the patient denies nausea, vomiting, abdominal pain,
shortness of breath, chest pain. She reports low grade fevers at
home associated with chills which are not new. She reports a
sore throat that she feels is due to the NG tube. She also feels
that she is starting to have symptoms of URI with sinus fullness
and sore throat. Currently her abdomen does not feel distended
to her and she does not have crampy pain.
Past Medical History:
1. Ovarian Cancer:
-s/p Platinum-based chemotherapy with complete clinical response
[**2104-4-16**].
-s/p consolidation oral topotecan completed 12/[**2103**].
-s/p one cycle of oral VEGF receptor inhibitor for marker-only
relapse with progression in [**2105-10-17**].
s/p six cycles of paclitaxel and carboplatin [**11/2105**] through
4/[**2105**].
-s/p Arimidex [**3-/2106**] to [**7-21**].
-s/p carboplatin/gemcitabine x 6 cycles completed [**11-20**]
-s/p GM-CSF on protocol 04-305 [**2-19**]; progression after one cycle
-started Doxil [**3-22**]; last dose [**2107-5-24**]
2. Hysterectomy
3. Thrush
4. Anemia
Social History:
Lives with her husband. Does not smoke or drink. Used to work in
Human Reasources; now works part time.
Family History:
Her mother developed uterine cancer in her 50s. Her maternal
grandfather developed [**Name2 (NI) 499**] cancer in his 50s. She also had a
maternal aunt who developed esophageal cancer in her 50s. A
maternal cousin developed "brain cancer" in her 30s. She has
one sister who is alive and well. There is no history of breast
or ovarian cancer in her family, according to the patient's
verbal report.
Physical Exam:
T 98.4 HR 93 BP 130/75 RR 18 O2 sat 100% RA
Gen: Thin, comfortable appearing woman, with NG tube in place.
NAD.
HEENT: PERRL, EOMI, sclera anicteric, MMM.
Neck: NO JVD or thyromegly.
Nodes: No axillary or cervical lymphadenopathy.
Lungs: CTA bilaterally
CV: regular, tachycardic. No MRG
Abd: Distended, soft, only minimally tender to deep palpation.
No guarding or rebound. Quiet bowel sounds are present.
Rectal: No stool in the vault.
Ext: No C/C/E.
Neuro: Alert and oriented.
Pertinent Results:
MCV 87
6.3\10.5/384
/31.3\
N:75.5 L:14.4 M:8.1 E:1.7 Bas:0.3
Hypochr: 1+
139 | 101| 5/116 AGap=16
3.4 | 25 | 0.6\
Ca: 9.2 Mg: 1.6 P: 2.7
ALT: 96 AP: 87 Tbili: 0.3 Alb: 3.8
AST: 90 LDH: 250 Dbili: TProt:
[**Doctor First Name **]: 87 Lip: 77
CT: [**2107-5-17**]
IMPRESSION:
1) Significant progression of the disease with new hepatic
lesions,
enlargement of retroperitoneal and mesenteric lymphadenopathy,
and ascites.
These findings are consistent with progression of metastatic
ovarian
carcinoma.
2) Prominence of the terminal ileum with fecalization of its
contents.
Although, no obvious mass is noted in the right lower quadrant,
metastatic
disease causing mild obstruction is not entirely excluded.
Correlation with clinical symptoms is recommended. If
necessary, a small bowel follow through could be performed.
Brief Hospital Course:
A/P: 53 year old woman with metastatic ovarian cancer presents
from OSH with partial SBO.
1) pSBO: This has been documented on multiple KUB done at [**Hospital 8125**]
Hospital. Patient improved with NG tube drainage and enemas.
However, she remained distended and required surgical
intervention. After surgical intervention, she remained in the
ICU for several days, and was closed two days after initial
exploration. She recovered slowly, and was maintained on TPN
until she could tolerate a significant amount of PO intake.
Given that she presented several weeks ago with BRBPR this is
very concerning for progression of her disease and possible
erosion into the bowel.
2) Low grade fever: Pt had fevers recurrently throughout the
course of her hospital stay, and had a positive culture in the
urine which cleared after appropriate antibiotic therapy.
3) Dropping hematocrit. In the post-operative period, Mrs. [**Doctor Last Name 31224**] hematocrit dropped slowly over the course of around a
week from 31 to 26 at which time she was transfused and
stablized with a hematocrit of 26.6.
Medications on Admission:
Doxil (last dose was [**2107-5-24**])
Lorazepam 0.5 mg po prn
Compazine
Fioricet
Nystatin
Morphine 1-2 mg IV prn
Zofran IV prn
Lorazepam IV prn
Cepacol prn
Chloraseptic prn
Fioricet prn
Tylenol prn
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*200 ML(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. 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*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Nystatin 100,000 unit/mL Suspension Sig: 5-10 MLs PO QID (4
times a day) as needed for thrush.
Disp:*200 ML(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
small bowel obstruction, with disseminated ovarian carcinoma
Discharge Condition:
Stable
Discharge Instructions:
Please follow up with your primary care doctor and your
oncologist within the next week. Please follow up with Dr.
[**Last Name (STitle) **] in two weeks time. You may shower and eat a regular
diet. Please work with the visiting nurses/pt to increase your
strength. Please take 100mg of colace twice a day, and you may
use dulcolax to help your bowels move. If you develop fevers,
chills, nausea, vomitting, or if your wounds begin to drain,
please call Dr.[**Name (NI) **] office or return to the hospital.
Followup Instructions:
Work with PT. Follow up with your primary care physician, [**Name10 (NameIs) **]
oncologist, and Dr. [**Last Name (STitle) **] as requested. Please do not lift
any heavy objects for 4 more weeks.
Completed by:[**2107-7-8**]
|
[
"E878.8",
"285.9",
"112.0",
"458.29",
"197.7",
"560.81",
"183.0",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.23",
"54.62",
"99.15",
"38.91",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
7721, 7740
|
5684, 6780
|
393, 463
|
7845, 7853
|
4829, 5661
|
8414, 8641
|
3896, 4299
|
7029, 7698
|
7761, 7824
|
6806, 7006
|
7877, 8391
|
4314, 4794
|
274, 355
|
491, 3120
|
3142, 3759
|
3775, 3880
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,530
| 145,307
|
13945
|
Discharge summary
|
report
|
Admission Date: [**2131-2-24**] Discharge Date: [**2131-3-27**]
Date of Birth: [**2081-10-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 4679**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2131-2-24**]
Flexible bronchoscopy
[**2131-2-24**]
EGD
[**2131-2-24**]
PEG placement and esophageal stent placement
[**2131-3-5**]
Percutaneous tracheostomy
[**2131-3-6**]
Right bacilic PICC line
[**2131-3-8**]
CT-guided drainage RLL collection
History of Present Illness:
49 yo M s/p esophageal perf repair at [**Hospital3 **] Hospital [**2131-1-1**]
c/b prolonged ICU course and persistent leakage, transferred
from
[**Hospital3 **] Hospital to [**Hospital1 18**] in respiratory distress for suspected
R thorax emphyema. In [**Hospital1 18**] [**Name (NI) **] pt was immediately intubated for
respiratory distress.Pt was also in septic shock. Admitted to
SICU.
Past Medical History:
steakhouse syndrome, s/p right thoracotomy with RML wedge
biopsy,
esophageal repair, mediastinal debridement, pedicled intercostal
muscle flap
HIV, unknown CD4, on HAART
HTN
pneumonia
alcohol withdrawal with delirium tremens
Social History:
ETOH: prior abuse, h/o DTs
Lives with partner, sister and mother very supportive
Family History:
NC
Physical Exam:
T 100.8 P 98 BP 117/68 RR 40s O2 86% on 15L NRB.
GENERAL [ ] All findings normal
[ ] WN/WD [ ] NAD [ ] AAO [x] abnormal findings: intubated,
sedated
HEENT [x] All findings normal
[ ] NC/AT [ ] EOMI [ ] PERRL/A [ ] Anicteric
[ ] OP/NP mucosa normal [ ] Tongue midline
[ ] Palate symmetric [ ] Neck supple/NT/without mass
[ ] Trachea midline [ ] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY [ ] All findings normal
[ ] CTA/P [ ] Excursion normal [ ] No fremitus
[ ] No egophony [ ] No spine/CVAT
[x] Abnormal findings: intubated, sedated. diminished breath
sounds over R lung field, decreased at L lung base. R
thoracotomy
incision
CARDIOVASCULAR [ ] All findings normal
[x] RRR [x] No m/r/g [x] No JVD [ ] PMI nl [x] No edema
[ ] Peripheral pulses nl [ ] No abd/carotid bruit
[ ] Abnormal findings:
GI [ ] All findings normal
[x] Soft [ ] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred [ ] All findings normal
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO [ ] All findings normal
[ ] Strength intact/symmetric [ ] Sensation intact/ symmetric
[ ] Reflexes nl [ ] No facial asymmetry [ ] Cognition intact
[ ] Cranial nerves intact [x] Abnormal findings: intubated,
sedated
MS [ ] All findings normal
[x] No clubbing [ ] No cyanosis [x] No edema [ ] Gait nl
[ ] No tenderness [ ] Tone/align/ROM nl [ ] Palpation nl
[ ] Nails nl [ ] Abnormal findings:
LYMPH NODES [x] All findings normal
[ ] Cervical nl [ ] Supraclavicular nl [ ] Axillary nl
[ ] Inguinal nl [ ] Abnormal findings:
SKIN [ ] All findings normal
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening [x] Abnormal findings:
R
thoracotomy incision
Pertinent Results:
[**2131-2-23**] 11:00PM WBC-38.4* RBC-2.99* HGB-8.8* HCT-29.2* MCV-98
MCH-29.3 MCHC-30.0* RDW-16.4*
[**2131-2-23**] 11:00PM ALBUMIN-2.4* CALCIUM-8.5 PHOSPHATE-3.0
MAGNESIUM-2.5
[**2131-2-23**] 11:00PM cTropnT-<0.01
[**2131-2-23**] 11:00PM ALT(SGPT)-35 AST(SGOT)-72* ALK PHOS-300* TOT
BILI-0.4
[**2131-2-23**] 11:00PM GLUCOSE-120* UREA N-26* CREAT-0.8 SODIUM-136
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-14
[**2131-2-24**] 03:35AM PT-15.4* PTT-29.2 INR(PT)-1.4*
Test Name Value Reference Range Units
[**2131-3-12**] 03:15
COMPLETE BLOOD COUNT
White Blood Cells 19.0* 4.0 - 11.0 K/uL
Red Blood Cells 2.80* 4.6 - 6.2 m/uL
Hemoglobin 7.8* 14.0 - 18.0 g/dL
Hematocrit 26.4* 40 - 52 %
MCV 95 82 - 98 fL
MCH 27.7 27 - 32 pg
MCHC 29.3* 31 - 35 %
RDW 16.8* 10.5 - 15.5 %
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 1000* 150 - 440 K/uL
VERIFIED BY REPLICATE ANALYSIS
Test Name Value Reference Range Units
[**2131-3-19**] 05:35
Report Comment:
Source: Line-PICC
COMPLETE BLOOD COUNT
White Blood Cells 15.3* 4.0 - 11.0 K/uL
Red Blood Cells 2.99* 4.6 - 6.2 m/uL
Hemoglobin 8.5* 14.0 - 18.0 g/dL
Hematocrit 28.4* 40 - 52 %
MCV 95 82 - 98 fL
MCH 28.3 27 - 32 pg
MCHC 29.8* 31 - 35 %
RDW 17.6* 10.5 - 15.5 %
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 802* 150 - 440 K/uL
Test Name Value Reference Range Units
[**2131-3-19**] 05:35
Report Comment:
Source: Line-PICC
RENAL & GLUCOSE
Glucose 112* 70 - 100 mg/dL
Urea Nitrogen 17 6 - 20 mg/dL
Creatinine 1.0 0.5 - 1.2 mg/dL
Sodium 135 133 - 145 mEq/L
Potassium 6.0* 3.3 - 5.1 mEq/L
VERIFIED BY REPLICATE ANALYSIS
NO HEMOLYSIS
Reported to and read back [**Street Address(1) 41705**] AT 0640 [**2131-3-19**]
Chloride 99 96 - 108 mEq/L
Bicarbonate 29 22 - 32 mEq/L
Anion Gap 13 8 - 20 mEq/L
ENZYMES & BILIRUBIN
Alanine Aminotransferase (ALT) 32 0 - 40 IU/L
Asparate Aminotransferase (AST) 41* 0 - 40 IU/L
Alkaline Phosphatase 233* 40 - 130 IU/L
Bilirubin, Total 0.2 CHEMISTRY
Calcium, Total 9.5 8.4 - 10.3 mg/dL
Phosphate 4.7* 2.7 - 4.5 mg/dL
Magnesium 2.2 1.6 - 2.6 mg/dL
CXR [**2131-2-23**] admission
Confluent opacity involving mid and lower right lung with round
lucencies, suggestive of cavitation and/or abscess formation.
Ground-glass
opacification of the left mid lung. Small-to-moderate right
pleural effusion.
Findings concerning for infection with cavitary lesions in the
right lower
lung. Correlation with CT exam from the outside hospital, which
by report was
performed at the OSH.
[**2131-2-24**] EGD w/ stent
A fistula was found in the lower esophagus. There was a deep
fistula at approximately 35cm with upstream ulceration and
visible suture material. The GE junction is located at
approximately 47cm
Successful placement of a 20Fr [**Company 2267**] traction PEG
tube using the standard pull technique.
Successful insertion of a 23mm x 155mm fully covered metal
esophagal stent [REF 1675, LOT [**Numeric Identifier 41706**]] under fluoroscopic
guidance, with the middle of the stent positioned over the
fistula, and the bottom of the stent above the GE junction. The
stent was deployed smoothly, and the endoscope was reinserted to
confirm appropriate location.
Otherwise normal upper endoscopy.
Fluoroscopic images viewable on Centricity.
[**2131-3-15**] CXR
FINDINGS:
Multifocal pneumonia including dense right lower lobe
consolidation with
abscess has not really changed much since [**2131-3-13**]. A
pigtail catheter
in the right lower lobe abscess is unchanged in position and
presumably within
the abscess cavity. Residual stent is present. Tracheostomy tube
is in
standard position
[**2131-3-12**] CT chest
IMPRESSION:
1. Overall similar size of large right lower lobe complex fluid
collection.
Pigtail catheter appears in appropriate position inside the
collection. Tube
patency cannot be assessed.
2. Progression of multifocal areas of peripheral lung
consolidation
consistent with infection.
3. Increased fluid and air surrounding esophageal stent.
4. No acute process in the abdomen or pelvis.
[**2131-2-28**] esophagus
1. No evidence for leak around the esophageal stent, only the
distal
two-thirds were fully evaluated.
2. Smooth narrowing and stricturing at the distal
esophagus/gastroesophageal
junction, likely related to edema or esophageal dysmotility in
the setting of
a metallic stent along a large segment of the esophagus.
[**2131-2-26**] Cardiac echo
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function. Pulmonary artery hypertension.
[**2131-3-14**]
Liver US :
1. Contracted gallbladder, without evidence of cholecystitis.
2. No evidence of biliary obstruction.
Brief Hospital Course:
Mr. [**Known lastname 41707**] is a 49 y/o man with a h/o well controlled HIV on
Atripla, EtOH abuse, and recent esophageal rupture s/p surgical
repair on [**2131-1-1**] at and OSH c/b persistent leak who presented
in
septic shock to [**Hospital1 18**] on [**2131-2-23**] with large necrotizing lung
abscess
[**1-11**] esophageal-pleural fistula. He was empirically started on
Vanco/[**Last Name (un) **]/Mica and had an esophageal stent placed [**2131-2-24**]. He
slowly
improved, weaning off pressors, though required trachetomy
[**2131-3-7**] for
prolonged ventilation and then weaned to trachmask. Surgery for
the patient's collection was discussed but due to the
parenchymal
(rather than pleural) nature of his collection it was felt he
may
require pneumonectomy but did not likely have pulmonary reserve
for this large operation, additionally with risk to re-opening
his esophageal perforation or disrupting his pulmonary
vasculature. He eventually underwent IR guided drainage with
pigtail drain that helped his clinical status somewhat but the
fluid was loculated so could not be drained much. He had
several
bronchoscopies and abscess cultures while on antibiotics, this
grew coag negative staph and yeast. His gram stains showed GNRs,
GPRs and budding yeast. He was transferred to the floor [**2131-3-17**].
Once on the floor, the patient continued to improve.
Summary of events:
[**2-23**]: Transferred from [**Hospital3 **] Hospital, intubated; central
line placed and pressors started in ED. Admitted to TICU.
Empiric antibiotics started (Vanc/[**Last Name (un) **]/Mica--not Fluconazole
given prolonged QTc); bronchoscopy performed with BAL sent. CT
chest concerning for necrotizing pneumonia on right in setting
of suspected persistent esophageal leak, possible fistula.
Interventional pulmonology consulted w/ repeat bronchoscopy
unrevealing. EGD revealed a defect along the right wall of the
esophagus at approximately 35cm. GI consult obtained w/
esophageal stenting performed and PEG placed. BAL gram stain
showing 2+ GPR, 2+ GNR; culture pending. Pressors weaned slowly
overnight with good UOP maintained.
-[**2-25**]: Desaturation to 90% w/ mild-moderate improvement
following suctioning of copious secretions. ID with no change in
Rx; Thoracic with hold TF and conservative management.
-[**2-26**]: Continued copious secretions but stable on vent. VL<20,
CD4>400, OSH blood:GPRs, GPCs, cultures pending. Ruled out for
TB. Discussed with thoracics, poor surgical prospects. had
planned to g-tube study, held meds and TF via PEG. Re-consider
on [**2-27**]. CD4 count>400, VL<20.
-[**2-27**]: Given persistent copious secretions, bronchoscopy
performed with visualized moderate loose, milky secretions. BAL
sent w/ gram stain showing GPR, GNR, yeast. Culture pending. OSH
blood cultures reported as: 1 bottle NGTD and 1 bottle w/
diptheria and coag negative staph, suspicious for contaminants.
EKG w/ QTc 412. Few episodes of desaturation, resolved with
suctioning. Pan-cultured for fever spike to 101.8. Levophed
weaning.
-[**2-28**]: MAP <65 in afternoon, restarted on levophed (stopped at
23:00) and infused 1uPRBC. Esophagram study with no extrav of
contrast. Restarted TFs via PEG per thoracic and nutrition recs.
Tolerated CPAP overnight from 4pm - 2am, then tachy.
-[**3-1**]: Given Hct of 24 and MAPs < 65 requiring levophed 0.08,
transfused 1uPRBC. Levo weaned to off, sedation decreased (Fent
100->50, Midaz off), PRN ativan, great improvement in MS. Sister
and mother in to visit, discussed prognosis with Dr. [**First Name (STitle) **].
-[**3-2**]: Fever to 102.4; blood cultures sent. CDiff toxin x2
negative; 3rd pending. Fentanyl discontinued, and pt
transitioned to Tylenol, dilaudid. Given poor sleep/wake cycle
and concern for associated delirium, nightly Seroquel started.
Decreased oxygenation in the setting of persistent copious
secretions; some improvement seen with increase in PEEP,
continued suctioning. Free water flushes started for
hypernatremia (Na 150), with improvement to 145.
-[**3-3**]: bronched, BAL sent; placed on CMV afterwards due to resp
distress w/ goal to wean back to CPAP in am, propofol added for
intermittent hypertension/tachycardia
-[**3-4**]: ID consulted and agreed with current
antibiotics/antifungal although they believe that definitive
treatment is right pneumonectomy but patient is not a good
candidate surgically; Thoracic surgery decided to do bedside
trach on [**3-5**]; consents obtained; throughout the day patient
would intermittently become agitated/tachypneic resulting in
mild desaturation so fentanyl gtt was added to his sedation
regimen
-[**3-5**]: Bedside bronch and trach, CT chest, TFs resumed, HLIV,
weaned levophed; febrile 102.1 - cx sent;
-[**3-6**]: R PICC placed; to IR [**3-7**] for drainage of right lung
abscess; spiked fever overnight, no new cultures drawn
-[**3-7**]: IP did not find a safe spot for US guided drainage- would
need CT guided drainage, fever to 101.7, not cultured
-[**3-8**]: went to CT-guided drainage although very little was
drained ~20ml, sent for cultures; patient tolerated procedure
well; per ID consult: sent for B-glucan and Aspergillus
Galactomannan Antigen
-[**3-9**]: d/c'd fent/prop gtt; started oxycodone, ativan, morphine
breakthrough; C. diff sent, loperamide d/c'd
- [**3-10**]: weaned peep to 10;
- [**3-11**]: afebrile, spent the entire day on trach collar - stable,
ambulated with PT/OT, sat in chair
- [**3-12**]: afebrile, PT/OT OOB to chair, ID rec'd CT chest and Bld
cx x 3, continue current abtx and drainage per thoracic. [**Hospital1 **]
tube flushes, performed daily by thoracic. Thorcic to discuss
prognosis [**3-13**] w/ pt.
- [**3-13**]: Bronched. Post-CXR unchanged. Decreased O2 after bronch.
Req recruitment breaths. Now back on vent. CT chest showed
abscess relatively unchanged since [**3-5**]
- [**3-14**]: Stayed on trach collar. Out of bed/ambulating. Working on
rehab placement. RUQ u/s for elevated alk phos - no e/o
cholecystitis.
- [**3-15**]: c/o trouble breathing/swallowing in the afternoon, CXR
unchanged, thoracic performed bronchoscopy, thick mucus cleaned
out, but otherwise clear airways, able to clear secretions well.
Case management to eval for rehab facility. Vanc d/c, continue
[**Last Name (un) 2830**]/mica x 4 weeks per ID
-[**3-16**]: hypoNa, hyperK
-[**3-17**]: transferred to [**Hospital Ward Name 121**] 9
Following transfer to the Surgical floor he gradually
progressed. From a GI standpoint he was tolerating his tube
feedings but the preparation was changed to Nepro as he had
persistent elevated potassium in the 6 range. This was
effective and over a 5 day period his potassium was in the 4.0
range.
A speech and swallow study was done on [**2131-3-20**] for placement of
a PMV (as he had a cuffless trach tube in place). He tolerated
it well and also was started on a diet of thin liquids and
pureed solids. Unfortunately he appeared to aspirate and was
made NPO and his trach tube was changed to cuffed. He
eventually spiked to 102 and his WBC was 28K. Cipro was added
to his antibiotic therapy and a chest xray showed some increased
opacities in the RUL and LLL. He has gradually improved with
pulmonary toilet and antibiotic therapy and hid trach tube was
downsized to a #6 portex, cuffed tube on [**2131-3-25**].
The Infectious Disease service is following him closely and
recommends 4 weeks of therapy with Micafungin and Ertapenum (or
Meropenum 500 mg q6hrs). The stop date is [**2131-4-5**] for those
antibiotics and the stop date for the Cipro is [**2131-3-28**]. Please
see the page 1 referral for lab tests which need to be done
weekly and reported to the [**Hospital **] Clinic.
The Nutrition service currently recommends changeing his tube
feedings to 2 cal HN at 40/hr now that his potassium is in the
4.0 range. His renal function repains stable with a BUN/creat
of 15/0.9.
On [**2131-4-16**] his esophageal stent will be removed and he will be
admitted to the hospital following that for further management.
In the interim he will be transferred to rehab to help increase
his strength and mobility. He was discharged on [**2131-3-27**].
Medications on Admission:
ASA 325 daily
atripla 1 tab daily
combivent 2-4 puffs q4 prn
lisinopril 5 mg qd
protonix 40 mg
Discharge Medications:
1. efavirenz 200 mg Capsule [**Date Range **]: Three (3) Capsule PO DAILY
(Daily).
2. tenofovir disoproxil fumarate 300 mg Tablet [**Date Range **]: One (1)
Tablet PO DAILY (Daily).
3. acetaminophen 325 mg Tablet [**Date Range **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever .
4. ipratropium bromide 0.02 % Solution [**Date Range **]: One (1) Inhalation
Q6H (every 6 hours).
5. emtricitabine 10 mg/mL Solution [**Date Range **]: Two [**Age over 90 8821**]y (240)
mg PO Q24H (every 24 hours).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Age over 90 **]: One (1) Inhalation Q3H (every 3 hours).
7. heparin (porcine) 5,000 unit/mL Solution [**Age over 90 **]: 5000 (5000)
units Injection TID (3 times a day).
8. micafungin 100 mg Recon Soln [**Age over 90 **]: One Hundred (100) Recon
Soln(s)mg Intravenous Q24H (every 24 hours): thru [**2131-4-5**].
9. ertapenem 1 gram Recon Soln [**Month/Day/Year **]: One (1) gm Intravenous once
a day: thru [**2131-4-5**].
10. ciprofloxacin in D5W 400 mg/200 mL Piggyback [**Month/Day/Year **]: Four
Hundred (400) mg Intravenous Q12H (every 12 hours): thru
[**2131-3-28**].
11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
12. sodium chloride 1 gram Tablet [**Month/Day/Year **]: One (1) Tablet PO TID (3
times a day).
13. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One
(1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
14. aspirin 81 mg Tablet, Effervescent [**Last Name (STitle) **]: One (1) Tablet,
Effervescent PO once a day.
15. oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: 10-15 mg PO Q3H (every 3
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Right lung empyema and esophageal-pleural fistula
Bilateral pleural effusions
Chronic respiratory failure requiring tracheostomy
Aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were transferred to [**Hospital1 18**] on [**2131-2-22**], after complications
from esophageal surgery [**2131-1-1**] at [**Hospital3 **] Hospital. You had a
large necrotizing lung abscess secondary to esophageal-pleural
fistula. You were very sick and required ICU management for
weeks. Your breathing was compromised and you need a
tracheostoomy tube along with a feeding tube to maintain your
nutrition. You will also need long term antibiotics and for
that reason, a PICC line was placed.
* Work hard at rehab to regain your strength.
* Your trach tube will eventually come out.
* You will continue follow up with Thoracic Surgery, Infectiuos
Disease and Gastroenterology.
* On [**2131-4-16**] the esophageal stent will be removed and you will be
admitted to the hospital after the procedure for further
management.
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2131-4-3**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Infectious Disease : Dr. [**Last Name (STitle) **] [**2131-4-24**]
Department: ENDO SUITES
When: MONDAY [**2131-4-16**] at 9:30 AM. Report at 8:30AM to the
[**Hospital Ward Name 516**], [**Hospital Ward Name 1950**] Building, [**Location (un) **], GI unit. You will be
admitted to the hospital after the procedure to the Thoracic
Surgery service...Dr. [**Known firstname **] [**Last Name (NamePattern1) **].
Completed by:[**2131-3-27**]
|
[
"038.9",
"511.9",
"510.0",
"285.29",
"787.22",
"288.60",
"238.71",
"785.52",
"995.92",
"303.91",
"V08",
"518.53",
"862.32",
"E911",
"507.0",
"458.29",
"117.9",
"276.7",
"291.0",
"513.0",
"401.9",
"511.89",
"486",
"908.6",
"305.1",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.24",
"31.1",
"96.6",
"34.04",
"45.13",
"42.81",
"38.93",
"43.11",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
18788, 18887
|
8685, 16846
|
319, 574
|
19081, 19081
|
3274, 8662
|
20308, 21056
|
1356, 1360
|
16992, 18765
|
18908, 19060
|
16872, 16969
|
19264, 20285
|
1375, 3255
|
271, 281
|
602, 993
|
19096, 19240
|
1015, 1242
|
1258, 1340
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,005
| 100,612
|
26434
|
Discharge summary
|
report
|
Admission Date: [**2191-1-27**] Discharge Date: [**2191-2-3**]
Date of Birth: [**2128-6-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Pt referred after cardiac cath revealed 50% LM, 70%LAD, 100%RCA
for CABG
Major Surgical or Invasive Procedure:
CABGx3 (LIMA->LAD, SVG->Ramus, SVG->PDA
History of Present Illness:
Increasing frequency ofchest pain w/associated SOB x several
months. +ETT at OSH which lead to cardiac cath then referal to
[**Hospital1 18**]
Past Medical History:
HTN, ^chol, L rotator cuff surgery, Legionaires PNA(30yrs ago)
Social History:
Married lives w/wife. Retired water works
remote tobacco (quit 30 years ago), raree ETOH use,
Family History:
nc
Physical Exam:
Preop:
GEN: 62yoM NAD
Neuro: Grossly intact
Pulm: CTA B
Cor: RRR
Abdm: obese, soft, NT, +BS
Ext: Warm well perfused
D/C
VS 98.2 92SR 127/71 20 96%RA
Gen: NAD
Neuro: A&Ox3 MAE follows commands. Left peripheral vision
deficit. Cognitively slow to respond to direct questions
Pulm: CTA B
Cor: RRR, sternum stable, incision C&D
Abdm: Soft NT/ND/NABS
Ext warm, well perfused. L LE incision C&D
Pertinent Results:
[**2191-1-27**] 08:07PM GLUCOSE-123* UREA N-14 CREAT-1.0 SODIUM-141
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14
[**2191-1-27**] 08:07PM ALT(SGPT)-27 AST(SGOT)-24 LD(LDH)-240 ALK
PHOS-43 AMYLASE-45 TOT BILI-1.0
[**2191-1-27**] 08:07PM ALBUMIN-4.3
[**2191-1-27**] 08:07PM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2191-1-27**] 08:07PM WBC-7.6 HCT-42.5
[**2191-1-27**] 08:07PM PLT COUNT-148*
[**2191-1-27**] 08:07PM PT-13.0 PTT-24.9 INR(PT)-1.1
[**2191-1-27**] 07:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2191-1-27**] 07:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2191-2-2**] 06:30AM BLOOD WBC-7.6 RBC-3.76* Hgb-11.7* Hct-31.8*
MCV-85 MCH-31.2 MCHC-36.9* RDW-15.4 Plt Ct-119*
[**2191-1-31**] 12:13AM BLOOD PT-13.6* PTT-25.6 INR(PT)-1.2
[**2191-2-2**] 06:30AM BLOOD Glucose-110* UreaN-19 Creat-0.9 Na-141
K-3.5 Cl-107 HCO3-22 AnGap-16
Brief Hospital Course:
Pt admitted from OSH [**1-27**], prepped for OR on [**1-28**]
Pt to OR fro CABG on [**1-28**], please see OR report for full
details, in summary had CABGx3 with LIMA->LAD, SVG->Ramus,
SVG->PDA. Pt tolerated operation well. In immediate postop
period pt hemodynamically stable, successfully extubated and
weaned from all vasoactive medications. On post-op day 1 patient
was transferred to postop surgery floors for continued postop
recovery.
On POD2 was noted to be lethargic, neurology consulted and pt
had head CT that revealed multiple small infarcts involving R
parietal/occipital area with main deficit being L peripheral
vision loss and slow cognitive response.
Pt was transferred back to ICU for stroke w/u that included Heme
eval/carotid US/LE ultrasound. After largely negative w/u pt
returned to floors where he had an uneventful hospital course.
Medications on Admission:
Lisinopril 20 QD
HCTZ 12.5 QD
Atenolol 100 QD
Zocor 20 QD
ASA 81 QD
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 10 days.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
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
every 4-6 hours as needed for pain.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p cabg x3 c/b CVA(rt parietal)
PMH: HTN, ^chol, L rotator cuff surgery, Legioaires PNA(30 yrs
ago)
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean nad dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds
Followup Instructions:
Dr [**Last Name (STitle) 4783**] in [**3-12**] weeks
Dr [**First Name (STitle) **] ([**Hospital1 65344**] neurology in 6 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Completed by:[**2191-2-3**]
|
[
"368.46",
"272.4",
"997.02",
"413.9",
"285.1",
"401.9",
"414.01",
"287.5",
"E878.2",
"998.11",
"781.8",
"434.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"36.12",
"36.15",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4210, 4257
|
2236, 3093
|
393, 434
|
4402, 4409
|
1257, 2213
|
4610, 4807
|
819, 823
|
3211, 4187
|
4278, 4381
|
3119, 3188
|
4433, 4587
|
838, 1238
|
281, 355
|
462, 606
|
628, 692
|
708, 803
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,939
| 158,139
|
54306
|
Discharge summary
|
report
|
Admission Date: [**2190-12-26**] Discharge Date: [**2191-1-3**]
Date of Birth: [**2126-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 year old male with past medical history of type 2 DM and
hypertension who called EMS today as he was feeling weak for
past two weeks. He reports last seeing his PCP at [**Name9 (PRE) 2025**] in [**Month (only) **]
[**2190**]. He reports his PCP graduated so he was looking for a new
PCP but has not found one. He reports running out of his
medications on [**Month (only) **] sixth. He reports feeling weak and
progressive shortness of breath over the past two weeks to a
point where he is having difficulty with instruments activities
of daily living which is why he called EMS today.
.
He does not report fever, headache, double vision, earache,
rhinorrhea, chest pain, palpatations, dizziness, syncope,
abdominal pain, nausea, joint pain or dysuria.
.
In the ED, initial VS were: 97.9 106 187/92 18 98%. Labs
notable for 1014 with anion gap of 16, sodium of 123, potassium
of 5.3, lactate of 3.1, trace urinary ketones, negative serum
tox, serum osmolarity elevated at 341 with osmolar gap of 20 and
normal complete blood count. He was volume resuscitated with
3LNS and started on IV insulin gtt for hyperosmolar nonketotic
hyperglyecemia. Blood cultures were drawn. Vitals prior to
transfer were 145/81 16 96%RA.
.
On arrival to the MICU, he reports feeling better without any
complaints. He does not report any ingestion or alcohol history
and was wondering whether he can establish care with a female
provider at [**Hospital1 18**]. He also reports having significant weight
loss over past month.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Type 2 DM diagnosed 10 years ago
Hypertension
Social History:
Lives alone. On [**Social Security Number 111254**]social security
- Tobacco: None
- Alcohol: None
- Illicits: None
Family History:
Does not want to talk about his family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 106 187/92 18 98%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, Dry mucous membrane, oropharynx clear,
EOMI, PERRL
Neck: supple, low JVP. No cervical or supraclavicular
lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE PHYSICAL EXAM:
VS: 97.2 (98.5) 125/73 (108-177/50-85) 62 18 97%RA
FSBS: 190 -[12H]-> 352 -[22H]->255 -> 203 -[28G/12H]-> 290
-[4H]-> 226
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, low JVP. No cervical or supraclavicular
lymphadenopathy. No carotid bruits.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, grossly normal sensation
Pertinent Results:
ADMISSION LABS:
[**2190-12-26**] 03:40PM BLOOD WBC-6.5 RBC-5.22 Hgb-15.4 Hct-47.9 MCV-92
MCH-29.5 MCHC-32.1 RDW-12.7 Plt Ct-174
[**2190-12-26**] 03:40PM BLOOD Neuts-87.1* Lymphs-9.5* Monos-2.8 Eos-0.3
Baso-0.4
[**2190-12-26**] 03:40PM BLOOD PT-9.4 PTT-25.5 INR(PT)-0.9
[**2190-12-26**] 03:40PM BLOOD Glucose-1014* UreaN-41* Creat-1.9*
Na-125* K-5.3* Cl-84* HCO3-25 AnGap-21*
[**2190-12-26**] 11:39PM BLOOD ALT-26 AST-21 CK(CPK)-93 AlkPhos-72
TotBili-0.4
[**2190-12-26**] 11:39PM BLOOD Lipase-31
[**2190-12-26**] 07:23PM BLOOD CK-MB-2 cTropnT-<0.01
[**2190-12-26**] 11:39PM BLOOD CK-MB-2 cTropnT-<0.01
[**2190-12-26**] 03:40PM BLOOD Calcium-9.3 Phos-6.0* Mg-2.6
[**2190-12-26**] 07:23PM BLOOD Albumin-3.6 Calcium-8.6 Phos-2.3*# Mg-2.3
[**2190-12-26**] 11:39PM BLOOD %HbA1c-13.5* eAG-341*
[**2190-12-26**] 11:39PM BLOOD Triglyc-211* HDL-29 CHOL/HD-7.5
LDLcalc-146*
[**2190-12-26**] 03:40PM BLOOD Osmolal-341*
[**2190-12-27**] 03:31AM BLOOD Osmolal-306
[**2190-12-26**] 11:39PM BLOOD TSH-0.59
[**2190-12-26**] 03:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2190-12-26**] 03:49PM BLOOD Glucose-GREATER TH Lactate-3.1* Na-128*
K-5.2* Cl-86* calHCO3-27
[**2190-12-26**] 03:49PM BLOOD freeCa-1.09*
[**2190-12-26**] 08:28PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.026
[**2190-12-26**] 04:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.024
.
RELEVANT LABS:
[**2190-12-26**] 07:23PM BLOOD CK-MB-2 cTropnT-<0.01
[**2190-12-26**] 11:39PM BLOOD CK-MB-2 cTropnT-<0.01
[**2190-12-29**] 05:00PM BLOOD CK-MB-3 cTropnT-<0.01
.
DISCHARGE LABS:
[**2190-12-26**] 08:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2190-12-26**] 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2190-12-26**] 08:28PM URINE
.
MICRO:
[**2190-12-30**] RPR: NON-REACTIVE
[**2190-12-26**] MRSA SCREEN: NEGATIVE
[**2190-12-26**] URINE CULTURE: NO GROWTH
[**2190-12-26**] BLOOD CULTURE-NO GROWTH
[**2190-12-26**] BLOOD CULTURE-NO GROWTH
Brief Hospital Course:
Mr. [**Known lastname **] is a 64 year old male with past medical history of
type 2 diabetes mellitus (DM) and hypertension who called EMS
today as he was feeling weak for past two days likely due to
hyperglycemia and volume depeletion from hyperosmolar nonketotic
hyperglycemia in setting of stopping his oral diabetic
medications.
.
.
ACTIVE ISSUES:
# Hyperosmolar nonketotic hyperglycemia: Presented with serum
glucose > 1000, arterial pH > 7.3, serum bicarb > 15 and minimal
ketonuria. Likely precipitant is stopping his oral diabetic
medications due to poor outpatient follow-up, especially
glipizide. He did not have evidence of infection or ischemia.
He was treated in the MICU with insulin drip at 11 U/hr until
his serum glucose < 300 at which point the insulin drip was
overlapped with insulin lantus 10 units ad then the drip was
discontinued. He was also given IV fluids NS @ 250 cc/hr until
serum sodium normalizes then D51/2NS as serum glucose < 300.
His serum electrolytes were also monitored closely and repleted
as needed. While on the medicine floor, care focused on better
glucose control with QACHS fingersticks and insulin sliding
scale. The patient had multiple teaching sessions with nursing
and [**Last Name (un) **] staff, in order to learn how to control his blood
glucose appropriately. By the time of discharge, the patient
was feeling more comfortable administering insulin to himself,
but was still having difficulty. On day of discharge [**Last Name (un) **]
recommended restarting Metformin as part of his diabetic
regimen. Additionally, he was continued on aspirin and
simvastatin. He was started on an ACE inhibitor, which was
well-tolerated.
.
# Acute kidney injury ([**Last Name (un) **]): Likely due to volume depeletion
from above. He was volume resuscitated as above. His
creatinine was 0.7 at the time of discharge.
.
# Osmolar gap: Likely due to lactic acidosis from hypovolemia in
setting of above. No history of ingestion of ethylene glycol or
methanol. No urinary ketone to suggest diabetic ketoacidosis.
His gap resolved prior to transfer from ICU to medicine floor.
.
# Dyspnea on exertion for past two weeks: Likely due to volume
depletion in setting of above. This resolved prior to transfer
from the ICU to the medicine [**Last Name (un) 5355**].
.
# Thrombocytopenia: Platelets dipped briefly to 121, but then
stabilized in the 150s. At the time of decrease, heparin was
discontinued empirically. Patient was otherwise asymptomatic.
.
.
TRANSITIONAL ISSUES:
- Question of psychiatric disorder per ED resident: Difficult to
assess in setting of HONK, and in the acute setting of
hospitalization. Additionally, patient had concerns over
possible onset of dementia. Consider addressing as an
outpatient with neurocognitive evaluation.
- He will need a new PCP since his prior one was a resident and
graduated and he was here because he ran out of medications.
- Code: DNR/DNI
- Housing: Patient relinquished his apartment while
hospitalized. He would like to reside in [**Hospital3 **].
- Colonoscopy: Patient is due for screening colonoscopy. Should
be arranged by his future outpatient provider at first visit.
Medications on Admission:
Aspirin 81 mg po qdaily
Glipizide unknown dose twice a day (ran out of prescription)
Metformin unknown dose twice a day (ran out of prescription)
Simvastatin unknown dose twice a day (ran out of prescription)
Discharge Medications:
1. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. lancets Misc Sig: One (1) lancet Miscellaneous three
times a day: For Free Style Lyte Glucometer.
Disp:*1 package* Refills:*2*
4. Glucose monitoring supplies
Test strips for Free Style Lyte glucometer.
Dispo: 1 package
Refills: 2
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Lantus 100 unit/mL Solution Sig: Twenty Eight (28) units
Subcutaneous AT dinner.
7. Humalog 100 unit/mL Solution Sig: see sliding scale units
Subcutaneous QACHS: See sliding scale.
8. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis:
Hyperosmolar nonketotic hyperglycemia
.
Secondary diagnoses:
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
.
It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted to the
hospital because your blood sugars were very high. This is
because you stopped taking your diabetes medications. You were
treated with insulin in the hospital. It is very important that
you do not miss any of your medications so that you can stay
healthy.
.
Please note, the following changes were made to your
medications:
- INCREASE simvastatin dose to 20 mg by mouth daily
- START insulin glargine 28 units subcutaneously at nighttime
- START insulin sliding scale, as described
- START lisinopril 10 mg by mouth daily
- START metformin 500mg twice a day
- STOP glipizide
.
It is very important that you keep all of the follow-up
appointments listed below.
.
Wishing you all the best!
Followup Instructions:
You will be followed by the physician at your rehabilitation
facility. Afterwards, please call [**Telephone/Fax (1) 250**] to establish a
primary care physician at [**Hospital1 **] [**Hospital **]
Please be sure to keep the following appointment:
Dr. [**Last Name (STitle) 978**] at 9AM on [**2191-1-11**]
[**Last Name (un) **] Diabetes Center
1 [**Last Name (un) **] Pl, [**Location (un) 86**] [**Numeric Identifier 718**]
Call [**Telephone/Fax (1) 2384**] with any questions.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
[
"276.2",
"585.9",
"584.9",
"783.21",
"403.90",
"276.52",
"250.20",
"V15.81",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10329, 10412
|
6104, 6441
|
296, 302
|
10554, 10554
|
3982, 3982
|
11556, 12160
|
2511, 2560
|
9546, 10306
|
10433, 10433
|
9310, 9523
|
10705, 11533
|
5579, 6081
|
2600, 3269
|
10513, 10533
|
8626, 9284
|
1867, 2287
|
247, 258
|
6456, 8605
|
330, 1848
|
3998, 5563
|
10452, 10492
|
10569, 10681
|
2309, 2357
|
2373, 2495
|
3294, 3963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,088
| 185,018
|
12007
|
Discharge summary
|
report
|
Admission Date: [**2185-6-24**] Discharge Date: [**2185-7-13**]
Date of Birth: [**2123-2-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing chest pain and shortness of breath
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x2 (LIMA-LAD, SVG-PDA), Mitral Valve
Replacement (27mm St. [**Male First Name (un) 923**] mechanical)
History of Present Illness:
This is 62 year old male with known coronary artery disease.
Last [**Month (only) **] he underwent successful PTCA and stenting of his
left anterior descending artery. In addition, he has known
severe mitral regurgitation which has been followed by serial
echocardiograms which have demonstrated worsening mitral
regurgitation and increased pulmonary pressures. A repeat
cardiac catheterization was performed [**2185-4-13**] which
showed severe two vessel disease. Given the progression of his
symptoms, he has been referred for surgical evaluation.
Currently, he admits to mostly exertional symptoms. He
occasionally experiences chest pain at rest. He has 2 pillow
orthopnea. He feels his routine ADL's are moderately limited by
the above symptoms.
Past Medical History:
- Coronary artery disease s/p stenting of LAD [**2184**]
- Mitral valve prolapse with mod-severe mitral regurgitation
- Hypertension
- Dyslipidemia
- History of Asthma, reactive airway disease
- Anemia
- History of GIB r/t esophagitis (from ASA) [**2184**]
- Hiatal hernia, GERD
- BPH
- Depression
- Attention Deficit Disorder
- Ventral Hernia
Past Surgical History:
- Duodenal bypass secondary to gastric outlet obstruction [**2175**]
Social History:
Lives with: Wife
Occupation: Technical writer
Cigarettes: Denies
ETOH: Denies
Illicit drug use: Denies
Family History:
Father with history of MI, carotid disease, passed away age 88.
Mother with pulmonary edema, died at age 63 of stroke.
Maternal grandfather passed away age 45 from CAD.
Physical Exam:
Admission exam
Pulse: 73 Resp: 18 O2 sat: 96% room air
B/P Right: 157/97 Left: 146/94
Height: 67 inches Weight: 93 kg/205 lbs
General:Middle aged male in no acute distress
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] holosystolic murmur best
heard at LLSB
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x] - ventral hernia noted
Extremities: Warm [x], well-perfused [x]
Edema: trace
Varicosities: None
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2185-6-24**] TEE
Conclusions
Pre-CPB:
This is a limited study because only esophageal views were
obtained. The patient has a history of gastric bleeding and
ulceration, and so gastric views were avoided.
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen.
The mitral valve leaflets are moderately thickened. Moderate to
severe (3+) mitral regurgitation is seen. The jet is eccentric.
The anterior leaflet is very myxomatous and elongated.
There is no pericardial effusion.
Post-CPB #1:
The patient is paced, on epinephrine.
There is a mitral ring repair which has an eccentric jet of MR.
There is [**Male First Name (un) **] demonstrated on 2-D, 3-D and M-mode. Patient was
returned to CPB for MVR.
Post-CPB #2:
The patient is AV-Paced, on and infusion of epinephrine.
There is a prosthetic valve in the mitral position with no MR
and a mean gradient of 3 mmHg.
Preserved biventricular systolic fxn.
No AI. Aorta intact.
The tip of the SGC is at the PA bifurcation.
.
[**2185-7-13**] 03:39AM BLOOD WBC-10.3 RBC-3.26* Hgb-10.3* Hct-31.4*
MCV-96 MCH-31.6 MCHC-32.9 RDW-17.6* Plt Ct-434
[**2185-7-12**] 05:23AM BLOOD WBC-10.5 RBC-3.24* Hgb-10.2* Hct-31.3*
MCV-97 MCH-31.6 MCHC-32.7 RDW-17.6* Plt Ct-348
[**2185-7-11**] 04:17AM BLOOD WBC-11.4* RBC-3.35* Hgb-10.4* Hct-32.5*
MCV-97 MCH-31.2 MCHC-32.2 RDW-17.4* Plt Ct-467*
[**2185-7-13**] 03:39AM BLOOD PT-25.2* PTT-127.6* INR(PT)-2.4*
[**2185-7-12**] 12:26PM BLOOD PT-24.4* INR(PT)-2.3*
[**2185-7-12**] 05:23AM BLOOD PT-24.0* INR(PT)-2.3*
[**2185-7-11**] 04:17AM BLOOD PT-28.5* PTT-30.6 INR(PT)-2.7*
[**2185-7-10**] 02:57AM BLOOD PT-27.9* PTT-73.8* INR(PT)-2.7*
[**2185-7-9**] 03:46AM BLOOD PT-23.7* PTT-68.6* INR(PT)-2.3*
[**2185-7-8**] 04:58AM BLOOD PT-16.7* PTT-66.1* INR(PT)-1.6*
[**2185-7-7**] 05:49PM BLOOD PT-14.4* PTT-65.0* INR(PT)-1.3*
[**2185-7-7**] 09:48AM BLOOD PT-14.5* PTT-88.2* INR(PT)-1.4*
[**2185-7-7**] 02:58AM BLOOD PT-14.1* PTT-85.1* INR(PT)-1.3*
[**2185-7-6**] 03:28AM BLOOD PT-13.9* PTT-86.9* INR(PT)-1.3*
[**2185-7-5**] 01:33AM BLOOD PT-13.7* PTT-81.7* INR(PT)-1.3*
[**2185-7-4**] 04:14AM BLOOD PT-13.3* PTT-67.8* INR(PT)-1.2*
[**2185-7-13**] 03:39AM BLOOD UreaN-17 Creat-0.7 Na-139 K-4.0 Cl-103
[**2185-7-12**] 05:23AM BLOOD Glucose-106* UreaN-15 Creat-0.6 Na-140
K-4.0 Cl-105 HCO3-27 AnGap-12
[**2185-7-11**] 04:17AM BLOOD Glucose-102* UreaN-14 Creat-0.6 Na-141
K-4.0 Cl-106 HCO3-26 AnGap-13
Brief Hospital Course:
The patient was a same day admission and brought to the
operating room on [**2185-6-24**] where the patient underwent CABG x2
and Mitral Valve Replacement with Dr. [**Last Name (STitle) **]. Initial attempt
was made to repair his valve, however a transesophageal
echocardiogram revealed systolic anterior motion and an
eccentric jet of mitral regurgitation. At this time it was
decided to replace the valve. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable but critical condition for recovery and invasive
monitoring. He developed rapid atrial fibrillation and was
cardioverted to sinus rhythm with the aid of amiodarone.
Subsequently, he required electrical cardioversion. Hemodynamic
support was achieved with epi, vasopressin and levophed for
several days post-operatively. Coumadin was initiated for
atrial fibrillation and a mechanical aortic valve with a heparin
bridge until therapeutic. His laboratory values revealed acute
kidney injury and likely hepatic shock immediately
post-operatively, but these values trended toward normalization
with time. He was treated for a Klebsiella pneumonia with
meropenum and ciprofloxacin per the recommendations of the
infectious disease service.
On [**7-7**] (POD 13), the patient was extubated and found to be
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. He did develop a moderate left pleural
effusion. It was decided to aggressively diurese this, rather
than perform a thoracentesis in the setting of elevated INR.
CXR will be followed as an outpatient. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 19 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to the LifeCare center of [**Location 15289**] in good condition
with appropriate follow up instructions.
The [**Hospital 228**] rehab length of stay is expected to be less than
30 days.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation 1-2puffs daily prn SOB
2. ALPRAZolam 0.5 mg PO DAILY
3. Rhinocort Aqua *NF* (budesonide) 32 mcg/actuation NU daily
prn
4. Hydrocodone-Acetaminophen (5mg-500mg [**1-3**] TAB PO Q6H:PRN pain
5. LaMOTrigine 100 mg PO BID
6. Lisinopril 40 mg PO DAILY
7. MethylPHENIDATE (Ritalin) 30 mg PO QAM
8. MethylPHENIDATE (Ritalin) 20 mg PO QPM
9. Metoclopramide 10 mg PO QIDACHS
10. Nitroglycerin SL 0.4 mg SL PRN cp
11. Pantoprazole 40 mg PO Q12H
12. Sertraline 100 mg PO DAILY
13. Tamsulosin 0.4 mg PO HS
14. Metoprolol Succinate XL 100 mg PO DAILY
15. Amlodipine 5 mg PO DAILY
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 0.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. LaMOTrigine 100 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. Metoclopramide 10 mg PO QIDACHS
6. Pantoprazole 40 mg PO Q12H
7. Sertraline 100 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Albuterol-Ipratropium [**1-3**] PUFF IH Q4H:PRN dyspnea
10. Amiodarone 400 mg PO DAILY
11. Metoprolol Tartrate 75 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
12. Nystatin Oral Suspension 5 mL PO QID
13. Potassium Chloride 20 mEq PO BID
Hold for K >4.5
14. Simvastatin 10 mg PO DAILY
15. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
16. Warfarin MD to order daily dose PO DAILY mechanical mitral
valve
17. MethylPHENIDATE (Ritalin) 30 mg PO QAM
18. MethylPHENIDATE (Ritalin) 20 mg PO QPM
19. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation 1-2puffs daily prn SOB
20. Rhinocort Aqua *NF* (budesonide) 32 mcg/actuation NU daily
prn
21. Furosemide 80 mg PO BID Duration: 7 Days
then decrease dose as clinically indicated
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
- Coronary artery disease s/p stenting of LAD [**2184**]
- Mitral valve prolapse with mod-severe mitral regurgitation
- Hypertension
- Dyslipidemia
- History of Asthma, reactive airway disease
- Anemia
- History of GIB r/t esophagitis (from ASA) [**2184**]
- Hiatal hernia, GERD
- BPH
- Depression
- Attention Deficit Disorder
- Ventral Hernia
Past Surgical History:
- Duodenal bypass secondary to gastric outlet obstruction [**2175**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- 1+
small to moderate left pleural effusion on CXR
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2185-8-3**] at 1:15PM
Cardiologist Dr. [**Last Name (STitle) **] [**2185-7-13**] at 1:20PM
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 6699**] in [**4-7**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2185-7-13**]
|
[
"314.00",
"276.2",
"997.31",
"287.5",
"401.9",
"553.3",
"E879.8",
"276.8",
"511.9",
"280.0",
"424.0",
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"272.4",
"V49.87",
"311",
"429.5",
"493.90",
"518.51",
"584.9",
"530.81",
"427.31",
"570",
"414.01",
"041.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"36.15",
"38.91",
"96.6",
"38.97",
"39.61",
"33.24",
"33.23",
"96.72",
"99.61",
"35.24"
] |
icd9pcs
|
[
[
[]
]
] |
9730, 9797
|
5503, 7818
|
357, 484
|
10277, 10492
|
2830, 5480
|
11280, 11842
|
1861, 2032
|
8626, 9707
|
9818, 10162
|
7844, 8603
|
10516, 11257
|
10185, 10256
|
2047, 2811
|
271, 319
|
512, 1264
|
1286, 1630
|
1740, 1845
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,535
| 194,864
|
42429+58527
|
Discharge summary
|
report+addendum
|
Admission Date: [**2190-3-12**] Discharge Date: [**2190-4-3**]
Date of Birth: [**2141-2-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Vicodin HP / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Head bleed, transfer from OSH
Major Surgical or Invasive Procedure:
[**2190-3-12**] Right EVD placement
[**2190-3-12**] Cerebral angiogram with Coiling Left MCA aneurysm
[**2190-3-12**] Left craniotomy evacuation of left intraparenchymal
hemorrhage
[**2190-3-13**] ICP monitor insertion
[**2190-3-19**] Cerebral angiogram
[**2190-3-21**] right EVD replaced
[**2190-3-26**] stent assisted coiling of left MCA aneurysm
History of Present Illness:
Pt is a 49f who was found down in a parking lot. She was
intubated at the scene and taken to OSH where CT head showed a
left temporal bleed with 6mm of midline shift. She was
transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
Migraines, CVA at age 20
Social History:
unknown
Family History:
unknown
Physical Exam:
On Admission:
BP: 127/72 HR: 58 R 16 O2Sats 100%
Gen: WD/WN
HEENT: Pupils: PERLA 1.5-1mm
Intubated. No eye opening. Localizes LUE, Withdraws briskly LLE.
Minimal withdrawal RLE, flexion RUE
On Discharge:
EO spont
Follows commands
Expressive aphasia
Full motor
Pertinent Results:
CT HEAD W/O CONTRAST [**2190-3-12**]
Interval craniotomies, coiling of MCA aneurysm and placement of
ventriculostomy catheter with improvement in extensive
previously seen
subarachnoid hemorrhage. Post-operative pneumocephalus.
CT HEAD W/O CONTRAST [**2190-3-13**]
1. Post left craniotomy changes, with unchanged subarachnoid
blood products within the left frontoparietal, temporal and
right frontal lobes.
2. Unchanged position of a right frontal approach
ventriculostomy catheter
terminating at the right lateral ventricle.
3. No evidence of new hemorrhage or mass effect since the
[**2190-3-12**]
study.
CT Head [**2190-3-15**]
1. Increasing areas of low attenuation and loss of [**Doctor Last Name 352**]-white
and white
matter differentiation in the territory of the left MCA, may be
secondary to evolving infarction or evolving edema adjacent to
the hematoma.
2. Stable appearance of subarachnoid blood, without evidence of
new
hemorrhage.
3. Slight enlargement of the left frontal extra-axial collection
beneath the left craniotomy changes.
4. Unchanged mass effect with 5.5 mm of rightward shift of the
normal midline structures. No evidence of uncal herniation.
CT Abd/Pelvis [**2190-3-15**]
1. No retroperitoneal hematoma, as clinically questioned.
2. Indeterminate 17-mm hypodense lesion within the left lobe of
the liver.
Ultrasound is recommended for further evaluation,
non-emergently.
3. Small bilateral pleural effusions with associated atelectasis
CTA Head [**2190-3-16**]
1. No evidence of vasospasm with symmetric, patent bilateral
MCAs.
2. Metallic coil in unchanged position at the bifurcation of the
M1 and M2
segments. A small residual aneurysm is likely present in this
region.
3. Unchanged appearance of subarachnoid, intraparenchymal, and
intraventricular hemorrhages. No new foci of hemorrhage are
visualized.
4. Stable areas of low attenuation in the territory of the left
MCA are most likely due to vasogenic edema from the surrounding
hematomas, although an underlying evolving infarction cannot be
totally excluded.
5. Unchanged position of the right frontal ventriculostomy
catheter without evidence of hydrocephalus.
6. Unchanged post-surgical changes in the left frontal lobe
CXR [**2190-3-16**]
AP single view of the chest has been obtained with patient in
sitting semi-upright position. Comparison is made with the next
preceding
similar study of [**2190-3-14**]. The patient remains
intubated, ETT in
unchanged position. A right-sided PICC line has now been
adjusted and its tip is seen to terminate in the mid portion of
the SVC. Nasogastric tube reaches well into the stomach where it
is curled up as before.
No interval changes are seen in the normal-appearing
cardiovascular pulmonary status on this portable chest
examination.
CXR [**2190-3-17**]
In comparison with the study of [**3-16**], the endotracheal tube
appears
to have been removed. Other monitoring and support devices
remain in place. Little change in the appearance of the heart
and lungs
CTA [**2190-3-17**]
1. No evidence of vasospasm. Bilateral MCA are patent.
2. A coil pack is present in the left MCA bifurcation of M1 and
M2 with a 3.5 mm dilatation just medial and superior to the coil
pack likely representing residual aneursym.
3. Subarachnoid blood mildly decreased since the prior exam.
4. Stable left frontal intraparenchymal and intraventricular
hematomas as well as stable left frontal subdural collection
causing a stable mass effect with 7 mm midline shift to the
right.
5. Stable areas of low attenuation in the territory of the left
MCA are most likely due to vasogenic edema from the surrounding
hematomas, although an underlying evolving infarction cannot be
totally excluded.
6. Stable position of the right frontal ventriculostomy catheter
without
evidence of hydrocephalus.
CT head [**2190-3-19**]
Right common carotid artery arteriogram shows widely patent
right
internal carotid artery, middle cerebral artery and anterior
cerebral artery with no evidence of spasm.
Left common carotid artery arteriogram shows that the left
internal carotid artery, left anterior cerebral artery and left
middle cerebral artery are patent with no evidence of spasm. The
aneurysm is still patent with coils at the tip where the rupture
site was.
Left vertebral artery arteriogram shows that both PCAs are
patent.
[**Known firstname **] [**Known lastname 35962**] underwent cerebral angiography which showed that
there was no vasospasm. We did not treat the aneurysm on this
setting since she would require Plavix for the stent and she
still had a ventricular catheter in. After the ventricular
catheter is removed, she will be brought back for definitive
treatment of this aneurysm.
CXR [**2190-3-20**]
Previous mild pulmonary edema has almost resolved. Heterogeneous
opacification in the infrahilar right lower lung could be
residual edema and atelectasis or early pneumonia. Pleural
effusion on the right is small if any. Heart size top normal.
Nasogastric feeding tube ends in the stomach. Right PIC line
ends close to the anticipated location of the superior
cavoatrial junction. No pneumothorax
CXR [**2190-3-21**]
The right lower lobe opacity is again redemonstrated, concerning
for
infectious process in the right lower lobe. Dobbhoff tube tip is
in the
stomach. The right PICC line tip is at the cavoatrial junction.
No pleural
effusion or pneumothorax is demonstrated.
CXR [**2190-3-22**]
Tip of the right PIC line projects over the upper right atrium
and would need to be withdrawn 2.5 cm to confidently place it in
the low SVC. No
endotracheal tube seen below C6, the upper margin of this film.
Feeding tube is looped in the stomach. Minimal pulmonary edema
has developed in the right lower lobe and the heart though still
normal size is slightly larger. No pneumothorax. Pleural
effusions small if any.
CT head [**2190-3-22**]
1. Decrease in residual intraparenchymal, subarachnoid, and
intraventricular hemorrhage with no new foci of hemorrhage.
2. Slight decrease in edema surrounding the left temporoparietal
hematoma,
although residual sulcal effacement and rightward shift of the
normal midline structures persist.
3. Small amount of post-surgical pneumocephalus around the right
ventriculostomy catheter, without evidence of hemorrhage.
4. Stable post-craniotomy changes with a decrease in size of the
adjacent
subdural and subgaleal hematomas
[**2190-3-22**] LENS
No evidence of right or left deep vein thrombosis.
[**2190-3-23**] CT head FINDINGS: There is a right-sided ventriculostomy
catheter through a right frontal burr hole approach. The
catheter appears to course through the frontal [**Doctor Last Name 534**] of the right
lateral ventricle but terminates just lateral to the ventricle
itself. A small amount of postoperative pneumocephalus is
adjacent to the catheter and unchanged. The ventricles are
unchanged in size. There is no evidence of hydrocephalus. There
is trace if any residual intraventricular hemorrhage.
Again noted is a left temporal intraparenchymal hemorrhage which
is unchanged in size with surrounding edema. There is mild
rightward shift of the normal midline structures, measuring 5 mm
(2, 16). This is unchanged from the prior exam. Residual
subarachnoid hemorrhage is present in the left hemisphere.
Persistent edema and cortical swelling of the left frontal and
parietal lobes is noted as before. No new foci of blood are
visualized. Hypodense areas in the left temporal lobe are again
seen and may relate to a combination ischemic changes and edema.
Post surgical left frontal craniotomy changes are stable. There
is a small
post-surgical subdural hematoma which is unchanged in size.
Mineralization of the membrane is present. The small
post-surgical subgaleal hematoma appears to be slightly smaller
in comparison to the prior exam.
There is mucosal thickening in the left maxillary sinus and an
air-fluid level in the sphenoid sinus. These are unchanged. The
mastoid air cells and middle ear cavities are clear.
IMPRESSION:
1. No evidence of hydrocephalus.
2. Right ventriculostomy catheter courses through the right
lateral ventricle but terminates just lateral to the ventricle.
Correlate with catheter function and if the position is
desirable/appropriate. Followup closely as clinically indicated.
3. Unchanged appearance of left intraparenchymal and
subarachnoid hemorrhage without evidence of new bleeding.
4. Stable post-surgical changes after left frontal craniotomy.
CT [**2190-3-24**] FINDINGS: Since the prior study approximately 24
hours earlier, there has been no change in size of the
ventricles. There is no evidence of hydrocephalus. No
intraventricular hemorrhage is identified. A
ventriculostomy catheter through a right frontal burr hole is
unchanged in
position. It appears to course through the frontal [**Doctor Last Name 534**] of the
right lateral ventricle with the tip terminating just lateral to
the ventricle within the parenchyma. This is unchanged since the
prior exam. A small amount of postoperative pneumocephalus is
adjacent to the catheter tract and also unchanged.
The left temporal parenchymal hemorrhage and surrounding
vasogenic edema is unchanged from the recent exam. There is
effacement of the adjacent sulci and mild, 3 mm, stable
rightward shift of the normal midline structures. There is no
evidence of uncal herniation. The basal cisterns are patent.
Residual subarachnoid hemorrhage is present in the left
hemisphere. No new foci of hemorrhage is identified.
A metallic coil is present in the region of the left MCA with a
slight amount of metallic streak artifact. Post-surgical changes
from a left frontal craniotomy are unchanged. There is a small
residual subdural hematoma with mineralization of the membrane.
No fracture is identified. Mucosal thickening is present in the
left
maxillary sinus. The remainder of the paranasal sinuses, mastoid
air cells
and middle ear cavities are clear.
IMPRESSION:
1. Unchanged size of the ventricles, without evidence of
hydrocephalus.
2. Unchanged position of the right ventriculostomy catheter,
which appears to terminate just lateral to the right lateral
ventricle.
3. Unchanged appearance of left temporal parenchymal hemorrhage,
subarachnoid hemorrhage, and post-surgical changes from left
frontal craniotomy
[**2190-3-26**] Cerebral angiogram
Final Report
DIAGNOSIS: Subarachnoid hemorrhage from ruptured left middle
cerebral artery aneurysm.
INDICATION: The patient had large hematoma of the left temporal
lobe, the
aneurysm was partially coiled and the hematoma evacuated.
Following this, she was brought back for elective stent-assisted
coiling.
PROCEDURE PERFORMED: Left internal carotid artery arteriogram,
left MCA
stent-assisted coiling of left bifurcation aneurysm. Right
common femoral
artery arteriogram.
ANESTHESIA: General.
BILAT LOWER EXT VEINS [**2190-3-30**]
No evidence of deep vein thrombosis in either leg
Brief Hospital Course:
Ms. [**Known lastname 35962**] was admitted to the Neurosurgery service and an
emergent EVD was placed for developing hydrocephalus. She was
then taken emergently for cerebral angiogram where preliminary
embolization of the left MCA aneurysm was performed. Post
angiog she was taken emergently to the operating room for a left
craniotomy for evacuation of the left temporal clot. Post
procedure she remained intubated. On POD 1 the patient remained
in the ICU for close neuro monitoring. Her subgaleal drain was
removed and staples were placed at the drain site. A repeat head
CT was orderred secondary to a rise in her ICPs which showed
post surgical changes and stable hemorrhage. Mannitol was given
x 2 and a ICP bolt was placed. Overnight she had an increase in
her ICP to low 30s which resolved independently. On [**3-14**], off
sedation patient was purposeful in all 4 extremities, L>R. ICPs
remained stable. She was stable into [**3-15**] and on morning rounds
on [**3-15**] she was purposeful with her LUE and w/d in the other
three LLE>RLE. On morning rounds on [**3-16**] she was more awake with
Eye opening and otherwise her exam was stable. She underwent a
CTA of the head which showed no vasospasm. TCD was repeated and
also showed no vasospasm. Patient was weaned to extubate and
bolt was removed. She was extubated on the evening of [**3-16**] and
her tube feeds were restarted. She was also febrile to 101.4 and
she was pancultured. On the morning of [**3-17**] was doign well off
the ventilator and CSF was sent from her EVD for culture and lab
testing.
[**3-18**]; TCDs were performed that showed slower velocities and
little evidence of vasospasm. She was taken off of Neo and her
blood pressure was liberalized. Seroquel was started around the
clock for delerium.
[**3-19**]; She was agitated overnight and her EVD was dropped from 20
to 15. She also received a unit of PRBC's. Patient went to angio
to rule out ongoing vasospasm.
Her EVD was clamped afterwards but ICP's were elevated overnight
and the drain was opened.
She was extubated on [**3-20**], she had stridor that improved with
nebulizer. Tm 100.7,
and Ciprofloxacin 400 mg IV Q12H started for + sputum. She
continued to be restless and was aggitated.
On [**3-21**], she was very alert, NICOTENE patch was strated for
request for cigarretes. EVD to was at 20-and she seemed to be
seems to be dumoping CSF fluid when moving and restless in bed.
The ICU was weaning the seroquel due to EKG changes with QTC
elevation. There was scant serous drainage from staple insertion
site around the EVD cath. EVD was clogged and she was taken to
the OR Sunday night to change out EVD.
On [**3-22**], she was neuologically stable and the EVD was clamped.
Sutures/staples were removed. She was seen by speach and swallow
and was cleared for thin liquids and ground solids. She had low
ICP's with a clamped drain on [**3-23**]. CT head was stable on [**3-23**]
and [**3-24**]. The EVD was removed on [**3-24**].
She remained stable and was returned to the angiography suite on
[**2190-3-26**] for completion of coil of left MCA aneurysm with stent
assist. This was uneventful and she was started on asa and
plavix. She remained in the ICU one more day and was
transferred to floor status on [**3-27**]. She was impulsive and
required supervision to prevent her from leaving the hospital.
Her sutures and antibiotics were discontinued on [**3-29**]. Sceening
LENS on [**3-30**] were negative. Seroquel was being weaned due to EKG
changes. Keepra was stoppedo n [**4-1**]. UA was done for dysuria but
was negative. She was denied coverage for acute rehab by [**Company 57702**]. She was being screened for a [**Hospital1 1501**].
On [**4-2**], seroquel was added for impulsive and aggressive
behavior. Patient continued to attempt to leave hospital. She
was denied [**Hospital1 1501**] and it was decided that patient is safe for
discharge home with 24hr supervision. Her nimodipine was
discontinued and patient was discharged home with daughter.
Medications on Admission:
unknown
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*3 Patch 24 hr(s)* Refills:*2*
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 23 days.
Disp:*23 Tablet(s)* Refills:*0*
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Left MCA aneurysm
Hydrocephalus
Cerebral edema
Left Intracerebral hemorrhage
delerium
elevated intracranial pressure
anemia requiring blood transfusion
stridor
H. Flu pneumonia
dysphagia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - always.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You are to continue plavix for 1 month and continue
aspirin until seen in follow up with Dr. [**First Name (STitle) **]
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in weeks.
??????You will need a CT scan of the brain without contrast.
??????You will also need to be seen in 6 months with an MRI/MRA
Completed by:[**2190-4-3**] Name: [**Known lastname 14461**],[**Known firstname **] Unit No: [**Numeric Identifier 14462**]
Admission Date: [**2190-3-12**] Discharge Date: [**2190-4-3**]
Date of Birth: [**2141-2-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Vicodin HP / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 40**]
Addendum:
Patient was discharged home with home VNA services.
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2190-4-3**]
|
[
"348.4",
"293.0",
"786.1",
"348.5",
"285.9",
"331.4",
"787.20",
"V12.54",
"430",
"784.3",
"482.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.10",
"88.41",
"96.6",
"39.72",
"02.21",
"01.39",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
20241, 20423
|
12307, 16335
|
336, 687
|
17276, 17366
|
1355, 12284
|
19467, 20218
|
1040, 1049
|
16393, 16973
|
17066, 17255
|
16361, 16370
|
17426, 19444
|
1064, 1064
|
1278, 1336
|
266, 298
|
715, 950
|
1078, 1264
|
17381, 17402
|
972, 999
|
1015, 1024
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,367
| 112,688
|
46415
|
Discharge summary
|
report
|
Admission Date: [**2120-9-20**] Discharge Date: [**2120-10-21**]
Date of Birth: [**2060-7-1**] Sex: F
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5378**]
Chief Complaint:
s/p fall
mechanical AVR s/p rheumatic fever and on coumadin
Major Surgical or Invasive Procedure:
SDH drainage of blood by neurosurgery with drain in place for
one day.
History of Present Illness:
60 year-old woman with a history of rheumatic fever s/p
mechanical AVR on coumadin presents s/p falling in shower [**9-19**].
Pt reports that while taking a shower on Thursday, she slipped
and fell out of the tub, landing with her low back on the edge
of
the tub and banging the side of her head into the wall. She was
unable to get up by herself, and called her daughter for
assistance, who was asleep and took ~10 minutes to hear pt's
calls. Denies any LOC, dizziness, lightheadedness, weakness
before the fall; pt insists she simply slipped. Per pt, she had
only a tiny amount of bleeding from her head, and thus she took
some advil and went to bed with a heating pad. Reports being
able
to walk at that time with no difficulty and no unsteadiness.
By the morning of [**9-20**], pain had significantly increased, and pt
was unable to move as a result. Pain was mostly in her low
back/coccyx and in her pelvis, especially around the pubis.
Reports only mild headache, mild chronic neck stiffness. She
took
600 mg advil without relief and went to her PCP's office, where
she arrived in a wheelchair due to inability to walk from the
pain. She was seen and was sent to ED for further evaluation.
In ED, labs with INR 4.8. Given this, head CT and
abdominal/pelvic CT were performed to rule out head and
retroperitoneal bleed; both were negative. Additionally, plain
films of LS spine and pelvis were negative for fracture. Pt was
then admitted to the Observation unit for further pain control.
At ~midnight, she reported to the RN that she was unable to
urinate.
On further questioning, she reports that she had been having
difficulty urinating since her fall Thursday, but not
previously.
This was manifested mostly as a difficulty in initiating stream
of urine, though perhaps also associated with a decreased flow
rate. Denies incontinence, and denies any change from her
baseline constipation.
Additionally, pt had single temperature to 100.3 while in ED,
and
ED started empiric zosyn, for concern for epidural abscess.
Foley
placed with total ~430 cc out when seeing pt, unclear what
exact output was after initial placement.
ROS: Denies malaise, feeling ill. One episode of vomiting in ED,
possibly secondary to pain meds. Denies any other
constitutional,
pulmonary, cardiac, gastrointestinal, urologic, dermatologic, or
neurologic symptoms.
Past Medical History:
1. Rheumatic fever as child, now s/p AVR with mechanical valve
in
[**4-/2102**], on coumadin
2. Hypertension
3. Depression
4. h/o chronic abdominal pain, now resolved
5. s/p TAH
Social History:
Widowed. Lives alternately with daughter, mother. [**Name (NI) **] EtOH,
drugs.
Family History:
HTN
Physical Exam:
Tm 100.3, Tc 99.8 BP 121/47 HR 93 O2 sat 96% RA
General: Appears stated age, in mild distress from pain, though
appears relatively comfortable when not moving
[**Name (NI) 4459**]: NC/AT Sclera anicteric. OP clear
Neck: FROM, but with some (chronic) mild neck "tightness".
Lungs: Clear to auscultation bilaterally
Back: Spinal tenderness ~ L4/5 to coccyx
CV: RRR, nl S1, S2, no murmur. 2+ carotids without bruit
Abd: Soft, normoactive bowel sounds. +tenderness over symphysis
pubis and somewhat laterally as well
Extr: No edema
Neurologic Examination:
Mental Status: Alert and oriented to person, place and date,
cooperative with exam, normal affect
Attention: Able to tell full story with good details
Language: Fluent, no dysarthria, no paraphasic errors No neglect
Cranial Nerves: Pupils equally round and reactive to light, 3 to
2 mm bilaterally, brisk. Extraocular movements intact, no
nystagmus. Facial sensation and facial movement normal
bilaterally. Hearing intact to finger rub bilaterally. Normal
oropharyngeal movement. Tongue midline, no fasciculations.
Motor:
Normal bulk and tone bilaterally, fasiculations absent in upper
and lower extremities. No tremor.
Strength: D T B WF WE FiF [**Last Name (un) **] FiA IP Q H DF PF TE
Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5
No pronator drift
Decreased rectal tone
Sensation was intact to light touch, pin prick, temperature
(cold), vibration, and proprioception, except decreased to
absent
pinprick on right perianal area.
Reflexes: B T Br Pa An
Right 2 2 2 2 2
Left 2 2 2 2 2
Grasp reflex absent.
Toes were downgoing bilaterally
Coordination is normal on finger-nose-finger, rapid alternating
movements, heel to shin.
Gait was narrow based and normal, negative Romberg.
Pertinent Results:
[**2120-9-20**] 08:40PM WBC-9.2 RBC-3.40* HGB-10.9* HCT-31.2* MCV-92
MCH-32.0 MCHC-34.8 RDW-12.4
[**2120-9-20**] 08:40PM NEUTS-77.8* BANDS-0 LYMPHS-16.3* MONOS-3.8
EOS-1.5 BASOS-0.6
[**2120-9-20**] 08:40PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2120-9-20**] 08:40PM PLT COUNT-170
[**2120-9-20**] 05:24PM URINE HOURS-RANDOM
[**2120-9-20**] 05:24PM URINE GR HOLD-HOLD
[**2120-9-20**] 05:24PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-<=1.005
[**2120-9-20**] 05:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2120-9-20**] 04:55PM GLUCOSE-83 UREA N-9 CREAT-0.7 SODIUM-142
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
[**2120-9-20**] 04:55PM WBC-6.2 RBC-3.23* HGB-10.4* HCT-29.7* MCV-92
MCH-32.1* MCHC-34.9 RDW-12.6
[**2120-9-20**] 04:55PM NEUTS-48.4* LYMPHS-41.4 MONOS-6.6 EOS-3.0
BASOS-0.7
[**2120-9-20**] 04:55PM PLT COUNT-160
[**2120-9-20**] 04:55PM PT-27.6* PTT-40.2* INR(PT)-4.8
Brief Hospital Course:
Pt was admitted to neurology and was found to have a bleed into
a pre-existing Tarlov's cyst (in the lumbrosacral roots as they
exit the cord). She was initially monitored for difficulties
producing urine and feces, with question of conus medullaris
syndrome but this has since resolved. On admission, her INR was
4.4 and this is likely the reason for her bleed. Her high INR
was reversed with Vitamin K and FFP. She was then found to have
a headache for which she recieved a CT scan of her brain showing
a large SDH on the left. The pt was seen by neurosurgery and
they placed a drain into the SDH and removed 300 cc of blood.
After the sx, pt remained in the ICU for several days and then
was stable enough for transfer to the floor. After a few days,
pt was found to have a thrombus on her AVR, measuring 1.5 cm as
well as an aortic aneurysm of 5 cm that has been stable in past
months per cardiology. This aneurysm is an effect of the AVR
and cardiology has advised watching it. We have also begun her
on a heparin drip and coumadin again in light of her AVR thombus
and her goal PTT is 50-70 and her INR goal is 2.0 minimum. We
repeated the cardiac echo and found a resolution of the thrombus
after several days of anticoagulation. The patient finally
attained an INR of 2.3 on [**2120-10-21**] at which time she was
discharged in stable condition.
Medications on Admission:
CLONAZEPAM 1MG--One three times a day
COUMADIN -As directed
HYDROCHLOROTHIAZIDE 25 MG--One tablet by mouth every day
IBUPROFEN 200MG--2 three times a day as needed for abdominal
pain
MECLIZINE HCL 25MG--One as needed for dizziness
METOPROLOL SUCCINATE 50 MG--One tablet by mouth every day --
hold for sbp<100, hr<50
Lexapro
Calcium
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO QD (once a day).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal Q6H PRN
() as needed for anal pain.
8. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
9. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for PRN.
10. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Fall leading to subdural hemmorhage s/p drainage
2. Supratherapeutic INR
3. Aortic valve thrombus (not seen on most recent ECHO)
4. Hypertension
5. Anxiety
Discharge Condition:
Stable, tolerating an oral diet, afebrile, ambulatory.
Discharge Instructions:
Return to care if severe headache, nausea, vomitting, or fever
occur
Please take all your medications as prescribed. Please call your
doctor or return to the emergency department if you notice
fevers, chills, worsening headaches, prolonged bleeding, changes
in your vision, difficulty moving your arms or legs, increasing
confusion or somnolence, bowel or bladder incontinence, chest
pain, difficulty breathing or any other symptoms concerning to
you.
Followup Instructions:
Please follow up with your doctor in [**2-21**] weeks. Please follow
up with the coumadin clinic within one week of discharge, and
weekly thereafter.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,843
| 187,638
|
11211
|
Discharge summary
|
report
|
Admission Date: [**2207-2-27**] Discharge Date: [**2207-4-3**]
Date of Birth: [**2158-2-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Nafcillin
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Hypotension, oliguria
Major Surgical or Invasive Procedure:
Incision and Drainage Left Lower Extremity [**3-5**], [**3-16**], [**3-17**],
[**3-25**] [**2206**]
Upper Endoscopy
History of Present Illness:
49F with h/o CAD s/p 5v CABG, DM2, and HTN, admitted with L leg
erythema, fever, and now with [**Last Name (un) **]. Pt initially awoke on Wed [**2-25**]
with fevers to 102.5 and shaking chills, along with multiple
episodes of nausea and nonbilious, nonbloody emesis.
Significantly decreased po intake over the next 3-4 days as
well. On Thurs [**2-26**], pt subsequently developed L foot swelling,
erythema, and pain, along with a large blister on the medial
aspect of her L foot. Over the course of three days, she took 3
tabs of ibuprofen tid, unsure of dose. She denied orthostatic
sx. Pt presented to the ED on Friday morning [**2207-2-27**]-- at that
time, was febrile to 102.1 with rigors (was given ibuprofen and
tylenol). She was started on zosyn/vancomycin for cellulitis and
admitted to medicine. Creat at that time was 1.6. Since then,
BCx have grown out coag + staph in [**3-29**] bottles.
.
After admission, pt progressively became more hypotensive, with
diminishing urine output over the day yesterday. Was given 6L
0.9NS on the floor, with BPs remaining in mid-80s systolic. She
also developed new onset RUE weakness; MRI was negative for
acute stroke. She was transferred to MICU last night, where she
has remained febrile and hypotensive, and was started on
dopamine. Pt currently being followed by podiatry and vascular
surgery, who feel that this is acute charcot foot with overlying
soft tissue infection.
.
Currently, pt c/o nausea and continued dry heaves. Denies
dyspnea, orthostatic sx, or chest pain. Says she has been told
about mild CKD in the past, but is unsure about her baseline
creatinine. She has never been told about proteinuria in the
past, and denies regular NSAID use (aside from acute use in past
few days).
Past Medical History:
PAST MEDICAL HISTORY: [**Known firstname **] has got a number of medical
problems stemming from hypertension and diabetes. She has had
diabetes for a long period of time and her most recent
hemoglobin A1c level was notably elevated at 14%. She has a
history of coronary artery disease and had a CABG in [**2197**]. She
reportedly has an ejection fraction of 50 to 55%. She has a
history of hyperlipidemia and hypertension. With respect to her
bypass, she has had stents placed as well. Her CABG was
complicated by a sternal wound infection. Her most recent echo
was obtained on [**2205-4-25**]. This reveals ejection fraction of
greater than or equal to 55% with no evidence of endocarditis.
She has never had a colonoscopy and she had her last mammogram
three years ago. She also has anemia and her most recent
hematocrit was 30%. She has an elevated platelet level greater
than 500.
* CAD s/p 5v CABG in [**2197**], with subsequent 4v CABG 6 months
later
* DM2, diagnosed in [**2197**], complicated by retinopathy and
neuropathy, poorly controlled
* HTN
* hyperlipidemia
* anemia
PAST SURGICAL HISTORY: In [**2197**] and [**2198**], she had her coronary
artery bypass. She has had three C-sections.
OB/GYN HISTORY: She denies any history of pelvic infections.
She denies any history of abnormal Pap smears, and her last was
obtained in [**2198**]. She denies any complications of cesarean
section.
Social History:
She is married. She denies tobacco, drug, or alcohol use. She
is a housewife.
Family History:
She reports her mother developed lung cancer, she was a smoker.
She had a grandmother and an aunt who had breast cancer,
grandmother was [**Name2 (NI) **] in her 60s and her aunt was in her 50s.
There is no other family history of cancer.
Physical Exam:
Vitals: T: 98.0 BP: 102/58 P: 69 R: 20 O2: 98% 4L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, EOMI, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2. [**1-31**] holosystolic
murmur loudest on left sternal border. no rubs, gallops
Abdomen: Normoactive bowel sounds, obese, soft, non-tender,
non-distended, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ DP on R, LLE wrapped in ACE
bandage. Ankle ROM intact bilaterally. 1+ pitting edema
bilateral lower extremities to knees with severe left foot
edema.
Skin: Warm 2cm x 2cm erythematous and purplish discoloration
across the anterior aspect of the lower leg.
Neuro: alert and oriented x 3, strength 5/5 in all extremities
Pertinent Results:
LABS ON ADMISSION:
[**2207-2-27**] 12:05PM BLOOD WBC-10.5# RBC-4.46 Hgb-12.4 Hct-37.2
MCV-84 MCH-27.9 MCHC-33.4 RDW-13.7 Plt Ct-206
[**2207-2-27**] 12:05PM BLOOD Neuts-90.4* Lymphs-4.6* Monos-3.9 Eos-0.6
Baso-0.6
[**2207-2-27**] 12:05PM BLOOD PT-12.0 PTT-24.9 INR(PT)-1.0
[**2207-2-27**] 12:05PM BLOOD ESR-114*
[**2207-2-27**] 12:05PM BLOOD Glucose-534* UreaN-39* Creat-1.6* Na-130*
K-4.6 Cl-89* HCO3-28 AnGap-18
[**2207-2-28**] 03:30PM BLOOD ALT-25 AST-28 AlkPhos-120* TotBili-0.7
[**2207-2-28**] 07:16AM BLOOD Calcium-7.8* Phos-4.0# Mg-1.8
[**2207-2-28**] 03:30PM BLOOD Cortsol-28.3*
[**2207-2-27**] 12:13PM BLOOD Glucose-404* Lactate-2.6* K-4.4
[**2207-3-2**] 12:20PM BLOOD freeCa-0.96*
LABS ON TRANSFER FROM THE ICU:
[**2207-3-2**] 03:36AM BLOOD WBC-10.2 RBC-3.43* Hgb-9.6* Hct-28.2*
MCV-82 MCH-27.9 MCHC-34.0 RDW-14.2 Plt Ct-254
[**2207-3-2**] 03:36AM BLOOD Plt Ct-254
[**2207-3-2**] 01:44PM BLOOD Glucose-117* UreaN-52* Creat-3.9* Na-130*
K-4.1 Cl-100 HCO3-17* AnGap-17
[**2207-3-2**] 01:44PM BLOOD Calcium-6.9*
[**2207-3-2**] 12:20PM BLOOD Type-ART pH-7.35
[**2207-3-2**] 12:20PM BLOOD Lactate-0.8
[**2207-3-2**] 12:20PM BLOOD freeCa-0.96*
LABS ON SECOND TRANSFER FROM ICU:
LABS ON DISCHARGE:
MICROBIOLOGY:
[**2207-3-1**] URINE URINE CULTURE-FINAL INPATIENT
[**2207-2-28**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2207-2-28**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2207-2-27**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL INPATIENT
[**2207-2-27**] BLOOD CULTURE Blood Culture, Routine-FINAL {STAPH
AUREUS COAG +}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
IMAGING:
3/5 L foot x-ray:
1. Findings concerning for possible osteomyelitis superimposed
on an evolving Charcot's joint, although no radiographic
evidence of ulcer. Extensive osseous destruction and lucencies
involving the medial and mid cuneiforms, second and third
metatarsal bases, and navicular bone. While findings could in
part relate to an evolving Charcot's joint, new since [**3-/2205**],
they are in conjunction with overlying soft tissue gas and
swelling, making superimposed osteomyelitis of concern.
Recommend clinical correlation for soft tissue
defect/ulcer and further evaluation with nuclear medicine study
or MRI.
2. Gas noted in anterior ankle. Given known leg cellulitis,
proximal extent not evaluated.
[**2-28**] MRI/MRA Head: No signs of infarct.
[**3-1**] CXR:
Comparison is made to the prior study from [**2207-2-27**]. The heart
is enlarged. There is atelectasis at the left lung base with a
small left pleural effusion. This is status post median
sternotomy. Right lung is relatively clear.
[**3-1**] Renal ultrasound: No evidence of hydronephrosis.
[**3-2**] TTE:
The left atrium is mildly dilated. 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 diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild tricuspid regurgitation. Normal biventricular
cavity sizes with preserved global and regional biventricular
systolic function. Mild pulmonary artery systolic hypertension.
Compared with the prior report (images unavailable for review)
of [**2205-4-25**], the findings are similar.
Brief Hospital Course:
49 year old F with hx of CAD, DM, HTN presented with left lower
extremity pain and erythma secondary to acute charcot foot with
overlying cellulitis. On floor patient developed hypotension and
oliguria despite 6 L NS IVF due to MSSA sepsis. She improved
and was sent out to the floor where she continued treatment for
MSSA bacteremia and L Charcot foot, cellulitis and osteomyelitis
until she developed a GI bleed from a Dieulafoy lesion. After
endoscopy with endoclips and cautery, she was stabilized and
sent back to the floor for continued management. After
returning to the floor her course was then complicated by
another debridement and then renal failure due to AIN from her
nafcillin.
.
# Left Charcot foot with osteomyelitis and overlying cellulitis:
Patient presented with left lower extremity pain and erythema.
She was seen by podiatry and vascular surgery who felt this was
consistent with an acute Charcot foot. She then became
hypotensive and oliguric requiring MICU admission where she was
found to be septic with MSSA. Her foot was the presumed source
and a CT of her leg showed several gas pockets within the foot
and ankle. Patient underwent I&D on [**3-5**] with swab and tissue
cultures showing MSSA. Infectious disease was consulted and
recommended at least a 6 week course of nafcillin, however after
her final debridement cultures were growing enterobacter and
klebsiella, and she developed AIN her antibiotic regimen was
changed to ciprofloxacin and vancomycin. She will need 6 weeks
of vancomycin from the date of her last debridement on [**2207-3-24**],
and 4-6 weeks of ciprofloxacin from [**2207-3-24**], this course will be
outlined during her ID appointment in [**Month (only) 547**]. She will need
weekly labs that include: cbc, diff, bun, cr, lfts, esr,
crp,vancomycin trough and have ALL THE LABS faxed to the
infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**].
.
# Dieulafoy lesion: She had a hematocrit drop while on the floor
and was found to have melena. She was transferred to the ICU for
GI bleed and required 12 units of blood in less than 48 hours.
She had a few EGDs on [**3-8**] and on [**3-9**] showing clot in stomach
from a Dieulafoy lesion. The gastroenterologists were unable to
intervene on first two endoscopies but able to cauterize and
place clips on the third endoscopy which was performed with
intubation in the OR for direct visualization. Her hematocrit
then stabilized, and she was started on a PPI, she had no
further evidence of GI bleeding during her stay, and GI felt
that it was safe for her to be started on anticoagulation.
.
# MSSA bacteremia: The source of her bacteremia was likely her
left foot given same speciation and sensitivites. There were no
signs of endocarditis on transthoracic echocardiogram but the
study was deemed suboptimal. The patient declined a
transesophageal echocardiogram but this was felt to not be
necessary as she will already require a 6 week course of IV
antibotic therapy. Due to her new allergy to nafcillin as a
result of the AIN, her antibiotics were changed to
vancomycin/ciprofloxacin as above for the bacteremia.
.
# Left upper extremity deep venous thrombus: She was found to
have a DVT surrounding her PICC in her left arm. She was
initially started on a heparin drip as a bridge to coumadin, the
left arm PICC was removed and PICC was placed in her right arm.
She will complete a three month course of coumadin, if she
becomes subtherapeutic on coumadin there is no indication for
bridging with heparin, so she can be continued on coumadin until
her INR is back in the therapeutic range.
.
# Acute renal failure: Patient developed oliguria very soon
after admission, and urine sediment showed muddy brown casts
consistent with ATN. The etiology of her ATN was likely
hypotension leading to hypoperfusion while she was septic from
MSSA. Her creatinine steadily improved and returned to near her
baseline. Then around [**2207-3-26**] her creatinine started to increase
again, it peaked at 2.0 and renal was consulted. Examination of
the urine showed white cells and cellular casts, renal felt that
this was consistent with AIN, most likely from Nafcillin. They
also felt that there was a component of congestive heart failure
that was also contributing. Her antibiotics were changed to
vancomycin and she was started on more aggressive diuresis of
lasix 80mg IV twice a day. Given the large amount of excess
fluid, she will currently be continued on the same dose of IV
lasix. If her creatinine increases again, or diuresis starts to
slow, she can then be transitioned back to an oral dose, she was
admitted on 40mg po daily. Creatinine at the time of discharge
was 1.2, her renal function will need to be continually
monitored as her vancomycin dosing may change as her renal
function changes. We held her valsartan in the setting of her
renal failure and also while she was getting IV lasix, if she
needs better blood pressure control can restart valsartan 80mg
daily if her creatinine is back to her baseline of 1.0.
.
# RUE weakness: She acutely developed difficulty raising her
right arm on [**2-28**] but had a negative head MRI after code stroke
was called. Neurology felt this was a brachial plexus
neuropathy, likely pressure related from non-invasive
measurements done in the ED. MRI of C-spine showed severe canal
and foraminal narrowing at C5-6 and C6-7 with cord deformity but
no signs of abscess. Spine was consulted who recommended a CT
scan of her C-spine for better evaluation but felt this was
non-critical. She should follow-up with the spine clinic after
discharge and her rehabilitation stay.
.
# Hypocalcemia with hyperphosphatemia: In the setting of acute
renal failure, she had a low ionized calcium and
hyperphosphatemia. Sevelamer was started with meals to help
correct this imbalance until her renal function improved. Once
her renal function improved, the sevelamer was discontinued.
.
# CAD: She had no complaints of chest pain or SOB throughout her
stay. She was continued on ASA, plavix and statin initially
until she developed a GI bleed. At that time her
anticoagulation was stopped, and not restarted until a week
after final EGD. She was resumed on aspirin and statin but her
plavix continued to be held given her need for warfarin.
.
# DM: She was continued on ISS with Lantus. She needed
continual uptitration of her lantus dose for improved glycemic
control. Her humalog sliding scale from the hospital was
included in her paperwork.
.
# Acute on chronic diastolic congestive heart failure: Her EF
>55% on transthoracic echocardiogram. She was initially
euvolemic but developed volume overload from IV fluids and blood
products. She continues to be on aggressive diuresis with lasix
given her total volume overload, and fact that her renal
function improved with diuresis she was discharged on 80mg IV
BID, and will likely need up to a week more of diuresis with IV
lasix, we would recommend continuing as long as her creatinine
remains stable. We held her valsartan in the setting of her
renal failure and also while she was getting IV lasix, if she
needs better blood pressure control can restart valsartan 80mg
daily if her creatinine is back to her baseline of 1.0.
.
# Dyslipidemia: She was continued on atorvastatin.
.
# Thyroid nodule: Incidental finding on C-spine MR, elevated TSH
with normal T4 consistent with [**Month/Day (4) **] euthyroid, she will need
further outpatient follow up of the thyroid nodule after rehab.
Medications on Admission:
amlodipine 10, atorvastatin 80, plavix 75 mg, furosemide 40 mg
daily, gabapentin 300 mg po tid, imdur 30 mg po daily,
metoprolol 100 mg po bid, valsartan 80 mg daily, ASA 325, Fe
sulfate, MVI, sertraline 100mg, ativan 0.5mg QID:PRN
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for severe anxiety.
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
13. Hydromorphone 2 mg Tablet Sig: 1-2 mg PO Q6H (every 6 hours)
as needed for pain: hold for sedation, RR<12.
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
17. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
19. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
20. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours).
21. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
22. Furosemide 80 mg IV BID
Hold for SBP<100
23. Insulin Lispro 100 unit/mL Solution Sig: Sliding Scale As
directed Subcutaneous ACHS: Please follow attached sliding
scale.
24. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
MSSA bacteremia
Left Charcot foot
Left lower leg cellulitis
Acute renal failure
Dieulafoy Lesion causing an upper GI bleed
Secondary:
Diabetes mellitus
CAD s/p CABG
Discharge Condition:
Mental Status: Confused - sometimes, usually oriented x 3, but
has difficulty with attention
Level of Consciousness: Alert and interactive usually, will at
times be very sleepy but very easily arousable.
Activity Status: Bedbound, currently requires assistance to get
out into the chair
Discharge Instructions:
You were admitted to the hospital for pain in your left foot.
Your blood pressure dropped, and you were found to have a
bacteria in your blood stream likely from your infected foot.
You had a deep infection in your left foot and lower leg that
required clean out in the OR. You improved on antibiotics.
During your stay you also had a bleeding artery in your stomach,
which required a stay in the ICU and an upper endoscopy done by
gastroenterology with clipping of the artery. Also, during your
stay you were found to have an allergic reaction in your kidneys
to one of the antibioitics, and your kidney function improved
with removal of the antibiotics. You will need close follow up
with podiatry after you leave for monitoring of the healing of
your left leg. Also, since your hospital stay was very
prolonged and complicated you will need a lot of rehabilitation
to get your strength back.
.
We made multiple changes to your medication regimen during your
stay:
1. STARTED Coumadin 5mg daily for a left arm DVT
2. STARTED Sucralfate four times per day
3. STARTED Dilaudid 1-2mg every 6 hours as needed for pain
4. STARTED Pantoprazole 40mg daily
5. STARTED Ciprofloxacin 500mg twice a day for 4-6 weeks from
[**2207-3-24**], ID will address stopping this medication during your
appt
6. STARTED Vancomycin 1g every 24 hours for 6 weeks from [**2207-3-25**]
7. DECREASED Metoprolol to 50mg twice a day
8. STOPPED Valsartan due to your kidney failure
9. STOPPED Plavix when you had bleeding from your stomach,
follow up with your PCP and cardiologist about restarting this
medication
10. STOPPED Lasix 40mg daily by mouth
11. STARTED Lasix 80mg IV twice a day
12. DECREASED home ativan dose due to somnolence to 0.5mg twice
a day as need for anxiety
13. ADDED dilaudid 1-2mg every 4-6 hours as needed for pain
Please continue to take all other medications as previously
prescribed
Followup Instructions:
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2207-4-22**] at 9:50 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: PODIATRY
When: TUESDAY [**2207-4-14**] at 11:40 AM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
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"790.7",
"537.84",
"285.1",
"713.5",
"585.9",
"250.50",
"530.85",
"486",
"250.80",
"785.50",
"730.07",
"453.83",
"403.90",
"787.91",
"414.00",
"250.60",
"584.9",
"428.33",
"V45.81",
"362.01",
"731.8",
"041.11",
"707.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.31",
"77.49",
"77.69",
"99.60",
"83.39",
"38.93",
"96.72",
"86.01",
"96.04",
"44.43",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
18614, 18680
|
8607, 16118
|
301, 419
|
18899, 18899
|
4881, 4886
|
21123, 21811
|
3749, 3989
|
16402, 18591
|
18701, 18878
|
16144, 16377
|
19212, 21100
|
3335, 3635
|
4004, 4862
|
240, 263
|
6085, 8584
|
447, 2196
|
4900, 6065
|
18914, 19188
|
2241, 3311
|
3651, 3733
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,264
| 182,130
|
9142
|
Discharge summary
|
report
|
Admission Date: [**2103-3-30**] Discharge Date: [**2103-4-4**]
Date of Birth: [**2061-5-10**] Sex: F
Service: SURGERY
Allergies:
Ultram / Wellbutrin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy, adhesiolysis, closure of
mesenteric defect.
History of Present Illness:
The patient is a 41 year old woman with a history of gastric
bypass in [**2092**], s/p recent total colectomy with ileostomy and
g-tube placement in [**12/2102**] who is seen in surgical consultation
for abdominal pain.
In [**2102-12-1**], she was acutely ill from c-diff colitis
requiring total abdominal colectomy with end ileostomy. She has
recovered somewhat well from this procedure and has been at
home.
She presented with increasing abdominal pain after being
seen in Dr. [**Last Name (STitle) 15645**] office today. She states that she has been
nauseated for approximately 2 weeks, and her pain has increased
over that period of time. Specifically, she states that the
pain
is diffuse and localized to her lower quadrants bilaterally.
She
has been eating and drinking well up until the past 48 hours,
and
she has had ostomy output until approximately 48 hours ago.
Past Medical History:
PMH:
- Seizure disorder, has not had seizure in 4+ years. Described
as grand mal seizure possibly in the setting of ultram.
- DJD L5-S1, facet DJD and L4-L5 annular tear.
- Systolic/diastolic congestive heart failure due to
cardiomyopathy of unclear etiology, likely viral diagnosed in
9/[**2101**]. EBV IGM neg, CMV IGM equivocal, Lyme neg
- Depression
- Chronic back pain with narcotic dependence
- Nausea, weight loss, nutritional deficiencies of unclear
etiology, possibly related to depression, malabsorption or
related to her gastric bypass.
- Normocytic anemia per notes attributed to iron deficiency in
the past although no evidence in lab values here.
PSH:
s/p gastric bypass laparoscopic [**2092**]
s/p revision of jejunjejunostomy [**2092**]
s/p abdominoplasty [**2093**]
s/p total colectomy, ileostomy, g-tube [**2102-12-26**]
Social History:
She works as an administrative assistant. Denies any previous or
current tobacco use, no current alcohol use. No illegal drugs or
IV drug use.
Family History:
Father with cirrhosis of the liver.
Physical Exam:
Temp 97.3 HR 87 BP 150/92 100% RA
- NAD, awake/alert and uncomfortable in bed
- RRR
- lungs clear to auscultation
- abdomen soft, moderately distended, tympanitic, tender to
palpation diffusely across abdomen with + tap tenderness, +
voluntary guarding, and mild rebound tenderness
- ostomy pink and slightly dark in color with no output in bag;
with digital manipulation of stoma able to pass small finger
pass
fascia, but it is relatively tight
no peripheral edema
Pertinent Results:
[**2103-3-30**] Abd CT : 1. Mesenteric volvulus with small bowel
ischemia, probably venous. Tis is a surgical emergency.
2. NG tube traverses the gastrojejunal anastomosis with no
evidence of
extraluminal contrast, air, or other sign of perforation.
[**2103-3-30**] 03:10PM WBC-11.4*# RBC-5.36# HGB-14.3# HCT-45.9#
MCV-86 MCH-26.6* MCHC-31.0 RDW-16.2*
[**2103-3-30**] 03:10PM NEUTS-82* BANDS-0 LYMPHS-10* MONOS-7 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2103-3-30**] 03:10PM PLT COUNT-453*
[**2103-3-30**] 03:10PM PT-14.5* PTT-32.5 INR(PT)-1.3*
[**2103-3-30**] 03:10PM ALT(SGPT)-143* AST(SGOT)-154* ALK PHOS-342*
TOT BILI-0.8 DIR BILI-0.5* INDIR BIL-0.3
[**2103-3-30**] 03:10PM GLUCOSE-136* UREA N-17 CREAT-0.8 SODIUM-133
POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-25 ANION GAP-18
Brief Hospital Course:
Ms. [**Known lastname 18036**] was evaluated in the Emergency Room, resuscitated
with IV fluids, had her stomach decompressed with a nasogastric
tube and had an urgent Abd CT done which showed a mesenteric
volvulus with small bowel ischemia. She was taken to the
Operating Room urgently for an exploratory laparotomy, lysis of
adhesions and reduction of the volvulus ( see formal Operative
note for more details ) her hemodynamics improved during and
after the procedure and she was taken to the Surgical ICU,
intubated but in stable condition.
She was extubated without any difficulty on post op day #1 and
the pain service was consulted for help with her pain control as
she has chronic pain, mainly back oain, and was on Methadone and
Oxycodone pre operatively. She was treated with a Dilaudid PCA
and eventually a Ketamine drip was added. Her methadone was
also resumed as she had a functioning ostomy.
Following transfer to the Surgical floor her pain manageement
was the major issue and she was seen daily by the Chronic pain
service to help with adjustments. On post op day # 4 her
ketamine was discontinued and she was transitioned to oral pain
medication including her pre op methadone and dilaudid 4-8 mg PO
q3 hrs prn pain.
She was tolerating a stage 5 diet and her ostomy was active.
Her abdominal wound was clean without drainage or evidence of
erythema.
After an uneventful post op course she was discharged to home on
[**2103-4-4**] with VNA services for wound and ostomy care.
Medications on Admission:
CYANOCOBALAMIN - 1,000 mcg/mL Solution - 1 injection sc monthly
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth weekly x 8 weeks
FOLIC ACID - 1 mg Tablet - one Tablet(s) by mouth daily
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth daily
LEVETIRACETAM - (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth twice a day
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth three times a day
as needed for anxiety
METHADONE - 10 mg Tablet - 2 Tablet(s) by mouth three times a
day
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every8
hours
as needed for nausea
OXYCODONE - 10 mg Tablet - 1 Tablet(s) by mouth every 4-6 hours
as needed for pain
TIZANIDINE - 4 mg Tablet - two Tablet(s) by mouth hs
VENLAFAXINE [EFFEXOR] - (Prescribed by Other Provider) (Not
Taking as Prescribed: Pt is taking 300mg per day.) - 100 mg
Tablet - 3 Tablet(s) by mouth daily
ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomina
Discharge Medications:
1. Methadone 10 mg/mL Concentrate Sig: Twenty (20) mg PO TID (3
times a day).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
Disp:*250 ml* Refills:*2*
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Four (4)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for sleep.
6. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for spasm .
7. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every 3 hours as
needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
8. Cyanocobalamin 1,000 mcg/mL Solution Sig: 1000 (1000) mcg
Injection once a month.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
10. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
11. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Volvulus, internal hernia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
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 [**9-14**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your staples will be removed at your first post op visit.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2103-4-10**]
2:10
Provider: [**Name10 (NameIs) 81**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2103-4-10**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Phone:[**Telephone/Fax (1) 2723**]
Date/Time:[**2103-4-20**] 2:45
Completed by:[**2103-4-4**]
|
[
"338.29",
"560.81",
"338.18",
"428.42",
"789.59",
"V45.86",
"311",
"345.90",
"553.8",
"V44.2",
"428.0",
"560.2",
"721.3",
"V45.3",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"54.75",
"46.81"
] |
icd9pcs
|
[
[
[]
]
] |
7269, 7352
|
3667, 5165
|
292, 362
|
7423, 7423
|
2852, 3644
|
9189, 9631
|
2309, 2346
|
6275, 7246
|
7373, 7402
|
5191, 6252
|
7574, 8867
|
2361, 2833
|
238, 254
|
8879, 9166
|
390, 1268
|
7438, 7550
|
1290, 2132
|
2148, 2293
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,549
| 106,233
|
2789
|
Discharge summary
|
report
|
Admission Date: [**2168-10-31**] Discharge Date: [**2168-11-3**]
Date of Birth: [**2094-3-23**] Sex: F
Service: MEDICINE
Allergies:
Lorazepam / Morphine / Penicillins / Zosyn
Attending:[**First Name3 (LF) 1850**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
74 yr old female with hx of afib/flutter, tachy-brady syndrome
s/p [**First Name3 (LF) 4448**] in [**10/2168**], CHF (EF 20%), COPD s/p trach in [**8-/2168**]
who was sent to ED for evaluation of pacemker. In ED, EP
interrogated pacer and found that the pacer was functioning
properly. However, she was also found to have a fever to 101.4.
The pt was asymptomatic and is currently being treated with a
7-day course of augmentin for presumed sinusitis (given chronic
NGT) and UTI.
.
Also in [**Name (NI) **], pt was found to have different BP in each arm. A CT
of the chest was done to assess for subclavian vein stenosis but
it could not be assessed given the artifact from her pacer
wires.
.
On arrival to the ICU, pt's only complaint was a sore throat and
mild nausea. She denies chest pain, sob, vomiting, diarrhea, abd
pain, headache, dysuria, fevers or chills. She did not some
increased sputum from her trach tube.
Past Medical History:
* recent hx of enterococcal UTI and sinusitis, treated with
Augmentin
* Afib/Aflutter
* Tachy-brady syndrome s/p dual chamber [**Name (NI) 4448**] in [**10-12**]
* CHF (Echo [**2168-8-18**]: LV EF < 20%. Global hypokinesis. 3+ MR, 2+
TR
* HTN
* COPD/asthma s/p trach in [**8-/2168**]
* s/p bowel perforation in [**8-/2168**]
* remote hx of seizure
* h/o lower GI Bleed in [**8-/2168**]
Social History:
.
SH: lives at [**Hospital1 700**]; daughter is HCP
former [**Name2 (NI) 1818**], no EtOH/drug use
Family History:
noncontributory; no known hx of heart/lung dz
Physical Exam:
temp 99.3, BO 117/43, HR 103, R 12, O2 100%
Vent: AC 500x12x5x40%
Gen: NAD, awake and alert, answ questions
HEENT: trach collar in place with some purulent drainage; mild
tenderness over maxillary sinuses; oropharynx clear, no erythema
CV: RRR, no murmurs heard
Chest: diffuse exp wheezes, rhonci more pronounced in right
chest anteriorly
Abd: +BS, obese, soft, nontender, nondistended
Ext: no edema, 2+ DP; pain on palpation of distal feet
bilaterally
Neuro: CN 2-12 intact, moves all extremities
Pertinent Results:
admit labs:
.
ABG: PO2-126* PCO2-70* PH-7.39 TOTAL CO2-44*
.
Chem: GLUCOSE-122* UREA N-42* CREAT-0.6 SODIUM-143 POTASSIUM-4.1
CHLORIDE-96 TOTAL CO2-40* ANION GAP-11 LD(LDH)-240
.
CBC: WBC-16.8* RBC-3.29* HGB-10.4* HCT-31.4* MCV-95 PLT
COUNT-305
NEUTS-83.7* LYMPHS-7.2* MONOS-6.1 EOS-2.8 BASOS-0.2
.
COAGS: PT-12.6 PTT-24.6 INR(PT)-1.1
.
Urine:
[**2168-10-31**] 07:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
CT Chest:
1. No evidence of central upper extremity vascular stenosis in
this limited study.
2. Multifocal air space opacities within the right and left
upper lobes, consistent with pneumonia. Mediastinal
lymphadenopathy is likely reactive.
3. Six millimeter nodular density within the right upper lobe.
3-month followup CT of the chest is recommended to ensure
stability and/or resolution.
4. Enlarged central pulmonary arteries, consistent with
underlying pulmonary arterial hypertension.
.
CT Sinus: Probable retention cysts with incompletely imaged
maxillary sinuses.
.
** Micro:
sputum:
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ 4 S
IMIPENEM-------------- 2 S
MEROPENEM------------- 0.5 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
.
Urine cx neg
.
Blood cx neg
.
Brief Hospital Course:
A/P: 74 yr old female with hx of afib/flutter, tachy-brady
syndrome s/p PCM, CHF, COPD s/p trach presents to [**Hospital Unit Name 153**] with
fever, diagnosed with psuedomonas pneumonia
.
1. Fever: CT of the chest and CXR showed RUL opacity and sputum
from admission grew out pseudomonas, pan-sensitive, except for
ciprofloxacin. Pt was given a dose of zosyn but developed hives
over her back and thighs so Zosyn was discontinued and she was
started on Aztreonam. Urine, blood ans stol cultures were all
negative. Given her chronic NGT a CT of the sinuses was done
and showed no signs of chronic sinusitis. On day of discharge,
pt had been afebrile x 48 hours. A PICC line was placed in
interventional radiology and pt should received 2 weeks of
Aztreonam for her pseudomonas pneumonia.
.
2. CHF: Pt has an EF of 20% on recent echo. Due to some
episodes of hypotension, her BP meds were held and she required
fluid boluses. Therefore, the pt remained positive during her
short hospital stay. On day of discharge, pt was hypertensive
and was tolerating her BP meds. She was started on
spironolactone and her hydralazine was stopped. Her dose of
Lasix may need to be decreased due to the addition of
Spironolactone. She was continued on metoprolol, lasix, ACE-I
and digoxin. Her digoxin level was therapeutic.
.
3. Tachy-brady syndrome s/p PCM: EP interrogated pacer on
admission and found that her [**Hospital Unit Name 4448**] was working properly.
Her device clinic appointment was cancelled as EP has already
since the patient.
.
4. COPD: Pt on chronic vent support. During her hospital stay,
pt was weaned and tolerated a pressure support trial of [**10-12**],
oxygenating well. Her flovent and combivent were continued.
.
5. BP difference: Per family, this is old. Cannot assess
subclavian stenosis on CT due to pacer wires.
.
6. Lung Nodule: On chest CT, pt was found to have a 6mm nodular
density within the right upper lobe that will need to be
followed with another CT in 3 months.
.
7. Anxiety: Pt's seroquel was continued and she was started on
prn seroquel.
.
8. FEN: Speech and swallow evaluated the patient and she passed
the bedside swallow exam. However, to further evaluate for
aspiration risk pt should have a video swallow.
.
8. Access: IR-placed PICC
.
9. Code: full
.
10. Ppx: SQ heparin.
Medications on Admission:
1. Augmentin 500mg po q8 x 7days (last dose on [**11-4**])
2. Bisacodyl 5mg prn
3. Digoxin 125 mcg qd
4. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
5. Acetaminophen 500mg q6 prn
6. Hydralazine 10 mg qid
7. Albuterol-Ipratropium 1-2 puffs q6
8. Furosemide 80mg [**Hospital1 **]
9. Metoprolol Tartrate 50 mg [**Hospital1 **]
10. Fluticasone 2puffs [**Hospital1 **]
11. Liquid Colace
12. Miconazole prn
13. Quetiapine 25 mg qhs
14. Lansoprazole 30 mg [**Hospital1 **]
15. Aspirin 81 mg qd
16. Lisinopril 20 mg qd
17. Heparin (Porcine) 5,000 tid
18. Phenol-Phenolate Sodium 1.4 % Mouthwash q4hrs prn
19. MgOx
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Quetiapine 25 mg Tablet Sig: one-half Tablet PO twice a day
as needed for anxiety.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane Q4H (every 4 hours) as needed.
13. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO BID (2 times a day).
14. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-10**]
Puffs Inhalation Q6H (every 6 hours) as needed.
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold for SBP<110 or P<60.
16. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-10**]
Puffs Inhalation Q4H (every 4 hours).
17. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO Q6H
(every 6 hours) as needed for pruritus for 1 weeks.
18. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
20. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
21. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 11 days.
22. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] TCU - [**Location (un) 701**]
Discharge Diagnosis:
Pseudomonas pneumonia
....
COPD s/p trach
CHF with EF of 20%
tachy-brady syndrome s/p [**Location (un) 4448**]
Discharge Condition:
stable - afebrile and satting well on Pressure Support of 10,
PEEP 5, FiO2 of 40.
Discharge Instructions:
Please return if you experience fever >101.5, worsening
shortness of breath, hypoxia, or any other worrisome symptoms.
Please take all medications as directed. You have been
prescribed an antibiotic for pneumonia.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2168-11-15**]
10:30
.
Please follow-up with Dr. [**Last Name (STitle) 9022**] at [**Telephone/Fax (1) **] within [**1-10**]
weeks.
.
The patient needs a video swallow evaluation within the next
week to determine if the NG tube can be removed. She passed
bedside swallow evaluation.
[**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 1851**]
|
[
"518.89",
"458.9",
"693.0",
"496",
"V15.82",
"427.31",
"482.1",
"V44.0",
"300.00",
"427.81",
"401.9",
"V45.01",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8943, 9019
|
3869, 6196
|
310, 332
|
9174, 9257
|
2409, 3846
|
9623, 10108
|
1827, 1874
|
6848, 8920
|
9040, 9153
|
6222, 6825
|
9281, 9600
|
1889, 2390
|
265, 272
|
360, 1283
|
1305, 1693
|
1710, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,796
| 172,049
|
49158+49159
|
Discharge summary
|
report+report
|
Admission Date: [**2105-3-21**] Discharge Date: [**2104-4-3**]
Date of Birth: [**2044-2-27**] Sex: M
Service: MEDICINE
ADMISSION DIAGNOSIS:
Pneumonia.
DISCHARGE DIAGNOSES:
1. Small bowel obstruction status post exploratory
laparotomy, lysis of adhesions and small bowel resection for
mesenteric ischemia.
2. Aspiration pneumonia.
HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old
male with a history of a small bowel obstruction in [**Month (only) 205**] of
the year [**2104**] who presented on the day of admission with
nausea and vomiting one day. He had two bowel movements the
day prior. He was not passing any flatus. He had no
complaints of any abdominal pain and complaining of some mild
shortness of breath. There was no history of any aspiration.
PAST MEDICAL HISTORY: Significant for sarcoid, gout, history
of compression fractures, history of syncope, chronic renal
insufficiency, orthostatic hypertension, osteoporosis, status
post cholecystectomy in [**2104-8-16**], history of MRSA, line
sepsis.
MEDICATIONS ON ADMISSION: Advil, Allopurinol, Celexa,
potassium, Oxycontin, Prilosec, Temazepam, testosterone,
Vicodin.
ALLERGIES: Colchicine.
PHYSICAL EXAMINATION: On examination he had an NG tube
placed in the Emergency Room with relief of nausea. He was
in no apparent distress. Sclera were anicteric. His mucous
membranes were dry. He had a left cervical lymph node that
was palpable. His chest was decreased throughout. His heart
was regular in rhythm. His abdomen was soft, nontender,
nondistended. He had a large midline scar. His extremities
were without edema. His rectal exam was guaiac negative
without any palpable masses. He was overall moderately
cachectic.
LABORATORIES ON ADMISSION: White count 19,000 with 90%
neutrophils and a hematocrit of 37, platelet count 408. Chem
7 137/4.3, 101/21, 38/1.2 and 106. ALT 25, AST 30, alkaline
phosphatase 30, amylase 54, total bilirubin 0l.4, albumin
3.7, lipase 28. His chest x-ray demonstrated left lower lobe
infiltrate. His KUB demonstrated air fluid levels.
He was admitted to the medical service for a left lower
infiltrate with a question of small bowel obstruction or
ileus. He had an NG tube that was placed, a low wall
resection and was placed on IV fluids and was given morphine
for his complaints of back pain.
HOSPITAL COUSRE: He continued to have moderate NG tube
output that were decreasing. He was passing gas and having a
bowel movement on hospital day one, however, he had an
increasing white count of 24,000. CT scan was ordered,
however, he developed acute respiratory distress and was
started on heparin for presumptive pulmonary embolism. At
that time of the evening he did not get a CT scan. On
hospital day two he continued to complain of some shortness
of breath. He was on subQ heparin. He got a CAT scan that
day that demonstrated dilated loops of small bowel with a
possible transition point. Later in the day he actually was
found minimally responsive and hypoxic with an acidotic with
a gas of 7.0. He was immediately intubated on the floor and
brought to the medical Intensive Care Unit. On that evening
and following into the day he required increasing doses of
pressors and IV fluid. His urine output decreased. His NG
tube outputs were increased as well and with this
deterioration and along with his medical condition along with
his CAT scan findings he was taken to the Operating Room
where a low midline incisions and multiple dilated loops of
small bowel were found along with an area of a closed group
obstruction of a loop of about 15 cm of bowel that was
ischemic. This was resected in the Operating Room and the
patient was reanastomosed primarily. He tolerated the
procedure overall very well.
Of note on the CT scan he had a massive amount of bilateral
basilar infiltrates secondary to aspiration, which he had
prior to his episode requiring intubation. He was brought to
the Surgical Intensive Care Unit and was started on broad
spectrum antibiotics.
1. Neurologically. He was sedated initially with propofol,
Ativan and morphine, which are all off now. He is increasing
mental status. He is awake, alert and he is slightly slow to
respond, but follows all commands.
2. Pulmonary. His cultures have demonstrated MRSA for which
he is on Vanco. He needs to complete a fourteen day course.
He is on day nine of that at this point in time, which is the
16th. He requires chest PT and suctioning for his decreased
ability of cough and he is also receiving Atrovent and
Albuterol nebs.
3. Cardiac. From a cardiac standpoint he has been
remarkably stable with a normal blood pressure. He obviously
does not require any pressors at this time and he is stable.
4. Gastrointestinal. He was started on tube feeds, which he
is on goal at 60. The exact type will be documented in the
page one via a post caloric feeding tube. He is to remain
NPO, but to continue follow up tube feeds until his follow up
appointment, which will also be documented on the page one.
5. Genitourinary. He has been remarkably stable with good
urine output. He was diuresed adequately with intermittent
doses of Lasix. He is not getting a standard dose of Lasix
at this time. His creatinine on the 16th is 0.8, but his BUN
is elevated at 57.
6. Hematologic. His hematocrit have been stable between 31
and 33. They are 33 today. He has been receiving subQ
heparin and Venodyne boots for deep venous thrombosis
prophylaxis.
7. Infectious disease. He is on as mentioned Vancomycin for
a bronchioalveolar lavage and a sputum culture that
demonstrated staph aureus. He did also have a pleural tap on
the right side to demonstrate if there is any infection,
which there has not been. He has also had stool sent off for
C-diff.
8. Endocrine. He is requiring sliding scale regular
insulin. His finger stick in the morning today was 101.
Otherwise his electrolytes have all been stable.
DISCHARGE MEDICATIONS: He is on Vancomycin 1 gram IV q 24
hours, Atrovent MDI four to six puffs q 4 hours prn. He is
on Albuterol four to six puffs MDI q 4 hours prn. He is on
sliding scale regular insulin. Colace 100 mg b.i.d. per
feeding tube. SubQ heparin 5000 units b.i.d., vitamin C 500
mg b.i.d., multi vitamin elixir q day, Reglan 10 mg q.i.d.
via the feeding tube q.i.d. As mentioned he has been getting
intermittent doses of potassium and Lasix, however, none at
this moment in time.
The patient is to follow up in General Surgery Clinic. This
will be documented on the page one. Overall his status is
good. He will be discharged to a rehab facility. Of note he
does need good chest physical therapy in order to maintain
good pulmonary toilet.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Last Name (NamePattern4) 103131**]
MEDQUIST36
D: [**2105-4-3**] 09:57
T: [**2105-4-3**] 09:55
JOB#: [**Job Number 103132**]
Admission Date: [**2105-3-21**] Discharge Date: [**2104-4-3**]
Date of Birth: [**2044-2-27**] Sex: M
Service: MEDICINE
ADMISSION DIAGNOSIS:
Pneumonia.
DISCHARGE DIAGNOSES:
1. Small bowel obstruction status post exploratory
laparotomy, lysis of adhesions and small bowel resection for
mesenteric ischemia.
2. Aspiration pneumonia.
HISTORY OF PRESENT ILLNESS: The patient is a 59 year-old
male with a history of a small bowel obstruction in [**Month (only) 205**] of
the year [**2104**] who presented on the day of admission with
nausea and vomiting one day. He had two bowel movements the
day prior. He was not passing any flatus. He had no
complaints of any abdominal pain and complaining of some mild
shortness of breath. There was no history of any aspiration.
PAST MEDICAL HISTORY: Significant for sarcoid, gout, history
of compression fractures, history of syncope, chronic renal
insufficiency, orthostatic hypertension, osteoporosis, status
post cholecystectomy in [**2104-8-16**], history of MRSA, line
sepsis.
MEDICATIONS ON ADMISSION: Advil, Allopurinol, Celexa,
potassium, Oxycontin, Prilosec, Temazepam, testosterone,
Vicodin.
ALLERGIES: Colchicine.
PHYSICAL EXAMINATION: On examination he had an NG tube
placed in the Emergency Room with relief of nausea. He was
in no apparent distress. Sclera were anicteric. His mucous
membranes were dry. He had a left cervical lymph node that
was palpable. His chest was decreased throughout. His heart
was regular in rhythm. His abdomen was soft, nontender,
nondistended. He had a large midline scar. His extremities
were without edema. His rectal exam was guaiac negative
without any palpable masses. He was overall moderately
cachectic.
LABORATORIES ON ADMISSION: White count 19,000 with 90%
neutrophils and a hematocrit of 37, platelet count 408. Chem
7 137/4.3, 101/21, 38/1.2 and 106. ALT 25, AST 30, alkaline
phosphatase 30, amylase 54, total bilirubin 0l.4, albumin
3.7, lipase 28. His chest x-ray demonstrated left lower lobe
infiltrate. His KUB demonstrated air fluid levels.
He was admitted to the medical service for a left lower
infiltrate with a question of small bowel obstruction or
ileus. He had an NG tube that was placed, a low wall
resection and was placed on IV fluids and was given morphine
for his complaints of back pain.
HOSPITAL COUSRE: He continued to have moderate NG tube
output that were decreasing. He was passing gas and having a
bowel movement on hospital day one, however, he had an
increasing white count of 24,000. CT scan was ordered,
however, he developed acute respiratory distress and was
started on heparin for presumptive pulmonary embolism. At
that time of the evening he did not get a CT scan. On
hospital day two he continued to complain of some shortness
of breath. He was on subQ heparin. He got a CAT scan that
day that demonstrated dilated loops of small bowel with a
possible transition point. Later in the day he actually was
found minimally responsive and hypoxic with an acidotic with
a gas of 7.0. He was immediately intubated on the floor and
brought to the medical Intensive Care Unit. On that evening
and following into the day he required increasing doses of
pressors and IV fluid. His urine output decreased. His NG
tube outputs were increased as well and with this
deterioration and along with his medical condition along with
his CAT scan findings he was taken to the Operating Room
where a low midline incisions and multiple dilated loops of
small bowel were found along with an area of a closed group
obstruction of a loop of about 15 cm of bowel that was
ischemic. This was resected in the Operating Room and the
patient was reanastomosed primarily. He tolerated the
procedure overall very well.
Of note on the CT scan he had a massive amount of bilateral
basilar infiltrates secondary to aspiration, which he had
prior to his episode requiring intubation. He was brought to
the Surgical Intensive Care Unit and was started on broad
spectrum antibiotics.
1. Neurologically. He was sedated initially with propofol,
Ativan and morphine, which are all off now. He is increasing
mental status. He is awake, alert and he is slightly slow to
respond, but follows all commands.
2. Pulmonary. His cultures have demonstrated MRSA for which
he is on Vanco. He needs to complete a fourteen day course.
He is on day nine of that at this point in time, which is the
16th. He requires chest PT and suctioning for his decreased
ability of cough and he is also receiving Atrovent and
Albuterol nebs.
3. Cardiac. From a cardiac standpoint he has been
remarkably stable with a normal blood pressure. He obviously
does not require any pressors at this time and he is stable.
4. Gastrointestinal. He was started on tube feeds, which he
is on goal at 60. The exact type will be documented in the
page one via a post caloric feeding tube. He is to remain
NPO, but to continue follow up tube feeds until his follow up
appointment, which will also be documented on the page one.
5. Genitourinary. He has been remarkably stable with good
urine output. He was diuresed adequately with intermittent
doses of Lasix. He is not getting a standard dose of Lasix
at this time. His creatinine on the 16th is 0.8, but his BUN
is elevated at 57.
6. Hematologic. His hematocrit have been stable between 31
and 33. They are 33 today. He has been receiving subQ
heparin and Venodyne boots for deep venous thrombosis
prophylaxis.
7. Infectious disease. He is on as mentioned Vancomycin for
a bronchioalveolar lavage and a sputum culture that
demonstrated staph aureus. He did also have a pleural tap on
the right side to demonstrate if there is any infection,
which there has not been. He has also had stool sent off for
C-diff.
8. Endocrine. He is requiring sliding scale regular
insulin. His finger stick in the morning today was 101.
Otherwise his electrolytes have all been stable.
DISCHARGE MEDICATIONS: He is on Vancomycin 1 gram IV q 24
hours, Atrovent MDI four to six puffs q 4 hours prn. He is
on Albuterol four to six puffs MDI q 4 hours prn. He is on
sliding scale regular insulin. Colace 100 mg b.i.d. per
feeding tube. SubQ heparin 5000 units b.i.d., vitamin C 500
mg b.i.d., multi vitamin elixir q day, Reglan 10 mg q.i.d.
via the feeding tube q.i.d. As mentioned he has been getting
intermittent doses of potassium and Lasix, however, none at
this moment in time.
The patient is to follow up in General Surgery Clinic. This
will be documented on the page one. Overall his status is
good. He will be discharged to a rehab facility. Of note he
does need good chest physical therapy in order to maintain
good pulmonary toilet.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By:[**Last Name (NamePattern4) 103131**]
MEDQUIST36
D: [**2105-4-3**] 09:57
T: [**2105-4-3**] 09:55
JOB#: [**Job Number 103132**]
rp [**2105-4-3**]
|
[
"507.0",
"V09.0",
"557.0",
"593.9",
"733.00",
"135",
"511.8",
"482.41",
"560.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"38.93",
"96.72",
"96.04",
"96.6",
"34.91",
"45.62",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
7188, 7349
|
12995, 14006
|
8071, 8191
|
8214, 8746
|
7155, 7167
|
7378, 7788
|
8761, 12971
|
7811, 8044
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,772
| 101,642
|
14510
|
Discharge summary
|
report
|
Admission Date: [**2132-8-6**] Discharge Date: [**2132-8-21**]
Date of Birth: [**2062-5-28**] Sex: M
Service:
CHIEF COMPLAINT: Difficulty swallowing x2 days
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old man
with a history of diabetes, hypertension and alcohol abuse,
as well as a recent embolic stroke diagnosed on [**2132-7-19**]. He presented with his initial stroke to [**Hospital3 **]
Hospital. He apparently had multiple small embolic strokes
that left him with a left sided residual hemiparesis. At
that time, he had a CT scan, MRI, cardiac echocardiogram and
Holter monitor. His head CT was significant for an area of
low attenuation at the left head caudate and another area
adjacent to the occipital lobe with no mass effect. His MRI
on [**7-20**] showed a wedge shaped infarct in the medial cortex of
the left occipital lobe and multiple smaller areas extending
from this area anterior into the left occipital lobe and
posterior temporal lobe, also significant for lesions in the
left cerebellar hemisphere, several small punctate lesions in
the brain stem and the right median lower pons and centrally
in the upper pons.
and there was a questionable lesion in the right cerebellar
hemisphere, as well as a possible region in the right
thalamus.
His MRA on [**7-20**] showed stenosis of the right vertebral artery
and abrupt termination of the distal left vertebral artery.
His basilar artery was patent without any significant
stenosis and he had an abnormal appearance of both posterior
cerebral arteries. He had a Holter monitor which showed no
evidence of any abnormal activity. His echocardiogram on
[**7-21**] was a transesophageal echocardiogram which showed his
left atrium was normal size, normal right ventricular and
left ventricular function with mild atheroma of the left
descending aorta and no evidence of a patent foramen ovale
and his tricuspid aortic
valve showed mild thickening. He was eventually discharged
from [**Hospital3 **] Hospital and sent to [**Hospital3 **] Manor for acute
rehabilitation from his multiple infarcts. According to his
primary care physician, [**Name10 (NameIs) **] was doing well in his
rehabilitation until Monday, [**2132-8-4**]. At that time,
he was noted to have significant left residual weakness in
both arms and legs, but he seemed motivated to participate in
rehabilitation and was able to feed himself, as well as
participate in group activities.
According to his primary care physician, [**Name10 (NameIs) **] was an acute
change in his behavior on the Monday prior to admission. He
appeared to be less interested in group activities and to
have a lot more difficulty with feeding himself. He was
observed to take food into his mouth, but then did not seem
to know what to do with it. He had pushed it around, but he
would not swallow it appropriately. He was also observed not
to have any choking with these events. He denied having any
swallowing problems himself when the patient is asked
directly.
REVIEW OF SYSTEMS: On admission, he denies chest pain,
shortness of breath, palpitations, abdominal pain, nausea,
dysuria and diarrhea.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type II
2. Stroke on [**2132-7-19**]
3. Hypertension
4. Coronary artery disease, status post myocardial
infarction at uncertain time in past.
5. Possible history of alcohol abuse
ADMISSION MEDICATIONS:
1. Plavix 75 mg po q day
2. Aspirin 325 mg po q day
3. Colace 100 mg po bid
4. Senokot 2 tablets po q hs
5. Zestril 10 mg po q day
6. Cardizem 90 mg po 4x a day
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: The patient reports a history of heavy
alcohol use in the past. When asked, the patient says he
used to drink about half a bottle of whiskey a day. History
of tobacco use in the past of a half pack per day, however he
has not smoked since his initial stroke on [**2132-7-19**]. He lives
in [**Location 3615**] and has four children in [**State 350**].
FAMILY HISTORY: The patient was unable to answer at that
time.
EXAMINATION ON ADMISSION:
GENERAL: The patient was sleepy, but easily arousable.
VITAL SIGNS: His blood pressure was 173/106. Pulse was 87,
respirations 18.
HEAD, EARS, EYES, NOSE AND THROAT: He was normocephalic,
atraumatic. Oropharynx was clear. Dry mucous membranes.
He had no carotid bruits. Audible breath sounds, but he
would not cooperate with holding his breath.
LUNGS: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm, S1, S2 normal, no murmurs,
rubs or gallops appreciated.
ABDOMEN: Soft, obese, nontender with normoactive bowel
sounds.
EXTREMITIES: He had no edema.
ADMISSION NEUROLOGIC EXAM: Mental status: He was oriented
to person and [**Location (un) 86**], but could not come up with the word
hospital. He said it was [**2093**] and that it was Spring. Asked
how he knew it was Spring and he said because the snow melts
in the Spring. He agreed that he was in the hospital when
asked and when asked if he was in school, he said no. The
patient was moderately attentive, able to name the days of
the weeks forwards and backwards, but unable to get past
[**Month (only) 1096**] on months of the year backwards. He recalled zero
objects at two minutes. He was able to repeat three objects,
however and was able to repeat sentences with mild
dysarthria. His naming was intact to ring, watch, eyeglasses
and pen. He had poor knowledge for current events. He said
that the current president is [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 780**] and when asked
if [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 780**] was still alive, he said probably not.
The patient had no spontaneous verbal output for responding
to questions, without any paresthesias or perseveration. His
sentence length was varied and up to at least five or six
words.
When asked if I was wearing a hat, he appropriately responded
no. He was able to demonstrate brushing his teeth. When
asked to pretend to drink a cup of coffee, he refused. His
writing was very poor. When asked to write today is a sunny
day, he started writing in the middle of the paper and then
quickly ran out of paper on the side of the page and tried to
write on the examiner's hand. When given a piece of paper
with two numbers written on it, he was only to name the
number on the right hand side and ignored the other number.
When asked to draw a clock, he drew a tiny circle on the
right hand side of the page and when asked to draw the
numbers on the face, he drew the 1 and 2 inside the circle
and then proceeded to draw the other numbers off the right
hand side of the paper.
Cranial nerves: His visual acuity was normal, but difficult
to test. He was able to name objects shown to him
appropriately, however when shown a visual acuity card, he
was only able to name the first number and then just appeared
to name numbers randomly. His pupils react normally to
light. His visual fields appeared possibly reduced over the
left hemifield, though again the patient would not cooperate
His optic fundi were normal in appearance. His eye
movements were normal and full. Sensation on his face was
decreased to light touch and pinprick over V1 through V3 on
the left base. He has a left facial droop. His hearing is
intact to bilaterally. He had a palate that
elevated in the midline with a good gag reflex. His
sternocleidomastoid muscles were 5/5 strength bilaterally.
His tongue was midline.
Motor system: The patient had decreased tone in the left
upper extremity and left lower extremity. No adventitious
movements. His drain on the left in his deltoid was one.
Biceps strength was [**4-1**], triceps strength was [**2-2**]. Wrist
flexors and wrist extensors only had 3/5 strength. His
finger flexors and finger extensors had minimal movement.
Iliopsoas on the left was 4/5 strength. His hamstrings were
[**3-4**]. Tibialis anterior was only [**2-2**] and his toe extensors
and toe flexors only had about 2/5 strength. His right upper
extremity and lower extremity had full strength throughout.
Sensory exam was difficult due to poor cooperation, however
the patient had sensation intact to light touch and position
sense in all four extremities. Decreased vibration sense
bilaterally in the lower extremities and pinprick decreased
over the left base and left leg, but not decreased in the
left arm. His reflexes were 2+ and symmetric throughout,
except for plantar responses upgoing in the left and
downgoing in the right. On coordination testing, the patient
was unable to cooperate on left upper extremity because of
weakness, however on his right finger nose finger test he
significantly overshot to the right on every motion. His
gait was not assessed on admission.
ADMISSION LABS AND STUDIES: White count 7.9, hematocrit
39.3, platelets 149. Sodium 135, potassium 3.5, BUN 10,
creatinine 0.8, glucose 204. His urine output was
unremarkable and he had a chest x-ray that showed no evidence
of any infiltrates or effusions. The patient had an MRI on
the night of admission which showed bilateral occipital
infarcts on FLAIR imaging. Diffusion weighted imaging was
unobtained due to problems with the scanner. Also, note was
made of a lesion in the right dome. His MRA was significant
for a hypoplastic left vertebral artery that possibly ended
in pica. His right vertebral artery was noted to be
significantly stenotic, although the basilar artery was
unremarkable.
The patient was admitted to the neurological service.
HISTORY OF HOSPITAL COURSE: The morning after admission, it
was decided to start him on a heparin drip due to the
stenosis in his right vertebral artery as well as the thought
that he may be continuing to throw emboli into his posterior
circulation. He had a angiogram on the [**8-7**] which
again was significant for right vertebral artery stenosis.
He remained stable over the weekend on heparin except for the
fact that he was unable to be propped up in bed at all
because his mental status significantly decreased any time
you sat him up. Due to the nature of his significant
inability to tolerate any position other than lying flat,
decision was made to try and place a stent in his right
vertebral artery.
On [**8-11**], he had a repeat angiogram in the interventional
radiology suite and two stents were placed in his right
vertebral artery. There were no complications of the
procedure and the patient did well.
The patient was briefly transferred out to the floor team on
[**2132-8-14**], but then was noted to have a fever to about 102?????? and
it was noted that in the area of his right wrist where he had
had his arterial line, he now had evidence of an infection
and right hand cellulitis. He had blood cultures, urine
cultures, a chest x-ray and an abdominal film done.
The chest x-ray and his abdominal film were both
unremarkable. His blood cultures ended up growing 4/4
bottles of coagulase positive Staphylococcus aureus bacteria
which were sensitive to oxacillin. The patient was started
on oxacillin for this infection as well as for his
cellulitis. He was also found to have an enterococcal
urinary tract infection which was treated with levofloxacin.
Surgery was also consulted regarding his right wrist
infection, however they recommended antibiotics only with no
debridement. After several days, his fever cleared and his
mental status improved significantly.
Overall, throughout his hospital course, he has had minimal
improvement in his right upper extremity and left lower
extremity weakness with progressive increase in tone and
hyperreflexia throughout his hospital course. He did improve
significantly after his right vertebral stent in the sense
that he is now able to tolerate multiple postural positions
without any worsening of his mental status.
The patient had a swallowing study which he successfully
passed and he will be started on a pureed and honey thickened
diet and advanced if he tolerates it. He is going to
continue on oxacillin, as well as continue Diltiazem for his
blood pressure control.
DISCHARGE DIAGNOSES:
1. Status post multiple embolic strokes in the past month
2. Hypertension
3. Diabetes
4. Coronary artery disease
5. History of prior heavy alcohol use
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Discharge to rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg po q day
2. Zantac 150 mg po bid
3. Oxacillin 2 gm intravenous q6h
4. Diltiazem 90 mg po qid
5. Multivitamin 1 tablet po q day
6. Aspirin 325 mg po q day
7. NPH insulin 5 units subcutaneous breakfast and dinner
time
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-190
Dictated By:[**Last Name (NamePattern1) 1203**]
MEDQUIST36
D: [**2132-8-20**] 08:22
T: [**2132-8-20**] 08:31
JOB#: [**Job Number 42864**]
|
[
"250.00",
"599.0",
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"401.9",
"682.4",
"438.20",
"433.21",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.90",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
12388, 12454
|
4012, 4072
|
12209, 12366
|
12477, 12950
|
9659, 12188
|
3409, 3622
|
3040, 3158
|
148, 179
|
208, 3020
|
6765, 9641
|
4086, 4679
|
4713, 6748
|
4697, 4697
|
3180, 3386
|
3639, 3995
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,505
| 159,479
|
17139
|
Discharge summary
|
report
|
Admission Date: [**2113-6-14**] Discharge Date: [**2113-6-19**]
Date of Birth: [**2053-1-31**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 61-year-old woman with
no significant past medical history who presented to an
outside hospital on [**2113-6-10**] with 8/10 abdominal pain and
nausea and vomiting. A right upper quadrant ultrasound at
that time showed cholelithiasis and sludge, and the patient
had subsequent cholecystectomy with lysis of adhesions on
[**2113-6-12**].
The patient had a fever to 102.8 postoperatively and elevated
LFTs with an AST of 170, ALT 204, alkaline phosphatase 134,
and right upper quadrant pain. A MRCP was negative (no
ductal dilatation or filling defects). She was transferred
to [**Hospital1 69**] for an ERCP on
[**2113-6-14**], however, before the procedure could be completed,
while she was lying on the table, the patient became hypoxic.
Apparently, a periampullary diverticulum was visualized at
that time with limited views of the pancreatic duct that
appeared normal.
The patient was sent to the MICU and found to be in pulmonary
edema that was resolved with diuresis. The patient stated
that her severe shortness of breath while on ERCP had started
more mildly even before the transfer to [**Hospital1 190**]. The patient had never before had chest pain,
shortness of breath, orthopnea, or PND. She said that her
symptoms were relieved with diuresis. In the MICU, she ruled
out for myocardial infarction by enzymes and a transthoracic
echocardiogram was normal, ejection fraction equals 60-70%
and normal P.A. systolic pressures. The patient was
transferred to the [**Company 191**] Medicine Service on [**2113-6-15**] for
subsequent ERCP.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Status post cholecystectomy ([**2113-6-12**]).
ALLERGIES: Penicillin and Bactrim.
MEDICATIONS: None.
SOCIAL HISTORY: Lives at home alone. Prior smoker two packs
per day, quit 23 years ago. Drinks two glasses of alcohol
per day.
PHYSICAL EXAMINATION: Temperature is 100.8, [**Known lastname **] pressure
124/70, heart rate 81, respiratory rate 18, and O2 saturation
is 93% on room air. In general, the patient is in no acute
distress, appears comfortable. Lungs: Few bibasilar
crackles, otherwise clear to auscultation bilaterally.
Heart: Regular, rate, and rhythm, normal S1, S2, no murmurs,
rubs, or gallops appreciated. Abdomen is soft, nontender,
nondistended, however, slight tenderness in the right
epigastric region. Extremities: No edema, warm bilaterally.
LABORATORIES: ALT of 180, AST of 85, alkaline phosphatase
200. CKs: 46, 38, and 30. Iron 21, TIBC 224, TSH 0.57,
ferritin 724, TRF 172. T bilirubin 3.3 and downtrending,
amylase 33, lipase 27.
The patient was admitted to the [**Company 191**] Medicine Service. She
remained afebrile, however, had low-grade fevers of 99.0 and
100 throughout her hospital stay. The patient still had a
slightly elevated white count of about 17. The patient was
continued on antibiotics, Levaquin and Flagyl throughout the
hospital stay. The Flagyl was discontinued on the last day
and the Levaquin was continued for three more days on the
patient's discharge. The patient had no evidence of
pneumonia per chest x-ray, no cough, and no sputum. The
patient's urinalysis was negative, and the patient had no
diarrhea, no nausea, and no vomiting, and felt well.
The ERCP was performed on [**6-16**], which revealed normal
esophagus, normal stomach, normal duodenum, a single
nonbleeding periampullary diverticulum with large opening was
found on the rim of the major papilla. Cannulation of the
biliary and pancreatic ducts was successful and deep with a
sphincter tone using a freehand technique. The common bile
duct, common hepatic duct, right and left hepatic ducts, and
biliary radicals were filled with contrast and well
visualized. The course and caliber of the structures were
normal with no evidence of extrinsic compression, no ductal
abnormalities, and no filling defects. A stent was
successfully placed in the common bile duct. Following stent
placement, there was passage of sludge from the common bile
duct.
The patient did well postprocedure over the weekend and
through Monday. The patient had a stress MIBI on [**2113-6-19**].
The preliminary report: The stress portion was normal with
no anginal pain, no electrocardiogram changes, and 7.5
minutes of exercise per standard [**Doctor First Name **] protocol. The MIBI
portion of the test was also normal showing no perfusion
defects and an ejection fraction of about 83%. A repeat
chest x-ray was also normal with almost entire resolution of
the bilateral pleural effusions which has been present
following the first ERCP attempt.
The patient was discharged in good condition with followup to
her primary care physician as well as Dr. [**Last Name (STitle) **] on
[**2113-6-19**].
DISCHARGE MEDICATIONS: Levaquin 500 mg q day for three days.
FOLLOW-UP APPOINTMENTS:
1. Dr. [**First Name (STitle) **] in [**2-9**] weeks.
2. Dr. [**Last Name (STitle) **] on [**7-18**] at 10:30 am for removal of the
stent.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ADF
Dictated By:[**Last Name (NamePattern1) 10034**]
MEDQUIST36
D: [**2113-6-19**] 17:04
T: [**2113-6-22**] 07:04
JOB#: [**Job Number 48119**]
|
[
"428.0",
"574.50",
"577.0",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.87",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
4941, 4980
|
5004, 5373
|
2043, 4917
|
156, 1722
|
1744, 1889
|
1906, 2020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,605
| 109,285
|
54393+59602
|
Discharge summary
|
report+addendum
|
Admission Date: [**2138-3-17**] Discharge Date: [**2138-3-22**]
Date of Birth: [**2075-2-22**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension, fever
Major Surgical or Invasive Procedure:
Hemodialysis, placement of a dialysis catheter
History of Present Illness:
Mr. [**Known lastname 32034**] is a 63 yo M s/p cadaveric renal transplant [**3-15**]
polycystic kidney disease on tacrolimus and prednisone,
metastatic prostate cancer, and MGUS who presents with fevers
from his rehabilitation facility. Of note, he had been recently
hospitalized at [**Hospital1 18**] [**Date range (1) 111347**] for shoulder and arm pains. He
developed leukocytosis and loose stools during this
hospitalization for which he was treated with flagyl empirically
for two weeks ending on [**3-8**]. Per his rehab records, PO
vancomycin was restarted on [**3-10**]. At rehab, stool had been C
diff+ as recently as 1/30 per the records available to us.
Per his wife, he developed a fever to 101F the evening prior to
admission, without any associated chills or sweats. He also
complained of left thigh pains.
Review of systems is otherwise negative for headache, vision
changes, neck stiffness, cough, chest or abdominal pain, rash,
discharge or redness from his urostomy site. He has had loose
stools, nonwatery, without any gross bleeding in ~2 weeks.
In the ED, vitals were T 98.5 P 120 BP 86/54 RR 16 O2 96%. The
sepsis protocol was initiated and a central line was placed.
Patient initially had a CVP of 2 cm, with good response to IVF
(~2L but total amount not clear from transfer notes). He
received solumedrol and dexamethasone, as well as zosyn 4.5g,
vancomycin 1g, and flagyl 500mg. He was also started on
neosynephrine for additional blood pressure support.
Past Medical History:
Polycystic kidney disease s/p cadaveric transplant x2 [**2118**]/[**2131**]
Metastatic prostate cancer (mets to spine) on Lupron
Chronic LE edema
SCC skin
HIT
MGUS
Hx c. difficile
RUE cellulitis
UGIB [**3-15**] gastritis
Gout
Social History:
Married, admitted from [**Hospital3 **]
Family History:
noncontributory
Physical Exam:
General chronically ill appearing, no acute distress
HEENT sclera white conjunctiva pink, L eye a little swollen with
crusting
Neck supple, LIJ in place
Pulm lungs clear bilaterally
CV regular rate S1 S2 II/VI systolic murmur
Abd soft +bowel sounds well healed scar RLQ mild discomfort to
palpation RLQ, urostomy with pink stoma no exudate or erythema
Extrem 2+ pitting edema bilateral LE with faint erythema of skin
bilaterally, patient says this is a chronic issue for him. range
of motion of LE bilaterally limited by discomfort. skin bruised,
tophi present
Neuro alert and oriented x3, moving all extremities
Pertinent Results:
[**2138-3-17**] 12:15PM BLOOD WBC-7.7 RBC-2.80*# Hgb-7.4*# Hct-24.8*#
MCV-88 MCH-26.5* MCHC-30.0* RDW-16.7* Plt Ct-169
[**2138-3-21**] 04:37AM BLOOD WBC-5.1 RBC-3.26* Hgb-8.5* Hct-27.8*
MCV-85 MCH-26.1* MCHC-30.6* RDW-16.3* Plt Ct-233
[**2138-3-17**] 12:15PM BLOOD PT-16.8* PTT-40.3* INR(PT)-1.5*
[**2138-3-18**] 01:55PM BLOOD PT-13.9* PTT-32.0 INR(PT)-1.2*
[**2138-3-17**] 07:46PM BLOOD Fibrino-399
[**2138-3-17**] 12:15PM BLOOD Glucose-141* UreaN-81* Creat-3.2* Na-146*
K-3.7 Cl-122* HCO3-10* AnGap-18
[**2138-3-20**] 04:52AM BLOOD Glucose-152* UreaN-113* Creat-5.2* Na-138
K-5.2* Cl-109* HCO3-13* AnGap-21*
[**2138-3-21**] 04:37AM BLOOD Glucose-173* UreaN-87* Creat-4.4* Na-143
K-4.3 Cl-111* HCO3-19* AnGap-17
[**2138-3-17**] 01:20PM BLOOD ALT-5 AST-10 CK(CPK)-12* AlkPhos-64
TotBili-0.3
[**2138-3-17**] 07:46PM BLOOD CK(CPK)-17* Amylase-45
[**2138-3-18**] 05:42AM BLOOD CK(CPK)-11*
[**2138-3-18**] 01:56PM BLOOD CK(CPK)-10*
[**2138-3-20**] 04:38PM BLOOD proBNP-[**Numeric Identifier **]*
[**2138-3-17**] 01:20PM BLOOD CK-MB-3 cTropnT-0.47*
[**2138-3-17**] 07:46PM BLOOD CK-MB-3 cTropnT-0.42*
[**2138-3-18**] 05:42AM BLOOD CK-MB-4 cTropnT-0.35*
[**2138-3-18**] 01:56PM BLOOD CK-MB-4 cTropnT-0.33*
[**2138-3-17**] 12:15PM BLOOD Calcium-5.8* Phos-3.0 Mg-1.2*
[**2138-3-21**] 04:37AM BLOOD Calcium-8.1* Phos-5.5* Mg-1.9
[**2138-3-17**] 01:20PM BLOOD Cortsol-20.9*
[**2138-3-21**] 04:37AM BLOOD Vanco-26.2*
[**2138-3-20**] 04:52AM BLOOD FK506-5.3
[**2138-3-17**] 12:27PM BLOOD Glucose-135* Lactate-1.2 Na-137 K-3.5
Cl-124* calHCO3-10*
[**2138-3-17**] 04:40PM BLOOD Lactate-1.0
CT Abd/Pelvis/Thigh 2/4/8:
1. Interval development of bilateral pleural effusions, left
greater than right, compared to the previous study of [**9-13**]. Extensive new subcutaneous stranding and fluid. While the
majority of this could represent anasarca, there is a more focal
area of soft tissue density in the medial right thigh (not fully
evaluated given the lack of intravenous contrast), which most
likely represents hematoma, although a metastatic focus or an
area of infection cannot be entirely excluded.
3. Diverticulosis without diverticulitis.
CXR 2/4/8:
1. Left IJ terminates at the origin of the SVC.
2. Moderate congestive heart failure.
Renal Ultrasound 2/5/8:
Transplant kidney in the left lower quadrant shows normal
echogenicity and vascularity. Size of the left transplant kidney
is 10.3 cm, grossly unchanged. There is no hydronephrosis,
calculus, or perinephric fluid collection. Doppler and spectral
analysis shows normal vascularity and waveform, with resistive
indices of 0.7, 0.6 and 0.6, within the range of normal, in the
upper, mid, and lower poles.
TTE [**2138-3-18**]:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with akinesis of the basal inferior wall and hypokinesis of the
more distal segments. There is mild hypokinesis of the remaining
segments (LVEF = 40%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. There is
moderate aortic valve stenosis (area 1.0cm2). Mild to moderate
([**2-12**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. There
is very mild mitral regurgitation. The estimated pulmonary
artery systolic pressure is high normal. There is a very small
anterior pericardial effusion.
CXR [**2138-3-20**]:
Worsening of pulmonary edema and bilateral pleural effusions
with overall distention in mediastinal vasculature consistent
with volume overload.
Brief Hospital Course:
1. Hypotension/Fever
Initially received broad spectrum antibiotics, stress dose
steriods and aggressive fluid rehydration. Although he required
pressors on admission, he was weaned off after less than 24
hours. Given his recent history of C diff and urine cultures
positive for pseudomonas, he was treated with vancomycin, zosyn
and flagyl empirically. There was no obvious source for
infection; blood cultures as well as PICC line cultures were
negative. During the course of his hospitalization, he devloped
worsening pulmonary edema with anuria, making it difficult to
support his blood pressure with IV fluids.
2. Acute on Chronic Renal Failure
Unclear etiology for acute worsening, perhaps secondary to
volume loss from recent C.diff, possibly secondary to
pseudomonal UTI, though per renal there is possibilty of chronic
pseudomonal colonization of patient's urine. He developed
anuria and was dialyzed by renal. After initiating dialysis,
the patient expressed his wish not to be put on dialysis. He
and his wife, who is his health care proxy, agreed to change
goals of care to make him CMO so that he could go home with
hospice.
3. Pulmonary Edema
Likely multifactorial causes including aggressive fluid
replacement, worsening heart failure, acute renal failure and
possible pseudomonal UTI. Echo demonstrated new wall motion
abnormality; however, upon review of the Echo with cardiology,
the feeling was that the basal wall akinesis was in fact present
on prior TTE. Cardiology was consulted and recommended PA
catheter placement to ellucidate etiology, catheter was not
placed due to comorbidities and change in goals of care.
4. ESRD s/p cadaveric renal transplant
Treated with tacrolimus and prednisone.
5. Metastatic prostate cancer.
Received Lupron
Patient was discharged on [**2138-3-22**] to go home with hospice. He
was given ativan and morphine for symptomatic control.
Medications on Admission:
Tacrolimus 2mg PO BID
Prednisone 10mg PO daily
Vancomycin 250mg PO QID
Lasix 100mg PO BID
Humalog insulin SS
Ferrous sulfate 300mg PO daily
Prevacid 30mg PO Daily
Hexavitamin
Fluoxetine 30mg PO daily
Allopurinol 100mg PO BID
Neurontin 100mg PO QHS
Epogen MWF
Dulcolax, mylanta, tylenol prn
Discharge Medications:
1. Lorazepam 2 mg/mL Concentrate Sig: [**2-12**] ml PO Q4H (every 4
hours) as needed.
Disp:*50 ml* Refills:*1*
2. Morphine Concentrate 10 mg/0.5 mL Solution Sig: 0.5-1 ml PO
every 4-6 hours.
Disp:*25 ml* Refills:*1*
3. Acetaminophen 650 mg Suppository Sig: One (1) Rectal every
6-8 hours.
Disp:*20 Supp* Refills:*2*
4. home oxygen
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] Hospice [**Location (un) 270**] East
Discharge Diagnosis:
End Stage Renal Disease
Acute Renal Failure
Heart Failure
Prostate Cancer-Metastatic
Discharge Condition:
The patient was discharged hemodynamically stable, afebrile and
with appropriate follow up.
Discharge Instructions:
You were admitted to the hospital with fever and low blood
pressure. You were treated for a presumed infection. You were
found to have a urinary tract infection which was treated. You
also required dialysis because of your end stage renal disease.
After discussion with you and your wife, it was decided to
pursue comfort measures only and you were discharged with home
hospice.
Please take all medications as prescribed.
Please call your PCP or your nephrologist if you have any
questions.
Followup Instructions:
Call if needed.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2138-3-22**] Name: [**Known lastname 18278**],[**Known firstname 33**] G Unit No: [**Numeric Identifier 18279**]
Admission Date: [**2138-3-17**] Discharge Date: [**2138-3-22**]
Date of Birth: [**2075-2-22**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
Please note the following clarifications of the [**Hospital 1325**]
hospital course.
# Septic Shock: Given that the patient presented with fevers
and hypotension, he clinically had evidence of septic shock.
His presentation was felt to be due to either UTI or C diff
infection, although it was uncertain at the time of discharge
whether an infection had truly been responsible for his clinical
picture.
# Acute Systolic CHF:
Patient was noted to have depressed EF, new as compared with
Echo from [**2137**]. His heart failure may have contributed to his
pulmonary edema.
# Pressure Ulcers:
Patient had stage 2 and stage 3 decubitis ulcers on his coccyx,
right elbow, and heel. These were treated with wound care, a
kinair bed, and frequent repositioning.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice [**Location (un) 18280**] East
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**2138-4-4**]
|
[
"041.7",
"198.5",
"428.0",
"599.0",
"707.03",
"038.9",
"585.6",
"584.9",
"707.01",
"E878.0",
"996.81",
"428.21",
"276.2",
"185",
"424.1",
"008.45",
"276.51",
"V44.6",
"275.41",
"403.91",
"995.92",
"E849.9",
"785.52",
"707.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
11464, 11719
|
6690, 8594
|
301, 350
|
9505, 9598
|
2852, 6667
|
10139, 11441
|
2186, 2204
|
8934, 9268
|
9398, 9484
|
8620, 8911
|
9622, 10116
|
2219, 2833
|
243, 263
|
378, 1864
|
1886, 2113
|
2129, 2170
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,112
| 121,197
|
11020
|
Discharge summary
|
report
|
Admission Date: [**2105-1-10**] Discharge Date: [**2105-1-16**]
Date of Birth: [**2027-8-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
CC:[**CC Contact Info 35687**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 yo F discharged from the hospital [**1-9**] (yesterday) after
prolonged stay. Pt had initially presented on [**12-8**] for R iliac
bleeding after removal of R hip infected hardware on [**12-8**],
admitted to vascular service. Her iliac vein was packed to stop
bleeding. Her course was complicated by hypotension requiring
pressors, rapid AF started on amiodarone, Gram neg bacteremia
(serratia and enterobacter) as well as MSSA wound infection. In
addition, she had VT requiring electrical cardioversion,
intubation. She was treated with broad spectrum antibiotics,
(2wks of vanco initially, then restarted on [**1-2**] for another
planned 2 wks in setting of fever, increased WBC) as well as
(2wks of meropenem, then followed by another 1 week of meropenem
from [**1-2**] to [**1-9**], which was discontinued just prior to
discharge given no evidence of further gram negative infection).
Her stay was notable for attempts at diuresis, complicated by
hypotension. She was difficult to weane off mechanical
ventilation as contributed to by a pneumonia (tx with 2 wk
course of vanco), pulmonary edema c large b/l pleural effusions,
myopathy. She had trach/PEG placed during the admission.
Pt was noted to be agitated last night at rehab, received ativan
and this morning was noted to be unresposive, hypoxemic with O2
sats in 70's, hypotensive to 70's/palp. Pt received 2 L NS en
route and in ED, initial vitals 98.8, HR 95, BP 86/62, 100% on
AC ventilation. She was started on levophed, received
vancomycin and ceftazidime. In addition, she was noted to have
? ST depressions in V4-V6, given ASA 300 PR. Cardiac enzymes
with nl CK, troponin 0.14. Notably she had cardiac enzymes leak
to 0.18 during her recent admission.
On arrival to MICU, pt arousable to painful stimuli, but unable
to provide further history.
Past Medical History:
Hyperlipidemia
CHF (EF 55%)
Gout
Anemia
Afib s/p cardioversion
Cardiomyopathy
L hip fracture [**2103-6-10**]
septic L shoulder
Asthma
Social History:
recent hospitalization for over a month, pt has sister and two
nieces who are involved in her care, nieces are HCPs.
Family History:
noncontributory
Physical Exam:
Vitals: Temp 98.0, HR 91 (AFib), BP 101/57, RR 16, O2 sat 100%
Vent: 400/16/0.6/5
Gen: elderly female, ventilated through trach, responsive to
painful stimuli such as suctioning, tracks
HEENT: head symmetric and atraumatic, PERRL, anicteric sclera,
OP clear
Neck: RIJ in place, no surrounding erythema or discharge
Cardiac: irregular, nl S1 and S2, II/VI SEM at apex
Lungs: decreased BS at bases, + crackles b/l, no wheezes
Abd: soft, + BS, NTND, no HSM, no rebound or guarding
Ext: cool, no pitting edema, palpable pedal pulses.
Neuro: moves all extremities, non-focal, minimally arousable
Pertinent Results:
EKG: Afib at 93, nl axis, no Q waves, ? ST depressions and T
wave inversions V4-V6, although poor baseline. Changes resolved
with resolution of hypotension
.
CXR [**1-10**]:
1. Large bilateral pleural effusions and bilateral lower lobe
consolidations which could represent atelectasis, however a
superimposed infection cannot be completely excluded.
2. Redemonstration of large amount of pneumoperitoneum.
.
CTA [**1-10**]:
1. No evidence of pulmonary embolism.
2. Stable large bilateral pleural effusion with worsening
bilateral patchy consolidations and areas of ground-glass
opacity in the aerated portions of both lungs. While this may
represent worsening pulmonary edema, superimposed infection is
not excluded.
.
CT head [**1-10**]: No intracranial hemorrhage or mass effect. Note
that MRI with diffusion-weighted imaging is more sensitive for
the detection of infarction.
[**2105-1-9**] 03:06AM BLOOD WBC-12.2* RBC-3.70* Hgb-10.9* Hct-33.2*
MCV-90 MCH-29.4 MCHC-32.8 RDW-17.6* Plt Ct-353
[**2105-1-10**] 08:40AM BLOOD WBC-24.7*# RBC-3.61* Hgb-11.0* Hct-33.3*
MCV-93 MCH-30.4 MCHC-32.9 RDW-17.0* Plt Ct-306
[**2105-1-11**] 04:06AM BLOOD WBC-12.3*# RBC-3.49* Hgb-10.5* Hct-32.0*
MCV-92 MCH-30.0 MCHC-32.8 RDW-17.6* Plt Ct-388
[**2105-1-16**] 03:59AM BLOOD WBC-13.6* RBC-3.43* Hgb-10.5* Hct-31.0*
MCV-90 MCH-30.7 MCHC-34.0 RDW-18.1* Plt Ct-376
[**2105-1-10**] 08:40AM BLOOD Neuts-93* Bands-0 Lymphs-1* Monos-3 Eos-2
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2105-1-11**] 04:06AM BLOOD Neuts-84.0* Lymphs-8.4* Monos-3.4 Eos-3.7
Baso-0.5
[**2105-1-9**] 03:06AM BLOOD PT-16.1* PTT-31.5 INR(PT)-1.5*
[**2105-1-16**] 03:59AM BLOOD PT-25.8* PTT-33.2 INR(PT)-2.6*
[**2105-1-9**] 03:06AM BLOOD Glucose-109* UreaN-19 Creat-0.5 Na-137
K-4.1 Cl-101 HCO3-30 AnGap-10
[**2105-1-16**] 03:59AM BLOOD Glucose-104 UreaN-16 Creat-0.4 Na-138
K-4.1 Cl-105 HCO3-29 AnGap-8
[**2105-1-10**] 03:40PM BLOOD ALT-33 AST-47* LD(LDH)-251* CK(CPK)-21*
AlkPhos-236* Amylase-57 TotBili-0.1
[**2105-1-10**] 03:40PM BLOOD Lipase-29
[**2105-1-10**] 08:40AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2105-1-10**] 03:40PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2105-1-9**] 03:06AM BLOOD Calcium-9.1 Phos-3.0 Mg-1.9
[**2105-1-16**] 03:59AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.9
[**2105-1-9**] 03:06AM BLOOD Vanco-24.6*
[**2105-1-15**] 08:30PM BLOOD Vanco-32.2*
[**2105-1-9**] 03:06AM BLOOD Digoxin-0.6*
[**2105-1-10**] 09:34AM BLOOD Lactate-1.4
[**2105-1-10**] 08:40AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2105-1-10**] 08:40AM URINE RBC->50 WBC-[**7-19**]* Bacteri-FEW Yeast-NONE
Epi-[**4-13**] TransE-0-2
Urine cx [**1-10**]: negative
Blood cx's [**1-10**]: negative x2
C. diff: neg x1
Brief Hospital Course:
A/P: 77 year old female with hx CHF, Afib, anemia, s/p hip
fracture, seeding of hardware from septic shoulder s/p removal,
recently discharged presents with MS changes, hypoxia and
hypotension.
.
# Hypotension: pt initially hypotensive to 70's, improved with
about 7 L of IVF NS. In addition, she required levophed, and
vasopressin. The patient did not tolerate turning vasopressing
off, so dobutamine was started after SvO2 was noted to be 68.
The patient responded well to dobutamine, BP stabilized and she
started autodiuresing. The dobutamine was discontinued on [**1-14**]
and she has been autodiuresing well. Her initial infectious
work-up revealed a positive urinalysis, however urine culture
was negative. Her WBC count was initially elevated to 24.7 with
L shift (up from about 14 prior to discharge), however was 13
the following day. In addition her chest CT was suggestive of a
new infiltrate in addition to her pleural effusion. She was
continued on vancomycin, restarted on meropenem and ceftazidime
was added given recent prolonged exposure to meropenem.
Ceftazidime was discontinued after several days after no
evidence of gram negative infection. Meropenem and vacomycin
were discontinued after 7 day course, cultures remained
negative, she remained afebrile and stable WBC count.
.
#Cardiac
*Atrial fibrillation - appears to be fairly well controlled,
unlikely to be major cause of hypotension. Continued amiodarone
and digoxin. Initially on coumadin 6mg but her INR was
supratherapeutic up to 6.2 and coumadin was held. Once back in
the normal range restarted at a dose of 2mg daily.
.
*CAD - Her elevated cardiac enzymes and lateral EKG changes
raise possibility of a cardiac cause, however pt had similar
findings during last stay, believed to be [**3-13**] demand. Cardiac
enzymes stable. Continued ASA, statin. BB, ACEI were held off
given hypotension. Should be restarted as tolerated.
.
* CHF, MR - Pt has a hx of severe MR. Did well with dobutamine
as above. Her after load reduction with ACEI was held off
initially given hypotension and should be restarted as
tolerated. She is volume overloaded at time of discharge and
will need continued diuresis.
.
# Respiratory Failure, hypoxemic: pt has been weaning off trach,
recently on pressure support. Initially placed on AC
ventilation, and once she diuresed changed to PS trials, which
she tolerated for several hours. Seen by Speech and swallow for
PMV, which she tolerated well for short periods of time, and
this should be attempted further at rehab as tolerated.
# FEN: Tube feeds
# Code: DNR as discussed with family recently
# Comm: Sister [**Name (NI) 18404**] [**Name (NI) **] [**Telephone/Fax (3) 35686**], PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
two daughters (pts niece - [**Name (NI) **] and [**Name (NI) **]) are HCP'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] lives
in the area, [**Doctor First Name **] lives in MD.
Medications on Admission:
Levothyroxine 75 mcg DAILY
Atorvastatin 20 mg DAILY
Amiodarone 200mg DAILY
Digoxin 125 mcg DAILY
Heparin 5,000 units SC
Warfarin 5 mg HS
Lansoprazole 30mg daily
Clonazepam 0.5 mg TID
Colace
Senna
Ipratropium
Discharge Medications:
1. Levothyroxine 75 mcg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet [**Doctor First Name **]: Two (2) Tablet PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY
(Daily).
4. Digoxin 125 mcg Tablet [**Doctor First Name **]: One (1) Tablet PO DAILY (Daily).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
7. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
8. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
9. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
11. Insulin Lispro (Human) 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Subcutaneous ASDIR (AS DIRECTED): Insulin Sliding Scale.
12. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
13. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
1. respiratory failure post tracheostomy
2. Hypotension
3. Sepsis
4. atrial fibrillation
5. CHF
6. Severe Mitral Valve Regurgitation.
6. MRSA pneumonia
1. respiratory failure post tracheostomy
2. Hypotension
3. Sepsis
4. atrial fibrillation
5. CHF
6. Severe Mitral Valve Regurgitation.
6. MRSA pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Please return to ED or call your doctor if you have chest pain,
shortness of breath, cough, dizziness, tenderness in your
joints, fever, hypotension or if there are any concerns at all
Followup Instructions:
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **],[**First Name3 (LF) 20**] B. [**Telephone/Fax (1) 3259**] within
2 weeks of your discharge
2. Please follow up with your orthopedic surgeon
Completed by:[**2105-1-16**]
|
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20,421
| 168,753
|
54010
|
Discharge summary
|
report
|
Admission Date: [**2171-10-7**] Discharge Date: [**2171-10-21**]
Date of Birth: [**2091-3-9**] Sex: M
Service: MEDICINE
Allergies:
Univasc / Celexa / Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
brain tumor
Major Surgical or Invasive Procedure:
[**2171-10-16**]: Brain biopsy
Tracheostomy Placement
History of Present Illness:
Mr. [**Known lastname **] is an 80yo gentleman with h/o low grade brain
tumor, transfusion dependent MDS, CAD, and AFib not on coumadin
who is transferred to [**Hospital1 18**] in the setting of hemorrhagic stroke
at the site of his brain tumor.
.
The patient initially presented [**2171-9-12**] to [**Hospital 794**] Hospital in
[**Hospital1 789**] because of concern for aspiration at his rehab
facility. On admission, his exam was notable for left sided
weakness secondary to recent stroke. A PEG was placed and he was
being treated for aspiration/nosocomial PNA with vanc and zosyn.
During his course, he had a brief MICU stay in the setting of
hypoxia, but was soon after sent back to the floor. He continued
to require pRBCs and platelet transfusions on a daily basis for
his MDS.
.
On [**9-25**], he was sent back to the MICU in setting of recurrent
hypoxia and altered mental status. He was intubated for hypoxic
respiratory failure felt to be due to increased secretions in
the setting of persistent MRSA pneumonia. CT Head was obtained
for further evaluation of mental status changes in the setting
of thrombocytopenia. CT revealed interval growth of tumor and
new R hemorrhagic lesion. It was unclear whether the bleed was
acute or subacute. Neurosurgery did not feel that the patient
was a surgical candidate, and the team pursued medical
management with mannitol, dilantin, and platelet transfusions.
His mental status improved and he was able to follow commands.
.
Because of concern for possible C diff as well as persistently
positive sputum cultures, the patient was continued on vanc PO,
vanc IV, and zosyn. Apparently, he must have been hypotensive at
some point as there is a note that states pressors were removed.
Zosyn was changed to cefepime because of concern that zosyn may
be contributing to thrombocytopenia.
.
The neurosurgery team at RI did not feel he was an operative
candidate, and the patient is being transferred to [**Hospital1 18**] for
neurosurgical evaluation for possible evacuation of hematoma.
.
Past Medical History:
Brain tumor: MR c/w low grade glioma; has been followed since
[**8-/2169**] without biopsy
Hemorrhagic stroke [**8-/2171**] at site of biopsy
CAD s/p CABG x 4 (LIMA->LAD, SVG->OM1, OM2, PDA) [**2168**].
HTN
AFib no longer on coumadin (has been on amiodarone)
Dyslipidemia
Myelodysplastic Syndrome: BM Bx [**8-1**] MDS vs CML, followed by
[**Month/Year (2) 2539**]
Prostate Cancer s/p radictal prostatectomy and simultaneous
penile implant [**2155**]
Hyperparathyroidism
h/o DVT, no CTA done b/c of CKD--treated w/ IVC filter and
lovenox, filter has since been removed. Was on warfarin until
hemorrhagic stroke.
Gout
Subclinical Hypothyroidism
Allergic Rhinitis
Reflux Pharyngitis
Colonic Polyps
? Essential Tremor
Anhedonia, attempted celexa but became lightheaded
Low back pain, ? spinal stenosis
Peripheral neuropathy
h/o Fen/Phen use
.
Social History:
Soc Hx: Married. Has been in nursing home.
Family History:
None
Physical Exam:
100.1 128->100 (sinus) 138/69 20 98% on AC 100% 500 20 +5
Awake, making eye contact, intubated and lying in bed with left
arm and leg extended.
Pupils equally round and reactive. Left eye ptosis and left
sided facial droop.
MMM, ET tube.
R PICC in place.
S1, S2, regular and borderline tachycardic, no murmur
appreciated.
Lungs mildly rhonchorous with good air movement.
Abd: PEG in place, +BS, soft and not tender.
Ext: some edema of LUE, but no LE edema. Good peripheral pulses.
Stage 2 sacral ulcers.
Right arms and leg have intact strength but left arm and leg are
0/5.
.
Pertinent Results:
[**2171-10-7**] 10:06PM PT-14.3* PTT-27.2 INR(PT)-1.2*
[**2171-10-7**] 10:06PM PLT SMR-VERY LOW PLT COUNT-43*
[**2171-10-7**] 10:06PM WBC-25.4* RBC-3.26*# HGB-10.1*# HCT-28.9*#
MCV-89 MCH-31.0 MCHC-34.9 RDW-15.2
[**2171-10-7**] 10:06PM CALCIUM-10.7* PHOSPHATE-3.8 MAGNESIUM-2.2
[**2171-10-7**] 10:39PM LACTATE-1.4
[**2171-10-12**] 06:10PM BLOOD WBC-18.9* RBC-2.61* Hgb-7.9* Hct-23.2*
MCV-89 MCH-30.2 MCHC-33.8 RDW-14.2 Plt Ct-57*
[**2171-10-16**] 03:47AM BLOOD WBC-17.8* RBC-2.88* Hgb-8.5* Hct-25.7*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.6 Plt Ct-43*
[**2171-10-14**] 03:45AM BLOOD WBC-20.1* RBC-2.69* Hgb-8.2* Hct-23.4*
MCV-87 MCH-30.5 MCHC-35.0 RDW-15.1 Plt Ct-40*
[**2171-10-20**] 03:10PM BLOOD WBC-16.8* RBC-2.59* Hgb-7.9* Hct-23.3*
MCV-90 MCH-30.6 MCHC-34.0 RDW-14.3 Plt Ct-66*
[**2171-10-20**] 03:10PM BLOOD Glucose-122* UreaN-56* Creat-1.4* Na-149*
K-4.3 Cl-107 HCO3-39* AnGap-7*
[**2171-10-16**] 03:47AM BLOOD Glucose-98 UreaN-55* Creat-1.1 Na-147*
K-3.6 Cl-106 HCO3-35* AnGap-10
[**2171-10-7**] 10:06PM BLOOD Calcium-10.7* Phos-3.8 Mg-2.2
[**2171-10-20**] 03:10PM BLOOD Calcium-11.3* Phos-3.3 Mg-2.1
[**2171-10-13**] 05:29AM BLOOD Vanco-53.0*
[**2171-10-16**] 03:00AM BLOOD Vanco-23.4*
[**2171-10-16**] 04:14AM BLOOD Type-ART PEEP-5 FiO2-50 pO2-93 pCO2-47*
pH-7.50* calTCO2-38* Base XS-11 Intubat-INTUBATED
Vent-SPONTANEOU
[**2171-10-7**] 10:39PM BLOOD Type-ART pO2-75* pCO2-56* pH-7.46*
calTCO2-41* Base XS-13
[**2171-10-8**] 04:00AM BLOOD Lactate-1.5
POsitive Serotonin Release Assay
POsitive Heparin PF4 Ab
Imaging
[**10-16**] Head CT
IMPRESSION: Postoperative changes consistent with right frontal
bone burr
hole and biopsy of right frontal lobe lesion. Small area of
layering of
hyperdense material in the lesion consistent with postoperative
blood
products. Mass effect remains similar when compared to prior
scan.
TTE :Very limited image quality. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is
normal-to-hyperdynamic (LVEF>60%). Right ventricular chamber
size and free wall motion are normal. The [**Month/Year (2) 8813**] valve leaflets
(3) are mildly thickened but [**Month/Year (2) 8813**] stenosis is not present.
[**10-8**] LENIS: IMPRESSION: No deep vein thrombosis.
[**Month/Year (2) 4338**] [**10-8**]
IMPRESSION:
1. Complex, multilocular right frontal intra-axial mass, now
demonstrating a cystic hemorrhagic component, inferiorly,
corresponding to the recent CT
studies, but new in comparison to the most recent cranial MR of
[**2171-7-15**].
2. The enhancing soft tissue nodular and cystic components are
not
significantly changed in comparison to prior studies, with no
new
enhancement.
3. Persistent opacification of the sphenoid sinus and mastoid
air cells.
COMMENT: A primary differential diagnostic consideration for
this tumor, based on the series of studies, is pleomorphic
xanthoastrocytoma (PXA) which may have cystic cavities,
hemorrhage and calcifications, and may undergo rhabdoid,
teratoid or even anaplastic dedifferentiation. Though previously
thought to affect only younger patients, occasional elderly
patients have recently been reported, with worse prognosis. Less
likely would be subependymoma undergoing cystic and hemorrhagic
involution or, even more remotely, highly unusual appearance of
oligodendroglioma or vascular malformation.
[**10-13**] EEG
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background and occasional bursts of generalized slowing, a few
of these
more evident just on the right. These findings indicate a
widespread
encephalopathy affecting both cortical and subcortical
structures.
Medications, metabolic disturbances, and infection are among the
most
common causes. There were no clearly epileptiform features. A
bradycardia was noted.
[**10-17**] CXR
FINDINGS: AP single view of the chest obtained with patient in
sitting
semi-upright position is analyzed in direct comparison with a
preceding
similar study obtained 12 hours earlier during the same date.
During the
interval, the patient has been extubated, and a tracheal cannula
has been
placed. The position is unremarkable. There is no pneumothorax
or any other placement-related complication. Previously
described right PICC line remains in unchanged position. The
patient is status post sternotomy, probably related to bypass
surgery. Other remarkable findings are prominence of the central
pulmonary vascular structures raising the possibility of
pulmonary hypertension. The next previous examination suggested
atelectasis - density in the left base cannot be evaluated
because of technical _____ of the present study (motion
blurring). No new parenchymal abnormalities in the accessible
lung fields.
MICROBIOLOGY DATA
[**10-8**] sputum cx: MRSA
Blood cx [**10-7**], [**10-8**] No growth
Urine cx [**10-8**] no growth
C diff negative x 3
Brief Hospital Course:
80yo gentleman with h/o MDS and brain tumor (most likely low
grade glioma) transferred intubated to [**Hospital1 18**] in the setting of
recent hemorrhage near tumor site, found to be febrile and
hypoxic with respiratory failure.
.
# Hypoxic Respiratory Failure: Etiologies of respiratory failure
include resolving infection vs fluid overload vs atelectasis c/w
findings on CXR. Patient originally intubated [**9-25**] at OSH. He
was initially treated here with Vanco/Zosyn for infiltrate on
CXR and fever with hypoxia which was narrowed to Vancomycin when
sputum cultures were positive for MRSA [**10-8**]. he completed
antibiotic course for MRSA PNA/VAP. He was diuresed net 8 liters
during length of stay. Respiratory status improved and he had
trachesotomy placed [**2171-10-17**]. At time of discharge, he was
tolerating trach collar with occasional CPAP with PSV overnight
for tachypnea. Echo showed LVEF 60%. Trach sutures should be
D/C'd [**10-27**].
.
# Seizure/Brain Tumor with Parietal Hemorrhagic Lesion: Patient
with known brain mass with hemorrhage on CT at OSH. His
platelets were maintained >50 to avoid further bleeding. He had
stereotactic brain biopsy with minimal decompression, and
post-op CT showing no new changes in lesion and no new
hemorrhage with prelim finding of low grade glioma. Pt had
witnessed seizure [**10-13**] although EEG c/w global encephalopathy.
He was loaded with Dilantin then bridged to Keppra which was
titrated up to 100mg PO BID. He has not had any further
seizures. mental status has improved since admission as well as
movement of LUE and LLE (initially hemiplegic .now moving both
LUE and LLE with approx. 3/5 strength. Sutures should be removed
from neurosurgery 10days from op ([**10-26**]) in office
([**Telephone/Fax (1) 1669**]). Pathology report from biopsy still pending.
.
# C.Diff: OSH records positive for Cdiff, but patient negative
here x 3. He was continued on PO Vanco through [**10-20**], 5 days
after he had completed antibiotics for PNA. WBC trending down
since admission and he has been afebrile. No abdominal pain.
Rectal tube in place.
.
#Hypercalcemia: Elevated calcium during admission; PTH WNL. Most
likely etiology includes humoral hypercalcemia of malignancy as
involvement of bone is unlikely.
Further workup deferred to outpatient treatment.
.
# Acid Base/Volume status: Pt diuresed and negative 9 liters
during LOS with slight bump in creatinine to 1.4 on [**10-20**],
stable. Further diuresis deferred given patient now clinically
hypovolemic with likely contraction alkalosis.
.
#Hypernatremia: Patient given free water flushes through NGT for
hypernatremia, increased to 150ml on [**10-20**]. Lytes were followed
[**Hospital1 **].
.
# MDS/HIT: Pt has h/o thrombocytopenia and anemia. He was
transfused total of 3 units PRBC and 17 bags platelets. We
attempted to maintain plt>50K [**1-26**] brain mass with hemorrhage and
neurosurgical procedure. He was found to be HIT positive with
positive antibodies and serotonin release assay so all heparin
products were avoided. Notably, he was epoetin prior to
admission but this was not continued during admission; he will
likely need to be restarted on this medication in the near
future in consultation with his hematologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2539**].
.
# CAD s/p CABG; HTN; Dyslipidemia: Patient had echo which showed
LVEF 60%. ASA was held [**1-26**] head bleed. He was continued on
statin and beta blocker. He has not tolerated ACEI in past [**1-26**]
hyperkalemia.
.
# h/o DVT: Patient had LENIS which [**Last Name (un) **] no DVTs in LE BL. He
was not anticoagulated given intracranial bleed.
.
# AFib: - Rate controled with beta blocker. No ASA or Coumadin
given brain mass and h/o bleed.
.
# Hyperglycemia: Was on SSI at OSH but does not carry Dx of
diabetes. Continued SSI.
.# Sacral Wound: Pt has sacral decubitus ulcer. Wound care was
consulted and patient had frequent position changes with Allevyn
foam dressing over open tissues. Also treated with Nystatin for
possible fungal component and Zinc x 10 days starting [**10-20**] to
promote wound healing.
.
# Gout: Stable. Continued Allopurinol
.
# GERD: Was on PPI at home, continued.
.
# FEN: Keeping I/O even. Repleting lytes prn. Continued on tube
feeds via PEG. Patient requires 200cc free water flushes q4hrs
to maintain serum sodium at normal levels and avoid
hypernatremia.
.
# PPx: Pneumoboots, PPI. NO HEPARIN.
.
# Access: R PICC
.
# Code: FULL
.
# Comm: Wife [**Name (NI) 730**] [**Telephone/Fax (1) 110723**]; [**Telephone/Fax (1) 110724**] (consented for blood
products over phone)
Medications on Admission:
Home Medications:
Warfarin 2mg up to 3 pills daily as directed--stopped after head
bleed
ASA 81mg daily
Metoprolol tartrate 25mg [**Hospital1 **]
Diltiazem 120mg daily
Zocor 40mg daily
Prednisone 30mg x 3 days
Protonix 40mg daily
Allopurinol 300mg daily
Epoetin
MVI daily
Polyethylene Glycol 17g daily prn
Tylenol PRN
Advair 500/50
Combivent
Insulin fixed and sliding
.
Meds on Transfer:
Metoprolol 12.5 [**Hospital1 **]
Vancomycin 250mg PO Q6H
Cefepime 2g IV q12h
SSI
Guaifenesin 200mg Q6H
Guaifenesin with codeine 10mg Q6H prn
Miconazole cream [**Hospital1 **]
Saccharomyces 250mg daily (probiotic)
Lasix prn
Combivent inhaler 6 puffs QID
Desenex powder [**Hospital1 **]
Morphine 2mg IV q3h prn
Sucralfate PO 1g QID
Discharge Medications:
1. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day)
as needed. Tablet(s)
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
3. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Allopurinol 100 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
6. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
8. Nystatin 100,000 unit/g Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Apply to affected areas.
9. Levetiracetam 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation QID (4 times a day).
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs
PO Q6H (every 6 hours) as needed for pain.
12. Ascorbic Acid 90 mg/mL Drops [**Hospital1 **]: Five (5) ml PO DAILY
(Daily).
13. Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily) for 10 days.
14. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) unit
Injection ASDIR (AS DIRECTED): Please check FSBS QID. For FSBS
0-70 give 1 amp D50. For FSBS 71-150, do not administer insulin.
For FSBS 151-200 give 2 units insulin. For FSBS
201-250, give 4 Units regular insulin. For FSBS
251-300, give 6 untis regular insulin. For FSBS
301-350, give 8 Units regular insulin. For FSBS 351-400 give
10 Units. For FSBS >400, [**Name8 (MD) 138**] MD. Give half doses when patient
is NPO
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary Diagnosis
1. Hemorrhagic CVA
2. Brain tumor, likely low grade glioma, final path pending
3. Ventilator Associated MRSA Pneumonia
4. Heparin induced thrombocytopenia
5. Seizure
6. h/o C. diff (at OSH)
Secondary Diagnosis
1. MDS
2. CAD s/p CABG
3. h/o DVT
4. AFIB
Discharge Condition:
Hemodynamically stable, afebrile, trachesostomy in place
tolerating trach mask with intermittent CPAP with PSV.
Discharge Instructions:
You were transferred from [**Hospital 794**] Hospital for further evaluation
of bleeding around your brain tumor that was seen on a CT scan.
We kept your platelets >50,000 to prevent any further bleeding.
You had a biopsy of this tumor. The final results of the biopsy
are still pending. Repeat imaging did not demonstrate any
further bleeding. You had a seizure during your hospital course
so we started you on an anti-seizure medication called Keppra.
Upon initial transfer, you had low oxygen saturations, fevers
and imaging consistent with pneumonia. You completed a course of
antibiotics for a hospital acquired pneumonia. We weaned down
your ventilator settings and you had a tracheostomy placed on
[**2171-10-17**].
Please keep all follow-up appointments as scheduled and take all
medications as prescribed.
Return to the ER or call your primary care doctor if you develop
fever >101, new numbness or weakness, change in mental status,
chest pain, shortness of breath or any other concerning
symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2171-11-11**] 1:00
Provider: [**Name10 (NameIs) 706**] [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2171-11-11**]
11:55
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2171-11-1**] 9:00
You should have your sutures from your brain biopsy removed on
[**10-26**]. Tracheostomy sutures should be removed [**10-27**].
|
[
"427.31",
"041.12",
"276.3",
"707.22",
"274.9",
"518.81",
"342.90",
"401.9",
"244.9",
"428.0",
"252.00",
"276.0",
"431",
"707.03",
"348.30",
"780.39",
"414.00",
"790.29",
"238.75",
"289.84",
"V45.81",
"191.1",
"272.4",
"997.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"93.59",
"99.04",
"96.72",
"99.05",
"31.1",
"01.13",
"33.22"
] |
icd9pcs
|
[
[
[]
]
] |
16211, 16309
|
8909, 13548
|
306, 362
|
16623, 16737
|
3987, 8886
|
17798, 18354
|
3369, 3375
|
14317, 16188
|
16330, 16602
|
13574, 13574
|
16761, 17775
|
3390, 3968
|
13592, 13944
|
255, 268
|
390, 2430
|
2452, 3293
|
3309, 3353
|
13962, 14294
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,093
| 189,496
|
3239
|
Discharge summary
|
report
|
Admission Date: [**2179-8-21**] Discharge Date: [**2179-8-27**]
Date of Birth: [**2100-6-24**] Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
left femoral neck fracture
Major Surgical or Invasive Procedure:
Left hip hemiarthroplasty
History of Present Illness:
79F who has been using walker for past week due to unsteadiness
on feet, who had mech fall [**2179-8-21**] AM, hit head, no LOC, OSH
films: neg head/c-spine; with new left femoral neck fracture.
Past Medical History:
Colon CA s/p resection, SVT s/p successful ablation, HTN,
Scoliosis & Kyphosis, Anxiety
Social History:
NA
Family History:
NA
Physical Exam:
NAD, AOx3
Ventilating comfortably
Severe scoliosis/kyphosis
LLE skin clean and intact, resolving hematoma under incision
staples in place over incision
No tenderness, deformity
Thighs and legs are soft
Resolving 0-1+ edema bilateral LE
No pain with passive motion
Saph Sural DPN SPN MPN LPN [**First Name9 (NamePattern2) 2189**]
[**Last Name (un) 938**] FHL GS TA PP Fire
1+ PT and DP pulses
Pertinent Results:
[**2179-8-21**] 11:20AM BLOOD LtGrnHD-HOLD
[**2179-8-21**] 04:53PM BLOOD Calcium-8.6 Phos-4.1 Mg-1.8
[**2179-8-22**] 01:39AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.7
[**2179-8-25**] 12:50PM BLOOD Calcium-8.4 Phos-2.0*# Mg-2.1
[**2179-8-26**] 06:05AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.9
[**2179-8-27**] 05:41AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.1
[**2179-8-21**] 11:20AM BLOOD estGFR-Using this
[**2179-8-21**] 11:20AM BLOOD Glucose-93 UreaN-29* Creat-0.6 Na-139
K-3.9 Cl-102 HCO3-31 AnGap-10
[**2179-8-21**] 04:53PM BLOOD Glucose-133* UreaN-29* Creat-0.8 Na-137
K-4.4 Cl-103 HCO3-30 AnGap-8
[**2179-8-22**] 01:39AM BLOOD Glucose-121* UreaN-30* Creat-0.7 Na-135
K-4.2 Cl-102 HCO3-29 AnGap-8
[**2179-8-25**] 12:50PM BLOOD Glucose-135* UreaN-35* Creat-0.7 Na-138
K-4.2 Cl-101 HCO3-31 AnGap-10
[**2179-8-26**] 06:05AM BLOOD Glucose-90 UreaN-31* Creat-0.6 Na-141
K-4.3 Cl-103 HCO3-34* AnGap-8
[**2179-8-27**] 05:41AM BLOOD Glucose-104* UreaN-28* Creat-0.6 Na-142
K-4.4 Cl-101 HCO3-36* AnGap-9
[**2179-8-21**] 04:52PM BLOOD
[**2179-8-22**] 01:39AM BLOOD
[**2179-8-22**] 12:50PM BLOOD
[**2179-8-23**] 06:09AM BLOOD
[**2179-8-24**] 06:23AM BLOOD
[**2179-8-25**] 05:57AM BLOOD
[**2179-8-26**] 06:05AM BLOOD
[**2179-8-27**] 05:41AM BLOOD
[**2179-8-21**] 11:20AM BLOOD PT-10.6 PTT-25.0 INR(PT)-1.0
[**2179-8-21**] 11:20AM BLOOD Plt Ct-265
[**2179-8-21**] 04:52PM BLOOD Plt Ct-259
[**2179-8-22**] 01:39AM BLOOD Plt Ct-177
[**2179-8-22**] 12:50PM BLOOD Plt Ct-181
[**2179-8-23**] 06:09AM BLOOD Plt Ct-147*
[**2179-8-24**] 06:23AM BLOOD Plt Ct-138*
[**2179-8-25**] 05:57AM BLOOD Plt Ct-164
[**2179-8-26**] 06:05AM BLOOD Plt Ct-215
[**2179-8-27**] 05:41AM BLOOD Plt Ct-280
[**2179-8-21**] 11:20AM BLOOD Neuts-83.5* Lymphs-11.4* Monos-4.8
Eos-0.2 Baso-0.2
[**2179-8-21**] 11:20AM BLOOD WBC-13.9*# RBC-3.45* Hgb-11.1* Hct-34.4*
MCV-100* MCH-32.2* MCHC-32.3 RDW-15.4 Plt Ct-265
[**2179-8-21**] 04:52PM BLOOD WBC-12.8* RBC-3.05* Hgb-9.8* Hct-30.6*
MCV-100* MCH-32.0 MCHC-31.9 RDW-15.6* Plt Ct-259
[**2179-8-22**] 01:39AM BLOOD WBC-7.8 RBC-2.63* Hgb-8.4* Hct-25.6*
MCV-97 MCH-31.8 MCHC-32.7 RDW-16.2* Plt Ct-177
[**2179-8-22**] 12:50PM BLOOD WBC-8.7 RBC-3.06* Hgb-9.6* Hct-29.7*
MCV-97 MCH-31.4 MCHC-32.4 RDW-16.7* Plt Ct-181
[**2179-8-23**] 06:09AM BLOOD WBC-9.3 RBC-2.63* Hgb-8.4* Hct-25.9*
MCV-99* MCH-31.9 MCHC-32.4 RDW-16.7* Plt Ct-147*
[**2179-8-23**] 04:20PM BLOOD Hct-25.5*
[**2179-8-24**] 06:23AM BLOOD WBC-6.8 RBC-1.96*# Hgb-6.1*# Hct-19.9*
MCV-98 MCH-31.2 MCHC-31.8 RDW-16.6* Plt Ct-138*
[**2179-8-24**] 03:50PM BLOOD Hct-27.6*#
[**2179-8-25**] 05:57AM BLOOD WBC-8.1 RBC-2.84*# Hgb-8.9*# Hct-26.9*
MCV-95 MCH-31.3 MCHC-33.0 RDW-16.6* Plt Ct-164
[**2179-8-26**] 06:05AM BLOOD WBC-7.6 RBC-2.96* Hgb-8.9* Hct-28.5*
MCV-96 MCH-30.1 MCHC-31.2 RDW-15.8* Plt Ct-215
[**2179-8-27**] 05:41AM BLOOD WBC-7.1 RBC-2.96* Hgb-9.4* Hct-28.7*
MCV-97 MCH-31.6 MCHC-32.6 RDW-15.4 Plt Ct-280
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a left femoral neck fracture. The patient was taken
to the OR and underwent an uncomplicated left hip
hemiarthroplasty. The patient tolerated the procedure without
complications and was transferred to the PACU stable. Please
see operative report for details. Post operatively pain was
controlled with a PCA with a transition to PO pain meds once
tolerating POs. The patient tolerated diet advancement without
difficulty and made steady progress with PT.
The patient required oxygen therapy with 4L nasal cannula
post-operatively. On POD 3, her O2 saturations decreased to the
80s and she was placed on a venturi mask at 40% oxygen. This was
found to be a result of subacute pulmonary edema caused by
volume overload by fluid resuscitation intraoperatively/blood
transfusions for acute blood loss anemia all in the setting of
underlying diastolic dysfunction. She was diuresed approximately
3.5 L over the course of the next 3 days, and her oxygen
requirement has been weaned down to 2L nasal cannula.
The patient was transfused 3 units of blood for acute blood loss
anemia.
Weight bearing status: As tolerated.
The patient received peri-operative antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 8 days post-discharge. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
Aspirin, Caltrate, Colace, Norvasc, Vit D3, paroxetine, eye
drops
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
standing dose
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID corneal
abrasion
5. Fluorometholone 0.1% Ophth Susp. 1 DROP RIGHT EYE DAILY
6. Enoxaparin Sodium 40 mg SC Q24H Duration: 8 Days
RX *enoxaparin 40 mg/0.4 mL inject into abdomen once a day Disp
#*8 Syringe Refills:*0
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE [**Hospital1 **]
8. diclofenac sodium *NF* 0.1 % OD TID
1 drop to Right eye TID * Patient Taking Own Meds *
9. Calcium Carbonate 500 mg PO TID
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
11. Artificial Tear Ointment 1 Appl LEFT EYE TID:PRN irritation,
dry eye
12. Artificial Tears Preserv. Free 1-2 DROP LEFT EYE QID:PRN dry
eye
13. Milk of Magnesia 30 ml PO BID:PRN Constipation
14. Paroxetine 20 mg PO DAILY
15. Senna 1 TAB PO BID
16. Tropicamide 1 % 1 DROP RIGHT EYE DAILY Duration: 1 Doses
17. Vitamin D 800 UNIT PO DAILY
18. Multivitamins 1 CAP PO DAILY
19. TraMADOL (Ultram) 25-50 mg PO Q4H:PRN pain
RX *Ultram 50 mg 0.5-1 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
20. Furosemide 40 mg PO DAILY
Discontinue lasix once patient is felt to have reached dry
weight or Cr increases >0.2
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Left femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Weight bearing as tolerated.
Discharge Instructions:
******SIGNS OF INFECTION**********
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
Wound Care: You can get the wound wet, but no baths or swimming
for at least 3 weeks. Any stitches or staples that need to be
removed will be taken out at 2-weeks following your operation at
your rehab facility (around [**9-4**]). No dressing is needed if wound
is non-draining.
******WEIGHT-BEARING*******
Weight bearing as tolerated
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You had excess fluid in your body for which we gave you IV
Lasix to help you void the excess. You should continue to take
PO Lasix to help maintain your fluid status as an outpatient.
Instructions will be on your prescriptions.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink 8-8oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on Fridays.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 8 days post-discharge.
Physical Therapy:
Weight bearing as tolerated.
Treatments Frequency:
Please have your staples removed at your rehabilitation facility
at post-operative day 14 (around [**9-4**]).
Followup Instructions:
******FOLLOW-UP**********
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week
post-discharge for evaluation. Call [**Telephone/Fax (1) 1228**] to schedule
appointment upon discharge.
Please follow up with your PCP regarding this admission and any
new medications/refills.
|
[
"E885.9",
"E878.1",
"737.30",
"300.00",
"285.1",
"458.29",
"276.69",
"820.09",
"401.9",
"518.4",
"733.00",
"V15.88",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
7275, 7322
|
4055, 5800
|
345, 373
|
7393, 7393
|
1177, 4032
|
9216, 9540
|
745, 749
|
5917, 7252
|
7343, 7372
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5826, 5894
|
7605, 7859
|
764, 1158
|
9030, 9059
|
9081, 9193
|
279, 307
|
7871, 9012
|
401, 597
|
7408, 7581
|
619, 709
|
725, 729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,601
| 122,355
|
35431
|
Discharge summary
|
report
|
Admission Date: [**2193-3-14**] Discharge Date: [**2193-3-21**]
Date of Birth: [**2118-11-23**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74 yo female with PMHx sig for HTN who presents to ED after fall
related to a syncopal event at work. Most of the history is
obtained through a co-worker as the patient is amnestic for the
event. Apparently, she was at work and then
complained of dizziness. She was then noted to fall backwards
and strike the back of her head on a marble floor. She had LOC
for ~ 1 minute before coming to. The patient does not remember
the event. She claims to remember having breakfast this morning
but she cannot recall simple details. She claims that she is at
the hospital visiting a friend and continues to believe this
even after it is reinforced that she fell at work. In ED, CT
head shows bifrontal contusions and a L frontal ICH.
Past Medical History:
HTN, the remainder is unclear due to
patient's impaired memory an inattention.
Social History:
Lives alone in [**Location (un) 2312**]. Works in sales at [**Last Name (un) 80764**] 5th Ave. No
tobacco, ETOH.
Family History:
Non-contributory
Physical Exam:
On Admission:
Vitals: AF; BP 153/83; P 77; RR 15; O2 sqt 100% RA
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: awake, alert, year - [**2145**], month - [**Month (only) 958**], place -
does not know, President - [**Last Name (un) 2753**], President before [**Last Name (un) 2753**] - does
not know. Difficulty with MOYF and unable to do MOYB. Fluent
speech with no paraphasic or phonemic errors. Difficulty with
multi-step commands. Difficult with repetition (no ifs, ands or
buts). Difficulty with low and high frequency objects. No
left/right mismatch. No apraxia/neglect. [**Location (un) **] intact.
Clock drawing is organized but she lists number and does not
make
out a clock face.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
IX, X: Palatal elevation symmetrical.
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. She does
not
comply with formal strength testing due to giveaway but moves
all
extremities symmetrically.
Sensation: intact to light touch.
Reflexes: 1+ symmetric
Coordination: FNF intact.
On Discharge:
XXXXXXXXXXXXXXXXX
Pertinent Results:
Labs on Admission:
[**2193-3-14**] 04:30PM BLOOD WBC-15.0* RBC-4.86 Hgb-13.9 Hct-41.9
MCV-86 MCH-28.6 MCHC-33.2 RDW-14.3 Plt Ct-239
[**2193-3-14**] 04:30PM BLOOD Neuts-75.2* Lymphs-20.0 Monos-3.7 Eos-0.8
Baso-0.4
[**2193-3-14**] 04:30PM BLOOD Plt Ct-239
[**2193-3-14**] 06:00PM BLOOD PT-13.2 PTT-20.8* INR(PT)-1.1
[**2193-3-14**] 05:26PM BLOOD Glucose-112* UreaN-20 Creat-1.0 Na-141
K-4.0 Cl-103 HCO3-24 AnGap-18
[**2193-3-14**] 05:26PM BLOOD CK(CPK)-85
[**2193-3-14**] 05:26PM BLOOD CK-MB-3 cTropnT-<0.01
[**2193-3-14**] 09:16PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2193-3-15**] 05:04AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2193-3-14**] 05:26PM BLOOD Calcium-10.2 Phos-3.0 Mg-2.1
[**2193-3-15**] 05:04AM BLOOD Triglyc-62 HDL-73 CHOL/HD-2.8 LDLcalc-120
Labs on Discharge:
XXXXXXXXXXXXXXXXXX
Imaging:
Head CT [**3-14**]:
There is a 1.5 x 2.3 intraparenchymal hemorrhage in the left
inferior frontal lobe (series 2 image 7). There is no
significant midline shift. There is bilateral frontal
subarachnoid hemorrhage (series 2, images 9, 11). The
subarachnoid hemorrhage extends to the vertex where it is seen
in the left frontal area (series 2, image 19) and in the left
parietal area (series 2, 17). Subarachnoid hemorrhage is also
seen in the right temporal area (series 2, image 5; series 401b,
images 15, 20, 44). There are non-depressed and non-displaced
fractures of the left frontal bone (series 3, image 41) and
right occipital bone (series 3A, image 22), with the latter
extending to the skull base (series 3A, image 4). There is
pneumocephalus about the occiput (series 3A, image 19).
Pneumocephalus is also seen posterior and anterior to the right
temporal bone (series 3A image 10) with a non- displaced
horizontal fracture of the right temporal bone (series 401b,
image 54) identified. There partial opacification of the mastoid
and epitympanum of the right. A locule of air is also seen in
the left middle cranial fossa (series 3A, image 8). The left
mastoid air cells are clear. The visualized paranasal sinuses
are clear. In the soft tissues overlying the left occiput there
is an 8 x 10-mm heterogeneous lesion containing calcifications
(series 2, image 7). Similarly, there is a 1.2 x 1.8-cm
heterogeneous soft tissue lesion containing punctate
calcifications in the right frontal scalp towards the vertex
(series 2, image 24). Soft tissue swelling is seen overlying the
left frontal area.
IMPRESSION:
1. Non-depressed, non-displaced fractures of the left frontal,
right
occipital and right temporal bones with pneumocephalus.
Extension of the
occipital bone fracture to the skull base is noted. CT of the
temporal bones and skull base can provide further evaluation.
2. Left inferior frontal intraparenchymal hemorrhage without
associated shift and bifrontal, left parietal, and right
temporal subarachnoid hemorrhage.
3. Two partly calcified subcutaneous nodules as described
above..
CT C-Spine [**3-14**]:
IMPRESSION:
1. No fracture or dislocation of the cervical spine.
2. Skull fractures with one extending to the base, and
horizontal fracture of the right temporal bone and
pneumocephalus, please refer to the head CT from earlier today.
Head CT [**3-15**]:
IMPRESSION:
1. No evidence for new hemorrhage. There is increased edema
surrounding the
left inferior frontal intraparenchymal hemorrhage, but again no
significant
mass effect is present. Subarachnoid hemorrhage is also
unchanged.
2. Multiple nondisplaced skull fractures are redemonstrated,
better
appreciated on initial head CT.
3. Apparent resorption of pneumocephalus.
4. Multiple soft tissue lesions, consistent with sebaceous or
epidermoid
cysts.
MRA Head [**3-16**]:
IMPRESSION: Normal MRA of the head.
MRI Head [**3-16**]:
FINDINGS: Correlation was made with the CT examination of
[**2193-3-15**]. As seen
on the CT, there is hemorrhagic contusion identified involving
both inferior frontal lobes, left greater than right side. There
are bilateral small subdurals identified at the parietal
occipital region measuring not more than 3 mm in width and are
not seen on the previous CT in retrospect. There is increased
signal identified on FLAIR images along the convexity sulci
indicative of subarachnoid blood. Small areas of increased
signal in the occipital horns bilaterally on FLAIR images
indicate a small amount of blood products in the ventricles.
There is no midline shift or hydrocephalus seen. Probable
sebaceous cysts are seen in the right parietal region.
IMPRESSION: Findings indicative of bilateral inferior frontal
hemorrhagic
contusions. Subarachnoid blood and intraventricular blood. No
midline shift
or hydrocephalus. Tiny bilateral parietal occipital subdural
hematomas. Soft tissue swelling over the skull. For evaluation
of fractures correlate with previous CT findings.
EKG [**3-14**]:
Sinus rhythm. Indeterminate axis. Early R wave progression. No
previous
tracing available for comparison. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 138 92 372/401 66 0 20
EEG [**3-15**]:
IMPRESSION: This is an abnormal EEG due to the presence of focal
slow
transients involving the left anterior to mid-temporal region;
this
abnormality typically correlates with an area of subcortical
dysfunction. The background slowing could be related to a number
of
conditions including: mild encephalopathy of toxic, metabolic,
traumatic, or anoxic etiology, diffuse lesions of deep white
matter or
midline structures, or excessive drowsiness. No evidence of
ongoing or
potential epileptogenesis was seen at the time of this
recording.
Cardiac Echo [**3-15**]:
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Carotid Duplex Study [**3-15**]:
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On
the right there is mild homogenous plaque in the ICA. On the
left there is
mild heterogenous plaque in the ICA. On the right systolic/end
diastolic velocities of the ICA proximal, mid and distal
respectively are 54/14, 95/27, 100/33 cm/sec. CCA peak systolic
velocity is 77 cm/sec. ECA peak systolic velocity is 85 cm/sec.
The ICA/CCA ratio is 1.29. These findings are consistent with
less than 40% stenosis. On the left systolic/end diastolic
velocities of the ICA proximal, mid and distal respectively are
98/26, 96/27, 81/19 cm/sec. CCA peak systolic velocity is 86
cm/sec. ECA peak systolic velocity is 80 cm/sec. The ICA/CCA
ratio is 1.13. These findings are consistent with less than 40%
stenosis. There is antegrade right vertebral artery flow. There
is antegrade left vertebral artery flow.
Impression: Right ICA stenosis less than 40%. Left ICA stenosis
less than 40%.
Brief Hospital Course:
Patient is a 74F admitted to [**Hospital1 18**] neurosurgery following a
syncopal event on [**2193-3-14**]. She sustained ICH and non-depressed
skull fracture in the event. She was initially admitted to the
ICU for monitoring for 24hours, and then transferred to the
stepdown unit on HD#2. Throughout her hospitalization, she
remained alert, oriented, sometimes variable from person only,
to person, place and year. Neurology was consulted during her
hospitalization to assist with her syncopal work up. Bilateral
carotid duplex, and TTE were performed and found to be negative
in causation of syncopal event. During chart review and
history, it was determined that the patient's PCP had recently
made changes to her antihypertiensive medications, and this is
presumed to be the likely cause of the event. She remained off
her antihypertensive medication during hospitalization, and was
without further incident. EEG was also performed to rule out any
occult seizure activity, which was also benign. She was seen and
evaluated by PT and OT, and also determined to be appropriate
for rehab placement. She was discharged on [**3-21**] to an
appropriate facility.
Medications on Admission:
HCTZ
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
9. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
L frontal traumatic ICH and bifrontal contusions and
non-depressed skull fractures
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2193-3-21**]
|
[
"285.9",
"272.0",
"780.2",
"800.22",
"401.9",
"733.90",
"244.9",
"E888.1",
"801.22"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12429, 12512
|
10231, 11398
|
324, 331
|
12639, 12663
|
2802, 2807
|
13759, 14120
|
1346, 1364
|
11453, 12406
|
12533, 12618
|
11424, 11430
|
12687, 13736
|
1379, 1379
|
2764, 2783
|
1678, 1678
|
281, 286
|
3575, 10208
|
359, 1093
|
2294, 2750
|
2821, 3556
|
1693, 2278
|
1116, 1197
|
1213, 1330
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,955
| 157,493
|
53138+59502
|
Discharge summary
|
report+addendum
|
Admission Date: [**2107-4-18**] Discharge Date: [**2107-5-5**]
Date of Birth: [**2058-6-1**] Sex: M
Service: SURGERY
Allergies:
vancomycin
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Wound infection
Major Surgical or Invasive Procedure:
[**2107-4-20**]: washout R groin
[**2107-4-29**]: Removal of infected femoral-to-femoral bypass
graft with redo femoral-to-femoral bypass graft using left
femoral vein of the thigh
History of Present Illness:
48M history of L->R fem-fem bypass in [**2105**] for occluded R
CIA/EIA recently underwent R groin cutdown with graft
thrombectomy/R popliteal cutdown with thrombectomy [**2107-3-24**] for
cold foot now returns with drainage for right groin wound. He
has noted purulent fluid draining from his right groin wound for
3 days. Yesterday the upper portion of the groin wound "opened
up" and drained more. He presented to [**Hospital3 **] and was
transferred to [**Hospital1 18**] for further evaluation. He was found to
have a fever to 102.8 F in the ED. He has some nausea and
generalized fatigue. He has also noted increased pain at the
dorsum of his right foot. This pain/tingling has been something
he has had since his surgery in [**2105**], but he reports it has been
more pronounced in the past 3 days.
Past Medical History:
PMH: HTN, BPH, GERD, recurrent UTIs, h/o EtOH abuse, hematuria
([**5-/2106**] cystoscopy and urine cytology neg, CT showed bilateral
non-obstructing renal stones)
PSH: R groin cutdown with graft thrombectomy/R popliteal cutdown
with thrombectomy [**2107-3-24**] (Dr. [**Last Name (STitle) **], Right fem-[**Doctor Last Name **]
thrombectomy, attempted right iliac thrombectomy, L to R
fem-fem
bypass with 8-mm PTFE graft and four compartment fasciotomy of
right leg, right inguinal hernia, left shoulder surgery
Social History:
Lives at home, currently unemployed. Recently incarcerated.
History of EtOH abuse, sober for the ~ 20 months. Smoker 1 ppd
in past. Denies IVDA.
Family History:
NC
Physical Exam:
On admission:
VS: 98.4 86 136/75 18 99%
Gen: NAD, AOx3
CVS: reg
Pulm: no resp distress
Abd: S/NT/ND
Wound:
- R groin wound with dehiscence ~3 cm upper portion of wound
with
foul smelling purulent drainage and serous drainage, probes ~5cm
deep. Minimal surrounding erythema. + induration
- R medial calf wound: staples intact, minimal surrounding
erythema (less than 1 cm) without drainage
On discharge: small amount serous drainage from right groin,
staples in place. Minimal left thigh incision erythema.
Palpable fem, [**Doctor Last Name **], DP and PT pulses bilaterally.
Pertinent Results:
[**2107-4-18**] 09:20PM WBC-6.7 RBC-4.74 HGB-13.8* HCT-42.3 MCV-89
MCH-29.0 MCHC-32.5 RDW-14.6
[**2107-4-18**] 09:20PM GLUCOSE-106* UREA N-14 CREAT-1.2 SODIUM-139
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-29 ANION GAP-12
[**2107-4-18**] 09:20PM NEUTS-82.6* LYMPHS-11.2* MONOS-2.7 EOS-3.0
BASOS-0.6
[**2107-4-18**] 09:20PM PLT COUNT-208
[**2107-4-18**] 09:20PM PT-11.1 PTT-25.9 INR(PT)-1.0
Blood Culture, Routine (Final [**2107-4-21**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
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---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final [**2107-4-19**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2107-4-19**]
2:55PM.
Reported to and read back by [**Doctor First Name 109447**] [**Doctor First Name **] #[**Numeric Identifier 109448**] [**2107-4-19**]
3:15PM.
Anaerobic Bottle Gram Stain (Final [**2107-4-19**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Brief Hospital Course:
Mr. [**Name14 (STitle) 20179**] was admited to the vascular sugery service on
[**2107-4-18**] with drainage from his right groin wound. He was
started on Linezolid, Cipro, and Flagyl given his Vancomycin
allergy. Blood cultures from admission eventually grew out MSSA
and Linezolid was switched to Nafcillin. On [**2107-4-20**] he was
taken to the OR for washout of the R groin and placement of a
VAC dressing. ID consult was obtained and recommended a 4 week
course of Nafcillin for his MSSA bacteremia and infected graft.
A RUE PICC line was placed on [**4-25**] for the purpose of IV
antibiotics.
Despite antibiotics, the wound failed to heal and the graft
eventually became exposed. Thus he was taken to the OR again on
[**4-29**] for excision of infected graft and a new L to R fem-fem
graft with left femoral vein of the thigh. Cultures of the
excised graft from the OR grew out nothing.
Postoperatively the patient did well, and was transitioned to PO
pain medications and a regular diet per pathway. He had a
palpable graft pulse and distal pulses throughout the remainder
of his hospital stay. An ACE wrap was applied to his entire
left leg and betadine paint was applied to his right groin
wound. ID recommended admission to [**Hospital1 **] for completion of
his four-week course of Nafcillin as the patient did not have
insurance, but the patient adamantly refused, despite clearly
understanding the risks of recurrent infection. Thus it was
decided to discharge the patient home on [**2107-5-5**], and he will
return to the hospital daily for infusions of Daptomycin.
Medications on Admission:
ASA 325', Simvastatin 20', Metoprolol 12.5'', not taking
coumadin (hematuria when taking)
Discharge Medications:
1. daptomycin 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous once a day for 4 weeks: labs per ID team.
Disp:*qs * Refills:*0*
2. PICC LINE ORDERS
DX: 996.62 Infected left->right fem-fem bypass graft, s/p
excision and redo
Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen
PICC line dressing change q week or more frequently if needed
3. Outpatient Lab Work
CBC with differential, BUN/Cr, AST/ALT, Alk Phos, Total bili
and CK q week
All laboratory results should be faxed to the Infectious Disease
R.N.s at ([**Telephone/Fax (1) 4591**]. All questions regarding outpatient
parenteral antibiotics should be directed to the Infectious
Disease R.N.s at ([**Telephone/Fax (1) 21403**] or to the on-call ID fellow when
the clinic is closed.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain .
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right groin infection with exposed PTFE fem-fem bypass graft
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
You were admitted with an infection in your right groin with
infection extending down to the level of your previous fem-fem
bypass graft. Your were treated with aggressive intravenous
antibiotics and removal or your infected graft and redo bypass
surgery with a vein from your left leg.
It was recommended by both your surgeon and the infectious
disease physicians that you go to a rehab facility on IV
nafcillin for a minimum of 4 weeks. You refused to go to the
inpatient facility to receive these necessary antibiotics and
verbalized your understanding that NOT getting 4 weeks of IV
nafcillin greatly increases your risk of getting further
infection, needed more invasive surgery and could lead to death.
Despite these risks, you still adamently refused to go to a
facility for nafcillin administration. Although there is no
other IV or oral therapy that is idea to treat your infection,
the ID team has agreed to set you up on daily Daptomycin IV
therapy at the [**Hospital1 18**] infusion center. You will be required to
come in daily to the [**Hospital Ward Name 516**] for infusions and it is
important that you DO NOT MISS [**First Name (Titles) 691**] [**Last Name (Titles) 4314**]. Taking
daptomycin is not ideal, and will not provide the same efficacy
, therefore you still risk having infection, need for further
invasive surgery and death.
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-4**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name Initial (NameIs) 455**] 709-2 (F) HEMATOLOGY/ONCOLOGY-7F
Phone:[**Telephone/Fax (1) 447**] Date/Time:[**2107-5-7**] 9:00
Provider: [**Name Initial (NameIs) 455**] 712-1 (F) HEMATOLOGY/ONCOLOGY-7F
Phone:[**Telephone/Fax (1) 447**] Date/Time:[**2107-5-8**] 9:00
Provider: [**Name Initial (NameIs) 455**] 712-2 (F) HEMATOLOGY/ONCOLOGY-7F
Phone:[**Telephone/Fax (1) 447**] Date/Time:[**2107-5-14**] 9:00
Completed by:[**2107-5-5**] Name: [**Known lastname 17945**],[**Known firstname 126**] Unit No: [**Numeric Identifier 17946**]
Admission Date: [**2107-4-18**] Discharge Date: [**2107-5-5**]
Date of Birth: [**2058-6-1**] Sex: M
Service: SURGERY
Allergies:
vancomycin
Attending:[**First Name3 (LF) 5118**]
Addendum:
Anemia in the post operative pperiod requiring 2 PRBC - this was
caused from acute blood loss from the surgical procedure.
Pt also had blood stream infection secondary to infected
prosthetic arterial graft. This required IV antibiotics. Pt
recieved PICC line. Discharged on IV antibiotics.
Discharge Disposition:
Home
[**Name6 (MD) 116**] [**Last Name (NamePattern4) 2878**] MD [**MD Number(2) 5119**]
Completed by:[**2107-6-2**]
|
[
"998.32",
"996.62",
"E870.0",
"E878.2",
"600.00",
"V15.81",
"530.81",
"285.1",
"998.2",
"401.9",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.39",
"39.49",
"38.97",
"39.31"
] |
icd9pcs
|
[
[
[]
]
] |
13122, 13269
|
4477, 6070
|
284, 468
|
7750, 7750
|
2650, 4454
|
12015, 13099
|
2031, 2036
|
6211, 7616
|
7666, 7729
|
6096, 6188
|
7901, 11582
|
11608, 11992
|
2051, 2051
|
2457, 2631
|
229, 246
|
496, 1313
|
2065, 2443
|
7765, 7877
|
1335, 1851
|
1867, 2015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,491
| 196,022
|
22756
|
Discharge summary
|
report
|
Admission Date: [**2194-12-26**] Discharge Date: [**2195-1-6**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABGx3(LIMA->OM1, SVG->OM2, LAD) [**2194-12-30**]
History of Present Illness:
This is an 81 year old male with past medical history
significant for hypertension, hypothyroidism, and gout who
presents from an outside hospital, having been admitted for
chest pain. The patient was in his usual state of health until
yesterday when while bringing trash out from his house to the
street, he experienced subtle substernal chest discomfort.
Thinking nothing of the event, the patient returned indoors, at
which point, the discomfort increased from a [**12-8**] to a [**2-5**]. At
that point, the patient rested in a chair and the pain completed
resolved without further intervention. The patient remained
chest pain free for the rest of the day. Despite being chest
pain free, the patient's wife urged him to seek medical
attention, at which point he was brought by ambulance to
[**Hospital3 1443**] hospital. At that ED, the patient was found
to have EKG changes including T wave flattening in V5-6 and some
peaking of T waves in V1-3. Troponins were drawn which
increased from 0.55 to 0.63 and 0.74. The patient remained
chest pain free in the ED, but was given nitro paste, lovenox,
mucomyst, and plavix. He was subsequently transferred to [**Hospital1 18**],
underwent cardiac catheterization, which revealed 3 VD.
Past Medical History:
Gout
Hypothyroid
Hypertension
s/p inguinal hernia repair
Social History:
Lives alone with his wife. [**Name (NI) **] tobacco or ethanol use.
Family History:
Noncontributory
Physical Exam:
VS: 98.4 128/50 80s 16-18 97%RA
GEN: pleasant, NAD, comfortable appearing male appearing his
stated age, well-nourished
HEENT: PERRL, EOMI, sclera anicteric, no conjuctival injection,
mucous membranes moist, no lymphadenopathy, no thryroid nodules
or masses, no supraclavicular lymph nodes, no posterior
lymphadenopathy, neck supple, full ROM, neg JVD, no carotid
bruits
[**Last Name (un) **]: CTA b/l
COR: RRR, S1 and S2 wnl, +S4, 3/6 systolic murmur best heard at
apex
ABD: non-distended with positive bowel sounds, non-tender,no
guarding, no rebound or masses
BACK: neg CVA tenderness
EXT: no cyanosis, clubbing, edema
NEURO: Alert and oriented x3. CNII-XII are intact
Pertinent Results:
EKG NSR 75, peaked T waves V1-V3, flattening of T waves V5-6
Pre-op CXR: No acute cardiopulmonary disease.
Cardiac Cath: Selective coronary angiography demonstrated three
vessel coronary artery disease in this right dominant
circulation. The LMCA was a large vessel without flow limiting
disease. The LAD had an 80% stenosis in the proximal vessel, a
70% stenosis in the mid vessel at S1, and a 40% stenosis at the
apex. The D1 and D2 were totally occluded proximally. The Ramus
intermedius was totally occluded in the proximal vessel with the
distal vessel filling by collaterals. The LCX was without flow
limiting disease about the AV groove. The OM1 was a small
vessel. The OM2 was a large vessel that was totally occluded
proximally and filled distally by collaterals. The RCA was
totally occluded in the proximal vessel.
[**2194-12-26**] 03:00PM BLOOD WBC-4.8 RBC-3.70* Hgb-12.4* Hct-34.8*
MCV-94 MCH-33.5* MCHC-35.6* RDW-13.4 Plt Ct-134*
[**2195-1-2**] 11:48AM BLOOD WBC-8.7 RBC-3.39* Hgb-10.6* Hct-29.8*
MCV-88 MCH-31.2 MCHC-35.4* RDW-14.1 Plt Ct-135*
[**2195-1-5**] 06:10AM BLOOD Hct-35.5*
[**2194-12-26**] 03:00PM BLOOD PT-13.3 PTT-35.3* INR(PT)-1.1
[**2194-12-26**] 03:00PM BLOOD Plt Ct-134*
[**2195-1-2**] 11:48AM BLOOD Plt Ct-135*
[**2194-12-26**] 03:00PM BLOOD Glucose-123* UreaN-19 Creat-1.2 Na-141
K-3.7 Cl-107 HCO3-27 AnGap-11
[**2195-1-1**] 01:05PM BLOOD Glucose-121* UreaN-23* Creat-1.5* Na-141
K-4.3 Cl-106 HCO3-25 AnGap-14
[**2194-12-29**] 05:54PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2194-12-29**] 05:54PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
Following the Cardiac cath, which demonstrated Severe 3 VD with
normal systolic function, the patient was seen by the cardiac
surgery and signed consent for CABG. On [**2194-12-30**] pt was brought to
the OR, after general anesthesia, pt underwent a coronary artery
bypass graft procedure x 3. Please see op summary for full
surgical details. Pt. tolerated the procedure well. Total CPB
time was 69 min & XCT was 53 minutes. Conditions on transfer to
CSRU were: MAP 88, CVP 6, HR 88 NSR. Pt. was in stable condition
being titrated on propofol and neo. Later that day, pt. was
initially weaned from propofol and extubated. After extubation
pt required constant care, prompting and reminding to keep
awake. Pt. was on 4l NC at this time, but needed to be converted
to 40% aerosol mask d/t lethargy & low sats. Sats initially went
up, but over the next 4 hrs sats decreased and pt. was then
re-intubated.
On POD #1 - pt was extubated again and now breathing well on his
own, making conversation, alert & oriented, neurologically
intact. He was completely weaned off of any drips.
POD #2 - pt. rec.'d 1UPRBC's for anemia (Hct24.1)Chest tubes
removed. Transferred to telemetry floor. foley removed. Pt was
in ST w/ freq. PAC's & PVC's. Both lopressor and Amio were
started.
POD #3 - pt had some course ronchi bilat. & 2+ edema. Otherwise
doing alright. Lopressor was increased and pt was encouraged to
increase mobility. Pacing wires removed.
POD #4 - pt. rec.'d 1UPRBC's for anemia (Hct29.5). Lungs were
CTAB today. HR 84 SR
POD #[**4-4**] - Pt. slowly progressed to an activity level for
discharge. He was no longer anemic. Still receiving amio for ST.
Last 3 days he was hemodynam. stable. P D/C PE:
T 98.9 P 80 BP 140/83 RR 20
Neuro: alert, oriented, non-focal
Pulm: CATB
Cardiac: RRR
Chest: sternum stable, -erythema/drainage
Abd: soft NT/ND +BS
Ext: warm, -edema
Medications on Admission:
TRANSFER MEDS
* plavix 75 mg daily
* lovenox
* lipitor 40 mg daily
* levothyroxine 0.05 mg daily
* allopurinol 100 mg twice daily
* lisinopril 10 mg daily
* lopressor 100 mg twice daily
* aspirin 325 mg daily
* nitroglycerine prn
* nitropaste 0.5 inch q6 hour
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. 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*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(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. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 7 days: Then decrease to 400 mg PO qd for 7
days, then decrease to 200 mg PO qd.
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*50 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABG x 3 (LIMA to OM1, SVG to LAD & OM2)
HTN
Gout
Hypothyroidism
s/p inguinal hernia repair
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# or driving for 1 month
no creams or lotions to incisions
may shower, no bathing or swimming for 1 month
Followup Instructions:
with Dr. [**Last Name (STitle) **] in [**11-30**] weeks
with Dr. [**Last Name (STitle) 5686**] in [**11-30**] weeks
with Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2195-1-22**]
|
[
"410.71",
"244.9",
"285.9",
"401.9",
"272.0",
"414.01",
"274.9",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"36.12",
"99.04",
"88.72",
"36.15",
"88.56",
"39.61",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7660, 7718
|
4201, 6066
|
279, 331
|
7862, 7868
|
2516, 4178
|
8037, 8230
|
1786, 1803
|
6376, 7637
|
7739, 7841
|
6092, 6353
|
7892, 8014
|
1818, 2497
|
229, 241
|
359, 1603
|
1625, 1683
|
1699, 1770
|
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